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Community-Based Participatory Research Methodology to Address Self-Care for Older Singaporeans

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Community-Based Participatory Research Methodology to Address Self-Care for Older Singaporeans.
Abstract
Population aging is associated with a higher prevalence of chronic respiratory health conditions. Pre-existing studies have shown that older persons, specifically individuals with chronic respiratory diseases, often lack sufficient knowledge about their respiratory condition, which can result in poor self-care. Self-Care for Older People (SCOPE) is a community-based participatory research intervention in Singapore. The purpose of the pilot program, SCOPE is to educate self-care technique that is targeted at older people with low socioeconomic status and low in health literacy in order to improve health-related knowledge. This study is a cluster randomized controlled trial in Western Singapore. A total of 80 low-income older people with chronic respiratory diseases will be recruited from the three selected senior activity centers in Western Singapore. The measurements taken included pulmonary function tests, self-reported respiratory health conditions, and respiratory health and disease knowledge questions. Findings from this study will assist in providing information for policy makers on chronic respiratory disease burden, improving health lifestyle practices and in planning for healthcare facility utilization among community-dwelling Singapore elderly population.
Keywords: Singapore Elderly Population; Quality of Life; Self-Care; Respiratory Disease; Pulmonary Function Tests; Low-Income Elderly; Community-Based Participatory Research Methodology; Respiratory Health and Disease Knowledge
Introduction
Singapore is projected to have the world’s fourth oldest population by 2050 due to declining fertility rates and increasing life expectancy (Christie, 2015). In 2016, nearly 10% of the population was above 65 years but this is expected to increase to 20% in 2030 (Lee et al., 2018). Singapore’s rapidly aging population poses a challenge both to healthcare professionals and policymakers who are striving to ensure a high quality of life for older persons.
An estimated 35% of the Singapore elderly population live in inadequate housing conditions, and about 25% of the Singapore elderly population have chronic respiratory diseases (Ang et al., 2018). Moreover, with access to healthcare in terms of affordability being the most salient determinant of health, the chronic health condition risks that are faced by the elderly are further accentuated by inadequate welfare benefits and economic isolation. These health issues and challenges could be part of the inequalities of the socioeconomic disadvantage faced by the low-income elderly, which are driven by lack of health knowledge due to poor literacy, and inadequate support from the community.
The Self-Care for Older Persons (SCOPE) is a pilot program designed to enhance older adults’ awareness and self-management of respiratory health conditions. The primary outcome measures from the SCOPE intervention program include chronic health conditions which are chronic obstructive pulmonary disease (COPD), and incidence of pneumonia. Furthermore, SCOPE includes chronic disease management, thus differing from the Chronic Disease Self-Management Program (CDSMP) conceptual basis of intervention (Lorig, 2015). As such, SCOPE will include secondary outcome measures including functional status, quality of life in improving respiratory health in Singapore elderly.
Self-care is a multidimensional health-related concept, and the definition of self-care will extend to routine coping with the effects of aging and living conditions (Sharma et al., 2012) (Tan et al.,2015). Self-care ability is an important health asset for all individuals especially the elderly (Liu, 2018). An inadequate self-care knowledge would result in a serious problem which is related to social determinants such as socio-economic characteristics (Choo & Lim, 2017). SCOPE accounts for cultural differences in knowledge transfer, the socioeconomically diverse aging urban environment, and senior activity centers’ capacity to administer the program. SCOPE is based on the hypothesis that regardless of the fundamental factors associated with physical weakness, frailty need not be inevitable with age but rather an avoidable condition (Lim et al., 2018).
The aim of SCOPE is to focus on foundational needs, such as respiratory health awareness, health empowerment, self-efficacy, positive behaviors, quality of life, healthcare system understanding and accessing and interacting with healthcare providers. In order to achieve these health outcomes, a study by Wang has shown that there should be collaboration with elderly welfare and social communities using community-based participatory research (CBPR) methodologies to focus the factors that may help low-income elderly population with improving their respiratory health conditions through self-care. Furthermore, CBPR approach would provide evidence that participatory methodology is ideal to create changes and community capacity building. This will help to develop and strengthen their processes and resources that low-income elderly communities need to survive, adapt, and thrive in the fast-changing Singapore. Thus, a CBPR initiative involving low-income community-dwelling elderly will be implemented in multiple phases so as to foster better participatory action research. To date, the determinants of respiratory health in Singapore elderly people living on low socioeconomic status. Means of assessing and addressing those determinants have not been well established.
SCOPE applies concepts from empowerment theory, to recognize people’s ability to strengthen their knowledge, skills and resources so to make right decision and have power over their own lives. SCOPE will help to transfer those skills and result in a favorable specific situation such as enhanced health outcomes (Israel et al., 2014). SCOPE will also utilize the social cognitive theory where self-efficacy is people’s beliefs in their capabilities to exercise control over their functioning and events that affect their lives (Bandura, 1977). The purpose of SCOPE is to focus on foundational needs, such as health awareness, health empowerment, self-efficacy, positive behaviors, quality of life, healthcare system understanding and accessing and interacting with healthcare providers. The aim of the proposed study is to achieve understanding, addressing and redressing Singapore elderly chronic health conditions. This will help to build a sense of empowerment and self-confidence among older people to cope broadly with chronic respiratory conditions associated with aging.
