Health maintenance and promotion activities are important for people of all ages. There is a special need for health education programs aimed at older people. The US population of people 65 years and older now numbers over 26 million . This accounts for slightly more than 11% of the American population and is increasing in both absolute as well as relative terms. For the most part, this population is healthy and active. Still, the likelihood of developing a chronic illness or disabling condition increases with age. Most noninstitutionalized aged have at least one chronic condition and many suffer from multiple conditions. Those most likely to suffer from multiple problems are over age 85 - the fastest growing segment of the elderly population.1,3
Health practices, social network participation and psychological functioning are well documented as key predictors of morbidity, mortality and institutionalization.4'6 The potentially beneficial effects of health education programs for altering health behaviors are beginning to be cited.7'10 Integrating health education and promotion activities into nursing practice should help maximize health and effective functioning in the middle and later years.
Patient education research has established four health education principles which nurses should be aware of in their role as primary providers of health education activities or participants on mul!idisciplinary health education teams:
1) No single educational input, by itself, should be expected to have significant, lasting impact on health behavior unless it is supported by other educational inputs.
2) The best combination of educational methods, media and messages for some patients is not necessarily the best combination for others.
3) The relative emphasis of health education for various behavioral changes should be proportional to their presumed or known association with medical outcomes.
4) Health education influences patient behavior primarily through changes in knowledge, attitudes, values, perceptions and social supports (relatives and significant others), and through changes in professional behavior toward patients including referrals, communication and reinforcement.8'9
Furthermore, summary reports from a series of national patient education demonstration studies have suggested the relative effectiveness of health education strategies which:
1) increase contact time with health care providers permitting more intensive patient counseling and education;
2) increase the number and variety of contacts between patients and health-care providers;
3) encourage active patient participation in health care decisions;
4) involve significant others in health regimens, and
5) include self-monitoring of health conditions and functioning.9'11
While it would be tempting to design educational programs for the elderly based on successful programs in other age categories, this should not be done without modification. For one thing, the goals of health education programs aimed at the young and old are very different. In younger populations, health education is designed to avoid the development of disease and disability. Health promotion efforts for the elderly should be aimed at reducing the dependency imposed by chronic conditions and postponing or preventing further decline in functioning.
In respect to this, elderly individuals - and the older population, in general - have unique problems and concerns. POT example, visual, hearing or cognitive impairments in the very old must be considered in obtaining a behavioral diagnosis of factors influencing desired health behaviors or in planning specific health education interventions for older persons.
In order to design effective strategies for educating the elderly or to judge which strategies will be most effective, it is important that nurses and other health care practitioners have a clear understanding of the dynamic biomedical and psychosocial processes of aging. Much of the effort in gerontological research over the past few decades has been directed towards dispelling myths about the inevitability of age-related declines in health and effective functioning. In diagnosing disease and illness in the elderly, it is important to differentiate what changes are agerelated and occur in everyone and what changes are pathological and represent the development of disease. While it is true that organ functioning, some cognitive abilities and psychomotor skills generally tend to decrease with age, we often fail to realize that there is a great variability in the way people age. In anticipating health needs or planning for health and human services for aging persons, we must not only be aware of general age-related changes, but we should also take into account these important individual and social variabilities.
Accumulated research from the behavioral and social sciences supports three central propositions about aging: 1) aging is a life long process that is determined by complex, interacting biological and psychosocial processes; 2) aging is not fixed for all time, but changes as society changes; and 3) because aging is not immutable, it is subject to some degree of human intervention and control.12
Stereotypes about the inevitability and universality of declines with aging are dangerous on at least two counts. First of all, they may affect how older people view themselves and their capabilities. Secondly, negative stereotypes about aging may also influence the treatment that elderly people receive from their families and health care providers.
In dealing with the elderly, the nurse clinician/educator faces the double challenge of integrating health promotion and maintenance activities into a medical care system traditionally oriented toward acute care needs, and facilitating health promoting behaviors in a population whose needs are typically ignored by the system.13 Older patients with chronic diseases and disabilities need help in understanding and coping with day-to-day health problems and long-term regimens. If the elderly take their aches and pains for granted as a normal sign of aging, they may fail to seek appropriate medical or nursing care. Compounding the problem, health care providers who hold similar stereotypes about aging may be less aggressive in the care of older patients.
