Health Promotion International, Vol. 30 No. 3 doi:10.1093/heapro/dau012 Advance Access published 28 March, 2014
# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
Health-promoting residential aged care: a pilot project in Austria Ludwig Boltzmann Institut Health Promotion Research, Vienna, Austria *Corresponding author. E-mail: [email protected]
SUMMARY Long-term care for the aged is an area that has not been in the focus of health promotion so far. The paper describes context, concept and project plan of a 2-year pilot project of comprehensive health-promoting setting development in residential aged care in Austria, and provides an overview over main experiences and results. Austria’s most relevant health promotion agencies, a specialized scientific institute and Austria’s largest provider of aged care acted as partners. The project aimed at developing elements of a comprehensive approach, but also providing evidence for the effectiveness of health promotion. Therefore, the project combined an organizational development approach with a scientific, randomized controlled study on mobility enhancement for residents. A comprehensive settings approach turned out acceptable for the main stakeholders of
aged care (owners and management, staff, residents and residents’ relatives). Strategy development, based on a systematic needs assessment, found staff health to be of special interest for the organization (ergonomics, workability over life course), and residents’ relatives, got more attention. The mobility study was able to achieve positive results on occupational performance, concerning quality-of-life indicators and reached also formerly inactive groups. After the end of the project, health promotion is still on the agenda of the organization; further developments will be monitored. Good support from the policy level and well-established networking between the aged care provider, health promotion agencies and a network for health promotion in health care seems to have been an important resource for success.
Key words: healthy ageing; settings approach; very old people; residential aged care
INTRODUCTION In Europe, long-term care for the aged is an area that has not been in the focus of health promotion so far. Especially, the settings approach has not yet been applied to aged care. Starting from this context, health promotion research has to answer questions in several areas: firstly, there is need for knowledge about the basic acceptability of health promotion by the main stakeholders of aged care; secondly, health promotion needs meaningful and feasible specifications for different target groups in this setting and there is need for knowledge about the effectiveness and sustainability of interventions and finally, there are many general questions concerning the implementation of the
settings approach, and the new setting ‘aged care’ can broaden our knowledge basis. These questions were the main research interests at the outset of the 2-year pilot project ‘Health Has No Age’ (German original: Gesundheit hat kein Alter—GHKA), a health promotion project for residential aged care in Austria, which was carried out from February 2011 to March 2013. The paper starts out with a short description of societal, policy and research contexts. The first main part presents the pilot project: context, stakeholders involved, concept, aims and objectives and project design. In the second main part, a short overview of the main experiences and results is provided. The discussion addresses the question what policy-makers, practitioners and 769
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KARL KRAJIC*, MARTIN CICHOCKI and VIKTORIA QUEHENBERGER
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researchers can learn from this Vienna example for further implementation of the settings approach in aged care.
SOCIETAL, POLICY AND RESEARCH CONTEXTS
Health promotion for the frail elderly? In most countries, aged care is organized as part of the social support system. But the complexity of problems and needs frequently associated with higher age have led to scientific and policy discussions, which ask for an integrated longterm care system including social care, health care (medical treatment and rehabilitation) and also prevention and health promotion (Ku¨mpers et al., 2010). The demand for health promotion also for the higher age groups is well in line with WHO’s ‘Healthy Ageing’ strategy and recent European Union initiatives (e.g. Caserta, 1995; European Commission DG Health and Consumer
Promoting health in long-term care settings? Even less scientific work has considered (residential) aged care as area for a complex and comprehensive settings approach. There is an early conceptual contribution in the US context (Minkler, 1984), and a recent conceptual contribution that discusses health-promoting aged care in an ecological context (Harris et al., 2008). There are also some recent policy and practice examples from the ‘Well for Life’ initiative in the state of Victoria in Australia. This programme tries to develop a more comprehensive perspective on the quality of life in aged care residences, focusing on core issues of health promotion like physical activity, nutrition and emotional wellbeing (Kruger et al., 2007; McKenzie et al., 2007; Victorian State Government, 2011).
‘HEALTH HAS NO AGE’: CONTEXT, CONCEPT AND AIMS OF A PILOT PROJECT Health promotion research in aged care settings is an integral part of the scientific programme of Ludwig Boltzmann Institut for Health Promotion Research (LBIHPR) in Vienna. The institute’s programme focuses on health promotion in organizational settings, especially in human service organizations, also considered as ‘people-processing organizations’ (Hasenfeld, 1972), like schools and hospitals. The development and implementation of the pilot project ‘Health has no Age’ (German: ‘Gesundheit hat kein Alter’—acronym GHKA) is a core element of research on health promotion in
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An ageing society and increasing need for long-term care Current society is often described as an ageing society—usually illustrated by the expected increase in the number of persons aged 65 and above. Still more relevant for this paper is the fact that the 80 plus generation is the fastest growing population group in most European countries (European Commission – DG Economic and Financial Affairs, 2011). Subsequently to the consistent rapid growth of this age group the demands for organized care are increasing: The likelihood of multi-morbidity, functional impairment, frailty, dementia, psychiatric conditions and shrinking social networks rises quickly with age. As a result, care for the elderly often means supporting persons with complex health and social problems. In the last decade, quality issues have been placed higher on the agenda of aged care, now not only focusing on structure but also on process and outcome. In this context, the construct ‘quality of life’ is seen as a central outcome of care processes in aged care and there are elaborate propositions for relevant dimensions relating strongly to health promotion, such as autonomy, well-being and functional competences (Kane, 2001).
Protection, 2007; Oxley, 2009; European Union Committee of the Regions, 2011). Looking at research literature, a wide range of papers on specific aspects of health and health promotion interventions can be found which address aged persons. But the group of highly aged still remains under-researched: users of residential care have rarely been considered as a potential target group for health promotion. There are only a few, rather problem-centred contributions which are related to specific issues like malnutrition, psychosocial health, medication problems, social isolation or physical activity with focus on injury prevention (based on a literature review by Horn et al., 2010).
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aged care. The pilot project is based on literature reviews, conceptual work and expert studies in the Austrian and German aged care sector. (Schaeffer and Bu¨scher, 2009; Brause et al., 2010; Horn et al., 2010; Krajic et al., 2010a; Krajic and Schmidt, 2010).
A comprehensive settings approach The project plan, developed in close cooperation with the main stakeholders, was based on a comprehensive settings approach for health promotion. This approach seemed especially appropriate as organizations providing residential aged care play a crucial role in regulating the lives of residents and to some extent, their families and carers and staff. Many users are vulnerable and dependent on the organization—the concept of the ‘total institution’ coined by the US social scientist Erving Goffman (Goffman, 1961) can still be used to describe some aspects of today’s aged care. ‘Comprehensiveness’ refers to three aspects: (i) a multi-dimensional understanding of health (ii) addressing health promotion needs of multiple target groups (iii) a multi-strategy settings approach.
A multi-dimensional understanding of health Health promotion in aged care considers physical, psychological and social dimensions and addresses (positive) health as a resource. Positive health is understood as a quality essential for the normal reproduction of individuals with biological, mental and social dimensions. Health promotion researchers might want to add a spiritual dimension, which can be argued to be very important for the target group of residents in aged care; in our understanding spirituality is an area relevant in both the mental and the social dimension of health. Health is understood as a quality of living systems that can be observed in subjective perspectives as well as by experts. Positive health is understood as referring to functional capacities and well-being, which can vary rather independently from the presence or absence of disease (Bauer et al., 2003; Bauer et al., 2006; Pelikan, 2007). To base health promotion work on an explicit concept of positive health seems especially relevant in health care in general and longterm care in particular. In aged care, there is a high prevalence of chronic disease and functional impairment—so it makes little sense to understand health promotion as primary prevention. An outline of this working concept has been published in German (Krajic et al., 2010b; Krajic and Schmidt, 2010), and in the context of an English language working paper (Krajic et al. 2010b). Target groups The pilot project aimed at optimizing health impact on all major groups that are associated with aged care settings: residents as the main users, staff, volunteer workers and users’ relatives. A multi-strategy settings approach Based on concepts from organizational research, change management and complexity theory, the pilot project aimed at developing the aged care setting into a ‘health-promoting environment’ for all people by increasing attention for health impact of its structures and processes (Dooris et al., 2007; Pelikan, 2007; Grossmann and Scala, 1993). In the five-fold typology of health promotion approaches proposed by Whitelaw (Whitelaw et al., 2001), this is described as the most comprehensive approach. Aims and objectives The GHKA project combined aims concerning scientific research, policy and practice development.
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Main stakeholders Project design and plans for financing and management were developed in close collaboration with three national partners, who are responsible for health promotion policy and practice on national and regional level: the Austrian Health Promotion Foundation (FGOE), the Vienna Health Promotion, Inc. (WiG) and the Main Association of Austrian Social Security Organizations (HVSV). Most important for the implementation of the project was the co-operation with the largest semipublic provider of residential aged care in Austria, the ‘Kuratorium Wiener Pensionistenwohnhaeuser’ (KWP), owned by the City of Vienna. KWP came out of a call to tender as practice partner, and offered three of its 31 units as pilot sites. Rather in the background and not upfront, the City Councillor for health and social affairs of Vienna was a central stakeholder who supported this co-operation between health promotion and aged care. In Vienna, the Councillor is politically responsible for both areas and, in addition, she represents the City as owner and main financing source for two organizations involved: the health promotion agency (WiG) and the aged care provider (KWP).
