Benefits to volunteers in a community-based health promotion and chronic illness self-management program for the elderly

Health Promotion and Disease Prevention Interventions for the Elderly: A Scoping Review from 2015-2019

In this study, a scoping review method is used to review the distribution and trends in health promotion research and explore the use and contribution of eHealth technologies in health promotion in the elderly. The study includes six search databases: PubMed, CINAHL, the CochraneLibrary, EMBASE, PubPsych, and ERIC (EBSCOhost), and studies published from January 2015 to October 2019, written in English, were included and analyzed. The findings of the study reveal that the amount of literature on promoting health for the elderly has increased, and some specific types of interventions are still favored in current health promotion efforts for older adults. The most commonly used methods were found to be health promotion (n = 322), followed by screening (n = 264), primary prevention (n = 114), and finally social support (n = 72). Beyond the above interventions, eHealth technology is also used in health promotion activities to prevent the elderly from falling and to improve home safety, etc. However, although the application of eHealth technology has been applied in areas such as fall prevention, mental health promotion, and home security monitoring, it is still immature, and thus more rigorous research is needed in different areas, especially in older populations, various professions, women, and people with dementia.

Volunteers' Experiences Delivering a Community-University Chronic Disease Health Awareness Program for South Asian Older Adults

Volunteers and voluntary organizations can connect preventative health care programs to communities and may play an important role in addressing the health needs of older adults. Despite this, tensions may exist in the structures that drive volunteers and voluntary organizations representing immigrant communities to provide unpaid labour to augment and supplement health care services. Furthermore, organizational challenges may exist for community agencies relying on volunteers to sustain a health screening and education program. The intervention program was led by one voluntary agency specifically for South Asian communities in partnership with the university and five local organizations. This paper draws on volunteer surveys (n = 22) and key informant interviews (n = 12) to detail volunteer experiences providing this intervention. Volunteers were university students and other community volunteers. A total of 810 adults participated in the intervention within the Greater Toronto Area, Ontario, Canada between October 2014 and June 2016. We found that volunteers often used their experience as a 'stepping stone' position to other education or work. They also gained from the knowledge and used it to educate themselves and their family members and friends. This paper provides a critical reflection on the role of volunteers in a preventative and educational healthcare intervention program for older adults from the South Asian community. Tensions exist when relying on volunteer labour for the implementation of preventative community health care programming and must be explored to ensure program sustainability as well as equity within the health care system.

Exercise intervention implemented by trained volunteers improves health-related quality of life among Japanese community-dwelling older females: an intervention study

[Purpose] This study aimed to evaluate the sustainability and efficacy of exercise intervention, as implemented by professionally trained volunteers, on the health-related quality of life among Japanese community-dwelling older females. [Subjects and Methods] We conducted a non-randomized observational prospective study of a six-month exercise intervention delivered by volunteers or health professionals. Health-related quality of life was scored using the Short Form 36 Health Survey before and after the intervention. Participants were classified into three groups, comprising those with improved health, maintained health, and reduced health. [Results] Among 127 Japanese community-dwelling females aged >65 years, 50 of 62 (80.6%) females involved in the intervention conducted by volunteers, and 55 of 65 (84.6%) females involved in the intervention conducted by health professionals, completed the six-month intervention program. Scoring revealed that interventions by both volunteers and health professionals had a maintaining or improving effect on scores in >70% of participants instead of an expected six-month aging decline. [Conclusion] Exercise intervention by trained volunteers was sustainable and effective for improving the health-related quality of life among Japanese community-dwelling older females. Professionally trained volunteers could benefit communities in helping older persons avoid the need for daily nursing care through promoting health activities.

Apoio social e o cuidado integral à saúde do idoso

Resumo O crescente envelhecimento populacional e as transformações socioculturais do nosso tempo conduzem a novas necessidades, não somente de cuidado, mas também para atender a uma nova perspectiva do conceito de saúde, no qual cuidar da doença se tornou ação limitada. Este estudo trata-se de um ensaio baseado na literatura científica e se propõe a pensar sobre uma pequena parte desta grande questão: o apoio social como parte da atenção integral à saúde do idoso. Para isso, realizou-se uma revisão narrativa da literatura nas bases de dados Pub Med/MedLine, Crochane e Scopus, bem como nas listas de referências dos artigos encontrados. Parte-se da compreensão do papel do apoio social e das redes microssociais na saúde do idoso. A seguir, discutimos formas de avaliar o apoio e a rede social e refletimos sobre o papel do apoio social no Sistema Único de Saúde. Por fim, aborda-se o manejo do apoio social. Como considerações finais, são destacados os principais desafios para que o Apoio Social seja realmente considerado um determinante da saúde das pessoas.

