Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers

Disability and Health Journal xxx (2017) 1e10

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Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers Kendall A. Leser a, *, Phyllis L. Pirie a, Amy K. Ferketich a, Susan M. Havercamp b, Mary Ellen Wewers a a b

The Ohio State University College of Public Health, 1841 Neil Ave., Cunz Hall, Columbus, OH 43210, USA The Nisonger Center at the Ohio State University, 1581 Dodd Drive, Columbus, OH 43210, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 7 July 2016 Received in revised form 18 January 2017 Accepted 21 January 2017

Background: People with developmental disabilities lead more sedentary lifestyles, consume poorer diets, as well as have higher rates of chronic conditions such as diabetes and heart disease when compared to members of the general population. Direct support professionals play a large social role in the lives of their clients with developmental disabilities, and thus have the ability to influence the health behaviors of their clients. Objectives: The overall purpose of this study was to examine the relationship between the dietary and physical activity behaviors of direct support professionals and their clients with developmental disabilities, as well as to assess how direct support professionals facilitate the health behaviors of their clients. Methods: A statewide random sample of direct support professionals (n ¼ 398) completed an online survey about their own dietary/physical activity behaviors and these same health behaviors of their adult clients with developmental disabilities. Pearson/Spearman correlations were used to examine the relationship between the health behaviors of direct support professionals and their clients with developmental disabilities. Results: Small-to-moderate correlations (r or r ¼ 0.127e0.333) between direct support professionals' and clients' behaviors existed for all dietary and physical activity health behaviors except for participation in some sort of moderate-to-vigorous physical activity each week (r ¼ 0.098, p ¼ 0.06). Conclusions: Direct support professionals appear to play a role in the dietary/physical activity behaviors of their clients; however, future research on this topic should also include other key members of the social networks of adults with developmental disabilities such as family members, roommates, and dayhabilitation providers. © 2017 Elsevier Inc. All rights reserved.

Keywords: Health promotion Developmental disability Nutrition Physical activity Direct support professionals

1. Introduction Obesity is one of the biggest public health problems facing the United States, as 34.9% of the general population is considered obese and thus are at risk for heart disease and diabetes, as well as other conditions such as high blood pressure, stroke, and cancer.1,2 Eating a poor diet and being physically inactive are two modifiable lifestyle behaviors that contribute to obesity among all members of society.2 Studies have shown that adults with developmental

* Corresponding author. Miami University, Scripps Gerontology Center, 396 Upham Hall, 100 Bishop Circle, Oxford, OH 45056, USA. E-mail address: [email protected] (K.A. Leser).

disabilities experience similar or slightly higher obesity rates than members of the general population.3e5 The dietary and physical activity behaviors of adults with developmental disabilities have not yet been assessed on a population-level; however, in smaller studies, researchers have consistently noted that the majority of adults with developmental disabilities do not meet the national recommendations for physical activity and dietary intake.6e11 People with developmental disabilities often rely on other people, such as their direct support professional providers, to assist them with making decisions related to their health behaviors. The primary role of direct support professionals is to help people with developmental disabilities live independent, self-directed lives, while assisting them with activities of daily living such as cooking, cleaning, grocery shopping, transportation, grooming and

http://dx.doi.org/10.1016/j.dhjo.2017.01.006 1936-6574/© 2017 Elsevier Inc. All rights reserved.

Please cite this article in press as: Leser KA, et al., Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers, Disability and Health Journal (2017), http://dx.doi.org/10.1016/j.dhjo.2017.01.006

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K.A. Leser et al. / Disability and Health Journal xxx (2017) 1e10