Preliminary work leading to current research
A similar study done in UK in 2017 by Smidth et al., (2017), Chronic Disease Self-Management Program (CDSMP) study which was a cluster randomized controlled trial in Singapore of 952 elders in 24 community centers, the study designed to evaluate the effects of a self-care program for the awareness in chronic disease and management of quality of life of elderly people and specific health measures (Smidth et al., 2017). Participants were affiliated with one of the senior activity centers, were aged 55 years or older, and did not have severe and life-limiting illnesses, or activities of daily living disability severe enough to prevent them from taking part in respiratory health screenings or training sessions. Subjects were assigned either attending weekly one-hour classes by a health trainer (CDSMP program), or to a control group. The primary investigator and her research colleagues partnered with hospitals and community health groups. The intervention in the study consisted of training to empower healthy and mildly disabled elderly to better use the healthcare system in Singapore, and to teach them to manage their health conditions. The lung functions were measured by peak expiratory flow measurements. The primary goal of the study is to create low-cost program for promoting health self-management that can improve elements of health status while reducing health care costs in populations with diverse chronic diseases (Ngooi et al., 2017).
Findings demonstrated that there were improvements at 6 months in weekly minutes of exercise; self-reported health in health distress; improvement of fatigue; ability to communication with health providers; and help to cope with disability. In addition to the primary findings, the study also found out that social connectedness with the community and healthcare professionals, and frequency of cognitive symptom management improved. (Ngooi et al., 2017). Participants also had fewer hospitalizations and days in the hospital.
Conceptual framework
This study was guided by Zimmerman’s (1995) theory of psychological empowerment. It refers to the individual attainment of mastery and control over one’s life through “perceptions of personal control, a critical understanding of the environment, and a proactive approach to life” (Zimmerman, 1995). This allows one to gain a heightened sense of understanding between what their aims are and how to achieve them (Zimmerman, 1995). Although psychological empowerment focuses on an individual level of inquiry, it is important to note its reliance and interconnectedness with socio-political, cultural, and contextual factors to embody the concept of person-environment fit (Zimmerman, 1995).
Empowerment refers to the process of gaining control over one’s self and surroundings to maximize abilities to produce satisfactory outcomes. Programs similar to SCOPE has been widely reported as an empowering health promotion strategy that gives participants their own empowerment through group programs to strive for better control over their lives. Specifically, SCOPE is a program that fosters positive thoughts and behaviors to enhance quality of life and respiratory health outcomes.
The highlights of SCOPE is the potential of empowerment in promoting and sustaining optimal respiratory self-care but there remains a lack of knowledge in exploring this phenomenon. Therefore, this study aimed to explore the promotion of respiratory self-care in Singapore elderly population, to shed light on its potential to motivate self-care.
Study design and methods
SCOPE is pilot program and a cluster-randomized control trial will be done on 80 low-income elderly in three senior activity centers in Western Singapore. The unit of randomization is the senior activity centers. The primary aim of the study is to evaluate a self-care intervention program aimed at enhancing respiratory health in older people in Singapore by caring for themselves. The primary outcome measures are the following indicators: normalized peak flow adjusted for age, gender and ethnicity. The questionnaires and forms for SCOPE will be submitted to Institutional Review Board for approval.
Association of Respiratory Therapy Singapore (ARTS), plans to implement SCOPE, their first public program from the organization together with Jurong Health (healthcare institution in West Singapore), and would need evaluation of the program through pilot experiment. ARTS provide volunteers for the study and have also partnered with three Seniors Activity Centers to reach out to older Singaporeans in a randomized controlled trial process.  The pilot study will be designed in order to effectively validate the impact of the project. Both control and intervention groups will receive a baseline assessment of physical and mental health status, and follow-up assessments at six and twelve months. In addition to this, the intervention group will also undergo a structured training program that will be conducted weekly over a period of six months (50 hours in total). Each intervention group will be composed of fifteen to twenty older persons and their training will be led by two trained Community Health Trainers. The content of training materials will focus on health promotion, respiratory disease prevention, health seeking behavior, chronic respiratory disease management and anti-stigmatization.
Data collection
Trained community health workers and volunteers from ARTS will interview participants at each study visit (baseline, six and twelve months). Participants will self-reported their demographics characteristics, respiratory health status, health behaviors, and quality of life. Trained and certified nurses from Jurong Health will collect data and spirometry tests using standard procedures to assess a participant’s baseline and to track respiratory health changes during the experiment.
Randomization and selection of sites
The western part of Singapore has one of the highest proportions of older adults (Choo & Lim, 2017). Thus, this pilot study will select senior activity centers in Western Singapore to ensure that the pilot study can be closed to generalizability of Singapore. Since the target population for SCOPE is low-income elderly, who are in greatest need of this type of self-care program, the districts chosen low-income, low education residents. Figure 1 shows the locations of the selected senior activity centers. The centers in the sample were paired up based on similarities in age, ethnicity, and gender distribution. One in each pair was randomly allocated by a computer algorithm as an intervention site and the other was the control.
Figure 1: Map and location of the participating senior activity centers

