Análisis de redes sociales para evaluar intervenciones educativas con adultos mayores

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1 Análisis de redes sociales para evaluar intervenciones educativas con adultos mayores XI Reunión de investigación demográfica en México, Sociedad Mexicana de Demografía 23 al 25 de mayo de 2012, Aguascalientes México Margarita Márquez Serrano Álvaro Javier Idrovo Velandia Edgar Leonel González González Lorena Elizabeth Castillo Castillo Investigadores del Instituto Nacional de Salud Pública Objetivo: Explorar el impacto de una intervención educativa de autocuidado para adultos mayores en sus niveles de conocimiento de las infecciones respiratorias agudas y la incidencia dentro de sus redes sociales. Método: Intervención educativa de siete sesiones con adultos mayores de Jiutepec Morelos durante la pandemia de influenza A(H1N1). Se utilizó un análisis de redes sociales egocéntricas para explorar la transmisión de conocimientos de autocuidado dentro de las redes sociales de los adultos mayores participantes y teoría de grafos para su representación. Resultados: Se incrementó el conocimiento sobre el uso correcto de antibióticos (p<0.05). El tamaño de la red fue de 94 individuos, 22 de ellos presentaron una infección respiratoria en los 4.5 meses siguientes. Los estadísticos de los individuos infectados son similares a los no infectados (p>0.05). No hay diferencias en la incidencia con respecto al sexo, parentesco o subredes. Discusión: Los adultos mayores incrementaron los niveles de conocimiento y prácticas de autocuidado pero no se redujo la incidencia de casos en sus redes sociales. Puede ser por su aislamiento, falta de reconocimiento y credibilidad entre amigos cercanos y familiares. El análisis de redes sociales egocéntricas es útil para evaluar los modelos de intervención para el autocuidado. Palabras clave: adultos mayores, auto-cuidado, redes egocéntricas, análisis de redes sociales, teoría de grafos, intervenciones comunitarias Introducción Several studies confirm that nursing interventions to transmit knowledge are effective to increase self-care practices, to modify unhealthy behaviors, and to diminish the occurrence 1

2 of diseases (Kreulen and Braden, 2004). However, the conventional approach is only interested in those who directly participated in the intervention, forgetting the individuals related to each participant. These persons may be intervened indirectly through social networks, but the principles to analyze this type of information are not usually known among public health nurses. To understand this indirect transmission of knowledge is highly relevant in developing countries where there are not enough public health nurses, and their interventions need to be amplified to all community members. This situation occurred during the influenza A(H1N1) outbreak in Mexico. The appearance of this epidemic in 2009 was a challenge for the Mexican health system (Idrovo, Fernández-Niño, Bojórquez-Chapela & Moreno-Montoya, 2011), in spite of the preparation initiated several years earlier (Mensua, Mounier-Jack & Coker, 2009). Nevertheless, the actions promoted by the community itself have not been widely disseminated or evaluated. One of these community interventions was realized with Mexican elders and their social networks. This was an opportunity to explore knowledge transmission and its potential impact on disease incidence through egocentric social networks (Wellman, 1988). Since some elders continue to have a good deal of vitality, we proposed that they can become promoters of self-care for themselves and their social networks in contextual situations such as an epidemic. It was expected that their possible effects would primarily be on their closest family members, since social networks usually weaken as age increases (Stephens, Alpass, Towers, & Stevenson, 2011; Waite & Das, 2010). This was supported by earlier studies in Mexico that showed that elders usually help younger members of their 2