finances.12e14 Direct support professionals make up a large part of the social networks for people with developmental disabilities, and many people with developmental disabilities view their direct support professional providers as role-models and as friends.12,15 The concept of social influence is a large part of Social Cognitive Theory, which posits that one way behavior can be influenced is through members of one's social network. Role-modeling (e.g., observing others perform certain health behaviors), incentive motivation (e.g., using rewards/punishments to modify behavior), and facilitation (e.g., providing tools or resources that make behaviors easier to perform) are key constructs of Social Cognitive Theory which help to explain how social influences can shape behavior.16,17 Research has shown how people, especially peers, influence the health behaviors (e.g., physical activity, dietary, smoking) of members of their social networks; however, the potential influence that direct support professionals have over the health behaviors of their clients with developmental disabilities has yet to be explored.18e21 Because direct support professionals play such a large social role in the lives of their adult clients with developmental disabilities, the overall purpose of this study was to examine the relationship between the dietary and physical activity behaviors of direct support professionals and their clients with developmental disabilities. It was hypothesized, based on what is known about role-modeling health behaviors, that there would be a positive relationship between the dietary and physical activity behaviors of direct support professionals and their clients with developmental disabilities. Two additional exploratory aims of this study were to examine how health promotion strategies (e.g., role-modeling, incentive motivation) used by direct support professionals are related to their client's dietary and physical activity behaviors, and to examine how a client's individual preference for a particular health behavior is associated with a direct support professional's perception of his/her ability to help the client perform healthy behaviors. 2. Methods 2.1. Participants The sampling frame consisted of direct support professionals (n ¼ 5283) who were listed as homemaker personal care aides in Ohio's Department of Developmental Disabilities online provider search database. To be eligible for the survey, direct support professionals had to have: 1) been 18 years or older; 2) worked with at least one adult client with a developmental disability in the state of Ohio 3) worked at least 10 hours a week with the client identified in #2; 4) worked as a direct support professional for the client in #2 for at least three months; 5) not been the parent of the client identified in #2; 6) received payment from either the Individual Options waiver or the Level One waiver (both waivers allow people with developmental disabilities to receive home-based care services from direct support professionals); and 7) worked as an independent provider of services. 2.2. Procedures This study was approved by The Ohio State University's Institutional Review Board. Participants were recruited via e-mail between March 2015 and July 2015 to complete an online survey on SurveyMonkey.com. Survey invitations were sent in three batches during this timeframe and sampled participants received up to three reminder e-mails. Those who started the survey, but who did not finish, received up to three reminder phone calls. A total of 4,682 survey invitations (88.6% of the sampling frame) were sent and interested participants completed a brief screener to determine

eligibility for full participation in the study. Surveys took approximately 25 min to complete and participants were given a $20 electronic gift card to an online mass merchant of their choice as a thank you for their time. Participants were asked if they were willing to be contacted in the future; of those who answered yes, 17% were contacted two-weeks later and asked to complete the survey a second time to establish test-retest reliability of survey items. Test-retest reliability was considered acceptable if r or r was greater than 0.70; however, if test-retest reliability was less than 0.70 then a Kappa coefficient was calculated (only items with fair agreement or higher, k ¼ 0.20 þ according to Landis and Koch (1977) were kept in the analysis).22 2.3. Measures Prior to implementation of the full survey, the questionnaire was pre-tested using cognitive interviews with five direct support professionals. Changes to the survey were made based on these cognitive interviews. The overarching purpose of this survey was to quantify the health behaviors (e.g., smoking, dietary, physical activity) of direct support professionals and their clients with developmental disabilitiesdthis manuscript focuses on dietary and physical activity health behaviors. 2.3.1. Demographic characteristics Age (in years), race (white/African American/other) and gender (male/female) were collected for both direct support professionals and their clients with developmental disabilities. Direct support professionals were asked to answer survey questions about an adult client with a developmental disability; if they provided care to more than one adult client, they were asked to report on the client that they provided the most hours of care to each week. For direct support professionals, educational status (high school or general education development (GED)/some college or associate degree/collegeþ) and marital status (married/never married/unmarried couple/divorced/separated/widowed) were also collected. For clients with developmental disabilities, direct support professionals reported on the type of developmental disability the client had (autism, cerebral palsy, Down syndrome, intellectual disability, two or more disabilities, or other). 2.3.2. Fruit and vegetable consumption This was assessed using two brief survey items that have been shown to have acceptable psychometric properties.23 Participants were asked: “How many servings of vegetables do you/does your client eat each day?” and “How many servings of fruit do you/does your client eat or drink each day?” The number of fruits and vegetables were added together to obtain the total daily servings of fruits and vegetables consumed. Test-retest reliability for daily fruit and vegetable consumption ranged from r ¼ 0.597 (k ¼ 0.672) for direct support professionals to r ¼ 0.729 for clients with developmental disabilities. 2.3.3. Sugar-sweetened beverage consumption Participants were asked: “In a typical week, during the past 30 days, how often did you/did your client drink regular soda pop that contains sugar?” Test-retest reliability was r ¼ 0.779 for direct support professionals and r ¼ 0.918 for clients with developmental disabilities. 2.3.4. Fast-food consumption This was measured by asking participants, “During the past 7 days, how many times did you/did your client eat fast food, including fast food meals eaten at work, at home or at fast-food restaurants, carryout or drive thru?” Responses were: never, once

Please cite this article in press as: Leser KA, et al., Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers, Disability and Health Journal (2017), http://dx.doi.org/10.1016/j.dhjo.2017.01.006

