Since the publication of a landmark report, Healthy People, The Surgeon General's Report on Health Promotion and Disease Prevention,1 many health professionals now believe that the care of the American people must change dramatically to reflect preventive care rather than treatment of disease. It is no secret that risks to good health are related not only to heredity and environment, but also to personal behaviors and lifestyles. To improve the health and quality of life for older adults, it is generally recommended that people stop smoking, reduce misuse of alcohol and drugs, improve nutrition, implement an appropriate exercise and fitness program, and control stress. TTie American Heart Association's2 1980 Committee Report on risk factors declared that no single risk factor is etiologic of coronary disease, but that for primary prevention it is important to recognize total risks and the interaction of many factors.
Important recent evidence points to the relationship between engaging in certain health practices and an increased life span, particularly for men.3 Significant risk-reduction research from Finland and Stanford University proclaim the value of community preventive programs in reducing disease.4,5
Knowing the risk factors and potential health benefits that result from a change in lifestyle is prerequisite to the more difficult task of motivating people to adopt different and healthier behaviors. The problem, of course, is to translate general risk reduction and health promotion activities into practices that individuals can suit to their personal requirements and present way of living.
The rationale for nurses to be facilitators and potentiators in a health promotion program are strong. All nurses teach. Community nurses in particular are skilled educators. They have a wealth of knowledge about health, are accustomed to helping well persons in the community, and have access to many health education materials.* Nola Binder's6 Health Promotion in Nursing Practice is an instructive and useful text for helping nurses develop strategies and goals for health promotion whether in the hospital or in the community. The concepts of risk factor reduction and lifestyle change emphasize the notion that in promoting health, clients ought to be the initiators of, or at least willing participants in, the process of change as they move toward more self-responsibility and self-care. This approach ensures that people retain ultimate choice of and control over what they do as they change behaviors to reduce risks.7
In an attempt to incorporate many of the foregoing ideas into the lifestyles of a population of elderly individuals, a program was envisioned for senior citizens at a local community center. The program planned to provide information about risks to heart health through group discussions and individualized counseling sessions. The philosophy adopted was similar to that formulated by a group of nurses who described selfcare as a framework that helps healthcare personnel assess the client's vision of his or her needs and goals.8 The process and ideas of the self-care framework are familiar, but the question remains: How do you carry out the ideal situation in a practical manner?
The spark for putting health promotion ideas into practice with senior citizens was provided by an announcement of community projects by a local American Heart Association (AHA). The AHA's goal was to support innovative approaches to problems that would benefit the cardiovascular health of citizens in the community. Projects were judged on the basis of applicant qualifications; and the need, importance, feasibility, objectives, benefits, methods, planned budget, and evaluation mechanism of the project. This funding opportunity was based on an image of the merger of theory and practice. The nurse planner decided to utilize self-assessment inventories to gather heart risk and other information and to share this information with clients to make the plans more personalized.
It is always prudent when writing a grant proposal to follow carefully any outline prepared by the funding agency. The AHA's outline called for a project summary, financial information, a description of the facilities available, methods of project implementation, background information on the rationale, procedures for project evaluation and reporting, and plans for the future. Attachments containing references, a biographical sketch, and other data were also requested.9 The AHA furnished helpful hints for writing the proposal, and these suggestions were meticulously followed.
Carrying Out Plans
Upon AHA approval of the grant proposal, the project was funded for one year with a budget of $5,500 allowing three programs to be conducted, each for a period of six weeks. The programs were offered to seniors attending the community center as "group discussions focusing on risks to heart health and ways to make personal lifestyle changes to reduce those risks." The series was advertised in brochures and on posters as "Choices for Health." Each week, hourly discussions were held on one major risk factor. Individual counseling sessions for personalizing goals were scheduled at the end of each series as well as after each session.
SELECTED HEALTH PROMOTION NEWSLETTERS*
Group discussions included topics on:
1. Heart health risks (using a selfcheck heart test);
2. Diet, cholesterol, and salt;
3. High blood pressure and diabetes;
4. Weight and exercise; and
5. Stress and relaxation.
Smoking and the use of oral contraceptives as significant risk factors were also included, but given less time than the other topics since the majority of these senior citizens were nonsmokers and were beyond the childbearing years. They used the information, however, among their families and friends.