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Therefore, a second focus on staff health was explicitly included to the project agenda already at the outset. Concerning residents’ relatives’ health, a literature search came up with little research on the phases after admission to residential care. Nevertheless, it seemed important for project stakeholders to look at health impact and potentials for improvement for this group as well. Further project aims and objectives refer to the expectations of health and social policy as well as health promotion practice actors. A major goal of organizations responsible for the development of health promotion was agenda setting for health promotion in aged care by providing scientific analysis of the potential of aged care as a new area for health promotion policy development. For this purpose, policy partners expected (i) scientific evidence on the effectiveness of some specific interventions; as mentioned, this was an important reason for the decision to choose mobility enhancement and organize the intervention as a controlled trial; (ii) the project was also expected to develop practical tools that would be helpful in further proliferation of health promotion in this sector. The aged care provider KWP was primarily interested in utilizing health promotion as a means to support a major re-engineering process currently on-going in the overall organization. The pilot sites thus were expected to gather transferable knowledge for KWP’s overall policy and other units. OVERALL PROJECT DESIGN The overall project was organized as a 2-year (February 2011- March 2013) process and combined systematic needs assessment, two main interventions, systematic evaluation and dissemination strategies of project experiences and results. Structure and process of the pilot project will be described under five main headings, (i) project initiation, (ii) needs assessment, (iii) interventions, (iv) project evaluation and (v) dissemination. Project initiation Following strategic decisions of the project plan and funding in the first half of 2010, the overall project management was set up in the context of HVSV and WiG, two expert organizations responsible for health promotion development.
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Scientifically, the main aim was to study acceptability, feasibility and viability of a comprehensive, whole organization setting approach of health promotion in residential aged care. This included critically analysing project architecture, feasibility and usefulness of needs assessment methods as well as the feasibility and effectiveness of an overall developmental approach. The second main scientific aim was to analyse feasibility, effectiveness and viability of specific health promotion interventions implemented, especially of a mobility enhancement intervention for residents, organized as a randomized controlled trial. For residents, ‘mobility’ had been identified as an important intervention area for several reasons: (i) the literature points at the crucial importance of ‘mobility’ in this population. Compared with community-dwelling elderly, the users of longterm care are more likely to be affected by impairments concerning activities of daily living (ADLs) (Horn et al., 2012). Yet the capability to perform ADLs is of huge importance for the aged and highly aged; in this group, physical constraints often go along with a decrease of autonomy (King et al., 2002). There is numerous evidence that mobility enhancement can cause a significant improvement of overall well-being (Netz et al., 2005). Results of the needs assessment carried out in the pilot project (see below) confirmed the relevance of mobility as an intervention area—this issue turned out to be the most frequently named area of concern. (ii) A mobility enhancement intervention was able to build on resources and traditions of the involved institution and thus could connect well to the users’ and provider’s expectations. (iii) Health policy partners of the project found ‘mobility’ attractive for several reasons, e.g. that the relevance of this dimension of health can be transported easily in the media and at the same time a mobility intervention promised some hard evidence on the effectiveness of health promotion on (physical) health. Concerning staff, a review of the Germanlanguage literature (Brause et al., 2010) found that aged care is perceived as even more stressful than acute medical care. Staff complains in particular about the problem of having to deal with complex physical, psychological and communication challenges often under the condition of staff shortages and narrow schedules (Simon et al., 2005). The review also identifies several staff health programmes in German-speaking countries (Brause et al., 2010), thus there was a good basis for building on established interventions.
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Needs assessment A comprehensive needs assessment was carried out between April and September 2011. Health promotion needs of residents were assessed on the basis of a sample of about 100 randomly selected residents in each of the three units (about one-third of the total number of residents), explicitly not using reduced communicative or cognitive abilities as a criterion for exclusion. Interviews were conducted as an open talk, but guided and documented using a standardized questionnaire. Focus was (subjective) health status and various factors relevant as health determinants in the setting. The questionnaire and interview strategy were developed by the LBIHPR on the basis of instruments for assessing quality of life in nursing homes. SLQA, a German language instrument, specifically designed to enable communication also with
people with mild dementia and communicative problems, served as a main source (Kneubuehler and Estermann, 2008). In addition, the functional health status and care needs of the interviewed persons were assessed by members of staff, utilizing NBA, a German assessment instrument (Wingenfeld et al., 2008). Concerning staff, a health questionnaire was distributed to all employees. The instrument was developed on the basis of existing German language instruments adapted to aged care working situations, including health status, working conditions and experiences as well as their perceived needs for health promotion. The staff survey was complemented by ‘health circles’, i.e. moderated group discussions for staff members which are frequently utilized in workplace health programmes in German-speaking countries (Aust and Ducki, 2004). Health circles are intended to create a more in-depth problem analysis and to locally elaborate some possible health-promoting solutions. The perspectives of volunteer workers and relatives were collected by focus group interviews with a semi-structured guideline. Main issues were perceived roles and functions as well as needs for support.
Interventions The project design combined the aim to demonstrate feasibility of an open, comprehensive developmental approach in aged care with the aim to produce hard evidence that health promotion can be effective in aged care in only 2 years project duration and a designated intervention period of 1 year. So there was a strategic decision to combine the aim of demonstrating feasibility of the comprehensive, bottom-up approach to settings development in aged care with a scientific study which would be able to provide hard evidence on the effectiveness of health promotion in one selected area. The project plan predefined a scientific study in a randomized controlled trial design. ‘Mobility enhancement for residents’ was selected as an intervention area on the basis of scientific literature and expert perspectives. Strategy development The project partners agreed that the project duration of 2 years was very short for an open, comprehensive settings approach. So the project plan
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These two partners also co-financed the project with the main source of external funding being FGOE, the main developmental agency for health promotion in Austria. Scientific project management was set up at LBIHPR, working in close collaboration with the overall management. A call for tender was initiated in October 2010 and finalized in January 2011. As a result, the aged care provider organization KWP became the practice partner, participating with three of its 31 aged care residences. The three units are of a comparable size (unit 1: 330 residents, 111 staff; unit 2: 290 residents, 148 staff; unit 3: 330 residents, 108 staff ) and offer a similar mix of aged care services: Nearly 90% of the users still lived individually in apartment units with basic services such as cleaning, technical support, food, animation groups; nursing care was only offered if specifically required. About 10% of residents needed continuous and intensive care (temporarily or permanently) and lived in nursing units organized as wards. In the project initiation phase (February – April 2011), each local unit was able to appoint a part-time (25%) project coordinator out of project funds. The core function of the co-ordinator was to provide administrative and practical support for implementation and coordination over the whole period. On the basis of kick-off meetings with local first and second level management and staff representatives, local project steering groups were set up in the three units. On the overall management level of KWP, initially there was one second level manager designated as a focal point for the project.
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Mobility enhancement study The project plan pre-defined mobility enhancement as area to look for hard evidence for the effectiveness of health promotion targeting residents of aged care facilities. The mobility intervention was developed to address not only physical, but also cognitive and social aspects of mobility. As mentioned before, mobility was also selected because in the aged care sector many facilities have a tradition to offer some kind of mobility enhancement programme, though most of these programmes—at least in Austria—have not been systematically described or evaluated. Thus, the project decided to develop and test a programme which on one hand builds on ‘evidence-based’ elements that would be very likely to produce effects; on the other hand, the programme was also expected to allow for broad participation, i.e. it had to avoid to be too demanding concerning functional health status and self-discipline of residents. In addition to a curriculum, the project plan included criteria for staff selection and training. Staff selection criteria were formulated rather close to organizational resources available, keeping the formal qualification level demanded comparatively low, to allow a continuation after the end of the project. Another important element was a pro-active invitation policy: traditional mobility programmes
are usually offered on a voluntary basis. This leads to self-selection of individuals interested in exercise who often have a mobility status clearly above average—and thus the programmes are likely to increase health inequality. To avoid such a bias and allow for generalization towards the ‘average’ resident, the project plan demanded random selection and active invitation. Project evaluation Between April 2010 and March 2013, the evaluation was conducted by LBIHPR in the framework of a formative and summative project evaluation, including perspectives on process as well as on outcome. A mix of qualitative and quantitative methods was applied. Concerning the overall project and strategy development, data were generated primarily by systematic documentation, participant and non-participant observations and interviews with different stakeholders. Evaluation of the mobility enhancement study included monitoring aspects of implementation of the programme to explore issues of feasibility and quality. Nevertheless, for this intervention there was a strong focus on quantitative outcome evaluation, aiming to measure improvement of mobility and other dimensions of positive health. Dissemination Considering the partners’ aims for policy and practice development, the project included a systematic dissemination strategy with measures starting from the very beginning, running parallel to all project phases (details described below). EXPERIENCES AND RESULTS The following section highlights experiences and results concerning the different steps and stages of the project. Experiences from the initiation phase In spring 2010 proposals for a comprehensive health promotion project were discussed with key social care actors of Vienna and a second Austrian region. These stakeholders showed interest, but also caution. In a first adaptation of project plans, a focus on the Vienna region was decided, where good political support was available. At first contact, provider organizations
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tried to avoid raising unrealistic expectations by defining ‘strategy development’ as an aim of the open process. Based on a rapid analysis of needs assessment results, local steering groups, prioritized action areas and defined some suitable measures to develop the setting into a healthpromoting environment for all relevant target groups. During this process, they were supported by an experienced health promotion development consultant, overall project management and LBIHPR as scientific support. The project partners accepted that the full-developmental cycle (selection and specification of intervention measures, implementation, evaluation, adaptation etc.) could not be completed for more complex measures in the 2-year period. Nevertheless, it was planned that at least some simple measures should be defined, implemented and evaluated in the project time-frame. Furthermore, the health promotion strategy was expected to include also middle- and long-term perspectives for the period after the end of the pilot project.