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during the past seven days, twice during the past seven days, three times during the past seven days, four times during the past seven days, five times during the past seven days, six times during the past seven days, seven times during the past seven days, or more than seven times during the past seven days. Test-retest reliability was r ¼ 0.535 (k ¼ 0.260) for direct support professionals and r ¼ 0.714 for clients with developmental disabilities. 2.3.5. Physical activity Participants were asked the following questions separately for vigorous and moderate physical activity: 1) In a typical week do you/does your client participate in vigorous/moderate intensity sports, fitness or recreational activities? (Yes/No) and 2) Thinking about the past 30 days, on average, how many hours per day do you sit and watch TV or videos? (0e5þ hours). Test-retest reliability for physical activity measures ranged from r ¼ 0.290e0.527 (Kappa coefficients ranged from k ¼ 0.385e0.525) for clients with developmental disabilities to r ¼ 0.239e0.469 (Kappa coefficients ranged from k ¼ 0.238e0.430) for direct support professionals. 2.3.6. Health promotion strategies No survey instruments currently exist which assess the health promotion strategies (e.g., role-modeling, incentive motivation, facilitation, etc.) used by direct support professionals to influence the dietary and physical activity behaviors of people with developmental disabilities; therefore for this study, survey items were adapted from survey instruments taken from studies that examined social cognitive constructs and the relationship between parental and child dietary/physical activity behaviors.24e28 The psychometric properties of all instruments used were considered acceptable for each individual scale. Examples of these items are detailed below. 2.3.7. Role-modeling Direct support professionals were asked to report how frequently in the past month they role-modeled healthy dietary behaviors (e.g., eat healthy food in front of client, eat fruits/vegetables in front of client) and unhealthy dietary behaviors (e.g., eat fast food in front of client, drink sugary drinks in front of client). Participants were also asked to report on how often in the past month they role-modeled healthy physical activity behaviors (e.g., client sees direct support professional being physically active, doing something physically active with client) and unhealthy physical activity behaviors (e.g., client sees direct support professional watch TV, use cell phone, use the computer or play video games) in front of their clients. Response options for the preceding questions were “less frequent” (never, seldom, several times a month) and “more frequent” (several times a week, most days, or every day). Test-retest reliability for these items ranged from r ¼ 0.327e0.761; Kappa coefficients ranged from k ¼ 0.213e0.608. 2.3.8. Incentive motivation Participants were asked to report on how frequently they use positive/negative reinforcement with food (e.g., giving/withholding special treats such as sweets/soda/salty snacks) and physical activity (e.g., allowing their client to watch extra TV and withholding TV from client). Response options for the preceding questions were “less frequent” (never, some days, several times a month) or “more frequent” (several times a week, most days, or every day). Testretest reliability for these items ranged from r ¼ 0.277e0.589; Kappa coefficients ranged from k ¼ 0.220e0.551. 2.3.9. Facilitation Direct support professionals were asked several questions about how frequently they facilitate certain dietary and physical activity

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behaviors of their clients. Example questions include: How often do you … 1) give your client soda pop?; 2) set limits on how many sweets, sodas, or salty snacks your client can have?; 3) prepare meals for your client that includes fruits and vegetables?; and 4) transport your client someplace for him/her to be physically active? Response options for the preceding questions were “less frequent” (never, some days, several times a month) and “more frequent” (several times a week, most days, or every day. Test-retest reliability for these items ranged from r ¼ 0.282e0.804; Kappa coefficients for these items ranged from k ¼ 0.201e0.565. 2.3.10. Perceptions of role in health promotion for client Direct support professionals were asked, “How much of a role do you think you have in promoting the health of your client with a developmental disability?” Response options: not much of a role, somewhat of a role, or a very large role. Participants were also asked, “How easy or difficult would it be for you to help your client … 1) be physically active; 2) eat more fruits and vegetables; 3) eat less meals from fast food restaurants; 4) drink less sugary drinks such as soda pop; and 5) watch less TV?” Response options were: very difficult, somewhat difficult, neither difficult or easy, somewhat easy, or very easy. Test-retest reliability for these items ranged from r ¼ 0.352e0.769, Kappa coefficients ranged from k ¼ 0.361e0.483. 2.4. Data analysis Descriptive statistics were used to describe the dietary and physical activity behaviors of direct support professionals and their clients with developmental disabilities. Pearson correlations were used for continuous variables (e.g., sugar-sweetened beverage consumption, fruit/vegetable intake) and Spearman correlations were used for categorical variables (e.g., weekly fast food consumption, daily TV time, participating in physical activity) to assess the relationship between direct support professionals' and clients' health behaviors. For this study, correlation coefficients were interpreted based on the guidelines set forth by Cohen (1988)– small (0.10e0.29), moderate (0.30e0.49) and strong (0.50þ). Spearman correlations were used to examine the relationship between direct support professionals' use of behavior change strategies (role-modeling, incentive motivation and facilitation) and the dietary and physical activity behaviors of their clients with developmental disabilities. A series of five simple logistic regression models were used to predict the odds of perceived difficultly in helping clients perform health behaviors (dependent variable) based on their clients' preference to be healthy (independent variable). All analyses were conducted in SPSS 22.0. 3. Results Survey data were collected from a total of 398 direct support professionals who completed survey information about themselves, as well as their clients with developmental disabilities. The response rate for this study was 9.7% (398/4104). Of the 4682 invitations sent, 168 were undeliverable and 410 did not meet eligibility criteria and thus were not used to calculate the study's response rates. 3.1. Sample characteristics Three hundred and ninety-eight direct support professionals completed the survey and provided health behavior information about themselves, as well as their clients with developmental disabilities. The majority of direct support professionals were white (73%) and female (87%), while 21% identified as African