MEAN AND RANGE OF HEART TEST SCORES
To illustrate the hazards involved in a meaningful way, and to gather information for nursing assessment and diagnosis, each participant was asked to score him- or herself weekly on selected lifestyle inventories. The Diethrich Heart Test helped to identify modifiable and nonmodifiable risk factors.10 Each person was given a folder to carry inventories, handouts, pamphlets, pencil and paper for notes and questions, and other material. Handouts suitable for posting on a refrigerator were prepared on high- and low-cholesterol foods. Relaxation methods were organized into a reference format that could be kept handy at a favorite chair for easy referral in stressful moments. Selected pamphlets that were available without charge from most AHAs were used: Why Risk Heart Attack?, High Blood Pressure, Choosing Margarines and Oils, Shake the Salt Habit, and Guide for Weight Reduction.
Written permission from both author and publisher were obtained for using the heart test, a diet- weight inventory, and a five-part stress profile. Written permission was also obtained for using a modified version of Nola !tender's Lifestyle and Health Habits Inventory, Health Values Scale, and Health Promotion Plan.6
Given the variety of self-check lists utilized, not all of the 32 women and men completed all of the inventories, and it was not required that they do so. Complete data on 12 of the participants were obtained and analyzed, and written health plans were developed for each. The plans formed a basis on which to develop mutually agreed upon goals for lifestyle changes. A contract was signed by both client and nurse for reducing risks to health. Personal counseling sessions were still provided for those who completed partial inventories or did not complete any. In a followup mailing three months later, progress toward achieving goals was ascertained from eight participants, and five responded to a six-month follow-up (see Table 1).
The program was judged to be a success based on participants' comments. Although the number of persons from whom data were collected was small, the program fulfilled the objective of promoting health for elderly adults. It enabled them to become aware of risks to heart health, served as an impetus for helping them make lifestyle changes, and proved the usefulness of group discussions for community nurses who want to facilitate self-care practices in older persons.
The average age of the 12 study participants was 72 years. Most were retired, of Jewish faith, and high school graduates. Half were at low risk and half were at medium risk on the heart test scores. The scores on modifiable risks showed a decreasing trend over time (see Table 1).
The most frequently rated hazards were stress (75%), weight (58%), and diet (50%). Three quarters of the group were in a medium-risk stress category and, as a group, were an average of 31 .2 pounds above their desirable weight levels, according to the 1983 Metropolitan Life Insurance Tables. Many were eating high-cholesterol and salty foods. Sleep was the most problematic area uncovered on the lifestyle and health habits inventory (55%). All but one person rated health as the number one value in their lives.
The average number of health goals chosen was 3.3. The most popular goals were to increase exercise, decrease stress, and decrease weight (58% each). The goal of changing dietary habits was rated lower (50%). Of the seven who responded to the three-month followup, increased exercise was indicated as the one lifestyle change attained (43%). Except for one participant who lost 30 pounds as a direct result of participation in the program, weight reduction was not achieved as a group (29%).
Although lack of exercise was not high on the list of hazards present within this group of seniors, they chose exercise as a goal and found it the easiest preventive method to accomplish. A risky diet pattern was a problem for half the group, and half chose its correction as a goal. Success in changing diet to include less red meat, butter, whole milk, cheese, and fewer eggs was low on the list of achieved health goals (14%) in the follow-up, (see Table 2).
Learning From Experience
This project was created out of one community nurse's need to develop an original risk-reduction program for seniors in the community. The participants were generally well, but lacked resources for obtaining specific information about health; they demonstrated a voracious appetite for it. The participants particularly enjoyed sharing group health discussions with the community nurse who could enter their lives and help them understand ways to alter habits to improve lifestyles. Since the elderly are enjoying longer and more productive lives, they are highly motivated toward learning self-care activities. Many of those participating in these sessions wanted to teach others new information they had learned. One person, in cooperation with the center's nutritionist, was able to have high-cholesterol liver eliminated from the luncheon menu, a change appreciated by many members.