Peer-led diabetes self-management programme for community-dwelling older people in China: study protocol for a quasi-experimental design

AIM

A protocol for a new peer-led self-management programme for community-dwelling older people with diabetes in Shanghai, China.

BACKGROUND

The increasing prevalence of type 2 diabetes poses major public health challenges. Appropriate education programmes could help people with diabetes to achieve self-management and better health outcomes. Providing education programmes to the fast growing number of people with diabetes present a real challenge to Chinese healthcare system, which is strained for personnel and funding shortages. Empirical literature and expert opinions suggest that peer education programmes are promising.

DESIGN

Quasi-experimental.

METHODS

This study is a non-equivalent control group design (protocol approved in January, 2008). A total of 190 people, with 95 participants in each group, will be recruited from two different, but similar, communities. The programme, based on Social Cognitive Theory, will consist of basic diabetes instruction and social support and self-efficacy enhancing group activities. Basic diabetes instruction sessions will be delivered by health professionals, whereas social support and self-efficacy enhancing group activities will be led by peer leaders. Outcome variables include: self-efficacy, social support, self-management behaviours, depressive status, quality of life and healthcare utilization, which will be measured at baseline, 4 and 12 weeks.

DISCUSSION

This theory-based programme tailored to Chinese patients has potential for improving diabetes self-management and subsequent health outcomes. In addition, the delivery mode, through involvement of peer leaders and existing community networks, is especially promising considering healthcare resource shortage in China.

Evaluation of a telephone-based physical activity promotion program for disadvantaged older adults

Background

Lack of adequate physical activity among older adults has been widely documented. Although interventions aimed at increasing physical activity that are based on behavioral strategies and theories have been shown to increase activity levels among older adults, little is known about responses to these interventions in different population segments.

Community Context

The Physical Activity for a Lifetime of Success (PALS) program attempted to translate a telephone-based, motivational support program for physical activity, Active Choices, for use by a low-income, ethnically diverse population of older adults living in southeast Seattle. This article describes the evaluation of PALS at the end of the 5-year program.

Methods

Evaluation data included a data set of participant physical activity assessments; internal study documents; and interviews with key PALS stakeholders, participants, volunteers, and people eligible for PALS who declined to enroll when invited.

Outcome

PALS demonstrated improved physical activity levels among the sedentary older adults who participated in the program, but the PALS model did not appeal widely to a diverse, low-income target population. Extensive recruitment efforts resulted in a low number of participants, and attempts to recruit peer volunteers were largely unsuccessful.

Interpretation

Considering the resources required to engage both participants and volunteers, PALS does not appear to be a sustainable model for delivering support for physical activity to community-dwelling minority and low-income older adults.

Different models to mobilize peer support to improve diabetes self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research

Much of diabetes care needs to be carried out by patients between office visits with their health care providers. Yet, many patients face difficulties carrying out these tasks. In addition, many adults with diabetes cannot count on effective support from their families and friends to help them with their self-management. Peer support programmes are a promising approach to enhance social and emotional support, assist patients in daily management and living with diabetes and promote linkages to clinical care. This background paper provides a brief overview of different approaches to mobilize peer support for diabetes self-management support, discusses evidence to date on the effectiveness of each of these models, highlights logistical and evaluation issues for each model and concludes with a discussion of directions for future research in this area.

Community-based disability prevention programs for elders: predictors of program completion

Strategies to foster elder well-being and reduce long-term care costs include efficacious community disability prevention programs. Program completion remains an important barrier to their effectiveness. We examined the association between provider relationships and client variables, and program completion in senior centers. Our mixed methods design used secondary data for 719 clients and primary data through telephone interviews with 20 nurses, 23 social workers, and 18 site managers. Quantitative data showed that higher client baseline self-efficacy positively influenced completion and minority status negatively influenced completion. Qualitative data showed that higher focus on provider-client relationships was associated with high completion.