Questionnaire
The first section will include a section of demographics characteristics:

  1. age,
  2. gender,
  3. ethnicity,
  4. marital status,
  5. education,
  6. occupation status,
  7. Household income.

The next section will be respiratory health status:

  1. Any previous hear attack
  2. Respiratory illness which are chronic such as COPD and asthma
  3. Self-confidence on respiratory disease management: On the scale 1 to  with 5 being most confident, how do you think you are managing your disease
  4. Frequency of health care utilization: Contact with health professionals and services,
    admission to a hospital or nursing home
  5. Respiratory health knowledge: On the scale 1 to 5 with 5 being most knowledgeable, known in detailed of current respiratory disease affecting me, and know ways to minimize the symptoms of the respiratory disease.
  6. *Done by trained healthcare professionals supported by Jurong Health, Spirometry Result, through spirometry test: measures of forced vital capacity, forced expired volume in one second (FEV1), FEV1/FVC ratio, and maximum mid-expiratory flow rate (FEF25–75).

The Last section will be health behaviors:

  1. Currently smoking : Yes/No, if yes, how many cigarettes smoke per week
  2. History of Smoking: Yes/No, if yes, how many cigarettes smoke per week
  3. Thanking any prescription medication to control symptom for the chronic respiratory disease such as albuterol: Yes/No
  4. Dyspnea scale (Crisafulli & Clini, 2010): 1 being get breathless with strenuous exercise; 2 being get short of breath when hurrying on the level or walking up a slight hill; 3 being walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level; 4 being I need to stop for breath after walking about 100 meters/300 feet or after a few minutes on the level; 5 being too breathless to leave the house or I am breathless when dressing
  5. Exercise/ Physical activity hours per week
  6. Quality of Life: 1 to 5 with 5 being feeling fullest in life and the chronic respiratory disease did not affect daily lives.

