Journal of Gerontological Nursing

Age and Health Perceptions Among Elderly Blacks

Martha A Smith, RN, MS; Henry M Plawecki, RN, PhD; Bernice Houser, RN, BA, MS; Juanita Carr, RN, BA, MS; Judith A Plawecki, RN, MA, PhD

Abstract

The number of individuals who reach the age of 65 continues to increase. In 1984, the number of Americans aged 65 and older was 28 million, or approximately 11.9% of the United States population.1 In 1984, the life expectancy of 65-year-olds averaged 16.8 additional years beyond their current chronological age.2 Brotman 3 suggests that by the year 2000, the number of individuals in the age range of 65 to 74 will increase 57%, and the population of those aged 85 years and over will nearly double.

In recent years, the growth in the total elderly population has been accentuated by an increase in the number of older individuals who are members of a minority group. Increases in the numbers of minority elderly will continue at a rate that will supersede the growth of the older nonminority population. In 1980, the minority elderly accounted for approximately 10% of the population aged 65 years and older. Blacks or AfricanAmericans, who represent nearly 12% of the population, have been consistently identified as the largest minority group in the United States. Currently, 2.1 million blacks are 65 years of age or over.1 As the decade of the 1990s progresses, blacks will represent a significant portion of the elderly minority population. By the year 2000, minority group members will comprise 20% of the total elderly population. Estimates by the United States Census Bureau indicate that 3 million blacks will be 65 years of age or over by that time. 1

According to Williams, older blacks are considered "a minority within a minority" because these individuals represent the elderly as well as the minority segment of the population.4 This "double jeopardy hypothesis" has become a major research protocol used in examining the health problems of the elderly minority. This hypothesis implies that, later in life, the effects of racial discrimination are combined with ageism so as to have a cumulative negative effect on the availability of health resources.5 To validate that double jeopardy exists, researchers must identify that the health differential increases with age when older groups of minorities and nonminorities are compared.

Another divergent theory suggests that the discrimination that minorities experience in their earlier lives may lessen as they become older.5 This has become known as the "age as leveler" hypothesis. Dowd and Bengston, using cross-sectional data, examined the double jeopardy and age as leveler hypotheses by using a sample of whites, blacks, and Mexican Americans from the Los Angeles area.6 The findings of these investigators generally support the double jeopardy hypothesis.

The necessity and urgency of dealing with the deliverance of appropriate care to minority group members is so profound that some experts have termed it a "geriatric imperative."7 The term "geriatric imperative" implies that a high priority must be assigned to those policies and procedures that effectively meet both the health and social needs of this unique group of elders. Although the health-care needs of this group have been documented, the delivery of services remains inadequate. For example, black people are disproportionately underrepresented in the caseloads of district nurses compared with the elderly majority.8 These researchers conducted a random selection of clients from the district nurses' book of services of Birmingham, Alabama. This investigation revealed that only 7% of all patients chosen were black. Other research has further documented the findings that the black elderly have been underrepresented in their use of community services.9-11

Butler points out that home-care services for elderly black individuals are scarce.12 As a result, families have been forced to care for them without any outside assistance. When relatives prefer to care for elderly family members, they must…

The number of individuals who reach the age of 65 continues to increase. In 1984, the number of Americans aged 65 and older was 28 million, or approximately 11.9% of the United States population.1 In 1984, the life expectancy of 65-year-olds averaged 16.8 additional years beyond their current chronological age.2 Brotman 3 suggests that by the year 2000, the number of individuals in the age range of 65 to 74 will increase 57%, and the population of those aged 85 years and over will nearly double.

In recent years, the growth in the total elderly population has been accentuated by an increase in the number of older individuals who are members of a minority group. Increases in the numbers of minority elderly will continue at a rate that will supersede the growth of the older nonminority population. In 1980, the minority elderly accounted for approximately 10% of the population aged 65 years and older. Blacks or AfricanAmericans, who represent nearly 12% of the population, have been consistently identified as the largest minority group in the United States. Currently, 2.1 million blacks are 65 years of age or over.1 As the decade of the 1990s progresses, blacks will represent a significant portion of the elderly minority population. By the year 2000, minority group members will comprise 20% of the total elderly population. Estimates by the United States Census Bureau indicate that 3 million blacks will be 65 years of age or over by that time. 1

According to Williams, older blacks are considered "a minority within a minority" because these individuals represent the elderly as well as the minority segment of the population.4 This "double jeopardy hypothesis" has become a major research protocol used in examining the health problems of the elderly minority. This hypothesis implies that, later in life, the effects of racial discrimination are combined with ageism so as to have a cumulative negative effect on the availability of health resources.5 To validate that double jeopardy exists, researchers must identify that the health differential increases with age when older groups of minorities and nonminorities are compared.