Using senior volunteers as peer educators: What is the evidence of effectiveness in falls prevention?

Peer education models are well established as a means of delivering health and social welfare information. Common themes identified in regard to peer education are that information sharing and transfer take place; attempts are made to influence knowledge, attitudes or behaviour; that it occurs between people who share similar characteristics or experiences; and that it relies on influential members of a social group or category. Although it is most often associated with younger age-groups, there is growing evidence of involvement of older people as peer educators. As part of community-based fall prevention interventions, there is considerable scope for contribution by peer mentors. This paper explores the theoretical basis for using senior volunteers as peer educators, discusses advantages and disadvantages of this model of service delivery for health promotion of older people and, specifically, reviews the evidence for effectiveness in relation to fall prevention.

What is the Optimal Duration of Participation in a Community-Based Health Promotion Program for Older Adults?

Optimizing duration of participation in health promotion programs has important implications for program reach and costs. We examined data from 355 participants in EnhanceWellness (EW) to determine whether improvements in disability risk factors (depression, physical inactivity) occurred early or late in the enrollment period. Participants had a mean age of 74 years; 76% were women, and 16% were non-white. The percent depressed declined from enrollment to six months (35% to 28%, p = .001) and from six to 12 months (28% to 22%, p = .03). The percent physically inactive declined over the first six months, without substantial change thereafter (47%, 29%, and 29%). Those remaining inactive at six months had worse self-rated health and more depressive symptoms initially; a subset of those increased their physical activity by 12 months. These data suggest that enrollment could be reduced from 12 to six months without compromising favorable effects of EW participation, although additional benefits may accrue beyond six months.

A five state dissemination of a community-based disability prevention program for older adults

OBJECTIVE

To describe challenges in disseminating the Health Enhancement Program (HEP), a community-based disability prevention program for community dwelling elders, and to examine program effectiveness in geographically dispersed sites.

METHODS

Within-group, pre-test-post-test comparisons of disability risk factors, health and functional status, and hospitalizations for 115 participants completing one year in HEP, and primary care provider awareness and perceptions of the program.

RESULTS

Most (77%) participants were women, with an average age of 73 years and an average of 3.5 chronic conditions. At one-year follow-up, compared with enrollment, fewer participants were depressed (8.8% vs 15.9%), physically inactive (15.8% vs 38.6%), at high nutritional risk (24.3% vs 44.1%), or experiencing restricted activity days (35% vs 48%). Severity scores on most measures also improved significantly. The proportion hospitalized was unchanged from the year prior to HEP, although risk factors predicted an increase in hospitalizations as for the control group in the randomized trial.

CONCLUSIONS

HEP reduced participants' disability risk factors. Sites varied on numbers enrolled and time to implement the program, likely due to differing referral bases, degree of physician awareness of HEP, and site readiness. However, the benefits of HEP participation were comparable with those reported previously.

Development of a complex intervention to test the effectiveness of peer support in type 2 diabetes

Background

Diabetes is a chronic illness which requires the individual to assume responsibility for their own care with the aim of maintaining glucose and blood pressure levels as close to normal as possible. Traditionally self management training for diabetes has been delivered in a didactic setting. In recent times alternatives to the traditional delivery of diabetes care have been investigated, for example, the concept of peer support which emphasises patient rather than professional domination. The aim of this paper is to describe the development of a complex intervention of peer support in type 2 diabetes for a randomised control trial in a primary care setting.

Methods

The Medical Research Council (MRC) framework for the development and evaluation of complex interventions for randomised control trials (RCT) was used as a theoretical guide to designing the intervention.

The first three phases (Preclinical Phase, Phase 1, Phase 2) of this framework were examined in depth. The Preclinical Phase included a review of the literature relating to type 2 diabetes and peer support. In Phase 1 the theoretical background and qualitative data from 4 focus groups were combined to define the main components of the intervention. The preliminary intervention was conducted in Phase 2. This was a pilot study conducted in two general practices and amongst 24 patients and 4 peer supporters. Focus groups and semi structured interviews were conducted to collect additional qualitative data to inform the development of the intervention.

Results

The four components of the intervention were identified from the Preclinical Phase and Phase 1. They are: 1. Peer supporters; 2. Peer supporter training; 3. Retention and support for peer supporters; 4.Peer support meetings. The preliminary intervention was implemented in the Phase 2. Findings from this phase allowed further modeling of the intervention, to produce the definitive intervention.

