The effectiveness of a bibliotherapy in increasing the self-management ability of slightly to moderately frail older people

Abstract

Objective

Self-management ability (SMA) is the ability to obtain those resources necessary for the production of well-being. With age, SMA becomes increasingly important, if one has a large variety of resources, physical and psychosocial losses due to the aging process can be substituted or compensated for. This study examined whether an increase in SMA would ensure sustainable levels of positive well-being among slightly to moderately frail older people.

Methods

A bibliotherapy was developed to increase the SMA of slightly to moderaterly frail older people, and to help these persons to sustain a certain level of well-being. The effectiveness of this bibliotherapy was examined by comparing the SMA, mastery, and subjective well-being of 97 older people participating in the bibliotherapy to those of 96 older people in a delayed-treatment control condition.

Results

The bibliotherapy resulted in a significant increase in SMA and mastery compared to the delayed-treatment control condition, and for SMA, this effect still existed 6 months after the intervention. The increase in SMA among older people who received the bibliotherapy prevented a decline in well-being as expected, but only in the short-term.

Conclusion

The current findings show that it is possible to counteract an age-related decline in well-being, even with only slight to moderate levels of frailty.

Practice implications

Cheap and easily accessible interventions, like the self-management bibliotherapy described in this article, may provide a useful addition to more traditional gerontological interventions.

Introduction

“To know how to grow old is the master work of wisdom, and one of the most difficult chapters in the great art of living”. As this quotation from the Swiss author Henri Frederic Amiel suggests, successful aging is not just a matter of growing old. It requires the proactive management of resources in an environment of increasing losses and declining gains [1]. In modern society, this process of self-management is becoming increasingly important. Due to medical and social developments, the number of healthy years after retirement has increased. Because this is a relatively unstructured stage of life with few clear social roles [2], giving meaning to this period requires a certain amount of pro-activity. Self-management interventions can provide older people with the abilities necessary for this. Furthermore, with a growing elderly population and increasing cutbacks in health care, our society faces the difficult task of making all ends meet. Increasing the self-management of older people could in part relieve this burden on the health care system: with higher levels of Self-management ability (SMA), older people will be better able to maintain an independent and autonomous lifestyle for a longer period of time. In this study, we developed a bibliotherapy aimed at increasing the SMA of slightly to moderately frail older people, which differs in a number of ways from existing self-management interventions.

First, most self-management interventions focus on teaching people how to cope with specific age-related problems, like depression (e.g., [3], [4]), loneliness (e.g., [5]), the increased risk of falling (e.g., [6]), insomnia (e.g., [7]), or chronic illnesses [8], [9], [10]. However, a substantial number of older people suffers from a mixture of problems in multiple life domains. This mixture of problems can create a gerontological condition called frailty. Frail older people are vulnerable to adverse outcomes like the dependence on others, chronic illness, and admission to an institution (e.g., [11]). Because frail older people lack reserves in multiple life domains, they may benefit more from a self-management intervention that provides them with a general cognitive and behavioural repertoire for dealing with different kinds of age-related problems rather than from interventions focusing on one specific problem.

Second, many interventions address the problems of older people who have already suffered substantial loss, like those residing in nursing homes. However, an increasing number of studies suggest that preventing age-related decline may be more effective than dealing with its consequences (e.g., [11], [12]). This is why self-management interventions may best be aimed at older people with beginning problems in physical or psychosocial life domains, without these problems being so serious as to have already resulted in substantial loss.

Third, although many intervention-studies of self-management have succeeded in affecting outcomes like depression [3], psychosocial functioning [13], and pain perception [9], there has been little theorizing concerning the specific self-management abilities underlying such effects. In some studies, it was suggested that general abilities like self-efficacy were responsible for the positive effects of self-management interventions (e.g., [14]). However, abilities like self-efficacy are quite unspecific unless they are aimed at a certain goal. The self-management intervention developed in the current study is based on the theory of successful self-management of aging (SSMA [15]), which gives a specification of the abilities that constitute an effective self-manager, and the goals at which these abilities should be directed. Because of its specificity, this framework offers clear guidelines for the development and evaluation of a self-management intervention.

Fourth, the format of a bibliotherapy may provide an important alternative to more traditional interventions. Although self-management interventions aim at increasing the autonomy of older people in the long-term, many of these interventions use extensive counseling and group sessions in the short-term (e.g., [6], [16]). Bibliotherapy, i.e., reading a self-help book for the treatment of psychosocial problems [17], may provide an important cost- and time-saving alternative to these extensive interventions. Because a bibliotherapy does not require face-to-face counselling, it can be effective in reaching a large group of older people who do not yet require institutionalized care. Furthermore, there is evidence indicating that bibliotherapy can be just as effective as more traditional interventions. For example, in studies aimed at reducing depression among older people [4], [18], or at the improvement of mind-body wellness for older adults with chronic illness [19], written or videotaped self-help treatments resulted in a clinically significant change compared to the change noted in a delayed-treatment control condition.

To extend the existing self-management interventions in respect of the four aspects mentioned above, we developed a self-management bibliotherapy for slightly to moderately frail older persons. The aim of this bibliotherapy was to increase SMA as defined by the SSMA theory [15]. According to this theory, SMA are the abilities people need for managing resources in such a way that sustainable positive well-being is reached. The SSMA theory distinguishes six self-management abilities: having a positive frame of mind, being self-efficacious, taking initiative, investing in resources for long-term benefits, taking care of a variety of resources, and taking care of a multifunctionality of resources.

Based on the social production functions theory [20], Steverink et al. argue that these abilities should be directed at the realization of physical and social dimensions of well-being in order to lead to successful aging. Physical well-being is realized when people obtain enough comfort, that is, the satisfaction of basic physical needs (e.g., food, drink, rest, and warmth), and stimulation, that is, the pleasant range of physical and mental activation ([20] also see [21]). Social well-being is realized when people receive enough affection, behavioural confirmation, and status [20], “as forms of positive evaluations for what a person is (affection), does (behavioural confirmation) and has (status)” [21].

To examine whether the bibliotherapy indeed increased the SMA of slightly to moderately frail elderly, and whether this increase helped them to maintain their present levels of well-being, we tested the following hypotheses. We expected that older people who received our bibliotherapy would show a greater increase in SMA than those who participated in the control condition. We expected to find this effect using a specific instrument addressing the underlying theoretical framework of the bibliotherapy, i.e., the Self-Management Ability-Scale (SMA-S [22]), and using an instrument measuring a more general concept of control, i.e., the mastery scale of Pearlin and Schooler [23]. We expected that this effect of our bibliotherapy on SMA would still exist after 6 months. Furthermore, we expected that older people who had received our bibliotherapy would show more maintenance of subjective well-being than those who participated in the control condition, because of the increase in SMA. Last, we expected that this effect of our bibliotherapy on well-being would still exist after 6 months.