Journal of Gerontological Nursing

Minority Wellness Promotion: A Behavioral Self-Management Approach

Frieda R Butler, PhD, MPH, BSN

Abstract

In addition to ADL assessment, health screening consisted of a comprehensive assessment of each resident in the area of physical, psychological, and social functioning in evaluating health status. An objective assessment by the nurse, as well as a subjective impression by the client, was included in the interview schedule. Included in the goals of assessment were the determinants of:

1. Relevant behaviors for change, and

2. The environmental events that maintain, discourage, or prevent identified problems.15

Identification and listing of all client problems is an important component of the assessment process. A problem may be defined as anything that interferes with the quality of life of the individual or limits the satisfactory performance of ADLs as perceived by the client or the provider. The provider should interview for changes in lifestyle that affect the health of the individual as well as physical, mental, social, and economic resources. The Table is a summary of the initial screening for these resources.

The results indicated that most residents over age 60 had good to excellent social resources (69%) and mental health resources (85%). However, most were mildly to severely impaired in economic resources (56%) and in physical health (80%). Seventy-six percent scored good to excellent on ADL. The remaining 24% apparently had lost some function since admission to the residence and were in danger of transfer to an institution.

As at NCBA, area-wide community health fairs can provide supplemental screening services. Such additional screenings include dental, vision, hearing, glaucoma, podiatry, chest, gynecological, and hematological (anemia, heart, and high risk cardiovascular) screening. This record then becomes a part of the resident's wellness center health record.

Individualized Planning and Implementation

When developing a care plan for NCBA residents, the nurse takes into consideration information from the Functional Assessment Inventory, health fair screening data, and nursing assessment performed in the center or home. The analyses focus on behavioral deficiencies as well as behavioral excesses in relation to desired outcomes. The patient and the nurse jointly develop the desired outcomes, which are extended over a reasonable period of time. Efforts are directed toward reducing negative behaviors which are incompatible with the desired goals.

A behavioral program is developed that increases opportunities for reinforcement. Programming can be planned which is appropriate for positive or negative behaviors. However, the use of punishment procedures that diminish reinforcement by means of an aversive stimulus or the removal of reinforcers is avoided. Rather, programming is aimed at decreasing the excessive or negative behavior while increasing a positive, adaptive behavior.13

When planning a protocol for health maintenance, it is important to recognize that a wide range of variations exist among the elderly. People age at different rates and with varying levels of health and disability. This variation among the elderly increases as the age increases. Also, it is important that nurses recognize the diversity in customs, beliefs, values, and traditions in the black elderly when planning care.19 A general health maintenance protocol has some value for the elderly, however, a more individualized plan for health maintenance is preferred.

Evaluation

General statistics obtained during two years of operation on a voluntary, nonfunded basis indicated that a significant number of healthcare contacts were made with clients. In consideration of full-time faculty teaching responsibilities, our analysis of the quantity and quality of gerontological nursing intervention and the outcomes that were measurable at this time were significantly positive. The greatest gains were made in assisting clients to stabilize their blood pressures and to control diabetes and weight using intensive behavioral self-management techniques. The exercise classes were the most popular of the classes with clients managing their own…

If one were to inquire of an elderly black woman about her health, she probably would respond, "I feel pretty good, thank you. My arthritis kept me from going to church yesterday, but I'm better now." Yet, most likely she will have multiple chronic diseases or disabilities, complicated by poverty and other social problems, all contributing to a gradual decline in function. This article focuses on one approach to maintaining health in older blacks who are essentially well and living in the community.

The primary indicator of health and well-being in the elderly is the ability to perform activities of daily living (ADL) with relative ease. The presence of disease no longer completely defines the level of health of an aging person. It is now recognized that the elderly (86% of whom have one or more chronic diseases)1 are far less concerned about medical diagnosis than their ability to perform necessary personal and household chores, and to go about their daily and social activities. When interviewing, a simple "How are you getting along at home" should elicit significant information concerning functional level. If a disabling condition arises, one of the first indicators of this may be the statement, "I am not able to get around well anymore. " This effect, rather than the condition itself, tends to hasten physical and mental deterioration in this population.

