The proportion of elderly in the United States population is rapidly increasing, with an estimate of 25,000,000 persons 65 years old and over by the year 1985.1 More significant is the dawning realization that this enormous group has a unique and complex set of poorly, or even totally, unidentified needs particular to deteriorating physical status and lifestyle changes. While the ideal is to maintain the individual's independence and sense of self-worth for as long as possible, we are, at present, utterly unequipped to realize this goal for the vast majority of the old. What we are doing now, and will continue to do without a radical change in the service systems available to the elderly, is to resort to some form of institutionalized, custodial care, which inevitably fosters a sense of dependence and subsequent loss of self-esteem. Because most previously active, functioning individuals are unprepared for the alterations coming with retirement, physical decline, loss of friends and loved ones, programs must be developed to help the aging person to learn and reinforce self-health care practices appropriate to meet these life changes. Such educational programs must be capable of addressing those areas of need peculiar to the individual to allow independent living for as long as possible. They must provide a means to identify those areas of need more generally prevalent in the aging community at large in order to establish mutually determined goals for care, to set priorities, and to allow for private and governmental agencies to elaborate existing programs and to develop new ones.
The following assessment instrument was designed to explore some of these broad issues as well as to serve as a practical starting point for the learning of good self-health maintenance practices. An invaluable corollary to the collection and analysis of data gained from the repeated administration of the instrument would be the ability to evaluate the effectiveness of the measures instituted as a result of these educational efforts.
Health Behavior Awareness Test
Interviewer's Introduction: I am going to relate to you a story describing a typical day in the life of an old woman, a Mrs. S, who lives alone. Once you have read it through, read it again, and stop when you recognize that Mrs. S is doing Or not doing something that might keep her from being as healthy and happy as possible. Then refer to Table I, The Health Behavior Awareness Test Rating, and find the type of behavior which is indicated by a rated number, eg, (1).
Mrs. S is a 78-year-old woman who lives alone in a rented apartment in Bridgeport. Her husband died several years ago. Her two sons and their families live in Hartford.
On a typical day in January, Mrs. S gets up at 10:00 A.M. She feels tired because she has not slept well. Even though the room feels cold, she does not put on her slippers because there are a number of little throw rugs throughout the apartment (1).
"I'm really not hungry now," she thinks, "but perhaps I'll feel like eating later" (2). Instead, she fixes a cup of coffee and lights her first cigarette of the day- the first of 35 (3).
"It's time for my medicine," she thinks. Although she has had a heart condition for many years, Mrs. S still docs not know one pill from the other, nor does she remember the careful instructions given her by the visiting nurse, for example, to take her pulse before taking her medicine. (4).
"Today I have a clinic appointment, and then I was going to go grocery shopping. Oh, but it's so cold and the street looks slippery. I don't think I'm going out today (5), and anyway, I have several boxes of macaroni and cheese left" (2). Mrs. S didn't know that she could get a ride if she needed it (6). Her decision to stay at home was not unusual, since Mrs. S often decided to stay at home alone, rather than ask one of several friends in the building to go out with her, to talk, or to share activities (7). "Oh, I'm not going to bother getting dressed (8); I'm not going anywhere. I think I'll watch television." She then begins to watch her favorite programs which go on uninterrupted until 4:00 P.M. In fact, Mrs. S does not even change positions in her chair (9).
After her programs are over, she thinks: "Maybe I'll take a nap now-but, you know, I'd better not because I will not be able to sleep tonight (10). Instead, Mrs. S goes to the window and watches the children coming home from school and wonders what her grandchildren are doing. She then goes into the kitchen and fixes her macaroni supper, watches the news, and goes to bed. Interviewer: That is the end of the story. You have noticed that Mrs. S (interviewer briefly provides feedback on each health item picked up by client). Now, what do you think would have most helped Mrs. S to have had a better day? Is there anything else?
Health education, an integral part of high quality health care, is a process that connects health information and health practices. The desired outcomes for health education are: (a) to maintain the highest possible level of wellness within the constraints of one's physiological status or lifestyle; (b) to help modify lifestyle or behavior when necessary; (c) to increase the array of health-promoting options for the investment of personal resources; and (d) to involve the consumer or client in the constructive and responsible use of the health care system.
Acquisition of such knowledge permits an individual's enunciation of his needs and meaningful participation in his own health maintenance such that the potential for self-care is maximized, the utilization of inflationary and inappropriate resources is minimized, and the perception of healthful actions as consonant with the individual's own values and goals is achieved.
HEALTH BEHAVIOR AWARENESS TEST RATING
But enter now a new perspective on health education-the concept of self-care-which challenges both the economic and philosophic lifelines of professional health care services...
The most obvious distinction between patient education and self-care education is captured clearly in the terms themselves. Patient education assigns a unique social role to the learner-that of a sick person under the care of another. Self-care education, in contrast, does not assume sickness, thereby assigning a generic meaning to care-that is, to look after. And in an autonomous way. Patient education goals are initiated in response to a state of disease; self-care educational goals are generally anticipatory of risk.
These are radically different starting points for formulating educational objectives, methods and measurements of outcomes. ..
Self-care education.. .derives its goal from the learner's perceived needs and preferences, regardless of whether or not they conform to professional perceptions of the learner's needs. It is the learner who determines the desired outcomes in accordance with his decision as to which risk he chooses to avoid (or not avoid); similarly, content is learner determined, learner preferences for educational methods are honored, and evaluation is in terms of criteria proposed by the learner.2
The concepts of self-care practices as discussed by Levin, Kinlein,3 and others,4 build upon principles considered essential in designing learning experiences for adults. The necessary criteria proposed by Gibb5 are as follows:
1. Learning must be problem centered;
2. Learning must be experienced centered;
3. Experience must be meaningful to the learner;
4. The learner must be free to look at the experience;
5. The goals must be set and the search organized by the learner; and
6. The learner must have feedback about progress toward goals.
Common to all of these criteria is participatory involvement on the part of the learner, whereby the learner becomes an active consumer rather than a passive recipient of new data.