3 family (Ham-Chande, Ybáñez-Zepeda, & Torres-Martínez, 2003; Pelcastre-Villafuerte, Treviño-Siller, González-Vázquez, & Márquez-Serrano, 2011). It has been known for several decades that social networks are a significant element in the transmission of acute respiratory infections. Some authors, such as Friedman and Aral (2001), define social networks for transmission of disease as networks of individuals connected by ties that can spread infection. Recently, evidence has shown that in social networks with a strong community structure (Girvan & Newman, 2002), interventions can be more effective and have more impact on the dynamic of the disease (Salathe & Jones, 2010). The ties between individuals include elements such as their conduct, close living conditions, and belonging to specific groups (Luke, & Harris, 2007). From this perspective, social networks can become a significant context in which to seek the prevention of contagion through practices based on sufficient scientific evidence. In the case of acute respiratory infections, these could be frequently washing hands and using masks or gloves (Jefferson, Del Mar, Dooley, Ferroni, Hewak, Prabhala, Nair, & Rivetti, 2009). Therefore, the objective of this work herein was to explore the potential usefulness of social network analysis to evaluate the impact of an educational strategy focused on the self-care of elders with respect to their knowledge of acute respiratory infection and its incidence within their social networks, thereby seeking to increase their empowerment, improve self-care, and promote actions to prevent the incidence of acute respiratory infections among members of social networks. METHODS 3

4 Context and participants. The intervention was conducted in the Calera Chica neighborhood of the municipality of Jiutepec, Morelos, between the months of September 2009 and January This is historically the period of the year with a higher incidence of acute respiratory infections and, specifically this year, corresponded to the period in which a recurrence was expected of influenza A(H1N1) (Fajardo-Dolci, Hernández-Torres, Santacruz-Varela, Rodríguez-Suárez, Lamy, Arboleya-Casanova, Gutiérrez-Vega, Manuell- Lee, & Córdova-Villalobos, 2009). A previous exploration of this community showed that roughly 30% of elders continued to work and only 8.2% had a retirement pension. Roughly 70% perceived their health as average or poor due to chronic illnesses, and slightly more than 50% presented with limitations to moving about, seeing, or hearing. In spite of having a family, only 2.5% lived with family members or friends. Initially, elders over the age of 60 years and residing in the neighborhood were invited to participate in a meeting to explain the study; they were identified using the snowball technique (Goodman, 1961). Eighteen elders attended this meeting, but only 10 decided to actively participate and were given the Mini-Mental test to evaluate their cognitive state. Adequate responses were required for their participation (Folstein, Folstein, & McHugh, 1975). These elders continued throughout the intervention, although in several sessions it was necessary to go to their homes to appeal for their attendance. All the actions were carried out as part of an academic practicum program at the National Institute of Public Health of Mexico, supported by the Secretary of Health of the state of Morelos, in which 120 families participated after signing informed consent. This intervention was approved and supervised by the faculty colleges at the National Institute of Public Health, 4

5 following the Mexican legislation of research with humans (Regulation of the General Law of Health in Research for Health, 1986). Most of the elders were women (7/10), were between 65 and 85 years old, married (8/10), and had low schooling levels (6/10 with an elementary education only). Half were homemakers, two were retired, and only three cases reported working in business. Most (7/10) mentioned having the emotional support of their families and 6/10 received material support from their partner or children. In addition, 5/10 of the cases mentioned having institutional public health services and 4/10 received support from governmental social programs. A summary of the intervention design is found in Figure 1, and its elements are explained below. Educative intervention. The educational strategy was based on the meaningful learning principles by Ausubel, which indicate that learning should be based on prior knowledge (Ausubel, Novak, & Hanesian, 1978). The experience included the following four stages: i) activation of knowledge, ii) acquisition of knowledge, iii) practice of knowledge, and iv) application and evaluation of knowledge. Thus, the participating elders first indicated what they knew about acute respiratory infections. Second, they acquired new knowledge during six sessions. They then modified some of their hygienic habits, including washing their hands with the correct technique before each meal, covering their mouths when coughing or sneezing and, finally, producing objects related to the prevention of acute respiratory infections. The sessions combined information in order to acquire the knowledge needed for self-care and the development of skills such as making low-cost liquid soap, correctly using a thermometer and masks and to participate in recreational activities such as making a handkerchief and a towel. A central theme of all the sessions 5