Most elderly persons are functional, active, and report feeling reasonably well most of the time.2 Sloane refers to elderly Americans who are generally quite healthy as the "well-derly. "3 However, the black elderly appear to be the least healthy and most likely to lose function, when compared to other aged population groups. Ample documentation exists to support the need for new approaches to the health problems of aged blacks. For example, the black elderly were rated highest in the ten leading causes of death when compared to the white elderly, with heart disease, malignant neoplasms, and cerebrovascular diseases receiving the highest ratings.4

In 1977, slightly more than half (51%) of blacks over the age of 65 had functional limitations in major activities (such as employment and housekeeping) as compared with one third (36%) of whites in the same age group. In addition, one fourth experienced chronic limitations in physical mobility as compared to one sixth of whites. This extreme disparity in health is more dramatic when one considers the older black population is growing more rapidly than older whites and younger blacks. Given the present trend, this will exceed the growth rate of whites over 60 by 26 percentage points, and for whites over 65 , by 24 percentage points.5

Jackson showed that the greater vulnerability of non-white elderly to chronic conditions and resulting limiting of activities followed the pattern of well-established relationships between health and income in the United States.6 It is felt that the health problems of aging blacks are not racially unique, but the amount of illness in the group is strikingly disproportionate to their white counterparts.8

Alternative Housing and Health Care

Being functionally independent while remaining in their own homes, enjoying the freedom, independence, and privacy that independent living provides, is the preference of many elderly people. When the elderly develop physical and financial constraints, residential facilities for the elderly, such as those established by the National Caucus and Center on Black Aging (NCBA), is a desirable alternative to elderly persons moving in with their adult children orto nursing home placement. These arrangements afford them continued independence without the demands of home ownership or rental and at an affordable or subsidized rate.

In addition to shelter, this facility offers activities which meet such needs as socializing, entertainment, and classes in arts, crans, and nutrition. A voluntary program whereby the resident is served one complete meal a day, helps to encourage socialization as well as to assure adequate nutrition. Since the facility was planned for essentially well elderly people, there was no health unit in the building. Whereas a medical clinic or similar unit probably was not needed, it later became apparent that a health maintenance facility would provide significant benefits to those at high risk for functional decline.

Most black family members who are potential caretakers, by necessity, work outside the home and cannot provide full-time care to their elderly members. In many instances, additional needed support services are simply not available in the community. For instance, home health care may be available, but is not always accessible to the black elderly7 and, in many instances, is limited due to decreasing funds and increasing demands. In other cases, black families are not aware of community resources or are neglected in community outreach efforts.

Further, even with the supportive environment of the congregate living facility, other factors contribute to declining performance in ADL activities and ultimate loss of independence. For one, medical care in the black elderly tends to be erratic and crisis oriented. A significant number of elderly with one or more chronic diseases do not stay under regular medical supervision, but seek medical care only during acute illness episodes and emergencies.

Even today, many continue to use home remedies passed down through generations or purchase readily available over-the-counter drugs. Often they are simply too poor to go to the doctor.10 Even with Medicare, Medicaid, and sliding fee scales, many state that they cannot afford the costs not covered by insurance. This is understandable given the fact that blacks age 65 and above are more concentrated at the lower end of the economic scale than are whites age 65 and over. Also, in 1977. 36.3% of older blacks were below poverty level as compared with J 1.9% of older whites.5 When NCBA clients were interviewed by the author during the administration of the Functional Assessment Inventory, other reasons given for a lack of continuity of care were a reluctance to travel alone, and reasons related to cultural attitudes and beliefs, such as a distrust of doctors and hospitals.9

Secondly, many of these older clients admitted to taking the prescribed medications only when feeling sick, discontinuing the required regimen when they felt better.9 Thus, there is a lack of preventive health care and gaps in ongoing disease-monitoring by Healthcare professionals for elders who are not sick enough for hospital ization nor debilitated enough for nursing home care. The final costs to the individual, family members, and to society are high and include a loss of productive services by the elderly, increased stress, and increased medical, hospital, and nursing home costs. This gap in health services begs for an effective, accessible, affordable, community-based health maintenance program to provide immediate and ongoing intervention.