Another divergent theory suggests that the discrimination that minorities experience in their earlier lives may lessen as they become older.5 This has become known as the "age as leveler" hypothesis. Dowd and Bengston, using cross-sectional data, examined the double jeopardy and age as leveler hypotheses by using a sample of whites, blacks, and Mexican Americans from the Los Angeles area.6 The findings of these investigators generally support the double jeopardy hypothesis.

The necessity and urgency of dealing with the deliverance of appropriate care to minority group members is so profound that some experts have termed it a "geriatric imperative."7 The term "geriatric imperative" implies that a high priority must be assigned to those policies and procedures that effectively meet both the health and social needs of this unique group of elders. Although the health-care needs of this group have been documented, the delivery of services remains inadequate. For example, black people are disproportionately underrepresented in the caseloads of district nurses compared with the elderly majority.8 These researchers conducted a random selection of clients from the district nurses' book of services of Birmingham, Alabama. This investigation revealed that only 7% of all patients chosen were black. Other research has further documented the findings that the black elderly have been underrepresented in their use of community services.9-11

Butler points out that home-care services for elderly black individuals are scarce.12 As a result, families have been forced to care for them without any outside assistance. When relatives prefer to care for elderly family members, they must assess the impact that decision will have on their resources, time, and stamina.

Unfortunately, many health-care providers have limited knowledge, experience, or understanding of the minority perspective as it relates to those decisions that influence the health and illness behaviors of this underserved group. To understand the behavior of any racial/ethnic group, one must become knowledgeable about their values and expectations, past experiences, and achievements in the social network, as well as their relationships with family, peers and others.13 A person's self-perception of physical and mental abilities, as well as health status, will influence one's willingness to seek and accept help. In addition, self-perception is greatly influenced by a number of other factors, such as culture, educational background, and socioeconomic status.

Perception is a major component in the process of human interaction.14 King defines perception as "a process of organizing, interpreting, and transforming sensory data and memory. It is a process of human transaction with the environment. It gives meaning to reality and influences one's behavior."14

A number of judgments are made during interactions between a nurse and patient. These judgments, which are based on perceptions, influence any exchange of information. Because the interactive process is reciprocal, the perceptions and resulting behavior of the person who initiates the interaction will influence the response of the recipient. For example, a nurse who uses inappropriate language or exhibits any demeaning behavior may discourage the patient from providing a complete response to health-related questions. Each individual's perceptions of the interactive process influences one's willingness to communicate and, therefore, affects the exchange of information.

An interaction's effectiveness can only be understood when consideration is given to its purpose or goal.14 Specific interventions that affect the attainment of mutually set goals between the nurse and patient need to be validated. Knowing how elderly minority patients perceive their physical and mental age as well as their health status may provide a better understanding of the patients' willingness and abilities to comply with prescribed regimens.

It is imperative that nurses understand how older persons perceive themselves. This knowledge can form the basis of therapeutic interactions by improving the care provider's understanding of a patient. Sharing one's self-perception can assist the nurse in identifying an individual's pattern of communication, establish some baseline knowledge of his biopsy chosocial strengths and capacities, and form the basis for setting mutual goals that will ultimately improve the patient's health. An older adult's self-perception reveals much about his biological, psychological, sociological, and cultural values, as well as his beliefs and attitudes.15-17

BACKGROUND

Society tends to consider all elderly persons as a homogeneous group. Guptill described society's reactions to age by arguing that: "all persons are influenced by the societal prescriptions of age; for every society has a variety of norms that apply to different age classifications. In addition, each person interprets these societal norms in light of his own social experiences and limitations of his physiological organism and behaves accordingly." 18

One commonly accepted belief of a youth-oriented society is that the repertoire of an individual's behaviors becomes more restricted and increasingly predictable as one becomes older.19 This belief is based upon the assumption that advanced age increasingly restricts an older person's behavior.