Please cite this article in press as: Leser KA, et al., Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers, Disability and Health Journal (2017), http://dx.doi.org/10.1016/j.dhjo.2017.01.006

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American and 6% identified their race as “other.” The age of direct support professionals ranged from 19 to 76 with a mean age of 43 ± 12.7. Eighty percent of direct support professionals had some form of academic training above high school and 50% reported being married. Eighty-two percent of direct support professionals reported being unrelated to their client, while 18% were siblings or other non-parental family members. The majority of clients with developmental disabilities in this sample were white (81%), 14% were African American and 5% reported their race as “other.” Just over half (51%) of clients with developmental disabilities in this sample were female. Sixty-percent lived with family members, 23% lived alone, 9% lived with roommates with developmental disabilities, and 9% resided in other environments. The age of clients with developmental disabilities ranged from 18 to 86, with a mean age of 36 ± 14.5. Thirty-five percent of clients with developmental disabilities were reported to have more than two developmental disabilities. Table 1 describes the detailed demographic characteristics of this sample.

3.2. Dietary and physical activity behaviors 3.2.1. Prevalence Table 2 provides an overview of the prevalence of the dietary and physical activity behaviors of direct support professionals and their clients with developmental disabilities. The majority (58.8%) of direct support professionals reported consuming the daily recommended number of fruits/vegetables each day, while less than half (38.9%) of clients with developmental disabilities were reported as consuming the daily recommended number of fruits/ vegetables each day. The majority of direct support professionals (84.1%) and their clients (72.8%) with developmental disabilities reported consuming one or less soda pop per day. Eighty-five percent of direct support professionals and 82.3% of clients with developmental disabilities were reported as consuming fast food at least once a week. The majority (60.4%) of direct support professionals reported watching less than two hours of television each day, while only 32.6% of those with developmental disabilities watched less than two hours of television each day. The majority (79.8%) of direct support professionals reported participating in

Table 1 Demographic characteristics of direct support professionals (DSPs) and clients with developmental disabilities (DD). DSPs (n ¼ 398)

Age, M (SD) 18-24 25-44 45-64 65þ Female Race White African American Other Education High School/General Education Development (GED) Some college/Associates Collegeþ Martial status Married Never married Unmarried Couple Divorced/Separated/Widowed Refused Relationship to client Unrelated Sibling Other (e.g., aunt/uncle, niece) Hours working with client per week, M (SD) 10-19 20-39 40þ Years working with client, M (SD) .25-1 1-5 5þ Disability type Autism only Cerebral Palsy only Down Syndrome only Intellectual Disability only 2 þ disabilities Other Client living status Lives alone Lives with family Lives in home with 1 þ roommates Other

Clients with DD (n ¼ 398)

n

%

n

%

43.0 (13) 30 185 169 14 346

e 7.5 46.5 42.5 3.5 86.9

36.4 (14) 109 171 102 16 196

e 27.4 43.0 25.6 4.0 50.5

292 83 23

73.4 20.9 5.8

324 55 19

81.4 13.8 4.8

78 184 135

19.6 46.2 33.9

199 85 31 79 4

50.0 21.4 7.8 19.8 1.0

328 39 31 31.4 (32) 177 127 94 5.3 (5) 69 172 157

82.4 9.7 7.8 e 44.5 31.9 23.6 e 17.3 43.2 39.4 41 44 36 79 134 48

10.7 11.5 9.4 20.7 35.1 12.7

90 239 35 34

22.6 60.1 8.8 8.5

Please cite this article in press as: Leser KA, et al., Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers, Disability and Health Journal (2017), http://dx.doi.org/10.1016/j.dhjo.2017.01.006

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Table 2 Prevalence of direct support professionals' (DSPs') and clients with developmental disabilities' (DDs') health behaviors. Health behaviors