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Needs assessment The needs assessment was carried out between April 2011 and August 2011. The data collection instruments and procedures proved applicable, providing relevant and valid results as basis for further development. Regarding residents, 345 interviews and health status assessments of randomly selected residents
were conducted, reaching more than one-third of the population. Questionnaire and interview strategy were adapted to the target group, applicable also in cases of mild forms of dementia; interviewers had experience in and were professionally trained for communication with aged care residents. As to staff, a questionnaire on workplace health (response rate: 60%) and,—as a second approach, ‘health circles’ involving 46 staff members from different professional areas were utilized. Focus groups with residents’ relatives and volunteers (40 persons each) added further perspectives. Some main results can be summarized for the target groups † Residents: as indicated in the literature, mobility turned out to be an area of major concern. Less widespread, but still rather common were worries in the areas of psychosocial health, chronic pain, lack of social support and security issues. A small minority of residents reported restrictions of autonomy and negative experiences with power relations in the institution. † Staff: specific area of concern was physical strain. Problems of communication and trust were named by up to a third of staff members (critical perspectives towards the management, but also towards colleagues). From an organizational perspective, maintenance of workability in the life course seems to be a central concern, especially in the group of nurses. † Relatives and volunteers: problems were identified mainly concerning lack of communication and information. In addition, concerns about residents’ medical care turned out to be a source for worries of relatives. Health promotion strategy development Local steering groups started their work in September 2011. In a first round, needs assessment results for all target groups were presented, based on a rapid first analysis. Developing a systematic and comprehensive ‘Health Promotion Strategy’ for the units turned out to be a difficult task. Given the short overall timeframe, the management of the pilot project pushed for a fast priority setting and for identification of measures which were simple and quickly to attain. The steering groups focused primarily on staff health issues, taking up proposals developed by local staff representatives in the ‘health circles’. Residents did not play a major role in this process: contrary to the initial plan, residents’
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showed interest, but also expressed scepticism if such a health promotion project would be supportive—or rather cause new problems. The fact that there were discussions with four interested provider organizations, and that only one provider finally decided to participate, indicates that health promotion—as a new topic—still has to demonstrate its usefulness to this sector. The process of setting up local project structures started with kick-off meetings of the project team, consisting of the directors of the units, other local management and staff representatives. Residents, staff and interested relatives of residents were introduced to the pilot project by public meetings. At these events, only very little open scepticism was articulated. Overall, the availability of local project resources proved very helpful to carry out operative work. The project co-ordinators, who were staff members of the residences, facilitated the communication. For the project management, they served also as informants on local developments. To select a co-ordinator with a professional profile close to health issues (two of the three co-ordinators were health professionals) turned out very helpful in communicating health promotion to target groups and to motivate them to participate in needs assessment and interventions. In the first months, the project team had to learn that some assumptions concerning the overall project architecture had to be revised. The strategic autonomy of the local management was much smaller than expected. Further, the participating residential aged care provider organization turned out to be in a fundamental re-engineering process of its core business, which was managed in a centralized fashion. So local management felt quite uncertain about the leeway it had for local developments. As consequence, a systematic co-operation structure with the central management of the aged care provider had to be set up for the ‘Health Promotion Strategy Development’ intervention (see below).
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realities of everyday work, and also seems to have slowed down developmental processes. By March 2012, local steering groups concluded their work, defining that everything that could be developed on their level was done. It was not before October 2012, close to the formal end of the project period, that a working group at the central management level met again, identifying an agenda for further health promotion development of the provider KWP. Figure 1 provides an overview on the main issues that were addressed in the process. Issues in bold letters with a dark frame were developed as far as specific concrete measures; issues in italics with a light frame were still in progress at the end of the project. Further issues, shown as normal text with a dashed frame, were dropped. Figure 1 indicates that comprehensiveness in the sense of addressing all target groups has remained on the agenda, with varying progress concerning complexity of approach and amount of concrete measures that could be defined or even implemented. For residents, project management accepted the focus on mobility enhancement due to the short-project period. The aged care provider had argued that further measures to safeguard or improve residents’ quality of life in problem areas identified by the
Fig. 1: Strategy development: progress in different areas until December 2012.
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representatives were not invited to the sessions as the steering groups did not want to discuss ambiguous staff health issues in front of residents. This was probably one reason why measures to promote residents’ health—beyond the predefined mobility enhancement intervention—did not become an issue on the local level. Another reason for the reluctance was the fact that the local management did not feel a sufficiently strong mandate from the provider’s central management. Local steering groups also focused rather on local and practical problems, while strategic questions were delegated to the central management. So—on finding out about this reluctance of the local level—the pilot project management had to push for initiating a strategic development on the central management level of the provider. A first meeting with the top management took place in January 2012, which was prepared in a so-called ‘Sparring Group’, consisting of second level management responsible for quality development, human resources and related departments. So—other than expected—strategic issues were discussed mainly at the central level. This was adequate with regard to the self-understanding of the provider, but moved definition of problems and possible solutions rather far away from the
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Mobility enhancement intervention The mobility intervention, organized as randomized controlled study, was carried out between November 2011 and May 2012. Participants of the intervention group (n ¼ 139, randomly assigned) were provided with a weekly training programme, based on a curriculum developed by specialists for occupational therapy and physiotherapy from Vienna Medical University. The curriculum contained 20 units to be conducted under supervision of trained staff, experienced in mobility enhancement interventions. Seven external assessors (physiotherapists and occupational therapists) tested the state of mobility in a baseline
assessment and conducted a second assessment at the end of the intervention. Changes were analysed and compared with a control group (n ¼ 137) which had received a placebo social intervention. The intervention was effective in terms of improving the intervention group’s performance concerning ADLs as measured by Canadian Occupational Performance Measure. This measure allows to examine changes in performance of everyday activities which were considered problematic in a first assessment. The intervention also improved subjective health status (measured by EQ5D, an instrument well established in aged care). Effects were small, but significant (significance P , 0.05). In the control group, no significant changes could be observed. Statistical analyses were conducted via a generalized linear mixed model for repeated measures supplemented by paired t-tests. Detailed results will be published in a separate paper. One result worth specific mentioning concerned inclusion of people with reduced functional health and unstable motivation for exercise. Through pro-active and personalized recruitment of participants by project coordinators several residents could be involved which had not taken part in exercise programmes of the institution beforehand. Positive results of the mobility intervention led to an internal roll-out of selected aspects of the programme and raised much external attention for the project as well. The first step of organizational roll-out was a systematic training in principles of the programme for all staff members of the overall enterprise who were offering mobility support courses for residents. In 2013–2014, a follow-up study will monitor this process. Dissemination The main measures of dissemination throughout the project period were presentations of the project and its intermediary results for different publics. The main media were the project website (www.gesundheithatkeinalter.at), public project events (three public conferences), and presentations at conferences and workshops. The project got considerable interest from aged care providers, professionals and scientists, mostly from the Vienna region. A web-based handbook on the practice of health promotion in residential aged care will include results and recommendations for organizations and professionals in longterm care practice. A project to disseminate and
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needs assessment were already on the agenda of the on-going reengineering process. Staff health became the central issue of health promotion ‘Strategy Development’ and got addressed at different organizational levels. On the local level, the steering groups proved to be a good communication format to identify and solve smaller, local problems. On the management level of the overall company, perspectives on staff health were strengthened by designating a responsible person who developed a concept for workplace health promotion. As a first measure, a training programme in basic ergonomics was implemented, first in the three pilot institutions but also in other units of the provider (on-going in 2013), aiming at empowering employees from different areas to act as ‘ergonomic health guides’ as additional element in their professional roles. The issue of safeguarding work ability of an ageing workforce was identified as relevant on the top management level. Initially, participation in a large-scale national programme was considered, but when learning about rather rigid conditions for participation, the provider decided to further develop its already on-going programme for age-appropriate workplaces. For volunteers, the local units were able to manage the issues brought up in focus groups, as support by a professional coordinator had already previously been established. Regarding the target group of user’s relatives, a first concept for involvement has been developed. The specific measure will be evaluated in a follow-up project (2013 – 2014). For all groups, some issues were explicitly dropped—most of them were accepted as relevant, but regarded too complex for the framework of a short health promotion project.
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market the handbook and encourage health promotion development in other Austrian aged care facilities is in preparation. Further scientific publications in German and English language journals, discussing specific aspects of project results, are in preparation.
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DISCUSSION
What are relevant health promotion issues for different target groups? Overall, the project indicates that health promotion makes sense for many actors in aged care. However, it is important to invest in translating health promotion principles and ideas into expectations of the field. One important step is to explicitly argue what the aims and intervention areas for the different target groups are. This pilot study provides us with some answers: –
For residents, mobility has been confirmed to be a core issue, but the needs assessment and scientific literature came up with several other issues as well, like psychosocial wellbeing, security, preserving autonomy, improvement of social support and even rather medical issues like pain management.
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Are there trends in aged care indicating that chances for health promotion are improving? Overall, on a societal level there are indications for changes in aged care. Especially nursing homes used to be considered as dealing with end-of-life stages, where limited effective (therapeutic) interventions are available. This understanding is put into questions by advances in medicine and other health professions, e.g. leading to a changing focus of therapeutic interventions from ‘healing’ to stabilization or improvement of ‘quality of life’ or the emergence of ‘palliative care’ as a special field. More demand is being created by the extension of those phases of higher age, in which some kind of social or nursing support is used. And, last not least, the growing number of people affected makes aged care issues politically more relevant. Organization, financing and also quality improvement of aged care are getting relevant issues in elections—aged care seems to climb up on political, but also professional and scientific agendas. The discussion on quality issues in aged care has gotten more prominent over the last years—quality was a core issue of the first two International Long-Term Care Policy Conferences organized in London 2010 and 2012.
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Does ‘Health has no Age’ contribute to ‘hard’ scientific knowledge about health-promoting aged care? Only in a limited way: the overall health-promoting settings approach of this pilot project basically is an experimental case study—a rather short one, and a not very controlled one. Owing to the very nature of the settings approach, it is a complex intervention in a complex field. As a result, there are many limitations to generalizing experiences and results. Nevertheless this pilot case allows learning about how the project, interacting with its specific context, was able to reach many of its aims. The authors are convinced that this will be helpful for further health promotion activities in aged care—hopefully some of them organized as scientifically supported experiments or at least as well-documented and evaluated practice projects. Therefore, the discussion tries to answer questions what policy-makers, experts, researchers, aged care professionals and managers can learn from this example when considering a similar kind of comprehensive settings approach project in aged care.
Regarding staff, issues like work ability of those involved in direct care obviously are relevant. There are shortages especially of qualified nurses in most countries, so providers have to invest in retention of their staff. In addition, needs assessment results underline what scientific literature and experience from other settings tell us: issues often targeted in staff health promotion like a trusting organizational culture, a good effort-reward balance and good leadership quality are probably crucial in aged care as well. Concerning residents’ relatives, it is important to understand the—potentially—strong interdependence between relatives and aged care organizations: relatives might want to feel unburdened by professional care, but many of them are interested in making a contribution by continuing their personal relationship with the residents, offering psychological and social support. This is more likely to succeed if accepted and supported by the organization. Needs assessment came up with indications that systematic information and communication could be helpful to involve and support relatives.