Society has accepted the belief that informal and intentional patterns of behavior have been established that are associated with chronological age. This belief implies that there is a direct relationship between age and expected, acceptable behaviors.19 Stereotypical attitudes directed toward the aged have so permeated the national consciousness that these beliefs are applied to everyone classified as elderly, regardless of an individual's perceptions of health status or age.20

AGE IDENTIFICATION

The discrepancy between perceived and chronological age has been of interest to gerontologists for many decades. It has been suggested that old age can be perceived as a combination of undesirable physiological and psychological changes that include loss of physical attractiveness, the onset of crippling chronic disease, and negative changes in an individual's character (eg, dependency, diminishing intelligence, etc).21 Research in numerous contexts, using a variety of methods, reaffirms the fact that negative stereotypes are so strongly attached to old age that "older persons themselves may subscribe to these negative stereotypes more so than younger persons."22

Bultena and Powers conducted a two-part longitudinal study of age perceptions of older adults.23 In the initial 1960 study, respondents were asked to describe themselves as middle-aged, elderly, or old. Those who regarded themselves as middle-aged were asked when they would be old. In the 1970 restudy, participants were again asked about their ages. Reference group comparisons were made by having the respondents compare aspects of their lives with those of other individuals their age. A significant identity transition occurred for persons who had claimed that they were middle-aged in I960. Three fifths of this group had recategorized themselves as elderly or old by 1970. Respondents who had shifted to an older age identity associated this change either to a loss of health or to decreased mobility. Conversely, some subjects who indicated in 1960 that they would be old in 10 years continued to reject that label in 1970. Good health and high levels of independence may have accounted for their reluctance to accept the label of "old."

Another study used a multiple classification analysis to determine relative and collective effects of age, informal support, demographic, physical, social, and mental health factors on the functional limitation of blacks aged 65 and over.24 After controlling for factors that also affect functional limitation, findings revealed that age failed to be identified as a strong determinant of physical functioning among older blacks.

Several studies have confirmed that the elderly of lower socioeconomic status are more likely than those of higher means to perceive themselves as older. Age perception also seems to differ between racial groups.25,26 Consequently, blacks who have fewer socioeconomic resources are believed to perceive themselves as older. Several variables that may contribute to this perception include poor health, low income, institutional care, retirement, loss of independence, and the death of a spouse.27 These factors may influence the individual to accept the perception of being old. Labeling theory states that society's negative attitudes and stereotypes of old age adversely affect an older person's self-image and, as a consequence, influence some elderly to reject their "old age identity" in favor of a younger and less stigmatized one.

PERCEPTIONS OF HEALTH

Health is defined by the American Nurses' Association as "an evolving process through which a person experiences life and in which the developmental and behavioral potential of an individual is realized to the fullest extent possible."28 This concept of health is influenced by sociocultural factors such as education, income, housing, nutrition, and the environment. These factors must be considered when a nurse attempts to assess the health status of elderly black individuals. Nurses must also attempt to gain an understanding of the patient's selfperceptions of age and health status.

An understanding of how patients perceive themselves and their health status contributes to developing an acceptable care plan. Learning about a patient's self-perceived health status will enhance understanding and increase perceptual accuracy as well as encourage the setting of mutually achievable goals. One's self-perception of health may differ significantly from objective assessments and, therefore, influence the patient's level of compliance. The older adult's selfperceived health status is an important indicator of the manner in which that person relates to the social world.29

Table

TABLE 1COMPARISON OF CHRONOLOGICAL AGE, PHYSICAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN MEN AND WOMEN RESPONDENTS

TABLE 1

COMPARISON OF CHRONOLOGICAL AGE, PHYSICAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN MEN AND WOMEN RESPONDENTS

How older persons perceive their health determines, at least in part, their feelings about the future.30 This study was designed to identify perceptions of age and health status among black elderly adults residing in the community. The questions focused on the relationships between actual chronological age and perceived mental and physical age and health status.

STUDY

Becoming knowledgeable about a patient's self-perceptions would assist the nurse in structuring appropriate health-care plans. Communicating this information to the nurse allows the patient to establish individuality, perceived capability, and general health assessment and, consequently, assists in increasing the accuracy and acceptability of health-care interventions.

Instrument

The instrument for this study was an 18-item interview schedule31 that was previously used to study age and health perceptions of both institutionalized and independent living adults.32 Demographic and perceptual questions were included in the instrument. The reliability of this instrument has been previously established by the test-retest method.33 The Pearson product-moment retest correlations for the following variables were: perceived physical age (.86), perceived mental age (.88), and perceived health status (.61). The coefficients were statistically significant (P<.05) for both perceived physical and mental age.33 The coefficient for health status may have been affected by the long interval of 9 months between the test and retest. Content validity was assured by repeated review by two experienced gerontological researchers.

Method

Several weeks prior to the initiation of the study, one researcher introduced the possibility of conducting the project to the social system from which respondents were to be selected. The reaction of the potential respondents to the research study was positive, enthusiastic, and encouraging.