Developing a Wellness Promotion Program

When it was observed that various residents at NCBA Estates were experiencing a decline in health and adaptive functioning, preventive measures under the umbrella of a wellness center appeared to be the most timely and pragmatic approach. With nurse faculty as primary providers, the center has been developing a coordinated continuum of health promotion and health maintenance activities which draw upon a number of existing health systems that are either a part of a nearby university medical facility or located within the general area. Necessary resources including medical consultation for staff have been readily available.

Conceptual Framework for the Wellness Program

The premise of self-care lends itself quite adequately to the structure of the wellness promotion concept. According to Orem, "Self-care is the practice of activities that individuals personally initiate and perform on their own behalf to maintain life, health and wellbeing . . . It is an adult's personal, continuous contribution to his or her own health and well-being."" It was anticipated that a self-care approach would be therapeutical Iy effective in that it would facilitate attainment of the following elements in the elderly as outlined by Orem:

1. Support of life processes and promotion of functioning;

2. Maintenance of normal growth and development;

3. Prevention and control of disease processes and injuries; and

4. Prevention of or compensation for disability.

The nurse supports and guides the individual in his/her self-care choices and activities. In doing so, she considers the person's age, environment, culture and lifestyle in order to promote optimal functioning. In other words, this concept of high level we I Ine ss which focuses on maximizing potential and recognizing the influence of environment,12 helps nurses to focus on the elderly's assets, strengths, and resources rather than on their liabilities.

Regarding the unique predicament of older blacks, scant attention has been paid to their strengths and coping skills, their family and extended family bonds, the impact their spiritual heritage has on their understanding and definition of health, and the fact that after having reached the age of 75 , they outlive their white counterparts. In this important area of inquiry, the present delivery system is dysfunctional in its orientation toward pathology and illness at the expense of health, ability, and capacity. Wellness promotion for the elderly then, may be defined as the enhancement of all those factors - physical, mental, emotional and social - which assist the elderly in maximizing the level of health.

Behavioral SelfManagement Approach

Based upon the previously described self-care concept and philosophy concerning weltness promotion in the black elderly, a behavioral self- management approach seemed most appropriate. Self-management techniques have been used to treat various problem behaviors in both adults and children.13 More recently, behavioral programs to increase independent behavior and other activities in the elderly have become increasingly popular with more dependent patients. For example, selfmanagement skills have been used to successfully teach elderly outpatients to control fecal and urinary incontinence.14,15 However, most behavioral management programs have been conducted in long-term care settings and have employed nursing home staff as the active agent in the program.

Wellness promotion in the community requires a different tack since it involves more active and independent clients, many of whom resist ongoing medical care and frequently resort to home remedies.8 Behavioral self-management involves teaching the client to use procedures to change their own problematic health-related behaviors. It is not necessary to change all unpleasant behaviors, but rather focus on behavioral deficits deemed most likely £o result in transfers of the client to an institution.16

More specifically, the nurse involves the elderly in improving his or her coping skills, developing self-control strategies aimed at reducing negative or harmful behaviors, encouraging positive, beneficial health behaviors, increasing knowledge through planned educational programming, and engaging in collaborative problem solving and decision making.

This approach was used successfully in the wellness promotion center. The nursing staff was able to integrate nursing theory with behavioral principles and apply them to the problems that were defined concerning aging and health. Since older blacks historically have not sought medical care, but have relied upon traditional, folk medicine, and self-healing approaches,9,10 this appeared to be the ideal group for teaching behavioral self-management skills. By capitalizing upon their inherent strengths (coping and survival skills under adverse conditions), assets and independence, one could successfully apply behavioral methods in dealing with various health problems.