A multifaceted and multidisciplinary approach to health education for the elderly is important. A recent review on psychosocial interventions in aging focusing on enrichment and prevention provides support for two popular gerontologicaJ health education research assertions:
1) it is possible to intervene in the lives of the elderly to reverse or alter factors thought to be associated with the aging process, and
2) a psychosocial approach which manipulates behavioral, psychological or environmental factors can be effective.14
Developing a Program
Developing and implementing a successful program of health education requires input from physicians, nurses, dentists, pharmacists and a range of health care providers; social service personnel; behavioral scientists and health educators; and gerontologists. It is essential to understand individual, social and environmental factors that impede or facilitate desired health behaviors essential to the design of programs.
There are a number of important factors impinging on the health and wellbeing of the elderly that should be the primary focus for health maintenance and promotion activities. The Technical Committee on Health Promotion and Maintenance for the White House Conference on Aging has identified physical .exercise, nutrition and appropriate drug use as some of the most important life style behaviors for health promotion and disease prevention among the elderly.
Despite a recent proliferation of health education counseling and education programs encouraging sound nutrition, moderate exercise and safe use of medications, there have been few systematic attempts to develop and evaluate behavioral-educational interventions for the elderly. Such programs can be useful in dealing with disability in old age. In some cases aging is associated with an increase in chronic diseases and disabilities which often necessitates the implementation of complex medical regimens. The nurse clinician/educator should work with elderly patients to help them understand their medical regimens and develop the appropriate skills for long-term compliance.
In recent years hospital- or clinicbased patient education programs have been incorporating concepts of selfcare, informal support and mutual help groups into their patient care programs. Most of these programs recognize that families, friends and mutual help groups can provide the support that will enable the elderly to cope with their health problems and live independently. Many formal support groups are established around self-care behaviors and specific health or social concerns.
The Stanford Arthritis Center sponsors a self-management community health education program for arthritis patients that utilizes lay people for patient education.16 The Widow-toWidow program is one example of a community support group that buffers the deleterious consequences of social losses.17 Many community senior centers are also beginning to address health and social needs of the noninstitutionalized elderly by offering individual and group oriented health education programs, nutritional and health prevention services, and a range of other services. The Growing Younger program in Idaho is just one example of a community group that has a very active wellness program for the elderly.18
The senior citizen should not be the only focus of educational activities. Health professionals working with the elderly must be made aware of factors in the health care delivery system which encourages or impede health promoting behaviors. FOr example, research indicates that provider/patient interaction is a major factor affecting health attitudes and behaviors, difficulties often arise in establishing successful relationships between the health provider and the elderly patient due to characteristics of the provider, the patient and/or the environment.19'20 The nurse educator/ researcher needs to identify barriers to successful provider-patient interactions and to work with members of the health care team as well as patients to make these encounters more gratifying to each parry.
In recent years, the Health Care Financing Administration has given support to an innovative alternative health care delivery system known as the social/health maintenance organization. This model system, conceived at Brandéis University, is designed to provide prepaid social and personal care services in the home as well as in medical settings for both healthy and chronically ill elderly. As such, this program offers a promising solution to two major institutional barriers to health promotion efforts:
1) the lack of reimbursement for preventive and health maintenance costs, and
2) fragmentation of health and social services. The designated demonstration sites will provide an excellent opportunity for testing the health effects of alternative prevention modalities.
Research on Wellness
There ts a growing health education/ behavioral sciences knowledge base for identifying risk factors associated with the development of disease and disability in the elderly. More specific knowledge is needed about the mechanisms for "curing" or "controlling" chronic progression. The Behavioral Sciences Research program at the National Institute on Aging is particularly interested in research designed to specify how psychosocial processes, interacting with biological processes, influence health and effective functioning in the middle and later years.22
Research is being encouraged on such issues as:
1) Maintaining vigorous health, effective functioning, and productivity through the middle years and into old age;
2) Encouraging people to adopt health promoting behaviors after they have reached old age;
3) Restoring functioning and reverse common forms of disability in old age in order to reinstate older people in productive roles, and preventing institutionalization in nursing homes; and
4) Compensating for age-related deficits and impairments.
Of special interest are studies on behavioral geriatrics research.23 These studies extend scientific understanding of how particular health behaviors and attitudes are acquired or changed as people grow older; how they are influenced by social contexts; how they relate to etiology or pathogenesis of particular diseases; how they interact with physiological and psychological aging processes to affect particular health outcomes; and how they influence the need for health care services or institutionalization. The translation of such knowledge into nursing practice and education has important implications for improving patient care and well-being.