6 was the strengthening of self-esteem so that the elders could change from being receivers of care to being promoters of their own health and that of their families. Seven educational sessions were held for approximately 70 minutes each, during the period September to December The first two sessions corresponded to the first stage in the Ausubel learning cycle, with the objective of activating the elders prior knowledge of acute respiratory infections. The method used was discussion among the participants. The second stage in the learning cycle was conducted during sessions 3, 4, and 5, with the objective of broadening the elders knowledge of acute respiratory infections. The method used in these sessions was the presentation of recreational activities by the facilitator. The objective of the third stage (sessions 6 and 7) was for the elders to expand and modify their practices. This was accomplished using the active method, in which each elder applied and adapted the knowledge that they had learned and maintained. The objective of the last stage in the learning cycle was for the elders to self discover their own knowledge, making it personal and replicating it with events and/or activities within their social networks. Identification of elders social networks. During the penultimate educational session, the researchers asked the elders to indicate the individuals with whom they had relationships (family, friends, neighbors, or work colleagues). When the elders (3 cases) had difficulties with reading or writing the facilitator helped to identify the members of their social networks. In this way all social network nodes and their connections among them were identified. Since the study considered that knowledge, and perhaps certain preventive practices, could be transmitted through the network, a directionality beginning with the facilitator (central node) out toward the periphery was taken into account. Information on the category of each node (i.e. instructor, direct participants, and their 6

7 relatives or friends) must be collected. Identification of focal nodes (also called egos ) should be based on their position as instructors of educative intervention. Nodes with direct link to egos are the first order alters, and the second order alters are the nodes without direct link to the egos (Wellman, 1988). Collected information was used to construct a symmetric matrix to represent bidirectional relationships between individuals. Measures. We surveyed participants about their knowledge of correct use of antibiotics and they were evaluated using a questionnaire with 10 questions (5 pertaining to the use of antibiotics) administered before and after the educational intervention. These questions were based on the questionnaire by Filipetto, Modi, Weiss, and Ciervo (2008) (Table 1). The practices were evaluated based on direct observation by the facilitator. Three important points were considered in the technique for using masks: use of the correct side, correct adjustment of the elastic straps to achieve a horizontal placement on the face, and verifying that the mouth and nose were completely covered. The hand-washing technique was evaluated based on their wetting the hands completely, the way in which they applied the liquid soap, assuring they rubbed the back and palms of the hands, the nails, the wrists and between the fingers, and completely rinsing the soap and drying with a towel. Analytic strategy. An egocentric approach of social network analysis was used to evaluate the intervention (Wellman, 1988). This analysis allowed the characterization of links between nodes or actors, the intensity and frequency of connections, and any qualitative attributes of nodes. In this case, network density and the out-degree were calculated using the program UCINET (Borgatti, Everett, & Freeman, 2002). The network density is a measurement used to express the extension of contacts among the nodes, and is calculated as the ratio of contacts between pairs of nodes that occur divided 7

8 by those that could potentially exist. The result is a value between 0 and 1, and the greater the number of ties observed the higher the value (Friedkin, 1984). The out-degree is the number of direct ties stemming from each node and represents the ability to access other nodes (Freeman, 1978/79). In general, when there are few social network members nearest to a node (i.e., relatives or intimate friends) the structural variation is reduced. However, when the social network has a lot of nodes with different level of kinship, it is possible to observe high variability in the network structure (Bernard, Killworth, McCarty, & Shelley, 1990). Graphic analysis of the network was realized with the NetDraw software (Borgatti, 2002). An option very powerful when the social network is big, egos are not known, or it is not possible to identify the network structure, is to performance a principal component analysis. In this way it is possible to identify latent structures where nodes with high eigenvalues are the mean individuals. Statistical methods. To complement social network analysis, first the variables were described and then the results of knowledge before and after the educational intervention were compared using McNemar s exact x 2 test. Finally, some of the characteristics of the infected cases were compared with noninfected cases using Fisher s exact test or the Mann- Whitney U test. The statistical analyses were performed with the Stata 11 program (Stata Corporation, College Station, TX). Results The elders social networks were mode 1 because they are composed of only one group of nodes, which are family members (children, daughters-in law, grandchildren, and godmothers), followed by friends and neighbors; the number of members varied between 4 8

