Self-care and health promotion are often seen today as a panacea with the potential of bringing "health to all." Self-care is thought to be the solution to the inadequacies of medical care. It is thought to be an economic remedy in a world of rising costs of health care which more and more countries have difficulty to meet. Self-care is also perceived to be a political remedy to the inequities in health resources distribution. And in addition, self-care is professed to become the social remedy redistributing power from the all powerful medical profession to the people.
This article focuses on self-care and the elderly, and in particular upon the crucial issue we as nurses must weigh critically: the issue of the potential and effectiveness of selfcare for the elderly. What kind of selfcare, to which population, with which health/disease conditions and under which circumstances is effective in bringing about better health and well-being for the elderly? Part of this topic focuses on how and when self-care gives the elderly and their families more freedom of action to achieve better health.
No doubt the issues of the "medical priesthood" and iatrogenesis1·2 as well as the economic, political, and social issues are of major importance. They warrant not only intense scientific attention, but there is also merit to the polemic aspects of discussions on responsibility for health and the many consequences of the various attitudes. Nevertheless, our immediate objective in nursing can be defined as shedding light on the effectiveness (the potential and limits) of self-care in providing health and freedom of action toward well-being among the elderly.
In this article we will discuss selfcare as a concept relating to individual versus wide scale community action. Then it presents a two-dimensional typology of self-care suggested by Fleming, Sellers, and Andersen3 relating the health condition to the kind of social interaction (eg, family, group) involved. As a third step, the article suggests alterations to this typology. A few factors characteristic of aging which have an impact upon the health condition are discussed as well as the need for social interaction, and the potential for receiving answers to health needs through social interaction. Finally, examples are used to demonstrate the specific potentials and limits of self-care for the elderly within this new typology.
To define health care behavior as selfcare, several basic conditions must be fulfilled. The "self" must initiate:
1 . The definition of a health care need;
2. The planning for action;
3. The decisions as to which steps to take;
4. The actual health related activity; and the "self" must retain:
5. The responsibility or accountability for the action.
This "self can be an individual acting on his/her own behalf, or it can be a family member or friend acting on another's behalf. It can also be a group or community identifying their own needs for health care, planning how to meet these needs, meeting them or having them met, and remaining responsible and accountable for their own health. These self-care activities can answer needs along the entire health continuum: prevention, acute care, care for chronic conditions, maintenance, and terminal care.
Self-care can be entirely centered within the competencies of the layperson, but it may also include approaching professionals for advice, teaching or intervention, as well as carrying out activities which health professionals prescribed.
Individual Versus Wide Scale Community Responsibility
While self-care focuses mainly upon the action of the individual and family, improved health for the elderly (as for other population groups) depends to a large degree upon social and environmental factors. The World Health Organization's primary health care strategy makes a concerted effort to address such vital topics as income maintenance (an issue of utmost importance to the health of the aged in developed and developing countries), adequate housing, clean water, sewage, clean air, adequate nutrition, and continued work and leisure activities.
It is vital to expand the self-care concept from the traditional focus upon individual, family, and small group action to widescale community action.4
One example of extensive community based self-care by and for the elderly can be found in the Israeli kibbutz. Kibbutzim are rural communes, where life is based on social egalitarianism and mutual responsibility. The governing principle is the rule "to each according to his/her needs, and from each according to his/ her ability." Many kibbutzim were founded by cohorts of young people some 50 years ago and now face an unprecedented rate of demographic aging with 30% to 40% of their members over age 65.
These communities have learned to define their needs for health care related to aging: they are active in health promotion and are planning sheltered housing and work settings specifically developed for disabled or frail elderly members (there is no institutionalized retirement and every kibbutznik has "a right" to work). They are planning and building rehabilitation and health-care centers as an integral part of the village.
In member committees and the general assembly, the community decides whether to consider outside institutional care as a viable alternative for impaired members, or whether the kibbutz commits itself to provide actual 24 hour care if needed. Most kibbutzim are successful and innovative in planning work, housing, and transportation. For example, one kibbutz industry developed a motorized tricycle which parkinsonians or stroke patients use with ease to get around in the community. However, they find it much more difficult to decide upon such questions as whether actual responsibility for personal care of bedridden aged should remain with the family or the community.
