Older People's Preventive Care Utilization

1. Introduction:

The global population aged above 60 years is projected to reach 2.1 billion by 2050. Hong Kong also has a rapid aging population. In 2018, there were around 1.27 million people aged 65 years or above, accounting for 17.9% of the total population in Hong Kong, which was estimated to increase to 2.44 million and 31.9% of the total population by 2038. Age increases with a sharp rise in multimorbidity. In Hong Kong, it was estimated that around 70% of the population aged 60 years or above had at least one chronic disease and 40% had multimorbidity. This will cause substantial burden to the health care systems.

Underutilization of preventive care in older people Encouraging older people's utilization of preventive care is crucial for reducing the pressure of population aging placed on the health care systems and promoting healthy aging. In England, it was estimated that regular health check-up can prevent 390 premature deaths and gain an additional 1,370 people being free of disease per million people before age of 80 years. A meta-analysis estimated that influenza vaccination in older people reduced hospital admission due to influenza or pneumonia by 27% and all-cause mortality by 47%. Adding pneumococcal vaccination to influenza vaccination can additionally prevent pneumonia and death by 15% and 19%, respectively. However, underutilization of preventive care was widespread. For instance, it was reported that only 40% of the Hong Kong older people had regular medical check-ups to screen for chronic diseases. In Hong Kong, free or subsidized influenza vaccination and pneumococcal vaccinations are provided for older people aged 50 years or above and those aged 65 years or above, respectively. However, only 45% of the target age group received seasonal influenza vaccines in 2020/2021 and 46% had received pneumococcal vaccines as of February 2021. In addition, older people were found to be much more hesitant about taking COVID-19 vaccination, with less than 20% of persons aged 60 or older being vaccinated 6 months after the COVID-19 vaccination programme launched in Hong Kong.

Linking to older people's decision-making preference Preventive care utilization involves a decision-making process of identifying available preventive care options, evaluating these options based on available information or by engagement with information seeking and finally choosing the favourable options. This is a cognitively demanding process. However, age increases with decline in cognitive function. Attributing to their declined cognitive function, older people tend to seek less information, favour fewer options and simpler information in decision making, and have poorer decision-making competence. However, older people were suggested to have better emotional and experiential skills which sometimes compensate their declined cognitive function in decision making. Older people's decision making tend to be gain-oriented and they were better at making use of positive information than negative information in decision making. Older people had greater cognitive engagement in decisions that were more emotionally relevant, and better performance in recognizing social norms-related cues in decision making. Older people's better performance in affective decision making may be explained using the Socioemotional Selectivity Theory (SST). According to SST, older people naturally perceive that they have limited time for future and hence they selectively pay more attention to the emotional contents of the decisions, put more effort to decisions that are more emotionally meaningful for them, and value more for optimizing emotional experience and maintaining emotional connectivity with others in decision making. Most existing studies to examine older people's decision making preference focused on the financial domain and few studies linked older people's decision-making preference to preventive care utilization.

Thus, older people should need support to facilitate preventive care utilization. First, due to decline in cognitive function, older people may need support for identifying available preventive care services suitable for their age groups and recognizing personal need for preventive care. The investigators' previous study found that older people generally had insufficient understanding about what preventive care was. For instance, healthy lifestyle was the most frequently mentioned preventive care while other preventive care services were not recognized. Some had misperceptions about preventive care. The investigators' recent qualitative study found that older people misinterpreted pneumococcal vaccination as a curative care rather than preventive care (unpublished data). Inability to distinguish preventive care from curative care shaped a misperception that need for preventive care depended on somatic symptoms. Second, information should be presented in a way of being emotionally relevant for older people, emphasizing the benefits of behaviours rather than prevention of loss, to eventually facilitate the achievement of emotional positivity, stability, and connectivity. However, current advocacy for preventive care in older people remains primarily based on the conventional three-level disease prevention model emphasizing prevention of loss. This may reduce older people's motivation to cognitively engage in understanding and making use of the information for preventive care utilization. Third, preventive care utilization requires older people to be more future-oriented, actively planning and striving for a better future. However, it was found that older people particularly those who were 70 years or above had a more negative view of and feeling helpless about the present-the present fatalistic perspective which impaired their decision making competence. This suggests the importance of promoting a positive future time perspective particularly in those who are 70 years or older for promoting their preventive health behaviours. Review of literature suggested that older people in general had lower self-efficacy in decision making. Meanwhile healthcare professional and family tend to leave the medical decisions to older people themselves to avoid feeling of regret once wrong decision is made, which is a case in Hong Kong regarding older people's COVID-19 vaccination.