Prevalence of DSPs' behavior

Dietary characteristics Daily fruit/vegetable intake (servings per day), M (SD) <5 5þ Daily soda pop intake (number of pops per day) M (SD) 1 >1 Don't know/refused Weekly fast food intake (fast food meals per week) None Once Twice Threeþ Don't know/refused Physical activity characteristics Weekly moderate-to-vigorous physical activity participation Yes No Don't know/refused Daily time spent watching TV (minutes per day) 0-120 121-300 301þ Don't know/refused

Prevalence of DDs' behavior

n

%

n

%

5.78(2.68) 164 234 0.37(0.90) 333 63 2

e 41.2 58.8

e 61.1 38.9

84.1 15.9 e

4.44(2.89) 243 155 0.72(1.40) 287 107 4

72.8 27.2 e

60 177 90 71 e

15.1 44.5 22.6 17.8 e

67 110 93 108 20

17.7 29.1 24.6 28.6 e

304 77 17

79.8 20.2 e

130 249 19

34.3 65.7 e

236 138 17 7

60.4 35.3 4.3 e

125 169 89 15

32.6 44.1 23.2 e

some sort of moderate-to-vigorous physical activity each week, while only 34.3% of clients with developmental disabilities were reported as participating in some sort of moderate-to-vigorous physical activity each week. Overall, small-to-moderate correlations (r or r ¼ 0.149e0.333, p < 0.500) were present for all clients'/direct support professionals' health behaviors except for participation in some sort of moderateto-vigorous physical activity each week (r ¼ 0.098, p > 0.05) (Table 3). When the correlations between clients' and direct support professionals' health behaviors were stratified by certain groups (e.g., age, race, gender) the magnitudes of the correlations changed in some instances. Findings suggest that the association between clients' and direct support professionals' daily fruit/ vegetable consumption was stronger for non-white clients (r ¼ 0.496, p < 0.01) compared to white clients (r ¼ 0.299, p < 0.01), for clients whose direct support professionals were family

members (r ¼ 0.496, p < 0.01) compared to those who were unrelated to the clients (r ¼ 0.297, p < 0.01) and for clients whose direct support professionals had worked with them for a longer period of time (r ¼ 0.420, p < 0.01) compared to those who had worked with them for less time (r ¼ 0.251, p < 0.01). The correlation between clients' and direct support professionals' weekly fast food consumption was stronger for clients whose direct support professionals were family members (r ¼ 0.461, p < 0.01) than those who were unrelated to the client (r ¼ 0.177, p < 0.05), as well as for female clients (r ¼ 0.329, p < 0.01) compared to male clients (r ¼ 0.130, p > 0.05). There was also a stronger relationship between direct support professionals' and clients' participation in weekly physical activity for those direct support professionals who were a family member of the client (r ¼ 0.307, p < 0.05) compared to those unrelated to the client (r ¼ 0.050, p > 0.05). In regards to time spent watching TV per day, there was a stronger correlation

Table 3 Correlations between direct support professionals' (DSPs) and clients with developmental disabilities' (DD) health behaviors. Health behaviors

Dietary characteristics Servings of fruits/vegetables per dayb Soda pop per dayb Fast food meals per weekc Physical activity characteristics Participates in weekly physical activityc Time spent watching TV per dayc

Overall correlation

Client age

Client race

Client gender

<33 years

33 þ years White Other Race

Male

0.333**

0.306**

0.370**

0.299** 0.496**

0.149** 0.227**

0.128 0.203**

0.158* 0.248**

0.098

0.125

0.258**

0.299**

Client residence

Client relationship to DSP

Female Family Othera Unrelated

Time DSP worked with client

Family <3.7 years

3.7 þ years

0.358** 0.309** 0.353** 0.308** 0.297**

0.496** 0.251**

0.420**

0.158** 0.058 0.239** 0.177

0.204** 0.123 0.053 0.228** 0.208** 0.130 0.329** 0.273** 0.143 0.177*

0.049 0.033 0.461** 0.027

0.274** 0.280**

0.047

0.086

0.087

0.307* 0.049

0.156*

0.197**

0.263** 0.242

0.153

0.104

0.136

0.037

0.050

0.352** 0.167* 0.261** 0.252** 0.271**

0.224

0.230**

0.292**

*p < 0.05; **p < 0.01. a ¼lives alone/with roommate(s)/foster home/etc.. b ¼Pearson Correlation. c ¼Spearman Correlation.