9 and 11. There are 51 nodes that are linked only to one ego ; they are named dependents, because this kind of actor gets information in only one way. The egocentric social network studied is seen in Figure 2. In this network, 94 people were included, in addition to the facilitator who is the central node. Note that in general, each elder had a social network independent of that of the others; only 4 elders, identified as a1, b1, d1, and h1, tended to have a more united network. The density was (standard deviation = 0.13), which suggests a high level of isolation of the participating elders. As can be seen, it was the facilitator who enabled the elders to connect, and thus their respective social networks. On average, the out-degree was 1.57 (standard deviation = 3.36), which was similar for those infected and noninfected (Table 2). Nevertheless, there were 7 participants (all elders or alter ) with an out-degree equal to or higher than the value of 10 of the ego (the facilitator). The other variables compared also did not show significant differences among the groups. Of all members of the network, 23.16% (n = 22) presented with acute respiratory infection during the follow-up period. Of the elders who received the intervention directly, 2/10 presented with acute respiratory infection, and of the other members of the network (excluding the instructor) 23.81% of individuals presented with acute respiratory infections. Thus no differences were found (p > 0.05) between having attended the educational intervention sessions and/or having received knowledge from the elder. In terms of family members or affiliation with elders participating in the intervention, those infected were 4/6 spouses, 6/25 children, 5/14 grandchildren, 3/12 sons- or daughters-in-law and 2/18 neighbors. This reflects that the cases were primarily concentrated among elders and children, corresponding to 37.5% and 35.7% of each category, respectively. When 9

10 comparing the incidence of infection, no significant differences were observed (p > 0.05, Fisher s exact test). Table 1 shows the results of the evaluation of knowledge. A statistically significant improvement (p < 0.05, McNemar x 2 test) on 4 of the 10 questions can be observed in this paired analysis. All these questions refer to the use of antibiotics for managing acute respiratory infections, which suggests that popular knowledge about this topic is insufficient to answer correctly. In regard to the questions for which no differences were found, it appears that this was because the baseline knowledge was high, which prevented observing changes. In terms of practices, it was observed that 9/10 of the elders correctly performed the technique for using masks and only one forgot to cover the nose. The technique for washing the hands was correctly performed by all the participants. One important observation not originally considered by the evaluation is that improved personal appearance was evident in the last as compared with the first session. In addition, they had nearly no dealings with others in the intervention at the beginning and at the end of the program integration among the elders was notably greater; there was also a notable change in participation during the sessions. Discussion During the 45 days of follow-up after the intervention of the members of the elders social networks, 20.16% presented with acute respiratory infection. There were no differences between infected and noninfected individuals, which suggests that there was not adequate transmission of the elders knowledge to members of their social networks, or said knowledge was not adequately received. This may be related to the fact that in Mexico 10

11 elders are usually regarded with disdain and not valued by younger members of the society. In this regard, Montes de Oca (2006) mentions that elders are excluded from their family network; they no longer function as transmitters of knowledge. These findings appear to be specific to these social networks, since recent evidence suggests that adults social networks can have a protective effect on acute respiratory infections. Isolated elders in the United Kingdom, for example, have a greater risk of acquiring acute respiratory infections (Jordan, Hawker, Ayres, Adab, Tunnicliffe, Olowokure, Kai, McManus, Salter, & Cheng, 2008). The interpretation of these findings should take into account that they are specific to the participants and cannot be extrapolated to other elders. A good deal of evidence exists that indicates that attitudes toward aging and elders are different for contexts within and outside countries (Mcconatha, Schnell, Volkwein, Riley, & Leach, 2003; Oberg & Tornstam, 2003) and, therefore, future studies are needed that explore the support that elders can provide. The lack of a control group and data based on self-reports by elders should be considered as limitations of our study. Nevertheless, we think the data are reliable given their adequate mental performance, which was even expressed by the improvement in knowledge. The elders adaptation and activation of known facts encouraged self-discovery of their own ability to create the objects and disseminate them within their social networks (Boltona, 1978). Although direct participants were few, this experience showed how small community interventions can amplify the effect to nonparticipant members. Currently it is well recognized that infectious and noninfectious diseases, healthy and unhealthy behaviors, and risk factors can be disseminated through social networks. 11