Application of Mental Models Approach and Patient Activation Approach for empowering older people Mental Models Approach (MMA): MMA was developed based on communication sciences, cognitive psychology and normative decision theories. It involves three stages: Step 1. Consult current scientific evidence and experts' opinions about what the target audience should know to make a good decision; Step 2. Describe what the target audience currently know and what they want to know about behaviours of interest; and Step 3. Prescribe information to bridge the gaps between what the target audience should know and what they currently know and want to know. For preventive care in older people, the whole procedure can help to design information to support decision for a specific preventive care that is personally relevant, emotionally meaningful and easy to process for older people.

Patient Activation Approach (PAA): PPA aims to empower individuals to take an active role in their health care and become positive about their future. It is suggested that high patient activation was associated with greater adoption of self-management health behaviours and use of health care services. It involves a series of pragmatic strategies developed based positive psychology and self-efficacy theory. Several strategies that are important for patient activation are identified from the literature. The first strategy is gaining knowledge by providing information that is personally relevant and mentally accessible. The second strategy is skill development. Skill development can be achieved by learning from personal experience of success and others' success, which subsequently help to enhance self-efficacy. The subsequent strategy is reinforcing the belief that they can succeed (i.e., reinforcing confidence) by guiding individuals to image a personalized scenario of taking preventive care step by step and encouraging individuals to personally experience the success by taking small steps. These strategies can form an iterative self-reinforcing process to finally activate older people in taking a proactive role in managing their health. 2. Aims and Hypotheses to be Tested:

While the investigators have a final goal of empowering older people's decision making for preventive care utilization, as a seed grant application, they propose to initiate the programme with a focus on empowering older people's decision making for vaccinations that are recommended for them including seasonal influenza vaccination and pneumococcal vaccination. With stringent policies for promoting vaccination rates among older people since Hong Kong was severely attacked by a new resurgence of COVID-19 caused by omicron variant in January 2022, uptake rates of COVID-19 vaccination among people aged 70-79 had reached 80% while that for people aged 80 or above remained at 55% as of 17 March 2022. COVID-19 vaccination may be recommended annually for older people. Since COVID-19 vaccination rate in older people is relatively higher, their experience of successfully taking COVID-19 vaccination could be used for enhancing their feeling of confidence in taking future vaccinations and utilization of other preventive care.

Specifically, the investigators will aim to design an intervention programme based on current evidence on older adults' decision-making preference, MMA and PAA to promote older people's uptake of seasonal influenza vaccination, pneumococcal vaccination, and COVID-19 vaccination (if recommended). The investigators hypothesize that the intervention programme will promote older people's confidence in knowledge and skills regarding vaccination decisions, perceived self-efficacy in self-management of health, positive emotional engagement with vaccination decisions and a positive future time perspective which will subsequently promote their uptake of the three recommended vaccines. 3. Plan of Investigation:

Although the investigators start with a primary focus on empowering older people's vaccination decisions, the interventions, if tested to be effective, set as at least 20% increase in uptake of any one of the three recommended vaccinations for older people in the intervention group compared with the control group with a statistically significant difference (p\<0.05), the project will be proposed to scale up to benefit a bigger sample of older people. The scale-up project will be proposed to encompass a wider scope of preventive care services for older people by adapting the interventions proposed in this application.

(i) Subjects Assuming that the investigators' intervention can increase the uptake of seasonal influenza vaccination or pneumococcal vaccination in the intervention group by 20% (a small effect size) compared with the control group, the investigators will need 100 subjects in each of the two arms to allow for a statistical power of 80% and type I error of 5% to detect such effect size. To allow for 20% dropout rate during the intervention period and outcome assessment, the investigators need to increase the sample size to 120 subjects per arm.

(ii) Methods The investigators will first identify potentially eligible subjects from on-going biweekly/monthly repeated cross-sectional population-based surveys on public psychobehavioural responses to the COVID-19 pandemic and vaccine hesitancy. The project has been run since 2020 and is expected to continue until 2023. Based on previous experience, around 15% of \~1,000 in each survey round were older persons aged 70 years or above. Based on current vaccination uptake statistics in older persons, the invest

• Changes in Patient Activation Measure from baseline to within 1 month after intervention ends [Срок оценки: At baseline and within one month after the end of the intervention (in the 1st follow-up assessment)]
• Changes in Emotional engagement with vaccination decisions measurement from baseline to within 1 month after intervention ends [Срок оценки: At baseline and within one month after the end of the intervention (in the 1st follow-up assessment)]
• Changes in Future time perspective measurement from baseline to within 1 month after intervention ends [Срок оценки: At baseline and within one month after the end of the intervention (in the 1st follow-up assessment)]
• Changes in lifestyle behaviours from baseline to within 1 month and 4 months after intervention ends [Срок оценки: At baseline and within one month (in the 1st follow-up assessment) and four months (2nd outcome assessment)after the end of the intervention]
• Changes in other preventive care utilization from baseline to within 1 month and 4 months after intervention ends [Срок оценки: At baseline and within one month (in the 1st follow-up assessment) four months (2nd outcome assessment) after the end of the intervention]