Methods (research design/ project design)
Figure 1: Study Overview

Phase 1: Relationship and community assessment which leads to problem identification
The project will be conceptualized and developed through dialogues with the relevant stakeholders such as Senior Activity Centers, Jurong Health, Association of Respiratory Therapists Singapore (ARTS), and with the participating communities through the help of volunteers from ARTS. There will be consultation sessions with community leaders, health workers, and community members. The aim of the consultation sessions and dialogues is to address key factors driving health inequalities and to evaluate a self-care intervention program aimed at enhancing the ability of mildly disabled and healthy older persons in Singapore to care for themselves. The primary outcome measures are the normalized peak flow which will adjust for age, gender and ethnicity. A decision maker team will form to assess, address, redress and reassess the recommendation and outcome of the self-care intervention respiratory programs. An agreement will be signed between members, researchers that participate in the project and the communities to ensure confidentiality and privacy will be respected at all times.
Phase 2: Baseline assessment (Data collection and Analysis)
The baseline assessment will consist of two components, an interviewer-administered questionnaire and clinical assessment on the participant’s respiratory health condition: baseline, six months, and twelve months of the intervention programs. The first stage will involve personal invitation via social media and door-to-door canvassing to make elderly people aware of the baseline survey and will distribute brochures to explain the purpose and needs of the baseline survey. The future stage shall consist of face-to-face administration of questionnaires by the interviewers (volunteers from ARTS) and using programs such as Qualtrics for data entry and conducting of clinical assessments. Before implementing the next stage of the first phase, consent will be obtained from study participants for both the baseline survey and follow-up survey at the start of the study. The participants will provide a participant information sheet which provides details about the research. The interviewers will describe the research to the respondent. The data collected will be de-identified and participants will be identified by a unique identifier such as last four digits of their medical records number. Names will be separated from the identifiers too. All identifiable information will code at the earliest possible stage. The participants will have the knowledge that their participation in the survey are completely voluntary and that they can withdraw from the study at any time without giving any reasons.
Questionnaire development and administration
A questionnaire will be administered to the study participants in the second stage of baseline survey. In developing baseline assessment questionnaire, population health framework from Singapore health ministry will be taken into account by including questions that capture both individual (such as past medical history, body weight, indoor air quality, and demographics) and contextual factors (such as socioeconomic status, health literacy, and access to health services). However, before developing the questionnaire, feedback will need to obtain from community advices (such as leaders in the community, and health professionals). An advisory board will be formed with a group of stakeholders from the Jurong Health, ARTS and Senior Activity Centers, which will meet regularly to provide feedback on the progress of the study and to address any concerns. The role of the advisory board is to advise the research team on the best approaches for contacting and recruiting participants; as well as administering and collecting questionnaire and clinical assessment data from participants. A pilot study will then conduct to optimize the content and administration of the baseline questionnaire.
Using the feedback from the pilot project responses, several survey questions may need to modify in the questionnaire so that it can be use as SCOPE baseline survey. Trained research assistants from each senior activity centers will personally invite every service elderly community resident (aged 65 years and older) from the senior activity centers to complete the interviewer-administered questionnaires and to participate in clinical assessments. The questionnaire will primarily design to obtain information on individual and contextual determinants to determine any factors that may influence chronic respiratory health conditions. However, questionnaire will also include questions that are used to evaluate general health, including past medical history of other health conditions for every participant. All baseline clinical health screening tests will conduct by trained health professionals and spirometers will be used to obtain measures of forced vital capacity, forced expired volume in one second (FEV1), FEV1/FVC ratio, and maximum mid-expiratory flow rate (FEF25–75). Measurements will be recorded according to the standards of the American Thoracic Society, and American Heart Association (Miller et al, 2015). Participants who demonstrate below normal test results on their spirometry may be referred to their family physician for follow-up.
Inclusions and exclusions
Study participants must be affiliated with one of the senior activity centers, aged 65 years or older, have chronic respiratory diseases such as COPD or obstructive sleep apnea and do not have cognitive impairment, severe and life-limiting illnesses, or activities of daily living disability severe enough to prevent them from taking part in health screenings or training sessions. The exclusions criteria are if the participants are not willing to do spirometry or if the participant is deemed unfit for the process such as recent surgeries and receiving chemotherapy or medication that may cause complications. Evaluation of participants for inclusion and exclusion criteria will go through standard screening interviews conducted in the three official languages in Singapore; English, Malay, or Chinese. The research team will also check verbally with potential participants that they feel the participants are physically able enough to attend the intervention with minimal trouble. For example, wheelchair bound participants will take part in those anthropometric screeners to determine if they are physically able to. Eligible subjects willing to participate in the study will receive detailed information on the objectives of the study, the requirements of participants, and privacy information before signing consent forms.
Sample
Statistical plan including sample size justification and interim data analysis. Power analysis will be conducted using pilot study data of sample size 80. The study will proceed as planned if power analysis justifies a sample size consistent with the study. If the power analysis justifies a sample size larger than that described in the study protocol, an amendment to the study will be proposed to IRB, if approved by participating non-profit organizations. Target sample size will be calculated based on the following: 1) the type of comparison (means of the pulmonary function tests results [FVC, FEV1, FEV1/FVC, and FEF25–75]); 2) estimated difference in means before and after the SCOPE program; 3) desired power of the study is 80%; 4) desired level of confidence is 95% confidence interval; and 5) prevalence of chronic respiratory health condition in the Singapore elderly population.
Intervention in actions