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Can aged care professionals foster strategic partnerships in ways that enhance a health promotion focus, and how? To foster strategic partnerships aged care providers and professionals could link up with existing health promotion resources, e.g. national and regional agencies and networks. To utilize networks of cities, workplace health promotion, hospitals and healthcare organizations should be useful: The pilot project was able to build on a basis of trust and understanding between aged care and health promotion actors, which was established throughout 10 years involvement of the aged care provider in a loosely coupled regional information network for health promotion. In the specific local context, this collaboration was facilitated by support from the political level, which helped to build bridges between health promotion and aged care. Building bridges is needed, as in many other regional and national contexts aged care and health promotion are managed and supervised strictly apart, in rather competing than cooperating ways. What strategies might be useful for managing such a complex project in a short timeline—and what can be done to make health promotion a normal part of organizational processes? Following Whitelaw et al. (2001, p.342), comprehensive settings approach projects need a pragmatic and more tactical orientation to the sustainable development of settings work. In principle, this holds true for all such projects, but
in the case of the pilot project this was sharpened by the narrow timeframe. The 2 year timeline set by the financing partners in the planning phase could only be accepted by negotiating realistic aims, targets and timelines for the project plan. To define ‘Strategy Development’ as core intervention for the comprehensive approach and— by that—not to promise full implementation included the risk that plans remain on paper. In this pilot project, this risk was managed by predefining the mobility enhancement intervention for residents and by highlighting staff health through ‘health circles’ as part of the needs assessment. ‘Health circles’ are not only diagnostic instruments, but provide quick and easily implementable solutions; health circles also generally enhance communication on staff health within the organization. It seems essential to involve various management levels in the health promotion process; especially the central management turned out to be crucial to achieve some organizational impact: The so-called ‘Sparring Groups’ as part of strategy development, and the transfer workshops for the middle- and top-management level in the last phases of the project seem to have served well for this purpose, as this helped to include health promotion into everyday management routines. Acceptance was probably further promoted by the fact that agenda setting was done primarily by internal staff, with project staff and scientists only in a supporting and collaborating role. On the other hand, there are some indications that the strong involvement of the central level concerning the ‘strategy development’ also contributed negatively to local developments, facilitating resignation processes of local level management. Yet the involvement of upper management levels, which in the current formal structure of the organization are responsible for strategy development, seems to have helped to keep health promotion on the organization’s agenda after the formal end of the project. On-going roll-out activities of mobility enhancement for residents, new ergonomic support roles for staff (‘ergonomic health guides’) and efforts to improve communication and cooperation with relatives indicate that health promotion is still relevant. Structural measures like the nomination of a healthy workplace focal point (third level management), formulation of a staff health action plan including a focus on work ability for ageing staff, are further indicators of effectiveness and sustainability. These developments are
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The quality movement in aged care can build on concepts, models and experiences developed in acute health care over the last 25 years. Outcome quality, including maintaining or improving subjective well-being and functional health seems to play an increasingly prominent role in aged care, and there are several reform movements addressing these issues (e.g. Palliative Care and EDEN Alternative). What about health promotion in this context? Project experiences of the pilot project have demonstrated that health promotion links well with this quality development; especially the settings approach provides a comprehensive perspective on health impact for all target groups affected. For health promotion actors, establishing strategic partnerships and promoting cooperation, rather than competing with the quality movement, seems promising.
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being scientifically monitored and evaluated in the follow-up project 2013 –2014, which will allow for further learning from this example.
How to manage difficult interactions between a rather top-down-oriented organizational culture and participatory principles of health promotion? For health promotion project management and scientific support, the principle of keeping equidistance to different proponents in organizational conflicts seems to be essential. Health promotion of course has a preference for participation and tends to be close to local levels. But, in order to remain relevant and effective in large-scale organizations, health promotion experts have to work with formal structures and the established culture. Health promotion projects that manage to work in a balanced way thus can be even more empowering by supporting staff to learn how to better use formal organizational structures, to solve problems in a more effective and sustainable way than what is possible on the local level. In the specific situation of the pilot project, the project provided added value by re-integrating local and staff perspectives in a complementary way into a top-down business re-engineering process, thus helping to balance a difficult overall change process. To what extent this effect will be sustainable after the formal end of the project will be monitored in the follow-up period.
At the end of a 2-year project period, the pilot project was able to demonstrate that setting— oriented health promotion can be conceptualized and implemented in residential aged care—at least if politically, organisationally, scientifically and also financially well supported. Health promotion has been accepted by the participating residential care provider as a contribution to their development on the organizational level (local and top management). A specific mobility enhancement intervention proved feasible, attractive and effective also for residents with reduced ( physical) functional capacities. By being able to provide hard data on effectiveness concerning subjective health and occupational performance, this intervention has turned into a strong marker for health promotion effectiveness in this sector. Several steps were undertaken to make at least some aspects of health promotion part of everyday organizational practice. At the end of the 2-year project period, some parts of the strategy and several concrete measures were still in process of specification or implementation. In terms of effectiveness and viability, a comprehensive settings approach in aged care seems promising but many questions concerning scope and depth of changes remain to be answered. A follow-up project will monitor this progress for the period 2013 –2014. FUNDING Implementation of the project was funded by the Austrian Health Promotion Foundation (FGOE), the Vienna Health Promotion, Inc. (WiG) and the Main Association of Austrian Social Security Organizations (HVSV). Evaluation and scientific analysis were financed partly out of the implementation project and to a large part by the Ludwig Boltzmann Society, a private non profit association organizing research, funded by the Austrian Federal Ministry for Science and Research. REFERENCES Aust, B. and Ducki, A. (2004) Comprehensive health promotion interventions at the workplace: experiences with health circles in Germany. Journal of Occupational Health Psychology, 9, 358–370. Bauer, G., Davies, J. K., Pelikan, J. M., Noack, R. H., Bro¨sskamp, U. and Hill, C. (2003) Advancing a theoretical model for public health and health promotion indicator
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How to overcome a narrow focus of health promotion on specific and widely accepted issues like mobility enhancement or ergonomics training? It is primarily an internal decision which problems/issues the organization wants to address in a health promotion context—and which not. Health promotion experts can of course argue for a broader approach (using results of the needs assessment, scientific literature, personal expertise etc.), but usually it requires external resources—such as tools, experts, change management support and external project funds, but also agenda setting by relevant, in many cases political actors. These actors need to be convinced that inclusion of health promotion issues on the agenda of quality assurance and development of the sector is useful for their goals.
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gemessen werden kann. Swiss Journal of Sociology, 34, 187– 210. Krajic, K. and Schmidt, C. (2010) Gesundheitsfo¨rderung als Beitrag zur Entwicklung der o¨sterreichischen Long ¨ berlegungen und Term Care? Konzeptuelle U ExpertInneneinscha¨tzungen. Universita¨t Linz, Linz. Krajic, K., Schmidt, C. and Christ, R. (2010a) ¨ sterreich: Gesundheitsfo¨rderung in der Long-Term Care in O Eine Status quo-Analyse. Soziale Sicherheit, 3/2010, 142–148. Krajic, K., Schmidt, C. and Schu¨ssler, S. (2010b) Health Promoting organisation Settings in Long-Term Care— Conceptualizing in the Framework of the Vienna Organisational Health Impact Model. Theory of Health and Health Promotion in Organizations, Part 3 of 6, LBIHPR, Vienna. Kruger, W.A., Thompson, C., McKenzie, R. and Naccarella, L. (2007) Well for life: a way of life. Annals of the New York Academy of Sciences, 1114, 337–342. Ku¨mpers, S., Allen, K., Campbell, L., Dieterich, A., Glasby, J., Kagialaris, G. et al. (2010) Prevention and rehabilitation within long--term care across Europe European Overview Paper. INTERLINKS project; European Centre for Social Welfare Policy and Research and others, Berlin/ Copenhagen/ Vienna. McKenzie, R., Naccarella, L. and Thompson, C. (2007) Innovation in aged care: well for life: evlaution and policy implications of a health promotion initiative for frail older people in aged care settings. Australasian Journal on Ageing, 26, 135–140. Minkler, M. (1984) Health promotion in long-term care: a contradiction in terms?. Health Education and Behavior, 11, 77–89. Netz, Y., Wu, M. J., Becker, B. J. and Tenenbaum, G. (2005) Physical activity and psychological well-being in advanced age: a meta-analysis of intervention studies. Psychol. Aging, 20, 272–284. Oxley, H. (2009) Policies for Healthy Ageing: An Overview. OECD, Paris, 42. Pelikan, J. M. (2007) Understanding Differentiation of Health in Late Modernity - by use of sociological system theory. In McQueen, D. V. and Kickbusch, I. S. (eds), Health and Modernity: The Role of Theory in Health Promotion. Springer, New York, pp. 74–102. Schaeffer, D. and Bu¨scher, A. (2009) Mo¨glichkeiten der Gesundheitsfo¨rderung in der Langzeitversorgung – ¨ berlegungen. Empirische Befunde und konzeptionelle U Zeitschrift fu¨r Gerontologie und Geriatrie, 42, 441–451. Simon, M., Tackenberg, P., Hasselhorn, H.M., Ku¨mmerling, A., Bu¨scher, A. and Mu¨ller, B. H. (2005) Auswertung der ersten Befragung der NEXT-Studie in Deutschland. Wuppertal. Victorian State Government, D. o. H. (2011) Improving emotional wellbeing for older people in residential aged care, Wellbeing, Integrated Care and Ageing Division, Victorian Government, Department of Health, Melbourne. Whitelaw, S., Baxendale, A., Bryce, C., Machardy, L., Young, I. and Witney, E. (2001) ‘Settings’ based health promotion: a review. Health Promotion International, 16, 339– 353. Wingenfeld, K., Bu¨scher, A. and Gansweid, B. (2008) Das neue Begutachtungsassessment zur Feststellung von Pflegebedu¨rftigkeit. Universita¨t Bielefeld, Bielefeld/ Mu¨nster.