Basic Components of Self-management

The primary components of community-based self-management are:

1. The definition and clarification of individual goals

An example is the case of Mrs. W, a resident of NCBA, a client in the Wellness Center, and a regular participant in the exercise program. Her personalized goals were established relating to improved mobility and increased strength and endurance.

2. Daily self-monitoring

Mrs. W was provided with written instructions (with illustrations) for simple exercises. On scheduled exercise days with the nursing instructor, participants were monitored for shortness of breath, fatigue, and complaints of myalgia. (No one had these problems.) Participants were taught self-pacing and the importance of daily repetition. The exercises were increased gradually in number, types, and intensity. The participants also were provided with a check-off sheet which they were obliged to bring with them to class.

3. Self-reinforcement

Self-reinforcement has been proven to be a powerful reinforcer in stimulating positive health behaviors. For example, Mrs. W was heard to say, "I feel stronger and not as stiff when I do my exercises daily. I am able to exercise longer and do not feel as tired during the day."

Also, participants were given tips for checking the results of daily exercising such as gross measurements of increases in muscle volume and measurements of flexibility and joint mobility.

Other reinforcement was provided in the form of frequent praise from nursing staff, immediate and short range positive feedback, and other social reinforcers, such as increased social contacts, group gatherings, and group approval.

Major Service Goals of Project

Health at a !00% level is usually unattainable by many, whether young or old, due to the Stressors of everyday life. According to Forbes and Fitzsimmons, "Wellness is the optimum in efficiency and health in body and mind, characterized by energy, vitality and zest for life. " They recommend a threelevel approach to high level wellness, namely: health maintenance, health support during acute illness, and rehabilitation.17 These three levels appear to correspond with the traditional primary, secondary, and tertiary levels of prevention. With this concept of wellness as a focus, the major goals of the project were:

1. To provide primary care to clients, using a behavioral selfmanagement model which focuses on client control of health; and

2. To develop and implement prevention strategies which would promote a maximum level of health in the well elderly by assisting them to be as independent as possible in their functioning, while enjoying life to the fullest.

Primary Care Objectives for Nursing Faculty

Nursing interventions to obtain the major goals of the project were to:

1. Assess the health status of the residents including functional level, healthcare needs, and social and emotional needs.

2. Evaluate the need for referral to appropriate medical facilities for care of acute illness or chronic, deteriorating conditions.

3. Assist the clients in establishing realistic health goals.

4. Monitor the treatment of illness where indicated.

5. Provide health teaching and guidance in specific areas such as nutrition, hypertension, and personal health habits.

6. Develop and implement stress management programs.

7. Assist the elderly in strengthening their abilities to maintain and promote their own health.

8. Assist clients in evaluation of attainment of goals.

9. Coordinate the care of common health problems and chronic illness.

10. Consult and collaborate with other healthcare providers and agencies to provide and coordinate services.

11. Develop and implement specific health screening programs such as high blood pressure and diabetes detection.

12. Develop and promote programs for the safe use of drugs.

13. Develop and implement prevention programs, ie, exercise.

14. Provide crisis intervention when necessary.

15. Provide opportunities for therapeutic verbal release.

16. Develop educational materials (packets) for dissemination to the public.

17. Assist in developing guidelines to duplicate the wellness center with cost-effective methods.

Outcomes

It was expected that by promoting wellness and functional ability through self-management, the clients would have:

- reduced risk of illness, accidents and disease;

- better management and control of existing chronic diseases;

- increased knowledge and better utilization of community health facilities;

- increased feelings of independence, control, strength and well-being;

- reduced risk of depression and dementia resulting from isolation and loneliness; and

- increased energy, vitality, and zest for living.

By emphasizing positive attitudes, self-care, and good health habits, we hoped to stimulate the elderly clients to take more responsibility for their own health, resulting in maintenance of functioning or even an improvement in overall functioning.