Conclusion

The MRC framework was instrumental in the development of a robust intervention of peer support of type 2 diabetes in primary care.

Trial registration

Current Controlled Trials ISRCTN42541690

An innovative approach for building health promotion program capacity: a generic volunteer training curriculum

PURPOSE

We examined the feasibility of creating a generic training curriculum for volunteers in health promotion programs for older adults by identifying common core content topics across 10 national programs. We also considered additional material that could augment common core content topics.

DESIGN AND METHODS

We reviewed in detail program manuals and associated materials from 10 national evidence-based or best practice health promotion programs for older adults that use volunteers. In Phase I, we created a spreadsheet matrix to track and tabulate the frequency of inclusion of elements across all 10 programs. We arrayed elements under appropriate topics, and program administrators reviewed and verified the information. In Phase II, we reviewed the matrix for comprehensiveness and added elements to augment the identified core topics. Program administrators again reviewed the matrix to ensure accuracy.

RESULTS

We found 67 elements of core content across 50% or more of the reviewed health promotion programs. We added 17 elements to enhance curriculum comprehensiveness; these included elements that were (a) in less than 50% of the reviewed programs but recommended by research staff, (b) introduced by research staff, or (c) recommended by program administrators.

IMPLICATIONS

Although there are many steps, questions, and issues yet to consider, our findings identify a significant body of general core content that supports the feasibility of creating a generic training curriculum for volunteers as an approach to enhance capacity in evidence-based or best practice health promotion programs.

Relationship between personality traits, job satisfaction, and job involvement among Taiwanese community health volunteers

OBJECTIVE

To understand the relationship between job involvement, job satisfaction, and personality traits among health volunteers in one Taiwan community. It is not easy to retain voluntary workers as part of health programs even though they have been trained. Previous research has shown that in order to increase job involvement, volunteers must effectively fulfill their needs to achieve and obtain job satisfaction.

DESIGN AND SAMPLE

Cross-sectional design. Surveys were mailed to 317 health volunteers at community health centers in I-lan County, northern Taiwan; 213 complete responses (67%) were received.

METHODS

The survey instrument included sociodemographic items and scales measuring locus of control, achievement orientation, job involvement, and job satisfaction.

RESULTS

Most respondents (94.8%) were female and their average age was 49.6 years. In terms of personality traits, most volunteers showed internal control orientation. Explainable variance for the prediction of job involvement from a combination of participation frequency, on-job training, achievement orientation, and job satisfaction was 33.6%.

CONCLUSIONS

The results suggest that there is a need to strengthen cooperative relationships among volunteers by initiating well-planned volunteer training programs and growth groups. These should involve the empowerment concept with the aim of enhancing the volunteers' interpersonal relationships and job satisfaction.

The relationship between personal traits and job satisfaction among Taiwanese community health volunteers

AIM

The purpose of the study was to understand the relationship between job satisfaction and personal traits in health volunteers in one community in Taiwan.

BACKGROUND

Among different kinds of community resources, the human resource is most essential for the process of developing healthy communities and cities. However, it is not easy to keep voluntary workers as part of health programmes even though they have been trained. Previous research has shown that to increase the job satisfaction of such a person, the volunteer needs to improve effectively his/her need to achieve. The need to achieve is an important part of a person's personal traits.

METHODS

A cross-sectional survey design was used to interview 317 health volunteers in various community health centres in I-lan county, northern Taiwan. The research instruments of this study included the 'locus of control orientation scale' for personality measurement, the 'achievement orientation scale' and the 'job satisfaction scale'.

RESULTS

Most of the sample volunteers were female with an average age of 49.55 years; the majority was married and living with their spouses. In terms of the volunteers' personal traits, most of them are internal control orientation. The job satisfaction of the volunteers who took part in this research was extremely high. Significant variables correlating with job satisfaction in this study were gender, educational level, religious preference, participation in training, working to promote community health, the willingness to work, the frequency of participating in job training, and cooperation with other volunteer partners. The explainable variance for the prediction of job satisfaction from a combination of achievement orientation and the frequency of collaboration with other people was 9.1%.