12 Another finding from this study was that the educational intervention improved the elders knowledge of acute respiratory infections. This was observed in relation to the unnecessary use of antibiotics, similar to that reported in the study by Filipetto et al. (2008). This has significant implications since at the time in which the intervention was conducted, antibiotics in Mexico were sold over the counter, and self-medication and lack of adherence to treatment was very common (Wirtz, Reich, Leyva-Flores, & Dreser, 2008). Satisfactory results were also observed with regard to preventive practices, such as hand-washing and the correct use of masks, although it is important to remember that the intervention was conducted during the epidemiological alert due to the influenza A(H1N1) and there was a large amount of publicity about these preventive measures (Aburto et al., 2008). Therefore, we cannot state that the results among participating elders were due to the educational intervention. These findings from the use of the meaningful learning principles by Ausubel et al. (1978) during this experience suggest that they can be useful for this type of community. In this case, making the soap, handkerchief, and towel were done in order to strengthen the preventive measures against acute respiratory infections. In conclusion, this study suggests that the educational interventions for Mexican elders are useful to improve their self-care, but do not appear to have a significant impact on members of their social networks. This can be explained, at least partially, by the isolation of this group or the lack of recognition from other members of society. Nonetheless, it was a pioneering experience that sought to have elders play a role as promoters of self-care by transmitting information to their social networks and not only be depositories of information during an important health contingency. Further nursing 12

13 interventions can be evaluated with simple elements of social network analysis and graph theory. 13

14 References Aburto, N. J., Pevzner, E., Lopez-Ridaura, R., Rojas, R., Lopez-Gatell, H., Lazcano, E., Hernandez-Avila, M., & Harrington, T. A. (2010). Knowledge and adoption of community mitigation efforts in Mexico during the 2009 H1N1 pandemic. American Journal of Preventive Medicine, 39, Ausubel, D. P., Novak, J. D., & Hanesian, H. (1978). Educational psychology: a cognitive view. 2nd ed. New York: Holt, Rinehart & Winston. Bernard, H. R., Killworth, P. D., McCarty C., & Shelley, GA. (1990). Comparing four different methods for measuring personal social networks. Social Networks, 12, Boltona, E. B. (1978). Cognitive and noncognitive factors that affect learning in older adults and their implications for instruction. Educational Gerontology, 3, Borgatti, S.P. (2002). Netdraw network visualization. Harvard, MA: Analytic Technologies. Borgatti, S. P., Everett, M. G., & Freeman, L. C. (2002). Ucinet for Windows: Software for social network analysis. Harvard, MA: Analytic Technologies. Cohen, S., Doyle, W. J., Skoner, D. P., Rabin, B. S., & Gwaltney, J. M. (1997). Social ties and susceptibility to the common cold. Journal of the American Medical Association, 277, Fajardo-Dolci, G.E., Hernández-Torres, F., Santacruz-Varela, J., Rodríguez-Suárez, J., Lamy, P., Arboleya-Casanova, H., Gutiérrez-Vega, R., Manuell-Lee, G., & Córdova- 14

15 Villalobos JA. (2009). Perfil epidemiológico de la mortalidad por influenza humana A (H1N1) en México. Salud Publica de México, 51, Filipetto, F. A., Modi, D. S., Weiss, L. B., & Ciervo, C. A. (2008). Patient knowledge and perception of upper respiratory infections, antibiotic indications and resistance. Patient Preferences and Adherence, 2, Folstein, M. F., Folstein, S.E., & McHugh P. R. (1975). "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, Freeman, L. C. (1978/79). Centrality in social networks. Conceptual clarification. Social Networks, 1, Friedkin, N. E. (1984). Structural cohesion and equivalence explanations of social homogeneity. Sociological Methods & Research, 12, Friedman, S. R., & Aral, S. (2001). Social networks, risk-potential networks, health, and disease. Journal of Urban Health, 78, Girvan, M., & Newman, M. E. J. (2002). Community structure in social and biological networks. Proceedings of the National Academy of Sciences of the United States of America, 99, Goodman, L. (1961). Snowball sampling. The Annals of Mathematical Statistics, 32, Guzmán, J. M., Huenchuan, S., & Montes de Oca, V. (2003). Redes de apoyo social de las personas mayores: marco conceptual. Notas de Población, 77,