Participants in the intervention group will attend weekly an hour classes on self-care education provided by a health trainer. Training will be conducted in English, Malay, and Mandarin as appropriate. The material aim is to promote improvements in self-care and health-seeking behavior and to teach participants the basic nature and management of chronic respiratory health conditions such as COPD. Participants will then fill in their health journals each month, complete questionnaires, and participate in three health screenings at baseline, six months, and twelve months.
The curriculum for the SCOPE will focus on the following topics: 1) Successful aging; 2) Basic respiratory physiology; 3) Nutrition and exercise; 4) Chronic disease management, and treatment; 5) Access to healthcare resources; 6) Self-efficacy and managing social dynamics; 7) Alternative medicine; 8) Personal health goals.
Outcomes of interest
The key clinical outcomes of the SCOPE from the survey will be better management of chronic respiratory disease such as COPD. The key outcomes from the clinical testing will be the pulmonary lung function tests such as FVC, FEV1, FEV1/FVC, and FEF25–75, through obtaining via spirometry to ascertain respiratory health. The primary contextual factors associated with respiratory health outcomes are crowding (the number of people who usually live in the household); social factors (family community social support); socioeconomic status (income, savings, and perceived financial strain); and access to health care services. The individual factors that will be considered as moderators are the highest level of educational attainment, lifestyle and behavioral factors, this includes dietary choices, housing conditions, and the limit of the participant’s mobility.
Phase 3 Action: Addressing and reviewing of SCOPE
The address and review phase form the most important of SCOPE, where critical community and policy-level interventions which will identify by pre-existing data and baseline assessment results which will be implemented to address and review SCOPE. The purpose of this phase is to plan to enhance self-efficacy in disease management and self-reported health status among Singapore elderly population, so to promote a healthier life. The secondary outcomes of the study are to address exposure-outcome which are: 1) Respiratory infections: The ways to encourage and interventions to improve hygiene, and ways to increasing immunization among elderly people and flu vaccination rates. Immunization and vaccination will help to ultimately reduce the risk of respiratory illnesses such as bronchitis through environmental study of housing conditions. 2) Self-management of chronic respiratory diseases such as obstructive sleep apnea and COPD: Educational programs or activities that need to develop interventions which will help educate Singapore elderly population on self-management on chronic respiratory diseases and redress access to health care services specific to the diagnosis and management of obstructive sleep apnea and COPD.
To address self-management of chronic respiratory disease, an intervention will be adopted for educational program which will achieve and sustain through partnerships with Association of Respiratory Therapists (Singapore). The educational program will not only raise awareness about long term effect of chronic respiratory diseases, but also provides skills in the self-administration of a questionnaire which will highlights the symptoms indicative of chronic respiratory diseases risk. This will provide resources for Singapore elderly to recognize, and aware the symptoms of chronic respiratory diseases. The ability to recognize the symptoms of chronic respiratory diseases is a crucial step in its diagnosis because studies have shown that an overwhelming majority of Singapore elderly population suffering from chronic respiratory diseases do not utilize and seek diagnostic services due to lack of awareness (Tan et al., 2015), (Huang et al., 2018).
These interventions are based on the pre-data and preliminary stage of development. The factors of improving respiratory health conditions for Singapore elderly will evolve and mature as the study of SCOPE progresses.
Discussion
This study’s purpose is to test the clinical (significant improvement in pulmonary function test; able to monitor and manage health risks and conditions; and understand personal physical risk factors and recognize the importance of their implications) and behavioral effects (such as awareness of their chronic disease; feel more confident and motivated for physical activities and manage medication regime and make sustained lifestyle changes). The goal of this study is to have determine any significant results on the implementation of a self-care program (SCOPE) in the community for low-income elderly with chronic respiratory diseases. With aging comes an increase of chronic respiratory health conditions that include not only serious chronic conditions, such as COPD, but also non-fatal health conditions of broader range, such as fatigue, anxiety, and chest pain, which may result in respiratory failure. The prevalence of chronic conditions for older people is higher than that for other age groups (Onselen, 2018). Given that chronic conditions account for more than 4 out of 5 deaths in Singapore, the management of chronic diseases and, more broadly, the care involved with routine coping and the effects of aging are increasingly important (Wang, 2012).
Many countries with aging populations have experimented with educational programs and Chronic Disease Self-Management Programs (CDSMPs) to improve personal disease management, and positive changes in health outcomes were reported from many CDSMPs in studies from various countries (Tanimura et al., 2016). Although educational programs have been studied in China, Japan, parts of Europe, and in the United States, no formal program has been conducted in Singapore. While, some educational programs have focused on multi-racial or multi-ethnic target populations in different countries, there has been no such program undertaken in Singapore. The design of the study and lessons learnt from liaising with senior activity centers’ representatives and community health workers will provide substantial information on how Singapore can successfully structure its community-level health resources for the elderly.
Furthermore, analyzing the success of SCOPE intervention program will also shed some light on the prevalence of chronic diseases and will reveal blind spots in disease awareness and health knowledge. Health education among older persons, particularly those with chronic illnesses, clearly has an important policy consideration and implication. An overview of current perspectives on the care of older persons found that while preventive and curative actions are important, the overall awareness of the health issues of older persons and care to ensure preservation of their functional status are more important (Cho et al., 2017). Older people with a lower level of socioeconomic status are relatively vulnerable, and they are more likely to have more years of inactive life and shorter life expectancy.
Additionally, the study will provide insights into health-seeking patterns in the population, which will be beneficial for healthcare professionals to understand how the low-income elderly currently interact with the healthcare system. Previous studies have argued the importance of socioeconomic status in the association with health behavior, access to medical care, morbidity, physical functioning, disability, and mortality (Kwan et al., 2017) (Leblanc & Jacelon, 2018). Older people with lower socioeconomic status oftentimes lack knowledge of how to access or interact with healthcare professionals, which is very likely to result in poor health and higher mortality. Despite their higher need, they still have lower utilization rates for healthcare as compared to general population (Huang et al., 2018). Thus, screening and training older persons with lower level of socioeconomic status on coping strategies for their health conditions can have a positive impact on their health management, and therefore their health.