Please cite this article in press as: Leser KA, et al., Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers, Disability and Health Journal (2017), http://dx.doi.org/10.1016/j.dhjo.2017.01.006

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K.A. Leser et al. / Disability and Health Journal xxx (2017) 1e10

between direct support professionals' and clients' behavior for male clients (r ¼ 0.352, p < 0.01) compared to female clients (r ¼ 0.167, p < 0.05). Table 3 provides overall correlations for each behavior, as well as correlations between direct support professionals' and clients' dietary/physical activity behaviors grouped by client age, client race, client gender, client's place of residence, client's relationship to the direct support professional, and the length of time the direct support professional worked with the client. 3.2.2. Health promotion strategies used by direct support professionals A series of health promotion strategies (e.g., role-modeling, incentive motivation) used by direct support professionals were assessed in relationship to their client's specific dietary behaviors (sugar sweetened beverage intake, daily fruit and vegetable consumption, weekly fast food consumption) and physical activity behaviors (participating in some type of weekly physical activity or not, daily time spent watching TV) using Spearman correlations. Some small, yet significant associations (r ¼ 0.105e0.517) were found between direct support professionals' use of health promotion strategies and their clients' dietary (Table 4) and physical activity behaviors (Table 5). 3.2.3. Perceptions of ability to promote clients' dietary/physical activity behaviors The majority (57%) of the direct support professionals in this study perceived themselves as having a large role in promoting the health of their clients, while 35% perceived themselves as having somewhat of a role and 7% did not believe they had much of a role in promoting the health of their clients. Direct support professional participants reported that it would be somewhat or very easy to help their clients perform healthier dietary behaviors such as eating more fruits/vegetables (62.1%), eating less meals from fast food restaurants (58.5%), and drinking less sugary drinks (57.3%). In regards to physical activity behaviors, direct support professionals were more divided in their perceptions of how easy or difficult it would be to help their clients be more physically active (40.6% very/ somewhat difficult vs. 43% very/somewhat easy) or watch less TV (44.2% very/somewhat difficult vs. 39.8% very/somewhat easy) (Table 5). Direct support professionals' perceptions of how difficult it would be to help their clients perform healthy dietary and physical activity behaviors was consistently predicted by their client's preference to eat healthy or be physically active (Table 6). 4. Discussion This is the first study to characterize the dietary and physical activity behaviors of direct support professionals and examine the relationship between direct support professionals' health behaviors and the health behaviors of their clients with developmental disabilities. Aside from consuming fast food on a weekly basis, the majority of direct support professionals in this study reported participating in healthy dietary and physical activity behaviors, which is somewhat surprising and unlikely, given that the estimates reported in this study were higher than what would be expected in the general population.2 In general, the demographic profile of direct support professionals who participated in this study was similar to the general workforce of direct support professionals. In this study, 50% were white (48% general profession) and 86.9% were female (90% general profession); however, participants in the current study may have been slightly more educated than those in previous studies (19% high school diploma/GED current study; 33% high school diploma/GED general profession).29,30 In this study, the majority of adults with developmental

disabilities were reported as consuming less than five fruits/vegetables each day, eating fast food on a weekly basis, and not participating in weekly physical activity. These findings are consistent with previous work in this area on the topic of diet and physical activity for people with developmental disabilities.6e10 Overall, there were small-to-moderate correlations between all dietary and physical activity behaviors (except for participation in weekly physical activity) of direct support professionals and their clients with developmental disabilities. When the association between clients' and direct support professionals' health behaviors were examined and stratified by group (e.g., age, race, gender) the magnitudes of the correlations changed for many health behaviors; which suggests that factors (other than direct role-modeling) may influence the relationship between direct support professionals' and clients' health behaviors and should be explored in future work. Even though some significant correlations existed between direct support professionals' use of role-modeling, incentive motivation, and other facilitators of behavior change it is somewhat surprising that the correlations were not stronger given that previous research suggests that these health promotion strategies play a large role in influencing one's health behaviors.18e20 Because some correlations between clients' and direct support professionals' health behaviors and use of health promotion strategies were small, it is likely that there are other social influences (e.g., family members, roommates, other direct support professional providers) impacting a client's dietary and physical activity behaviors that should be explored in future research. 4.1. Limitations This study has several limitations that should be noted. Even though this is one of the first studies to use random sampling to study the population of direct support professionals, the response rate for this study was low at 9.7%; however, response rates for online surveys are generally low.31 A number of participants (n ¼ 139) completed the eligibility screener and qualified for the survey but did not complete the survey, with the majority stopping after the consent form; several attempts were made to contact these participants but to no avail. In addition, the sampling frame for this study contained the names of all direct support professionals who provided care to both children and adults with developmental disabilities in the state; therefore, it is possible that the direct support professionals who provided care to children with developmental disabilities did not even attempt to complete the survey (and remained in the denominator when calculating response rates). Future work in this area should consider methods such as respondent driven sampling to recruit direct support professionals; this method allows researchers to collect data from hard-to-reach populations by using a method similar to snowball sampling while being able to track the number of people who are invited to participate in the survey.32 Another potential limitation of this study is non-response bias (due to item non-response), as several direct support professionals refused to answer questions about the dietary and physical activity behaviors of their clients with developmental disabilities, as well as refused to answer questions about role-modeling, use of incentive motivation, and other facilitators of their clients' health behaviors. One possible explanation for why direct support professionals may have refused to answer particular questions about their use of health promotion strategies was concern about disclosing information that could be perceived as violating the rights of their clients, which was a major concern expressed in recent focus group research with direct support professionals.33 Even though participants completed the survey online and in privacy, which is thought to reduce the effects of social desirability, social desirability may have also been a