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development. Proposal from the EUHPID consortium. European Journal of Public Health, 13(3 Supplement), 107–113. Bauer, G., Davies, J. K. and Pelikan, J. M. (2006) The EUHPID Health Development Model for the classification of public health indicators. Health Promotion International, 21, 153–159. Brause, M., Horn, A., Bu¨scher, A. and Schaeffer, D. (2010) Gesundheitsfo¨rderung in der stationa¨ren Langzeitversorgung - Teil II, Institut fu¨r Pflegewissenschaft an der Universita¨t Bielefeld, Bielefeld. Caserta, M. S. (1995) Health promotion and the older population: expanding our theoretical horizons. Journal of Community Health, 20, 283–292. Dooris, M., Poland, B. D., Kolbe, L., De Leeuw, E., McCall, D. S. and Wharf-Higgins, J. (2007) ‘Healthy Settings. Building Evidence for the Effectiveness of Whole System Health Promotion - Challenges and Future Directions’. In McQueen, D. V. and Jones, C. M., (eds), Global Perspectives on Health Promotion Effectiveness. Springer, New York, pp. 327–352. European Commission – DG Economic and Financial Affairs. (2011) The 2012 Ageing Report: Underlying Assumptions and Projection Methodologies 4/2011. European Commission DG Health and Consumer Protection. (2007) ‘Healthy Ageing, A Keystone for A Sustainable Europe’ EU Health Policy in the Context of Demographic Change. European Commission DG Health and Consumer Protection, Luxembourg. European Union Committee of the Regions. (2011) How to Promote Active Ageing in Europe. EU Support to Local and Regional Actors. European Union Committee of the Regions, Brussels. Goffman, E. (1961) Asylums. Essays on the Social Situation of Mental Patients and Other Inmates Garden City. Anchor Books, New York. Grossmann, R. and Scala, K. (1993) Health Promotion and Organisational Development: Developing Settings for Health. 9 edn. Wien, WHO-Europa; IFF. Harris, N., Grootjans, J. and Wenham, K. (2008) Ecological aging: the settings approach in aged living and care accomodation. EcoHealth, 5, 196–204. Hasenfeld, Y. (1972) People processing organizations: an exchange approach. American Sociological Review, 37, 256 – 263. Horn, A., Brause, M., Schaeffer, D. and Bu¨scher, A. (2010) Gesundheitsfo¨rderung in der Stationa¨ren Langzeitversorgung Teil I. Universita¨t Bielefeld, Bielefeld. Horn, A., Brause, M. and Schaeffer, D. (2012) Bewegungsfo¨rderung in der (stationa¨ren) Langzeitversorgung. In Geuter, G. and Hollederer, A. (eds), Handbuch Bewegungsfo¨rderung und Gesundheit. Hans Huber, Bern, pp. 305–318. Kane, R. A. (2001) Long-term care and a good quality of life: bringing them closer together. The Gerontologist, 41, 293–304. King, M. B., Whipple, R. H., Gruman, C. A., Judge, J. O., Schmidt, J. A. and Wolfson, L. I. (2002) The performance enhancement project: improving physical performance in older persons. Archives of Physical Medicine and Rehabilitation, 83, 1060– 1069. Kneubu¨hler, H. U. and Estermann, J. (2008) Warum Lebensqualita¨t im Pflegeheim bedeutsam ist und wie sie
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Health-promoting residential aged care: a pilot project in Austria Ludwig Boltzmann Institut Health Promotion Research, Vienna, Austria *Corresponding author. E-mail: [email protected]
SUMMARY Long-term care for the aged is an area that has not been in the focus of health promotion so far. The paper describes context, concept and project plan of a 2-year pilot project of comprehensive health-promoting setting development in residential aged care in Austria, and provides an overview over main experiences and results. Austria’s most relevant health promotion agencies, a specialized scientific institute and Austria’s largest provider of aged care acted as partners. The project aimed at developing elements of a comprehensive approach, but also providing evidence for the effectiveness of health promotion. Therefore, the project combined an organizational development approach with a scientific, randomized controlled study on mobility enhancement for residents. A comprehensive settings approach turned out acceptable for the main stakeholders of
aged care (owners and management, staff, residents and residents’ relatives). Strategy development, based on a systematic needs assessment, found staff health to be of special interest for the organization (ergonomics, workability over life course), and residents’ relatives, got more attention. The mobility study was able to achieve positive results on occupational performance, concerning quality-of-life indicators and reached also formerly inactive groups. After the end of the project, health promotion is still on the agenda of the organization; further developments will be monitored. Good support from the policy level and well-established networking between the aged care provider, health promotion agencies and a network for health promotion in health care seems to have been an important resource for success.
Key words: healthy ageing; settings approach; very old people; residential aged care
INTRODUCTION In Europe, long-term care for the aged is an area that has not been in the focus of health promotion so far. Especially, the settings approach has not yet been applied to aged care. Starting from this context, health promotion research has to answer questions in several areas: firstly, there is need for knowledge about the basic acceptability of health promotion by the main stakeholders of aged care; secondly, health promotion needs meaningful and feasible specifications for different target groups in this setting and there is need for knowledge about the effectiveness and sustainability of interventions and finally, there are many general questions concerning the implementation of the
settings approach, and the new setting ‘aged care’ can broaden our knowledge basis. These questions were the main research interests at the outset of the 2-year pilot project ‘Health Has No Age’ (German original: Gesundheit hat kein Alter—GHKA), a health promotion project for residential aged care in Austria, which was carried out from February 2011 to March 2013. The paper starts out with a short description of societal, policy and research contexts. The first main part presents the pilot project: context, stakeholders involved, concept, aims and objectives and project design. In the second main part, a short overview of the main experiences and results is provided. The discussion addresses the question what policy-makers, practitioners and 769
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KARL KRAJIC*, MARTIN CICHOCKI and VIKTORIA QUEHENBERGER
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researchers can learn from this Vienna example for further implementation of the settings approach in aged care.
SOCIETAL, POLICY AND RESEARCH CONTEXTS
Health promotion for the frail elderly? In most countries, aged care is organized as part of the social support system. But the complexity of problems and needs frequently associated with higher age have led to scientific and policy discussions, which ask for an integrated longterm care system including social care, health care (medical treatment and rehabilitation) and also prevention and health promotion (Ku¨mpers et al., 2010). The demand for health promotion also for the higher age groups is well in line with WHO’s ‘Healthy Ageing’ strategy and recent European Union initiatives (e.g. Caserta, 1995; European Commission DG Health and Consumer
Promoting health in long-term care settings? Even less scientific work has considered (residential) aged care as area for a complex and comprehensive settings approach. There is an early conceptual contribution in the US context (Minkler, 1984), and a recent conceptual contribution that discusses health-promoting aged care in an ecological context (Harris et al., 2008). There are also some recent policy and practice examples from the ‘Well for Life’ initiative in the state of Victoria in Australia. This programme tries to develop a more comprehensive perspective on the quality of life in aged care residences, focusing on core issues of health promotion like physical activity, nutrition and emotional wellbeing (Kruger et al., 2007; McKenzie et al., 2007; Victorian State Government, 2011).
‘HEALTH HAS NO AGE’: CONTEXT, CONCEPT AND AIMS OF A PILOT PROJECT Health promotion research in aged care settings is an integral part of the scientific programme of Ludwig Boltzmann Institut for Health Promotion Research (LBIHPR) in Vienna. The institute’s programme focuses on health promotion in organizational settings, especially in human service organizations, also considered as ‘people-processing organizations’ (Hasenfeld, 1972), like schools and hospitals. The development and implementation of the pilot project ‘Health has no Age’ (German: ‘Gesundheit hat kein Alter’—acronym GHKA) is a core element of research on health promotion in
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An ageing society and increasing need for long-term care Current society is often described as an ageing society—usually illustrated by the expected increase in the number of persons aged 65 and above. Still more relevant for this paper is the fact that the 80 plus generation is the fastest growing population group in most European countries (European Commission – DG Economic and Financial Affairs, 2011). Subsequently to the consistent rapid growth of this age group the demands for organized care are increasing: The likelihood of multi-morbidity, functional impairment, frailty, dementia, psychiatric conditions and shrinking social networks rises quickly with age. As a result, care for the elderly often means supporting persons with complex health and social problems. In the last decade, quality issues have been placed higher on the agenda of aged care, now not only focusing on structure but also on process and outcome. In this context, the construct ‘quality of life’ is seen as a central outcome of care processes in aged care and there are elaborate propositions for relevant dimensions relating strongly to health promotion, such as autonomy, well-being and functional competences (Kane, 2001).
Protection, 2007; Oxley, 2009; European Union Committee of the Regions, 2011). Looking at research literature, a wide range of papers on specific aspects of health and health promotion interventions can be found which address aged persons. But the group of highly aged still remains under-researched: users of residential care have rarely been considered as a potential target group for health promotion. There are only a few, rather problem-centred contributions which are related to specific issues like malnutrition, psychosocial health, medication problems, social isolation or physical activity with focus on injury prevention (based on a literature review by Horn et al., 2010).
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aged care. The pilot project is based on literature reviews, conceptual work and expert studies in the Austrian and German aged care sector. (Schaeffer and Bu¨scher, 2009; Brause et al., 2010; Horn et al., 2010; Krajic et al., 2010a; Krajic and Schmidt, 2010).
A comprehensive settings approach The project plan, developed in close cooperation with the main stakeholders, was based on a comprehensive settings approach for health promotion. This approach seemed especially appropriate as organizations providing residential aged care play a crucial role in regulating the lives of residents and to some extent, their families and carers and staff. Many users are vulnerable and dependent on the organization—the concept of the ‘total institution’ coined by the US social scientist Erving Goffman (Goffman, 1961) can still be used to describe some aspects of today’s aged care. ‘Comprehensiveness’ refers to three aspects: (i) a multi-dimensional understanding of health (ii) addressing health promotion needs of multiple target groups (iii) a multi-strategy settings approach.