RELEVANCE TO CLINICAL PRACTICE

The results suggest that there is a need to strengthen cooperative relationships among volunteer by initiating well-planned volunteer training programmes and growth groups with the aim of enhancing their interpersonal relationships.

"I help you, and you help me": facilitated telephone peer support among patients with diabetes

PURPOSE

The feasibility and acceptability of using an Interactive Voice Response (IVR)-based platform to facilitate peer support among older adults with diabetes was evaluated.

METHODS

Diabetes patients with poor glycemic control receiving care at a Veterans' Affairs medical center completed a baseline survey, received rudimentary training, and were matched based on their diabetes-related self-management needs. They were asked to contact their partner weekly using the toll-free IVR calling line. At the completion of the 6-week period, participants completed follow-up surveys and brief telephone interviews.

RESULTS

Forty of 76 patients screened for eligibility by telephone agreed to participate, and 38 completed the 6-week intervention (50% of eligible patients). More than 80% of the pairs spoke at least once a week for 2 of the 6 weeks of the intervention. A total of 79% of the participants reported that the IVR system was easy to use, and 90% stated that they would be more satisfied with their health care if this type of peer support service were available. Of the participants, 70% found the calls helpful in managing diabetes symptoms, 73% reported that their partner helped them improve their self-care, and 70% stated that they helped their partner do things to stay healthy. There were significant improvements in participants' reported diabetes self-care self-efficacy between baseline and follow-up assessments (P < .01). Qualitative assessments suggested that participants found meaning and positive reinforcement for their own self-care through supporting their partner's efforts to manage diabetes.

CONCLUSIONS

An IVR peer support intervention is feasible, acceptable to patients, and may have positive effects on patients' diabetes self-management and health outcomes that warrant more rigorous evaluation in a randomized trial.

Understanding the multidimensional nature of health promotion for older adults through the application of a conceptual framework

Over the next three decades, the proportion of Americans over age 65 will grow to exceed 25 percent of the population. Although research has shown that health promotion and disease prevention interventions for older adults can lead to positive health outcomes, our understanding of the effects of health promotion on the health and well-being of older people could be improved through the development and use of a conceptual framework. This article presents a conceptual model for understanding the determinants and consequences of engaging in health promotion activities for older adults, describes how to use the model to estimate the impact of health promotion programs on a variety of individual- and community-level outcomes, and then applies the model to two different health promotion programs for older persons: REACH II and the Senior Wellness Program.

Promoting health and preventing disability in older adults: lessons from intervention studies carried out through an academic-community partnership

This article describes a partnership between an academic center and community-based organizations for the purpose of improving the health of older adults. Three sequential randomized trials of interventions that have been conducted by this partnership, along with an effectiveness study of one of the interventions, are presented as evidence of the partnership's success. Characteristics of an effective partnership are highlighted; these include: (1) a shared vision and a commitment to achieving similar goals; (2) complementary expertise and resources; (3) a willingness to contribute time and effort on projects that are jointly undertaken; (4) regularly scheduled meeting times to review progress and barriers to progress; and (5) time spent getting to know each other on a personal level. The iterative nature of research and programming that is carried out as part of this partnership is described.

Outcomes of a community-based dissemination of the health enhancement program

OBJECTIVES

We previously found in an efficacy trial that a health promotion program prevented functional decline and reduced hospitalizations in community-dwelling older people with chronic conditions. We sought to evaluate the effectiveness of the program in its dissemination phase.

DESIGN

Outcome evaluation using a within-group, pretest-posttest design.

SETTING

Fourteen senior centers located throughout western Washington.

PARTICIPANTS

Three hundred four community-dwelling men and women aged 65 and older.

INTERVENTION

A disability-prevention, chronic disease-self-management program.

MEASUREMENTS

Participant characteristics, risk factors for disability, change in health and functional status, and healthcare use over 1 year of enrollment; participant satisfaction.

RESULTS

Participants were 71% female, had a mean age of 76, and reported three chronic health conditions on average. The percentage of participants found to be depressed decreased (28% at time of enrollment vs 17% at 1-year follow-up, P =.005). The percentage of physically inactive participants decreased (56% vs 38%, P =.001). Physical activity level and exercise readiness improved (Physician-based Assessment and Counseling for Exercise mean score 4.3 vs 5.1, P =.001). At follow-up, 83% rated their health the same as or better than a year ago, compared with 73% at time of enrollment. The proportion with impaired functional status, as measured by bed days and restricted activity days, stayed the same. The proportion hospitalized remained stable (23% at enrollment and follow-up, P = 1.0).