Please cite this article in press as: Leser KA, et al., Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers, Disability and Health Journal (2017), http://dx.doi.org/10.1016/j.dhjo.2017.01.006

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7

Table 4 Direct support professionals' (DSP) use of behavior change strategies and dietary behaviors of clients with developmental disabilities (DD). Behavior change strategy used by DSP

Role-modeling Drink sugary drinks in front of client n ¼ 387 More frequent Less frequent Eat healthy foods in front of client n ¼ 375 More frequent Less frequent Show enthusiasm towards eating healthy n ¼ 371 More frequent Less frequent Eat fruits/vegetables in front of client n ¼ 371 More frequent Less frequent Eat fast food meals in front of client n ¼ 370 More frequent Less frequent Eat sweets or salty snacks in front of client n ¼ 382 More frequent Less frequent Incentive motivation Praise client for eating fruits/vegetables n ¼ 356 More frequent Less frequent Reward client with snack food n ¼ 367 More frequent Less frequent Withhold snack food from client n ¼ 358 More frequent Less frequent Facilitation Supportive behaviors Give client fruit n ¼ 361 More frequent Less frequent Give client vegetables n ¼ 363 More frequent Less frequent Prepare meals with fruits/vegetables n ¼ 359 More frequent Less frequent Set limits on client's snack food n ¼ 353 More frequent Less frequent Sit with client during meals n ¼ 385 More frequent Less frequent Unsupportive behaviors Give client treats n ¼ 367 More frequent Less frequent Take client to get fast food n ¼ 368 More frequent Less frequent Give client soda pop n ¼ 378 More frequent Less frequent Encourages client involvement Help client make a healthy snack n ¼ 352 More frequent Less frequent Help client prepare meal with fruits/ vegetables n ¼ 344 More frequent Less frequent Allow client to eat snacks whenever n ¼ 357 More frequent

DSP Performance of Behavior

Correlation to Client Dietary Health Behaviors

n

%

Daily sugar sweete-ned bevera-ge Intake

27 360

7.0 93.0

272 103

72.5 27.5

Daily fruit/vegeta-ble Intake

Weekly fast food intake

0.151*

0.065

0.108* 308 63

83.0 17.0

275 96

74.1 25.9

27 343

7.3 92.7

0.107*

355 27

0.187*

0.348**

0.054

0.013

92.9 7.1 0.149**

233 123

65.4 34.6

39 328

10.6 89.4

13 345

3.6 96.4

271 90

75.1 24.9

264 99

72.7 27.3

258 101

71.9 28.1

141 212

39.9 60.1

305 80

79.2 20.8

69 298

18.8 82.2

47 321

12.8 87.2

49 329

13.0 87.0

202 150

57.4 42.6

0.101

0.113*

0.130*

0.174**

0.322**

0.376**

0.315**

0.061

0.193**

0.061

0.188*

0.061

0.025

0.045

0.235**

0.517**

0.347**

0.226**

0.214**

0.229** 202 142

58.7 41.3

145

40.6

0.188*

0.018

0.101 (continued on next page)

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K.A. Leser et al. / Disability and Health Journal xxx (2017) 1e10

Table 4 (continued ) Behavior change strategy used by DSP

Less frequent Allow client to help prepare meal n ¼ 336 More frequent Less frequent Help client set goals to improve eating habits n ¼ 353 More frequent Less frequent Take client to the grocery store n ¼ 365 More frequent Less frequent

DSP Performance of Behavior

Correlation to Client Dietary Health Behaviors

n

%

Daily sugar sweete-ned bevera-ge Intake

Daily fruit/vegeta-ble Intake

Weekly fast food intake

212

59.4 0.045

0.032

0.000

207 129

61.6 38.4 0.079

0.185**

0.024

207 146

58.6 41.4

117 248

32.1 67.9

0.179**

*p < 0.05; **p < 0.01, all correlations presented above are Spearman correlations. Table 5 Direct support professionals (DSP's) use of behavior change strategies and physical activity behaviors of clients with developmental disabilities. Behavior change strategy used by DSP