Self-Care: The Relevant Dimensions for Study
After reviewing the wide range of literature addressing self-care, Fleming, Sellers, and Andersen3 suggested a two-dimensional typology of self-care. The one dimension deals with the health condition:
1 . No diagnosable illness present;
2. Presence of a short-term, self-limiting, acute condition, and
3. Presence of a long-term, uncurable or chronic condition.
The other dimension deals with the interactional nature of the self-care activity:
1. The "primary group" which deals principally with activities that take FIGURE 1
THEORETICAL CELLS OF SELF-CARE*
place among people who share an affectionate bond as family or friends;
2. The secondary group without expert involvement in which people participate as equals in an activity to benefit them all in similar fashion with the express purpose of selfimprovement, such as an exercise group; and
3. The secondary group with expert involvement, where expertise is essential for the self-care activity to continue, such as a stress reduction group for hypertension control under leadership of health professional.3
To fit the conditions of the aging population, this typology must be altered and a new typology should include the bedridden on the dimension of the health condition. The interactional-type dimension is altered, to focus upon self, family, expert involvement, and community action.
In Figure I, there are examples in each of the sixteen theoretical cells describing self-care activities. These may help in forming specific questions addressed to evaluating effectiveness of self-care.
The elderly and their families and friends engage in all of these self-care activities and more. Communities are becoming more aware of the need for action for health promotion. There is a tremendous potential for more and better self-care in a majority of the healthy aged on a preventive level. Much can be done to encourage self-care during acute illness episodes and also with chronic conditions. Since the independent aged constitute the bulk of the aging population, effective self-care has the potential to make a major impact upon the health of the elderly. Nevertheless when asked to evaluate the potential effectiveness of the entire range of self-care behaviors, some basic facts must be considered related to demographic aging to grasp the resultant special needs of the aged and their families.
Demographic Aging's Impact on Health Care Needs
Both developing and developed countries are witnessing a steep increase in the number of aged. By the year 2000 the world's elderly population is expected to rise to 585 million, with twice as many people aged 80 years and over as there were in 1970. Worldwide morbidity patterns point toward chronic disease and accompanying disability. These facts have a huge social impact as described by Bernard Isaacs, one of the pioneers in gerontological research and services to the aged:
SELF-CARE AND HIGH MENTAL FUNCTIONING
What we are witnessing in the 'developed' societies of today (and the 'developing' societies in the very near future) is something that has never existed before on die present scale in human history: it is die Survival of die Unfittest. The advances made in mis century by medicine and the social services have combined to reverse a biological law. It is now normal for life to close, as it began, with a period of prolonged dependency; but whereas we have for long organized our society to care for the helpless infant and the developing child, we are only beginning to seek means of dealing with die problems created by dependency in old age . . .(Old people are desperate for help), not because families neglect (mem), not because mere (is) a shortage of beds or residential homes, but because the full implication of the biological change that has been taking place in mese last two or diree decades has yet to be grasped.5
Not only are the numbers of severely impaired elderly increasing, but at the same time this population has fewer and fewer interpersonal resources. Family caregivers are overburdened and often aged and sick themselves.6'7·8 Because of illness and disability, there is an increased need for interpersonal support, both practical and emotional, at die same time as die possible sources of diese supports are dwindling.
Increasing numbers of aged are in need of care described in die lower right quadrant of die typology: chronically ill or bedridden elderly whose only available interpersonal support is die professional or "self-care" in die form of well planned community action.
This does not mean that we should not study the preventive aspects of selfcare, as well as the effectiveness of selfcare behaviors along the health continuum. Quite to the contrary, they are of utmost importance. But we must be careful not to let a fascinating concept as self-care with its promise for economic savings and political and social equality blind us to when such promises are realistic and when such promises might result in self-neglect, rather than in self-care.
Severely chronically ill and dependent aged will continue to need a wide range of professional care, as will their primary caregivers. This only emphasizes the need for effective health education and self-care if health priorities of the majority of independent aged are not to be jeopardized by the overwhelming needs of the very impaired.
Let us use higher mental functioning as an example for understanding our new typology and the implications for necessary action. In Figure 2, examples of self-care behaviors in this important area are given.
The potential and limits of self-care are highlighted in this example of higher mental functioning. This health condition spans the range from potential full health and well-being to diseases which "rot the mind." At the healthy end of the continuum, health education and promotion can prevent significant disability by:
1. Encouraging old people to remain involved and active and by raising their awareness as to how physical well-being influences their mental functioning;
2. Teaching families the importance of including aged members in continued family responsibility, decision making, and activities;
3. Fighting stereotypes of "senility" and encouraging community responsibility for providing economic and social conditions which enable optimal mental functioning.