- 1. Brody JA, Brock DB: Epidemiologie and statistical characteristics of the U.S. elderly population. Draft 1982. In Finch CE and Schneider EL (eds) Handbook of the Biology of Aging, ed 2. New York, Van Reinhold, (in press).
- 2. Federal Council on the Aging, US Department of Health and Human Services: The Need for Long-term Care: Information and Issues. DHHS Pub No (OHDS) 81-20704. Washington, DC, Government Printing Office, 1981.
- 3. US Department of Commerce, Bureau of the Census: America in Transition: An Aging Society. Current Population Reports, Series P-23, No. 128, Washington, DC, Government Printing Office, 1983.
- 4. Kasl SV, Berkman LF: Some psychosocial influences on the health status of the elderly: the perspective of social epidemiology. In McGaugh JL, Kiesler SB (eds) Aging: Biology and Behavior. New York, Academic Press, 1981.
- 5. Kaplan GA, Camacho-Dickey T, Breslow L: Behavioral, Social, and Psychological Factors in Health: The Alameda County Experience. Paper presented at the 110th annual meeting of the American Public Health Association, Montreal, Canada, 1982.
- 6. Schoenbach VJ: Behavior and lifestyle as determinants of health and well-being in the elderly. In Phillips HT, Gaylord SA (eds): Aging: A Public Health Perspective. New York, Springer Publishing Co, forthcoming.
- 7. Bartlett E: A synthesis of methods. Patient Education Newsletter 1982; 5:17-18.
- Green L, Kreuter M, Deeds S, Partridge P: Health Education Planning: A Diagnostic Approach. Palo Alto, CA, Mayfield Publishing Company, 1980.
- 9. Green LW, Johnson KW: Health education and health promotion. In Mechanic D (ed) Handbook of Health, Health Care, and the Health Professions. New York, Free Press, 1983.
- 10. Lehmann P: Health education. In US Department of Health, Education and Welfare: Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Washington, DC: US Government Printing Office, 1979.
- 11. Garrity TF: A review of preliminary intervention results from the National High Blood Pressure Education Research program. In Haynes RB, et al: Patient Compliance to Prescribed Antihypertensive Medication Regimens: A Report to the National Heart, Lung, and Blood Institute (NIH pub no 81-2101), US Department of Health and Human Services, 1980.
- 12. Riley MW: Age strata in social systems. In Binstock KR, Shanas E (eds) Handbook on Aging and the Social Sciences (rev). New York, Van Nostrand Reinhold, (in press).
- 13. Kane RL, Soloman DH, Beck JC, Keeler EB, Kane RA: Geriatrics in the United Slates. Santa Monica, CA, Rand Corporation, 1981.
- 14. Rodin J, Cashmati C, Desiderato L: Psychosocial Interventions in Aging rwcusing on Enrichment and Prevention. Paper presented to the Academy of Behavioral Medicine Research, Reston, Virginia, 1983.
15. White House Conference on Aging: Repon of Technical Committee on Health Maintenance and Health Promotion. Washington, DC: US Government Printing Office, 1981.
- 16. Lorig K: Use of lay persons as patient educators. Patient Education Newsletter 1982; 5:29-30.
- 17. Hamburg B, Killilea M: Relation of social support, stress, illness, and use of health services. In US Department of Health, Education and Welfare: Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Washington, DC, US Government Printing Office, 1979.
- 18. Kemper DW, Deneen EJ, Giuffre JV: Growing Younger. Pamphlet on a Neighborhood Program Sponsored by the Boise Council on Aging. Boise, Idaho: Healthwise, Inc., 1981.
- 19. Haynes R, Sacken D, Taylor W (eds): Compliance in Health Care. Baltimore, Johns Hopkins University Press, 1979.
- 20. Haug M: Elderly Patients and Their Doctors. New York: Springer Publishing Company, 1981.
- 21. Bluestone J: Preventive Modalities in Three Social/Health Maintenance Organizations. Unpublished Working Paper, Center for Health Policy Analysis and Research, Brandeis University, Waltham, MA, 1982.
- 22. Department of Health and Human Services, National Institute on Aging: Health and effective functioning in the middle and later years. In NIH Guide for Grants and Contracts. Vol. 10, No. 10, September 4, 1981.
- 23. Department of Health and Human Services, National Institute on Aging: Health behaviors and aging: Behavioral geriatrics research. InNIH Guide for Grants and Contracts. VoI 12, No 11, November 11, 1983.