INITIAL HEALTH RISKS, HEALTH GOALS, AND GOAL ACHIEVEMENT
Stress, though not generally considered to be one of the worst risk factors for coronary disease, is common in the aging person and was evident in this group (75%). Stress can accompany normal body changes and the physical discomforts of aging, loss of significant others, and other common occurrences in later life. All three groups spent considerable time discussing ways of reducing stress. Dietary habits, obesity, and weight reduction were addressed at length and, as mentioned, gave at least one member motivation to start losing weight. Sleep problems were common among these participants and are common to the elderly population in general. Ways of understanding and alleviating these problems are important nursing responsibilities.11
Physical fitness is a current phenomenon in our society, and for many older persons staying fit has become a popular objective. In this project, the goal of increasing exercise to reduce risks may have been a result of increased awareness of the positive effects of fitness. This result may also have been due to the community centersponsored physical education program whose activities are strongly emphasized. Because the exercise goal was more easily accomplished (43%) than dietary change (14%), it may be prudent for nurses to support exercise programs while at the same time introducing new ways to change meal habits and decrease weight. Long-standing dietary patterns are notoriously difficult to alter, and addressing this issue requires considerable skill and ingenuity on the part of the nurse.
The project as a whole underscores the growing need for nurses to originate and develop community programs with groups of elderly adults that address health promotion activities and emphasize lifestyle changes. It reinforces the philosophy that the elderly can and will reduce health risks if given time, information, counseling, and follow-up. Completing lifestyle inventories may or may not be the method of choice, but this method can serve to make persons acutely aware of habits they can change.
Creating a successful program in a natural setting is a formidable challenge. The challenge consists of attending to group process skills along with providing accurate information, correcting misinformation, and encouraging the adoption of new ways of thinking and acting.
It could be argued that the benefits of teaching lifestyle changes to the elderly are not commensurate with the effort involved. On the contrary, the effort is most rewarding. As most adults are healthy most of the time, they tend not to engage in preventive behaviors unless they are sick or have been threatened with illness. Most seniors want to make changes in their lifestyles, and need the opportunity of a health promotion program to do so.
The invitation for nurses is to make room in our busy schedules for group health promotion activities in the community on a regular basis. By virtue of our background, education, and health value orientation, community nurses are in an excellent position to make important contributions to the physical, emotional, and health improvement of our senioT citizens.
- 1. US Dept of Health, Education, and Welfare: Healthy People, The Surgeon General's Report on Health Promotion and Disease Prevention. US Dept of Health, Education, and Welfare (Public Health Service) publication No. 79-55071. US Government Printing Office, 1979, pp 119-138.
- 2. American Heart Association Committee Report: Risk factors and coronary disease. Circulation 1980; 62(August):449A-455A.
- 3. Breslow L, Enstrom J: Persistence of health habits and their relationship to mortality. Prev Med 1980; 9:469-483.
- 4. Puska P: The North Karelia Project. Prev Med 1983; 12(January):191-195.
- 5 . Farquhar J : Community education for cardiovascular health. Lancet 1977; !(June 4):1192-1195.
- 6. Pender N: Health Promotion in Nursing Practice. Norwalk, Conn, Appleton-Century-Crofts, 1982.
- 7. Milsum JH: Health, risk factor reduction and lifestyle change, in Spradley B (ed): Readings in Community Health Nursing, ed 2. Boston, Little, Brown & Co, 1982, pp 27-37.
- 8. Goldstein N: Self-care: A framework for die future, in Chinn P (ed): Advances in Nursing Theory Development. Rockville, Md: Aspen Systems Corp, 1983, pp 107-121.
- 9. American Heart Association, Northeast Ohio Affiliate, Ine: Community Project Grants Application information. Cleveland, Ohio: American Heart Association, 1981, pp 1,4.
- 10. Diethrich EB: The Heart Test. New York, Simon and Schuster, 1981, pp 47-53, 125-126, 91-99.
- 11. Ebersole P, Hess P: Toward Healthy Aging. St Louis: CV Mosby Co, 1981, chaps 5, 15.
- This project was supported in part by the American Heart Association, Northeast Ohio Affiliate, Ine, in cooperation with the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.
SELECTED HEALTH PROMOTION NEWSLETTERS*
MEAN AND RANGE OF HEART TEST SCORES
INITIAL HEALTH RISKS, HEALTH GOALS, AND GOAL ACHIEVEMENT