Herein lie several basic and vital distinctions between adult and juvenile education:
1. Self-concept. The adult is generally an independent person. He provides for his own sustenance, he is self-directed, and does not require other persons to make decisions for him.
2. Experience. The adult enters the learning experience with a variety of other experiences. He may have attended any number of formal or informal educational institutions, he may have read widely, he may have traveled. The fact that he is older than a child implies that he has had more experiences upon which to draw.
3. Readiness to learn. The adult has a variety of social roles and developmental tasks and these, in part, determine the student's readiness to learn.
4. Time perspective and. orientation to learning. The adult usually plans to utilize his new learning immediately. Thus, his learning tends to be problem centered, whereas the youth's perspective is one of postponed application for later in life, and he tends to be more subject centered.1
Aging adults continue to grow until the moment of death. If we believe that institutionalization can be delayed and old people can continue to grow, to learn, to maintain independence, and optimal levels of functioning, then perhaps health education can be viewed as a primary preventive measure towards those ends.
No one will dispute the desirability of remaining at home for as long as possible, given riSat physical, psychosocial, and environmental circumstances permit the person to do so. However, there are certain prerequisites for independent living during old age which must be available:
1. Physician and/or geriatric nurse practitioner primary care services;
2. Visiting nurse services;
3. Homemaker and home health aid services;
4. Physical, occupational, and speech therapy;
5. Dental care;
6. Feeding programs;
7. Finanical assistance programs;
8. Social services;
9. Nutrition education;
10. Referral services and community resources information;
11. Budgeting and "consumerism" counseling;
12. Transportation services;
13. Family "respite" services;
14. Home safety education;
15. Pre- and post-retirement counseling;
16. Recreational, social, religious, and educational services; and
17. Ambulatory health care.6
Health education, as the process of teaching and learning health-supporting information, especially item numbers 9 through 17, can occur in a variety of settings such as in the home or in adult day-care programs.
Improved self-care practices as products of effective health education are candidates in search of a constituency among old people and those health professionals who assist old people in their care. Moreover, these ideas are consistent with the Standards of Geriatric Nursing Practices,7 specifically:
Standard II: Nursing diagnoses are derived from the identified normal responses of the individual to aging and the data collected about the health status of the older adult.
Standard VII: The older adult and/or significant other(s) participate in the ongoing process of assessment, the setting of new goals, the reordering of priorities, the revision of plans for nursing care, and the initiation new nursing actions.
Thus nurses who care for the elderly are charged with the responsibility of carrying out the mandates proposed by the American Nurses' Association. Moreover, because of the close and continuous nature of the nurse-client relationship, nurses are in a unique position to facilitate learning, to help the client realize changes in the self-health care behavior-goals embodied in the mandates above.
In as much as the essence of the self-health care concept is individually oriented, there is no universal body of theory which becomes appropriate content. Rather, the content to be learned must be derived from the careful identification of needs by the client. Hence the "Health Behavior Awareness Test"-a simple projective technique to determine the client's individual learning needs and to establish priorities among these. It can be seen that the ten areas of health awareness assessed by the test correspond to the prerequisites for independent living which we felt were particularly amenable to successful health education. If the content is indeed learner-determined, it follows then that the learning will be problem-centered, experientially based, and meaningful to the client. The instrument further permits dialogue between the client and interviewer and provides for feedback.
A second and equally inportant function of the test is its ability to allow the establishment of a base of statistically manageable, quantitative data that can be used to identify those areas of need common to the elderly population as a whole. Only then can we begin to plan effectively for the development of services essential to the promotion of good self-health care.
Success in health education-has to be measured in human terms-lives saved, suffering and disability reduced, productivity and creativity enhanced, and something called the quality of life made more rewarding for everyone. That sounds like a tall order to lay at the doorstep of health education. And, certainly it is, but. realistically, how could we be satisfied with Iess.s
It is not correct to assume that the test can accomplish all this, however, we believe that it is a first step in the right direction.
- 1. DuBois EE: Adult education and androgogy: New opportunities for the aging. In Spencer MS. Dorr CJ (eds): Understanding Aging: A Multidisciplinary Approach. New York. Appleton-Century-Crofts, 1975. pp 182-190.
- 2. Levins L.S: Patient education and self-care: How do they differ? Nurs Outlook 26:170-175. 1978.
- S. Kinlein ML: The seif-care concept. Am J Nurs 77:598-601,1977.
- 4. Milo N: A framework for prevention: Changing health-damaging to health-generating life patterns. Am J Pub Health 66:435-439. 1976.
- 5. Gibb JR: Learning theory in adult education. In Knowles MS (ed): Handbook of Adult Education. Chicago, Adult Education Assoc of the USA, 1960, pp 54-64.
- 6. Butler RN. Lewis Ml: Aging and Mental Health, 2nd ed. Saint Louis, C.V. Mosby Co, 1977. pp 217-233.
- 7. Standards of Gerontological Nursing Practice as developed by the Executive Committee of the Division on Gerontological Nursing Practice, American Nurses' Association, Kansas City, Missouri, 1976, pp 5-8.
- 8. Edwards C: Fédéral focus on health education: Conference proceedings. In Preventive Medicine USA. Health Promotion and Consumer Health Education, New York, Prodist, 1976, ρ 22.
HEALTH BEHAVIOR AWARENESS TEST RATING