A multi-dimensional understanding of health Health promotion in aged care considers physical, psychological and social dimensions and addresses (positive) health as a resource. Positive health is understood as a quality essential for the normal reproduction of individuals with biological, mental and social dimensions. Health promotion researchers might want to add a spiritual dimension, which can be argued to be very important for the target group of residents in aged care; in our understanding spirituality is an area relevant in both the mental and the social dimension of health. Health is understood as a quality of living systems that can be observed in subjective perspectives as well as by experts. Positive health is understood as referring to functional capacities and well-being, which can vary rather independently from the presence or absence of disease (Bauer et al., 2003; Bauer et al., 2006; Pelikan, 2007). To base health promotion work on an explicit concept of positive health seems especially relevant in health care in general and longterm care in particular. In aged care, there is a high prevalence of chronic disease and functional impairment—so it makes little sense to understand health promotion as primary prevention. An outline of this working concept has been published in German (Krajic et al., 2010b; Krajic and Schmidt, 2010), and in the context of an English language working paper (Krajic et al. 2010b). Target groups The pilot project aimed at optimizing health impact on all major groups that are associated with aged care settings: residents as the main users, staff, volunteer workers and users’ relatives. A multi-strategy settings approach Based on concepts from organizational research, change management and complexity theory, the pilot project aimed at developing the aged care setting into a ‘health-promoting environment’ for all people by increasing attention for health impact of its structures and processes (Dooris et al., 2007; Pelikan, 2007; Grossmann and Scala, 1993). In the five-fold typology of health promotion approaches proposed by Whitelaw (Whitelaw et al., 2001), this is described as the most comprehensive approach. Aims and objectives The GHKA project combined aims concerning scientific research, policy and practice development.
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Main stakeholders Project design and plans for financing and management were developed in close collaboration with three national partners, who are responsible for health promotion policy and practice on national and regional level: the Austrian Health Promotion Foundation (FGOE), the Vienna Health Promotion, Inc. (WiG) and the Main Association of Austrian Social Security Organizations (HVSV). Most important for the implementation of the project was the co-operation with the largest semipublic provider of residential aged care in Austria, the ‘Kuratorium Wiener Pensionistenwohnhaeuser’ (KWP), owned by the City of Vienna. KWP came out of a call to tender as practice partner, and offered three of its 31 units as pilot sites. Rather in the background and not upfront, the City Councillor for health and social affairs of Vienna was a central stakeholder who supported this co-operation between health promotion and aged care. In Vienna, the Councillor is politically responsible for both areas and, in addition, she represents the City as owner and main financing source for two organizations involved: the health promotion agency (WiG) and the aged care provider (KWP).
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Therefore, a second focus on staff health was explicitly included to the project agenda already at the outset. Concerning residents’ relatives’ health, a literature search came up with little research on the phases after admission to residential care. Nevertheless, it seemed important for project stakeholders to look at health impact and potentials for improvement for this group as well. Further project aims and objectives refer to the expectations of health and social policy as well as health promotion practice actors. A major goal of organizations responsible for the development of health promotion was agenda setting for health promotion in aged care by providing scientific analysis of the potential of aged care as a new area for health promotion policy development. For this purpose, policy partners expected (i) scientific evidence on the effectiveness of some specific interventions; as mentioned, this was an important reason for the decision to choose mobility enhancement and organize the intervention as a controlled trial; (ii) the project was also expected to develop practical tools that would be helpful in further proliferation of health promotion in this sector. The aged care provider KWP was primarily interested in utilizing health promotion as a means to support a major re-engineering process currently on-going in the overall organization. The pilot sites thus were expected to gather transferable knowledge for KWP’s overall policy and other units. OVERALL PROJECT DESIGN The overall project was organized as a 2-year (February 2011- March 2013) process and combined systematic needs assessment, two main interventions, systematic evaluation and dissemination strategies of project experiences and results. Structure and process of the pilot project will be described under five main headings, (i) project initiation, (ii) needs assessment, (iii) interventions, (iv) project evaluation and (v) dissemination. Project initiation Following strategic decisions of the project plan and funding in the first half of 2010, the overall project management was set up in the context of HVSV and WiG, two expert organizations responsible for health promotion development.
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Scientifically, the main aim was to study acceptability, feasibility and viability of a comprehensive, whole organization setting approach of health promotion in residential aged care. This included critically analysing project architecture, feasibility and usefulness of needs assessment methods as well as the feasibility and effectiveness of an overall developmental approach. The second main scientific aim was to analyse feasibility, effectiveness and viability of specific health promotion interventions implemented, especially of a mobility enhancement intervention for residents, organized as a randomized controlled trial. For residents, ‘mobility’ had been identified as an important intervention area for several reasons: (i) the literature points at the crucial importance of ‘mobility’ in this population. Compared with community-dwelling elderly, the users of longterm care are more likely to be affected by impairments concerning activities of daily living (ADLs) (Horn et al., 2012). Yet the capability to perform ADLs is of huge importance for the aged and highly aged; in this group, physical constraints often go along with a decrease of autonomy (King et al., 2002). There is numerous evidence that mobility enhancement can cause a significant improvement of overall well-being (Netz et al., 2005). Results of the needs assessment carried out in the pilot project (see below) confirmed the relevance of mobility as an intervention area—this issue turned out to be the most frequently named area of concern. (ii) A mobility enhancement intervention was able to build on resources and traditions of the involved institution and thus could connect well to the users’ and provider’s expectations. (iii) Health policy partners of the project found ‘mobility’ attractive for several reasons, e.g. that the relevance of this dimension of health can be transported easily in the media and at the same time a mobility intervention promised some hard evidence on the effectiveness of health promotion on (physical) health. Concerning staff, a review of the Germanlanguage literature (Brause et al., 2010) found that aged care is perceived as even more stressful than acute medical care. Staff complains in particular about the problem of having to deal with complex physical, psychological and communication challenges often under the condition of staff shortages and narrow schedules (Simon et al., 2005). The review also identifies several staff health programmes in German-speaking countries (Brause et al., 2010), thus there was a good basis for building on established interventions.
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Needs assessment A comprehensive needs assessment was carried out between April and September 2011. Health promotion needs of residents were assessed on the basis of a sample of about 100 randomly selected residents in each of the three units (about one-third of the total number of residents), explicitly not using reduced communicative or cognitive abilities as a criterion for exclusion. Interviews were conducted as an open talk, but guided and documented using a standardized questionnaire. Focus was (subjective) health status and various factors relevant as health determinants in the setting. The questionnaire and interview strategy were developed by the LBIHPR on the basis of instruments for assessing quality of life in nursing homes. SLQA, a German language instrument, specifically designed to enable communication also with
people with mild dementia and communicative problems, served as a main source (Kneubuehler and Estermann, 2008). In addition, the functional health status and care needs of the interviewed persons were assessed by members of staff, utilizing NBA, a German assessment instrument (Wingenfeld et al., 2008). Concerning staff, a health questionnaire was distributed to all employees. The instrument was developed on the basis of existing German language instruments adapted to aged care working situations, including health status, working conditions and experiences as well as their perceived needs for health promotion. The staff survey was complemented by ‘health circles’, i.e. moderated group discussions for staff members which are frequently utilized in workplace health programmes in German-speaking countries (Aust and Ducki, 2004). Health circles are intended to create a more in-depth problem analysis and to locally elaborate some possible health-promoting solutions. The perspectives of volunteer workers and relatives were collected by focus group interviews with a semi-structured guideline. Main issues were perceived roles and functions as well as needs for support.
Interventions The project design combined the aim to demonstrate feasibility of an open, comprehensive developmental approach in aged care with the aim to produce hard evidence that health promotion can be effective in aged care in only 2 years project duration and a designated intervention period of 1 year. So there was a strategic decision to combine the aim of demonstrating feasibility of the comprehensive, bottom-up approach to settings development in aged care with a scientific study which would be able to provide hard evidence on the effectiveness of health promotion in one selected area. The project plan predefined a scientific study in a randomized controlled trial design. ‘Mobility enhancement for residents’ was selected as an intervention area on the basis of scientific literature and expert perspectives. Strategy development The project partners agreed that the project duration of 2 years was very short for an open, comprehensive settings approach. So the project plan
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These two partners also co-financed the project with the main source of external funding being FGOE, the main developmental agency for health promotion in Austria. Scientific project management was set up at LBIHPR, working in close collaboration with the overall management. A call for tender was initiated in October 2010 and finalized in January 2011. As a result, the aged care provider organization KWP became the practice partner, participating with three of its 31 aged care residences. The three units are of a comparable size (unit 1: 330 residents, 111 staff; unit 2: 290 residents, 148 staff; unit 3: 330 residents, 108 staff ) and offer a similar mix of aged care services: Nearly 90% of the users still lived individually in apartment units with basic services such as cleaning, technical support, food, animation groups; nursing care was only offered if specifically required. About 10% of residents needed continuous and intensive care (temporarily or permanently) and lived in nursing units organized as wards. In the project initiation phase (February – April 2011), each local unit was able to appoint a part-time (25%) project coordinator out of project funds. The core function of the co-ordinator was to provide administrative and practical support for implementation and coordination over the whole period. On the basis of kick-off meetings with local first and second level management and staff representatives, local project steering groups were set up in the three units. On the overall management level of KWP, initially there was one second level manager designated as a focal point for the project.