Role-modeling Watch TV, use other electronics in front of client ¼ 374 More frequent Less frequent Do something physically active with client n ¼ 373 More frequent Less frequent Incentive motivation Praise client for being physically active n ¼ 365 More frequent Less frequent Reward client with TV and other electronics n ¼ 348 More frequent Less frequent Withhold TV, videos, computers, video games n ¼ 359 More frequent Less frequent Facilitation Transport client someplace to be physically active n ¼ 357 More frequent Less frequent

DSP performance of behavior

Correlation to client physical activity health behaviors

n

%

Participates in weekly physical activity

Daily hours spent watching TV

0.107*

0.027

56 318

15.0 85.0 0.205**

0.099

124 249

33.3 66.8 0.176**

0.089

266 99

72.9 27.1 0.044

0.107

74 274

21.3 78.7 0.130*

0.049

8 351

2.2 97.8 0.224**

0.039

175 182

49.0 51.0

*p < 0.05; **p < 0.01, all correlations presented above are Spearman correlations. Table 6 Client preference for physical activity/healthy diet associated with direct support professional's perceived difficulty of helping client perform healthy behaviors. Health behavior

Physical activitya Be physically active n ¼ 379 Very/somewhat difficult/Neither Difficult Somewhat/Vewry easy Watch less TV n ¼ 361 Very/somewhat difficult/Neither Difficult Somewhat/Very easy Dietaryb Eat more fruits and vegetables n ¼ 384 Very/somewhat difficult/Neither Difficult Somewhat/Very easy Eat less fast food meals n ¼ 359 Very/somewhat difficult/Neither Difficult Somewhat/Very easy Drink less sugary drinks n ¼ 342 Very/somewhat difficult/Neither Difficult Somewhat/Very easy

N (%)

Client preference OR

95% CI

nor Easy

216 (57) 163 (43.0)

2.74 e

1.77e4.25

nor Easy

217 (60.1) 144 (39.9)

2.22 e

1.41e3.49

nor Easy

145 (37.8) 239 (62.2)

3.91 e

2.47e6.21

nor Easy

149 (41.5) 210 (58.5)

2.34 e

1.48e3.71

nor Easy

146 (42.7) 196 (57.3)

3.34 e

2.06e5.40

*Simple logistic regression model: Very/somewhat difficult/neither difficult nor easy coded as 1; Very/somewhat easy coded as 0; all p-values ¼ 0.00. a independent variable: client does not want to be physically active (Yes ¼ 1, No ¼ 0). b Independent variable: client does not want to eat healthy food (Yes ¼ 1, No ¼ 0).

Please cite this article in press as: Leser KA, et al., Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers, Disability and Health Journal (2017), http://dx.doi.org/10.1016/j.dhjo.2017.01.006

K.A. Leser et al. / Disability and Health Journal xxx (2017) 1e10

potential limitation of the study. Direct support professionals reported higher than expected levels of socially desirable behaviors (e.g., fruits/vegetables, physical activity) and lowers levels of undesirable behaviors (e.g., sugar sweetened beverage consumption, TV viewing). While many survey items had acceptable test-retest reliability, several surveys items had less than ideal test-retest reliability, which is a notable limitation to the study. However, for items with questionable reliability, only those with greater than “fair” Kappa values (k ¼ 0.20þ) were included in this manuscript.22 Possible explanations for low test-retest reliability scores on some survey items include participants reacting to the first set of survey items by changing their dietary/physical activity behaviors or by purposefully changing their responses to survey items the second time they completed the survey.34 In addition, the use of direct support professionals as proxy reporters for their clients' health behaviors may be perceived as a possible limitation of the studydas family members and people with developmental disabilities themselves may be thought to provide more accurate information. However, the use of direct support professionals as proxy reporters has been used in surveys such as the National Core Indictors survey which examines the health and well-being of adults with developmental disabilities; therefore, we felt it was appropriate to allow direct support professionals to serve as proxy reporters in this study.

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5. Conclusion This study adds to the literature in a number of ways including: 1) characterizing the health behaviors of direct support professionals and their clients with developmental disabilities; 2) describing the association between direct support professionals' health behaviors and the health behaviors of their clients with developmental disabilities; and 3) examining how health promotion strategies are used by direct support professionals to influence their clients' health behaviors. A large portion of direct support professionals in this study considered themselves as having a role in the health promotion efforts of their clients with developmental disabilities; therefore, disability service organizations and families/ guardians of clients with developmental disabilities should work together to include direct support professionals in the client's programming/services related to health promotion. Future research on the topic of dietary and physical activity behaviors among adults with developmental disabilities should not only address direct support professionals, but also other key members of the social networks of adults with developmental disabilities such as family members, roommates, and day-habilitation providers. Examining how social influences impact the health behaviors of adults with developmental disabilities is a new concept in the field of developmental disabilities and merits continued study given that adults with developmental disabilities often depend on the assistance of others. Disclosures

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