Basic Assessment

When setting up this wellness center in a residential facility, the initial step was to develop a mechanism for assessing the residents. A simple but effective screening program is fundamental in establishing a wellness promotion center in order to:

1 . Identify individuals whose health conditions are at risk of deterioration;

2. Identify individuals whose functional capacities are impaired; and

3. Acquire baseline data on their physical health, mental health, economic status, social resources, and capacity for activities of daily living (ADL).

Informal assessment begins at first contact with the client and is conducted simultaneously with the client's orientation to the program. It is essential that nurses become adept at interviewing and communicating especially with clients who have sensory deficits. Functional evaluation is one of the most important aspects of the assessment process and should take place in the home whenever possible. The nurse should be cognizant of the fact that many disease conditions do not present in elderly clients as they do in the young.

Often vague and nonspecific symptoms may be of less significance than a good functional assessment. One pilot study suggests that the provider's knowledge of the client's functional ability is significantly different when the assessment is performed in the home.18 Careful screening for even the smallest losses in functioning is important. Cumulative incremental losses by degrees can eventually result in catastrophy for older clients.3

Table

TABLESUMMARY OF SCREENING

TABLE

SUMMARY OF SCREENING

In addition to ADL assessment, health screening consisted of a comprehensive assessment of each resident in the area of physical, psychological, and social functioning in evaluating health status. An objective assessment by the nurse, as well as a subjective impression by the client, was included in the interview schedule. Included in the goals of assessment were the determinants of:

1. Relevant behaviors for change, and

2. The environmental events that maintain, discourage, or prevent identified problems.15

Identification and listing of all client problems is an important component of the assessment process. A problem may be defined as anything that interferes with the quality of life of the individual or limits the satisfactory performance of ADLs as perceived by the client or the provider. The provider should interview for changes in lifestyle that affect the health of the individual as well as physical, mental, social, and economic resources. The Table is a summary of the initial screening for these resources.

The results indicated that most residents over age 60 had good to excellent social resources (69%) and mental health resources (85%). However, most were mildly to severely impaired in economic resources (56%) and in physical health (80%). Seventy-six percent scored good to excellent on ADL. The remaining 24% apparently had lost some function since admission to the residence and were in danger of transfer to an institution.

As at NCBA, area-wide community health fairs can provide supplemental screening services. Such additional screenings include dental, vision, hearing, glaucoma, podiatry, chest, gynecological, and hematological (anemia, heart, and high risk cardiovascular) screening. This record then becomes a part of the resident's wellness center health record.

Individualized Planning and Implementation

When developing a care plan for NCBA residents, the nurse takes into consideration information from the Functional Assessment Inventory, health fair screening data, and nursing assessment performed in the center or home. The analyses focus on behavioral deficiencies as well as behavioral excesses in relation to desired outcomes. The patient and the nurse jointly develop the desired outcomes, which are extended over a reasonable period of time. Efforts are directed toward reducing negative behaviors which are incompatible with the desired goals.

A behavioral program is developed that increases opportunities for reinforcement. Programming can be planned which is appropriate for positive or negative behaviors. However, the use of punishment procedures that diminish reinforcement by means of an aversive stimulus or the removal of reinforcers is avoided. Rather, programming is aimed at decreasing the excessive or negative behavior while increasing a positive, adaptive behavior.13

When planning a protocol for health maintenance, it is important to recognize that a wide range of variations exist among the elderly. People age at different rates and with varying levels of health and disability. This variation among the elderly increases as the age increases. Also, it is important that nurses recognize the diversity in customs, beliefs, values, and traditions in the black elderly when planning care.19 A general health maintenance protocol has some value for the elderly, however, a more individualized plan for health maintenance is preferred.

Evaluation

General statistics obtained during two years of operation on a voluntary, nonfunded basis indicated that a significant number of healthcare contacts were made with clients. In consideration of full-time faculty teaching responsibilities, our analysis of the quantity and quality of gerontological nursing intervention and the outcomes that were measurable at this time were significantly positive. The greatest gains were made in assisting clients to stabilize their blood pressures and to control diabetes and weight using intensive behavioral self-management techniques. The exercise classes were the most popular of the classes with clients managing their own programs on a daily basis.

