Health promotion for adults with intellectual disabilities: Evaluation of a multi-component intervention in community residences

People with intellectual disabilities (ID) have an increased risk for ill-health, partly due to low physical activity and an unbalanced diet. Caregivers who support adults living in community residences face a dilemma when trying to support healthy behaviours without encroaching on autonomy. The overall aim of this thesis was to evaluate the effects of a novel health intervention directed at both staff and residents in community residences for people with ID and to describe and analyse barriers and facilitators in the implementation process. An intervention was developed to promote physical activity and healthy diet among adults with ID in community residences. According to Social Cognitive Theory, behaviour, personal factors and environmental factors all interact. Therefore, the intervention entailed both strengthening the individual and influencing the social and physical context. The intervention comprised three components: 1) the appointment of a health ambassador; 2) a study circle for caregivers; and 3) a health course for residents. The intervention study was designed as a cluster randomised controlled trial including 30 residences and 130 individuals. The primary outcome was physical activity, measured through pedometry. Secondary outcomes were dietary quality measured through digital photography, BMI, waist circumference, satisfaction with life assessed on a scale and residence health promotion work routines assessed with a questionnaire. Outcomes were related to intervention fidelity. A separate study was conducted to develop and evaluate the scale used to assess satisfaction with life. To study barriers and facilitators in health education for adults with ID, data were collected through evaluation notes, observations and a group discussion with course leaders. To study the implementation process, interviews were conducted with managers and health ambassadors. A positive intervention effect was found on physical activity, with an average increase of 1 608 steps/day among participants in the intervention group (P = 0.045). A positive intervention effect was also found on work routines, with an average increase of 7.1 percentage points on a self-assessment scale among residences in the intervention group (P = 0.016). No significant effects were found on dietary quality, BMI, waist circumference or satisfaction with life. The qualitative studies suggested that it is important to support motivation for change during the process and to support the residents not only within the health course, but also within the social and physical context. Even greater effects might be achieved by improving the implementation strategies and the dietary aspect of the intervention. In order to maintain the positive effects in the long term, sustaining procedures must be established and issues regarding health promotion and empowerment should be continuously discussed among caregivers as well as at a management level. LIST OF SCIENTIFIC PAPERS I. Bergström H, Hagströmer M, Hagberg J and Elinder LS. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Research in Developmental Disabilities, 2013;34:3847-3857. II. Bergström H, Elinder LS and Wihlman U. Barriers and facilitators in health education for adults with intellectual disabilities – a qualitative study. Health Education Research, 2014;29:259-271. III. Sundblom E, Bergström H and Elinder LS. Understanding the implementation process of a multi-component health promotion intervention for adults with intellectual disabilities in Sweden. Journal of Applied Research in Intellectual Disabilities (accepted for publication). IV. Bergström H, Hochwälder J, Kottorp A and Elinder LS. Psychometric evaluation of a scale to assess satisfaction with life among people with intellectual disabilities living in community residences. Journal of Intellectual Disability Research, 2013;57:250-256.