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Mobility enhancement study The project plan pre-defined mobility enhancement as area to look for hard evidence for the effectiveness of health promotion targeting residents of aged care facilities. The mobility intervention was developed to address not only physical, but also cognitive and social aspects of mobility. As mentioned before, mobility was also selected because in the aged care sector many facilities have a tradition to offer some kind of mobility enhancement programme, though most of these programmes—at least in Austria—have not been systematically described or evaluated. Thus, the project decided to develop and test a programme which on one hand builds on ‘evidence-based’ elements that would be very likely to produce effects; on the other hand, the programme was also expected to allow for broad participation, i.e. it had to avoid to be too demanding concerning functional health status and self-discipline of residents. In addition to a curriculum, the project plan included criteria for staff selection and training. Staff selection criteria were formulated rather close to organizational resources available, keeping the formal qualification level demanded comparatively low, to allow a continuation after the end of the project. Another important element was a pro-active invitation policy: traditional mobility programmes
are usually offered on a voluntary basis. This leads to self-selection of individuals interested in exercise who often have a mobility status clearly above average—and thus the programmes are likely to increase health inequality. To avoid such a bias and allow for generalization towards the ‘average’ resident, the project plan demanded random selection and active invitation. Project evaluation Between April 2010 and March 2013, the evaluation was conducted by LBIHPR in the framework of a formative and summative project evaluation, including perspectives on process as well as on outcome. A mix of qualitative and quantitative methods was applied. Concerning the overall project and strategy development, data were generated primarily by systematic documentation, participant and non-participant observations and interviews with different stakeholders. Evaluation of the mobility enhancement study included monitoring aspects of implementation of the programme to explore issues of feasibility and quality. Nevertheless, for this intervention there was a strong focus on quantitative outcome evaluation, aiming to measure improvement of mobility and other dimensions of positive health. Dissemination Considering the partners’ aims for policy and practice development, the project included a systematic dissemination strategy with measures starting from the very beginning, running parallel to all project phases (details described below). EXPERIENCES AND RESULTS The following section highlights experiences and results concerning the different steps and stages of the project. Experiences from the initiation phase In spring 2010 proposals for a comprehensive health promotion project were discussed with key social care actors of Vienna and a second Austrian region. These stakeholders showed interest, but also caution. In a first adaptation of project plans, a focus on the Vienna region was decided, where good political support was available. At first contact, provider organizations
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tried to avoid raising unrealistic expectations by defining ‘strategy development’ as an aim of the open process. Based on a rapid analysis of needs assessment results, local steering groups, prioritized action areas and defined some suitable measures to develop the setting into a healthpromoting environment for all relevant target groups. During this process, they were supported by an experienced health promotion development consultant, overall project management and LBIHPR as scientific support. The project partners accepted that the full-developmental cycle (selection and specification of intervention measures, implementation, evaluation, adaptation etc.) could not be completed for more complex measures in the 2-year period. Nevertheless, it was planned that at least some simple measures should be defined, implemented and evaluated in the project time-frame. Furthermore, the health promotion strategy was expected to include also middle- and long-term perspectives for the period after the end of the pilot project.
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Needs assessment The needs assessment was carried out between April 2011 and August 2011. The data collection instruments and procedures proved applicable, providing relevant and valid results as basis for further development. Regarding residents, 345 interviews and health status assessments of randomly selected residents
were conducted, reaching more than one-third of the population. Questionnaire and interview strategy were adapted to the target group, applicable also in cases of mild forms of dementia; interviewers had experience in and were professionally trained for communication with aged care residents. As to staff, a questionnaire on workplace health (response rate: 60%) and,—as a second approach, ‘health circles’ involving 46 staff members from different professional areas were utilized. Focus groups with residents’ relatives and volunteers (40 persons each) added further perspectives. Some main results can be summarized for the target groups † Residents: as indicated in the literature, mobility turned out to be an area of major concern. Less widespread, but still rather common were worries in the areas of psychosocial health, chronic pain, lack of social support and security issues. A small minority of residents reported restrictions of autonomy and negative experiences with power relations in the institution. † Staff: specific area of concern was physical strain. Problems of communication and trust were named by up to a third of staff members (critical perspectives towards the management, but also towards colleagues). From an organizational perspective, maintenance of workability in the life course seems to be a central concern, especially in the group of nurses. † Relatives and volunteers: problems were identified mainly concerning lack of communication and information. In addition, concerns about residents’ medical care turned out to be a source for worries of relatives. Health promotion strategy development Local steering groups started their work in September 2011. In a first round, needs assessment results for all target groups were presented, based on a rapid first analysis. Developing a systematic and comprehensive ‘Health Promotion Strategy’ for the units turned out to be a difficult task. Given the short overall timeframe, the management of the pilot project pushed for a fast priority setting and for identification of measures which were simple and quickly to attain. The steering groups focused primarily on staff health issues, taking up proposals developed by local staff representatives in the ‘health circles’. Residents did not play a major role in this process: contrary to the initial plan, residents’
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showed interest, but also expressed scepticism if such a health promotion project would be supportive—or rather cause new problems. The fact that there were discussions with four interested provider organizations, and that only one provider finally decided to participate, indicates that health promotion—as a new topic—still has to demonstrate its usefulness to this sector. The process of setting up local project structures started with kick-off meetings of the project team, consisting of the directors of the units, other local management and staff representatives. Residents, staff and interested relatives of residents were introduced to the pilot project by public meetings. At these events, only very little open scepticism was articulated. Overall, the availability of local project resources proved very helpful to carry out operative work. The project co-ordinators, who were staff members of the residences, facilitated the communication. For the project management, they served also as informants on local developments. To select a co-ordinator with a professional profile close to health issues (two of the three co-ordinators were health professionals) turned out very helpful in communicating health promotion to target groups and to motivate them to participate in needs assessment and interventions. In the first months, the project team had to learn that some assumptions concerning the overall project architecture had to be revised. The strategic autonomy of the local management was much smaller than expected. Further, the participating residential aged care provider organization turned out to be in a fundamental re-engineering process of its core business, which was managed in a centralized fashion. So local management felt quite uncertain about the leeway it had for local developments. As consequence, a systematic co-operation structure with the central management of the aged care provider had to be set up for the ‘Health Promotion Strategy Development’ intervention (see below).
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realities of everyday work, and also seems to have slowed down developmental processes. By March 2012, local steering groups concluded their work, defining that everything that could be developed on their level was done. It was not before October 2012, close to the formal end of the project period, that a working group at the central management level met again, identifying an agenda for further health promotion development of the provider KWP. Figure 1 provides an overview on the main issues that were addressed in the process. Issues in bold letters with a dark frame were developed as far as specific concrete measures; issues in italics with a light frame were still in progress at the end of the project. Further issues, shown as normal text with a dashed frame, were dropped. Figure 1 indicates that comprehensiveness in the sense of addressing all target groups has remained on the agenda, with varying progress concerning complexity of approach and amount of concrete measures that could be defined or even implemented. For residents, project management accepted the focus on mobility enhancement due to the short-project period. The aged care provider had argued that further measures to safeguard or improve residents’ quality of life in problem areas identified by the
Fig. 1: Strategy development: progress in different areas until December 2012.
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representatives were not invited to the sessions as the steering groups did not want to discuss ambiguous staff health issues in front of residents. This was probably one reason why measures to promote residents’ health—beyond the predefined mobility enhancement intervention—did not become an issue on the local level. Another reason for the reluctance was the fact that the local management did not feel a sufficiently strong mandate from the provider’s central management. Local steering groups also focused rather on local and practical problems, while strategic questions were delegated to the central management. So—on finding out about this reluctance of the local level—the pilot project management had to push for initiating a strategic development on the central management level of the provider. A first meeting with the top management took place in January 2012, which was prepared in a so-called ‘Sparring Group’, consisting of second level management responsible for quality development, human resources and related departments. So—other than expected—strategic issues were discussed mainly at the central level. This was adequate with regard to the self-understanding of the provider, but moved definition of problems and possible solutions rather far away from the
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Mobility enhancement intervention The mobility intervention, organized as randomized controlled study, was carried out between November 2011 and May 2012. Participants of the intervention group (n ¼ 139, randomly assigned) were provided with a weekly training programme, based on a curriculum developed by specialists for occupational therapy and physiotherapy from Vienna Medical University. The curriculum contained 20 units to be conducted under supervision of trained staff, experienced in mobility enhancement interventions. Seven external assessors (physiotherapists and occupational therapists) tested the state of mobility in a baseline
assessment and conducted a second assessment at the end of the intervention. Changes were analysed and compared with a control group (n ¼ 137) which had received a placebo social intervention. The intervention was effective in terms of improving the intervention group’s performance concerning ADLs as measured by Canadian Occupational Performance Measure. This measure allows to examine changes in performance of everyday activities which were considered problematic in a first assessment. The intervention also improved subjective health status (measured by EQ5D, an instrument well established in aged care). Effects were small, but significant (significance P , 0.05). In the control group, no significant changes could be observed. Statistical analyses were conducted via a generalized linear mixed model for repeated measures supplemented by paired t-tests. Detailed results will be published in a separate paper. One result worth specific mentioning concerned inclusion of people with reduced functional health and unstable motivation for exercise. Through pro-active and personalized recruitment of participants by project coordinators several residents could be involved which had not taken part in exercise programmes of the institution beforehand. Positive results of the mobility intervention led to an internal roll-out of selected aspects of the programme and raised much external attention for the project as well. The first step of organizational roll-out was a systematic training in principles of the programme for all staff members of the overall enterprise who were offering mobility support courses for residents. In 2013–2014, a follow-up study will monitor this process. Dissemination The main measures of dissemination throughout the project period were presentations of the project and its intermediary results for different publics. The main media were the project website (www.gesundheithatkeinalter.at), public project events (three public conferences), and presentations at conferences and workshops. The project got considerable interest from aged care providers, professionals and scientists, mostly from the Vienna region. A web-based handbook on the practice of health promotion in residential aged care will include results and recommendations for organizations and professionals in longterm care practice. A project to disseminate and
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needs assessment were already on the agenda of the on-going reengineering process. Staff health became the central issue of health promotion ‘Strategy Development’ and got addressed at different organizational levels. On the local level, the steering groups proved to be a good communication format to identify and solve smaller, local problems. On the management level of the overall company, perspectives on staff health were strengthened by designating a responsible person who developed a concept for workplace health promotion. As a first measure, a training programme in basic ergonomics was implemented, first in the three pilot institutions but also in other units of the provider (on-going in 2013), aiming at empowering employees from different areas to act as ‘ergonomic health guides’ as additional element in their professional roles. The issue of safeguarding work ability of an ageing workforce was identified as relevant on the top management level. Initially, participation in a large-scale national programme was considered, but when learning about rather rigid conditions for participation, the provider decided to further develop its already on-going programme for age-appropriate workplaces. For volunteers, the local units were able to manage the issues brought up in focus groups, as support by a professional coordinator had already previously been established. Regarding the target group of user’s relatives, a first concept for involvement has been developed. The specific measure will be evaluated in a follow-up project (2013 – 2014). For all groups, some issues were explicitly dropped—most of them were accepted as relevant, but regarded too complex for the framework of a short health promotion project.