An appointment for an interview was scheduled at the respondent's convenience. The purpose of the study was explained to each subject. Prior to the interview, the respondents read the consent form and questions were addressed. The respondents were assured that their participation was voluntary and anonymous and that answers would be used only as part of an aggregate. The average time used to conduct an interview was 30 minutes.

The data collection method allowed one researcher to conduct all of the interviews. Identical introductory remarks were repeated prior to each interview. The interviewer read each question and repeated it if the respondent hesitated before replying. A three-digit number was used to code the consent form and the corresponding interview schedule. Only the interviewer had access to information that could identify any individual respondent.

Sample

The total sample consisted of 20 respondents. Ten black men and 10 women volunteers aged 65 and above who resided in a southern suburb of a large metropolitan area were used for this descriptive study. The subjects were solicited through social and familial contacts and volunteered to participate in the research study. All participants were retired and living independently. A convenience quota sampling method was used to select respondents.

The age range for the total group was from 65 to 91 years. The average age of the male respondents was 78.3 years; the mean age of the women was 74.5 years. Four women and six men were 75 years of age or older (Table 1).

Demographics

One man and one woman indicated having physical problems with limited mobility, and both used a cane as an aid. All respondents were retired, with 9 reporting that their income was adequate, 10 less than adequate, and 1 more than adequate. Three indicated having one illness, 7 indicated two illnesses, and 10 reported three or more illness. The mean number of illness per respondent was 2.75. The most common medical conditions identified were arthritis, high blood pressure, and heart trouble. Thirteen respondents reported occasional depression and 7 expressed feelings of loneliness.

Black Men

The range of education by grade level completed by the men was from grade 1 to grade 18 (master's degree level). Only 2 men attained a formal education at the 1 2th grade level or above: 1 man completed high school (grade 12), and the other was near completion of his master's degree (grade 1 8). The average grade level completed by the other 8 men was 5.50 years; the mean grade level for the total group of men was 7.4 years. Each of the 3 men who attained the highest educational level (grade levels 9, 12, and 18) indicated that their incomes were adequate or more than adequate. Three men who indicated that their income was less than adequate had an average grade level of 6.6 years.

The number of illnesses reported by men ranged from one to five, with the average being 2.3. Seven men identified arthritis, 6 hypertension, 3 heart trouble, and 3 ulcers as the most common illness conditions. Two men identified five health problems, 1 had four illness conditions, 1 indicated three conditions, and the other 6 men had one or two illnesses. Four men indicated that they often experienced loneliness, whereas 6 denied that feeling. Five respondents indicated having been depressed, whereas the other 5 denied that condition.

Black Women

The range of education by grade level achieved by women was from 5 to 14. Three women indicated the completion of grade 12, and 1 completed level 14, The average grade level completed by the remaining 6 women was 6.8. The mean grade level completed by the group of women was 9. 1 . None of the women indicated that her income was more than adequate, and 3 of those with the highest grade levels (grades 12, 12, and 14, respectively) indicated that their income was less than adequate. Only 1 woman, who had completed the 12th grade level, indicated that her income was adequate.

To summarize, 7 of the 10 women indicated that their incomes were less than adequate. Three indicated their incomes to be adequate, and none reported her income as more than adequate. The range of illness for the group of women was from one to six, wim an average of 3.2. One woman identified six illnesses, 4 indicated four, 1 had three illnesses, and 4 had one or two illness conditions. Nine women identified arthritis, 4 identified hypertension, heart trouble, glaucoma/ visual problems, and 3 noted urinary disorders or stomach/duodenal ulcers. Eight of the 10 females denied that they experienced loneliness, whereas 8 indicated having been depressed.

RESULTS

Twelve of the 20 participants stated that they felt physically younger than their actual chronological age (Table 1). This subgroup's average chronological age was 72.7 years; they indicated that they felt physically younger by 12.6 years. The calculated selfperceived physical age for this subgroup was 60. 1 years. Five respondents stated that their actual and perceived physical ages were the same. Three respondents indicated that they felt physically older than their chronological age by an average of 3.67 years.

An examination of the responses regarding perceived mental age revealed similar findings (Table 2). Eleven respondents stated that they felt mentally younger than their stated age. The average chronological age of those who felt younger mentally was 76.0 years, and they felt younger by an average of 15.54 years. The calculated selfperceived average mental age of this subgroup was 60.46 years. Six men perceived their mental age to be 16 years less than their chronological age. Five women responded that their perceived mental age was 14.8 years less than their chronological age. Seven of the 20 respondents indicated that their perceived and chronological mental age were the same, whereas none of the women and only 2 men reported that they felt mentally older by an average of 5 years.