CONCLUSIONS

Under real world conditions, the Health Enhancement Program reaches older people at risk of functional decline. Those enrolled for 1 year experience a reduction in disability risk factors, improvement in health status, no decrements in functional status, and no increase in self-reported healthcare use.

The public health perspective in health promotion and disability prevention for older adults: the role of the Centers for Disease Control and Prevention

As the United States federal public health agency, the role of the Centers for Disease Control and Prevention (CDC) in health promotion and disability prevention with older adults encompasses research, surveillance and program activities in aging. This article characterizes the objectives and context of prevention in later life and summarizes CDCs functions, collaborative partnerships with public health agencies and other organizations, and range of activities in older adult health. As a major focus of these efforts, chronic disease risk reduction is examined through CDC's efforts in the area of physical activity; a longitudinal investigation of osteoarthritis in an older biracial rural population; and chronic illness self-management programs as a prototype for secondary prevention. Other CDC activities highlighted include addressing the burden of vaccine-preventable diseases through CDC-funded programs to improve immunization coverage in older adults, and falls prevention interventions and resources. Future directions in aging at CDC are also outlined.

The psychological well-being of renal peer support volunteers

AIM OF THE STUDY

The purpose of this study was to describe the characteristics of renal peer support volunteers (PSVs) and explore the effects on their psychological well-being from helping others.

BACKGROUND

Dialysis patients, transplant patients and family members who become renal PSVs receive special training in empathy, listening, self-awareness and problem solving. The trained renal PSVs offer a unique service to others struggling to learn to live with renal failure because they have faced the same struggles.

METHODS

This exploratory study utilized a longitudinal design. The first time for data collection was immediately after the volunteers had completed a Kidney Foundation of Canada training programme. Subsequent interviews were at time intervals of 4, 8 and 12 months after the first interview. Information on the psychological well-being of the volunteers was collected at each interview in two different ways: the 38-item Mental Health Inventory (MHI) and open-ended questions.

FINDINGS

Thirty-one PSVs completed all four interviews. The average age of the volunteers was 45 years and almost half had a university level of education. They identified themselves as belonging to 12 different ethno-cultural groups. Analysis of the quantitative data from the MHI indicated that the mental health of the PSVs stayed remarkably stable over time. Analysis of the qualitative data from the open-ended questions revealed four major themes which, taken together, showed notable increases in personal growth and well-being for the PSVs over time.

CONCLUSION

After participating in a training programme, renal PSVs maintained, and possibly improved, their own well-being by helping others with chronic renal failure.

Volunteers' experiences of becoming arthritis self-management lay leaders: "It's almost as if I've stopped aging and started to get younger!"

OBJECTIVE

To determine whether undergoing training to become a lay leader and conducting an arthritis self-management course is associated with improvements in physical and psychological health status, arthritis self-efficacy, use of self-management techniques, and visits to the general practitioner. In addition, we aimed to describe the experiences of training and course delivery from the older volunteers' perspective.

METHODS

21 participants completed all assessments and had a median age of 58, median disease duration of 10 years, and either osteoarthritis (n = 13) or rheumatoid arthritis (n = 8). The study was a pretest-posttest design with qualitative data collected at 3 points in time: before training, 6 weeks after training, and 6 months after training. Quantitative data were collected through self-administered postal questionnaires at baseline and 6-month followup.

RESULT

Six months after training, participants reported small, significant increases in arthritis self-efficacy for pain (P = 0.002), cognitive symptom management (P = 0.004), and communication with their physician (P = 0.024) and a small, significant decrease in depressed mood (P = 0.04). Qualitative data supported these findings, with participants reporting more confidence, happiness, and a changed outlook on life in general. Volunteerism was associated with altruistic behavior and with filling the vocational void caused by retirement.

CONCLUSION

Findings support the value of volunteerism and training to become lay leaders in arthritis self-management programs. Volunteers reported positive changes both in themselves and in course participants. They enjoyed helping similar others and being involved in a worthwhile activity, and they valued their newly acquired status as lay leaders. Many had begun to apply their newfound knowledge about self-management to their own situation, reporting less pain and more willingness "to get on with life."