16 Ham-Chande, R., Ybáñez-Zepeda, E., & Torres-Martínez, A. L. (2003). Redes de apoyo y arreglos de domicilio de las personas en edades avanzadas en la Ciudad de México. Notas de Población, 77, Idrovo, A. J., Fernández-Niño, J. A., Bojórquez-Chapela, I., & Moreno-Montoya, J. (2011). Performance of public health surveillance systems during the influenza A(H1N1) pandemic in the Americas: testing a new method based on Benford s Law. Epidemiology & Infection, 139, Jefferson, T., Del Mar, C., Dooley, L., Ferroni, E., Hewak, B., Prabhala, A., Nair, S., & Rivetti, A. (2009). Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. British Medical Journal, 336, Jordan, R. E., Hawker, J. I., Ayres, J. G., Adab, P., Tunnicliffe, W., Olowokure, B., Kai, J., McManus, R. J., Salter, R., & Cheng, K. K. (2008). Effect of social factors on winter hospital admission for respiratory disease: a case-control study of older people in the UK. British Journal of General Practice, 58, Kreulen, G. J. & Braden C. J. (2004) Model test of the relationship between self-helppromoting nursing interventions and self-care and health status outcomes. Research in Nursing & Health, 27, Luke, D. A., & Harris, J. K. (2007). Network analysis in public health: history, methods, and applications. Annual Review of Public Health, 28, Mcconatha J.T., Schnell, F., Volkwein, K., Riley, L., & Leach, E. (2003). Attitudes toward aging: a comparative analysis of young adults from the United States and Germany. International Journal of Aging and Human Development, 57,

17 Mensua, A., Mounier-Jack, S., & Coker, R. (2009). Pandemic influenza preparedness in Latin America: analysis of national strategic plans. Health Policy and Planning, 24, Montes de Oca, V. & Hebrero M. (2006). Eventos cruciales en ciclos familiares avanzados: el efecto del envejecimiento en los hogares de México. Papeles de Población, 50, Oberg, P., & Tornstam, L. (2003). Attitudes toward embodied old age among Swedes. International Journal of Aging and Human Development, 56, Pelcastre-Villafuerte, B.E., Treviño-Siller, S., González-Vázquez, T., & Márquez-Serrano, M. (2011). Apoyo social y condiciones de vida de adultos mayores que viven en la pobreza urbana en México. Cadernos de Saúde Pública, 27, Salathé, M., & Jones, J. H. (2010). Dynamics and control of diseases in networks with community structure. PLoS Computational Biology, 6, e Stephens, C., Alpass, F., Towers, A., & Stevenson, B. (2011). The effects of types of social networks, perceived social support, and loneliness on the health of older people: accounting for the social context. Journal of Aging and Health, 23, Waite, L., & Das, A. (2010). Families, social life, and well-being at older ages. Demography, 47(Suppl), S87-S109. Wellman, B. (1988). Structural analysis: from method and metaphor to theory and substance. In: Wellman, B., & Berkowit, S. D. Social structures: a network approach. Cambridge: Cambridge University Press:

18 Wirtz, V. J., Reich, M. R., Leyva-Flores, R., & Dreser, A. (2008). Medicines in Mexico, : systematic review of research on access and use. Salud Publica de México, 50(suppl 4), S470-S

19 Figure legends Figure 1 General design of educational intervention with Mexican elders. Figure 2 Social networks of facilitator, elders, and their families, neighbors, and friends, expressing the potential pathways of knowledge transmission. 19

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