While the potential for self-care is severely impaired in the confused person, people can learn to prepare for such states and bolster against their impact. Old persons who suffer from confusional states due, for example, to heart disease, diabetes, or seizures, can arrange with a friend or a neighbor to check on them. They can leave a key so help can reach them, and can obtain appliances which minimize danger, such as an electric kettle which stops automatically when water boils. They can learn to accept confusional states as a limited illness episode and take charge of their lives again as soon as consciousness clears.
When families and .the immediate community learn and accept that confusional states are merely warning signals that something went wrong with an old person, far from being a sentence of "senility" - there is a wide range of activities to ameliorate the situation. Approaching "experts" for diagnosis and treatment is just one of these actions. Chronic brain syndromes become increasingly common with rising age. But even in the presence of this incapacitating condition, continued social, physical, and even mental activities can conserve whatever potential there is left. Families and communities face a tremendous challenge in learning all that is necessary to keep old people with considerable mental impairment in their home environment.
In advanced Alzheimer's disease or multi infarct dementia, the ability of the old person for self-care or even self decision is eroded. Years earlier, awareness of such a possible fate could lead people to leave penultimate wills9 in which they determine how, where, and by whom they would like to be cared for. Family self-help groups have been successful in supporting families facing these catastrophic illnesses. Caregivers learn self-care and are able to activate social and professional resources to provide necessary services.
This example demonstrates both the huge potential of self-care, as well as the limits of self-care in the traditional individual or family oriented mode. Not only are cognitively impaired people severely hindered in their self-care ability, but so are the family caregivers. The actual demands for care, the unpredictability of the experience, the lack of clear, available information, and the overwhelming emotional impact of watching a close human being decline into "senility" raise family members' anxieties to a level which precludes effective self-care. Community based planning and action is needed to provide care for both affected old people and their caregiver.
Self-care implies a demand for independence and self-reliance. While these concepts seem very attractive to those of us raised in Western cultures, we might cause ourselves and others less frustration if we acknowledge the basic human need for dependence and interdependence. In her recently completed dissertation on the construction of a tool measuring "Amae" - the Japanese concept for this vital human need, Minami quotes Takahashi as describing what a person seeks from others as five modes of dependence:
1. Seeking physical proximity;
2. Seeking attention;
3. Seeking help;
4. Seeking assurance; and
5. Seeking psychic support.10
The potential effectiveness of selfcare leading to improved health and well-being for the elderly, depends upon our ability to acknowledge and incorporate "Amae" within self-care.
- 1 . Silver GA: The 'care' in self-care, in NCHSR Research Proceedings Series. Consumer Self-care in Health. US Dept of Health, Education, and Welfare Publication No. (HRA) 77-3181, 1977.
- 2. niich I: Limits to Medicine. London, Penguin, 1977.
- 3. Renting GV, Sellers C, Andersen R: Selfcare - what are the relevant dimensions for study? Unpublished manuscript. University of Chicago, 1982.
- 4. Lancet: Self-care - self blame. Lancet 1981; 11(8251), 846-847.
- 5. Isaacs B, Livingstone M, Neville I: Survival of the Unfittest. London, Routledge and Kegan Paul, 1972.
- 6. Archbold PG: An analysis of parentcaring by women. Home Health Services Quarterly 1982; 3(2):5-25.
- 7. National Council for the Single Woman and her Dependents: The impact of caring on the single woman with elderly dependents. Unpublished manuscript, London, 1978. National Council for the Single Woman and her Dependents: The loving trap. Unpublished manuscript, London, 1979.
- 8. Klusmann D, Bruder J, Lauter H, Luders I: Beziehungen zwischen Patienten und ihren Familienangehörigen bei chronischen Erkrankungen des höheren Lebensalters. Bericht an die Deutsche Forschungsgemeinschaft. Hamburg, 1981.
- 9. Libow LS: The interface of clinical and ethical decisions in the care of the elderly. Mt Sinai J Med. 1 98 1 , 48:480488.
- 10. Minami H: The construction and validation of a measure of amae network. Unpublished doctoral dissertation. University of California, San Francisco, 1982.
SELF-CARE AND HIGH MENTAL FUNCTIONING