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market the handbook and encourage health promotion development in other Austrian aged care facilities is in preparation. Further scientific publications in German and English language journals, discussing specific aspects of project results, are in preparation.
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DISCUSSION
What are relevant health promotion issues for different target groups? Overall, the project indicates that health promotion makes sense for many actors in aged care. However, it is important to invest in translating health promotion principles and ideas into expectations of the field. One important step is to explicitly argue what the aims and intervention areas for the different target groups are. This pilot study provides us with some answers: –
For residents, mobility has been confirmed to be a core issue, but the needs assessment and scientific literature came up with several other issues as well, like psychosocial wellbeing, security, preserving autonomy, improvement of social support and even rather medical issues like pain management.
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Are there trends in aged care indicating that chances for health promotion are improving? Overall, on a societal level there are indications for changes in aged care. Especially nursing homes used to be considered as dealing with end-of-life stages, where limited effective (therapeutic) interventions are available. This understanding is put into questions by advances in medicine and other health professions, e.g. leading to a changing focus of therapeutic interventions from ‘healing’ to stabilization or improvement of ‘quality of life’ or the emergence of ‘palliative care’ as a special field. More demand is being created by the extension of those phases of higher age, in which some kind of social or nursing support is used. And, last not least, the growing number of people affected makes aged care issues politically more relevant. Organization, financing and also quality improvement of aged care are getting relevant issues in elections—aged care seems to climb up on political, but also professional and scientific agendas. The discussion on quality issues in aged care has gotten more prominent over the last years—quality was a core issue of the first two International Long-Term Care Policy Conferences organized in London 2010 and 2012.
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Does ‘Health has no Age’ contribute to ‘hard’ scientific knowledge about health-promoting aged care? Only in a limited way: the overall health-promoting settings approach of this pilot project basically is an experimental case study—a rather short one, and a not very controlled one. Owing to the very nature of the settings approach, it is a complex intervention in a complex field. As a result, there are many limitations to generalizing experiences and results. Nevertheless this pilot case allows learning about how the project, interacting with its specific context, was able to reach many of its aims. The authors are convinced that this will be helpful for further health promotion activities in aged care—hopefully some of them organized as scientifically supported experiments or at least as well-documented and evaluated practice projects. Therefore, the discussion tries to answer questions what policy-makers, experts, researchers, aged care professionals and managers can learn from this example when considering a similar kind of comprehensive settings approach project in aged care.
Regarding staff, issues like work ability of those involved in direct care obviously are relevant. There are shortages especially of qualified nurses in most countries, so providers have to invest in retention of their staff. In addition, needs assessment results underline what scientific literature and experience from other settings tell us: issues often targeted in staff health promotion like a trusting organizational culture, a good effort-reward balance and good leadership quality are probably crucial in aged care as well. Concerning residents’ relatives, it is important to understand the—potentially—strong interdependence between relatives and aged care organizations: relatives might want to feel unburdened by professional care, but many of them are interested in making a contribution by continuing their personal relationship with the residents, offering psychological and social support. This is more likely to succeed if accepted and supported by the organization. Needs assessment came up with indications that systematic information and communication could be helpful to involve and support relatives.
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Can aged care professionals foster strategic partnerships in ways that enhance a health promotion focus, and how? To foster strategic partnerships aged care providers and professionals could link up with existing health promotion resources, e.g. national and regional agencies and networks. To utilize networks of cities, workplace health promotion, hospitals and healthcare organizations should be useful: The pilot project was able to build on a basis of trust and understanding between aged care and health promotion actors, which was established throughout 10 years involvement of the aged care provider in a loosely coupled regional information network for health promotion. In the specific local context, this collaboration was facilitated by support from the political level, which helped to build bridges between health promotion and aged care. Building bridges is needed, as in many other regional and national contexts aged care and health promotion are managed and supervised strictly apart, in rather competing than cooperating ways. What strategies might be useful for managing such a complex project in a short timeline—and what can be done to make health promotion a normal part of organizational processes? Following Whitelaw et al. (2001, p.342), comprehensive settings approach projects need a pragmatic and more tactical orientation to the sustainable development of settings work. In principle, this holds true for all such projects, but
in the case of the pilot project this was sharpened by the narrow timeframe. The 2 year timeline set by the financing partners in the planning phase could only be accepted by negotiating realistic aims, targets and timelines for the project plan. To define ‘Strategy Development’ as core intervention for the comprehensive approach and— by that—not to promise full implementation included the risk that plans remain on paper. In this pilot project, this risk was managed by predefining the mobility enhancement intervention for residents and by highlighting staff health through ‘health circles’ as part of the needs assessment. ‘Health circles’ are not only diagnostic instruments, but provide quick and easily implementable solutions; health circles also generally enhance communication on staff health within the organization. It seems essential to involve various management levels in the health promotion process; especially the central management turned out to be crucial to achieve some organizational impact: The so-called ‘Sparring Groups’ as part of strategy development, and the transfer workshops for the middle- and top-management level in the last phases of the project seem to have served well for this purpose, as this helped to include health promotion into everyday management routines. Acceptance was probably further promoted by the fact that agenda setting was done primarily by internal staff, with project staff and scientists only in a supporting and collaborating role. On the other hand, there are some indications that the strong involvement of the central level concerning the ‘strategy development’ also contributed negatively to local developments, facilitating resignation processes of local level management. Yet the involvement of upper management levels, which in the current formal structure of the organization are responsible for strategy development, seems to have helped to keep health promotion on the organization’s agenda after the formal end of the project. On-going roll-out activities of mobility enhancement for residents, new ergonomic support roles for staff (‘ergonomic health guides’) and efforts to improve communication and cooperation with relatives indicate that health promotion is still relevant. Structural measures like the nomination of a healthy workplace focal point (third level management), formulation of a staff health action plan including a focus on work ability for ageing staff, are further indicators of effectiveness and sustainability. These developments are
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The quality movement in aged care can build on concepts, models and experiences developed in acute health care over the last 25 years. Outcome quality, including maintaining or improving subjective well-being and functional health seems to play an increasingly prominent role in aged care, and there are several reform movements addressing these issues (e.g. Palliative Care and EDEN Alternative). What about health promotion in this context? Project experiences of the pilot project have demonstrated that health promotion links well with this quality development; especially the settings approach provides a comprehensive perspective on health impact for all target groups affected. For health promotion actors, establishing strategic partnerships and promoting cooperation, rather than competing with the quality movement, seems promising.
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being scientifically monitored and evaluated in the follow-up project 2013 –2014, which will allow for further learning from this example.
How to manage difficult interactions between a rather top-down-oriented organizational culture and participatory principles of health promotion? For health promotion project management and scientific support, the principle of keeping equidistance to different proponents in organizational conflicts seems to be essential. Health promotion of course has a preference for participation and tends to be close to local levels. But, in order to remain relevant and effective in large-scale organizations, health promotion experts have to work with formal structures and the established culture. Health promotion projects that manage to work in a balanced way thus can be even more empowering by supporting staff to learn how to better use formal organizational structures, to solve problems in a more effective and sustainable way than what is possible on the local level. In the specific situation of the pilot project, the project provided added value by re-integrating local and staff perspectives in a complementary way into a top-down business re-engineering process, thus helping to balance a difficult overall change process. To what extent this effect will be sustainable after the formal end of the project will be monitored in the follow-up period.
At the end of a 2-year project period, the pilot project was able to demonstrate that setting— oriented health promotion can be conceptualized and implemented in residential aged care—at least if politically, organisationally, scientifically and also financially well supported. Health promotion has been accepted by the participating residential care provider as a contribution to their development on the organizational level (local and top management). A specific mobility enhancement intervention proved feasible, attractive and effective also for residents with reduced ( physical) functional capacities. By being able to provide hard data on effectiveness concerning subjective health and occupational performance, this intervention has turned into a strong marker for health promotion effectiveness in this sector. Several steps were undertaken to make at least some aspects of health promotion part of everyday organizational practice. At the end of the 2-year project period, some parts of the strategy and several concrete measures were still in process of specification or implementation. In terms of effectiveness and viability, a comprehensive settings approach in aged care seems promising but many questions concerning scope and depth of changes remain to be answered. A follow-up project will monitor this progress for the period 2013 –2014. FUNDING Implementation of the project was funded by the Austrian Health Promotion Foundation (FGOE), the Vienna Health Promotion, Inc. (WiG) and the Main Association of Austrian Social Security Organizations (HVSV). Evaluation and scientific analysis were financed partly out of the implementation project and to a large part by the Ludwig Boltzmann Society, a private non profit association organizing research, funded by the Austrian Federal Ministry for Science and Research. REFERENCES Aust, B. and Ducki, A. (2004) Comprehensive health promotion interventions at the workplace: experiences with health circles in Germany. Journal of Occupational Health Psychology, 9, 358–370. Bauer, G., Davies, J. K., Pelikan, J. M., Noack, R. H., Bro¨sskamp, U. and Hill, C. (2003) Advancing a theoretical model for public health and health promotion indicator
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How to overcome a narrow focus of health promotion on specific and widely accepted issues like mobility enhancement or ergonomics training? It is primarily an internal decision which problems/issues the organization wants to address in a health promotion context—and which not. Health promotion experts can of course argue for a broader approach (using results of the needs assessment, scientific literature, personal expertise etc.), but usually it requires external resources—such as tools, experts, change management support and external project funds, but also agenda setting by relevant, in many cases political actors. These actors need to be convinced that inclusion of health promotion issues on the agenda of quality assurance and development of the sector is useful for their goals.
CONCLUSION
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