Table

TABLE 2COMPARISON OF CHRONOLOGICAL AGE, MENTAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN MEN AND WOMEN RESPONDENTS

TABLE 2

COMPARISON OF CHRONOLOGICAL AGE, MENTAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN MEN AND WOMEN RESPONDENTS

Respondents were asked to rate their health status (Tables 1 and 2). The following four-point scale was assigned to their health descriptions: excellent (4 points); good (3 points); fair (2 points); and poor (1 point). One man rated his health status as excellent, 3 as good, 5 as fair, and 1 poor.

Those 4 individuals who felt the "same as physical age" or "other" had a health score of 2.0. One woman rated her health as "excellent" while 6 chose "good," and 3 selected "fair." The average health status score for the total subgroup of women was 2.8. The 7 women who "felt physically younger" had a mean health status score of 2.86, whereas the 6 who "felt mentally younger" had a score of 3.0. The total subgroup of men had an average health score of 2.4. The 5 men who "felt physically younger" had an average health score of 2.8, whereas the mean health score of the 6 who "felt mentally younger" was 2.83.

DISCUSSION

A significant percentage of the older black respondents in this study perceived themselves as either physically or mentally younger than their chronological age. Age self-perception seems to be directly related to perceived health status. Respondents who "felt" younger also rated their health status as better. Their relationship between perceived age and health status may be an attempt to deny the aging process or, being optimistic, may be a more relevant indicator of general well-being than any physically measurable indicator. The denial of old age may be an affirmation of reality and consistent with one's self-concept.34 Knowing the difference between one's chronological and self-perceived age may provide the nurse with information that can be used to plan more appropriate self-care activities.

The rather positive self-perception of this elderly group of blacks is especially encouraging when one reviews the obvious social, political, and economic barriers that members of this group have overcome. For example, the youngest participants of this study, the 65-year-old blacks, were children during the Depression, experienced World War II during their teen years, and were in their mid-20s when school segregation was banned. This intriguing group of black elders experienced segregation and limited educational and professional opportunities, and they still have restricted access to the health care system. It is obvious that elderly blacks represent a unique subgroup of survivors. Nurses must allow themselves the opportunity to understand the values, appreciate the perspectives, admire their ingenuity, emulate their persistence, and empathize with the tolerance that characterize the elderly black person. Nurses could learn a great deal about the strategies for successfully dealing with stressors from these individuals.

LIMITATIONS

The demographic characteristics of Ulis group of respondents, as well as the convenience method of selection, limit the applicability of this study's results. Volunteers for any descriptive study may have developed attitudes that are more positive than their age cohorts who refrained from becoming participants. A social system was used to select respondents, which consequently ignored those individuals who chose to live a more socially isolated or independent lifestyle. The selection process also excluded elders who were too impaired to participate and, as a result, may have displayed a more pessimistic attitude.

The sample was totally composed of independently living elderly blacks who have access to their sources of family or social support systems. These characteristics may have influenced the responses provided. The biopsychosocial and religious strengths that enabled the majority of this group to survive with an optimistic perspective would be an interesting research topic. It is obvious that this special group of elders has learned how to successfully adapt to the many social, psychological, and economic situations that have continuously confronted them throughout their lifetimes.

NURSING IMPLICATIONS

Assumptions often influence the communication process. Nurses, like members of other groups, may have accepted the stereotypes associated with blacks or the elderly. The acceptance of stereotypes is usually influenced by some form of social isolation. Interacting with the black elderly about age or health perceptions can allow nurses to demonstrate personal interest, obtain pertinent health-related data, and gain insights into the coping strategies that these individuals have successfully used for long periods. These interactions will ultimately result in individualizing care plans. Data from these interactions could assist nurses in developing appropriate teaching materials and strategies that could foster compliance to prescribed healthcare regimens. Finally, nurses need to recognize the absence of any direct relationship between chronological age and the physiological aging process. It is hoped that the results of this study will contribute to the belief that "you are only as old as you feel."

REFERENCES

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TABLE 1

COMPARISON OF CHRONOLOGICAL AGE, PHYSICAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN MEN AND WOMEN RESPONDENTS

TABLE 2

COMPARISON OF CHRONOLOGICAL AGE, MENTAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN MEN AND WOMEN RESPONDENTS

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