Table 1: Anticipated Measure and Data Collection Time Points
Variable in the success of SCOPE (improvement in access to chronic respiratory management knowledge and resources) How Measured Pre-intervention 6 months Post 12 Months Post
Feasibility Pre-existing data and notes from elderly communities. Ongoing
Acceptability Community focus group, and interviews. X X
Adherence Self-efficacy for adherence to medication regime, and lifestyle changes in nutrition, exercise, and stress management. Participate in weekly SCOPE intervention program X X X
Quality of Life Self-report questionnaire, and clinical assessment. X X X
Skills Skills demonstrated by professional health trainer for the SCOPE program. X X X
Demographics and Health Characteristics Singapore elder individuals aged above 65 years old, self-report/ medical record data extraction. X X X

 

Table 2: Description and project implementation schedule of intervention activities
Project Implementation Schedule Year 1 Year 2
First Quarter Second Quarter 
(Start)
Third Quarter Fourth Quarter First Quarter 
(End)
Second Quarter
Recruit study participants X
Identify community health worker in the community X
Measure baseline demographic characteristics, health levels, and behaviors and health expenditures X
Distribute diary to all participants to records episodes of illness/hospitalizations/ health care related expenditures X
Train the community health worker in older people self-care X X
Train and educate participants in self-care management X X X X
Conduct survey (baseline, 6 months, 12 months) to measure changes in self-care, functional status and quality of life of the participants X X X
Feedback group discussions with community health worker and care providers on attitudes towards older people X X
Collect diary from all participants; code and input data into database software such as Qualtrics X X
Conduct quantitative analysis of survey data X X
Conduct in-depth interviews with participants for post-intervention X X
Conduct qualitative analysis of the findings from the interview X X
Write Report X X X X
Attend and present in conferences X X

 
 
 
Conclusion
The information from this study will assist in addressing and reviewing many of the respiratory health issues involved including the provision of healthy lifestyle practices, in planning for older people to have the knowledge of self-care in their chronic respiratory diseases and accessing health service delivery. Even though the immediate goals are to address and review self-care for respiratory health conditions, the ultimate aim is to build sustainable community capacity by deriving and understanding the respiratory health needs, obstacles and barriers faced by low-income Singapore elderly.
The SCOPE community-based participatory research study will not only increase the chances of long term respiratory health outcomes for older people. Ultimately, the study will contribute to an understanding of the role of personal empowerment training on the health and well-being of elderly participants, but will also provide a foundation for introducing, evaluating, and facilitating future interventions programs and community-based health services for older people in Singapore.
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