However, controlled studies identifying the most effective behavioral selfmanagement techniques are called for. The US Surgeon General states that, "Society will achieve its health goals primarily through changes in behavior." The National Institute on Aging encourages and supports studies that demonstrate changes in health status of the elderly as a result of changes in health-related behaviors and attitudes.20 As relevant new scientific knowledge and technology concerning the aging process are acquired, behavioral geriatric research must develop an understanding of ways to modify health behaviors, which ultimately result in enhanced functioning and prevention of disability.

References

  • 1. Becker MH: The drug regimen and treatment compliance, in Haynes, Taylor, Sacke« (eds): Compliance in Health Care. Baltimore. MD. The Johns Hopkins University Press, 1979.
  • 2. Palmore E (ed): Normal Aging: Répons From the Duke University Longitudinal Study, 1955-1969. Durham. NC. Duke University Press, 1970.
  • 3. SloanePD: How to maintain the health of the independent elderly. Geriatrics, 1984: 39(10):93-104.
  • 4. United States Department of Health, Education and Welfare: Epidemiology of Aging. Washington, DC, NIH Publication No. 75-711. p. 30, 1972.
  • 5. United States Department of Health and Human Services: Characteristics of the Black Elderly. US Departmeni of Health, Education and Welfare, Publication No. (OHDS) 80-20057, 1980.
  • 6. Jackson JJ: Minorities and Aging. Belmonl, Wadsworth Publishing Co, 1980.
  • 7. Butler RN. Lewis Ml: Aging and Mental Health: Positive Psychological and Biomedical Approaches. St. Louis. MO, C.V. Mosby Co, 1982.
  • 8. Butler FR: A Resource Guide on Black Aging. Washington DC, Howard University Institute for Urban Affairs and Research. 1981.
  • 9. Watson WH: Folk medicine and older blacks in southern United States, in Watson WH (ed): Black Folk Medicine: The Therapeutic Significance of Faith and Trust. New Brunswick, NJ, Transaction Books, 1984.
  • 10. Primm BJ: Poverty, folk remedies, and drug misuses among the black elderly, in Watson, WH (ed); Black Folk Medicine: The Therapeutic Significance of Faith and Trust. New Brunswick, NJ. Transaction Books, 1984.
  • 11. Orem DE: Nursing: Concepts of Practice. New York. McGraw-Hill. 1979.
  • 12. Dunn HL: What High-Level Wellness Means. Can J Public Health; 1959; 50:447-457.
  • 13. Kaufer FH, Karoly P: Self-Management and Behavior Change: From Theory to Practice. New York, Pergamon. 1982.
  • 14. Whitehead WE, Burgio KL, Engel BT: Biofeedback treatment of fecal incontinence in geriatric patients. J Am Geriatr Soc 1985; 33:320-324.
  • 15. Burgio KL, Whitehead WE. Engel BT: Urinary incontinence in the elderly: Bladdersphincter biofeedback and toileting skills training. Ann Intern Med 1985; 103:507-515.
  • 16. Pinkston EM. Linsk ML: Care of the Elderly: A Family Approach. New York, Pergamon. 1984.
  • 17. Forbes EJ, Fitzsimmons VM: The Older Adult: A Process for Wellness. St Louis, MO, C.V. Mosby Co, 1981.
  • 18. Canadian Task Force on the periodic Health Examination. The Periodic Health Examination. Can Med Assoc J 1979; 121:1193-1254.
  • 19. Clavon A: The black elderly. J GerontolNurs 12(5):6-12.
  • 20. Abeles RP: Social and behavioral research supported by the national institute on aging. Academic Psvchologv Bulletin 1984; 6(2):227-240.

TABLE

SUMMARY OF SCREENING

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