The proportion of elderly persons in the American population is growing rapidly, with individuals over 65 years currently accounting for 12% of all Americans. It is estimated that this figure will rise to 20% within the next 50 years (Healthy People 2000, 1990), leading many experts to predict a health care crisis, because both acute and chronic illnesses increase with age (Gilford, 1988).
In an attempt to offset this future crisis, the Surgeon General has established national goals and guidelines directed toward health promotion and disease prevention. Specific recommendations for the older American include increasing, to at least 90%, the number of individuals over age 65 who have the opportunity to participate in a communitybased health promotion program (Healthy People 2000, 1990). Already, health care professionals have begun to implement health promotion programs focused specifically toward the elderly population.
These programs are designed to reduce this group's risk for various illnesses. One particular problem targeted for intervention is coronary artery disease and atherosclerosis.
Cardiovascular disease has developed quickly into the number one chronic illness in the United States, accounting for an estimated onesixth of the $500 billion spent on health care costs annually (American Heart Association, 1990): One of the strongest and most consistent predictors of cardiovascular disease has been found to be an individual's serum cholesterol level (Wallace & Anderson, 1987). Increased serum cholesterol, a major component in atherosclerosis, further accelerates a condition already precipitated by (he aging process. Indeed, the Framingham studies have shown that total serum cholesterol correlates with coronary artery disease in elderly men and women (Aronow, 1990). Additional studies, such as the Honolulu Heart Program (Benfante & Reed, 1990), have discovered a similar correlation between total serum cholesterol and increased risk of coronary artery disease in the elderly.
In a study by Fritzche and colleagues (1990), it was found that over 70% of persons aged 60 and older had serum cholesterol levels above the recommended level of 200 mg/ dL. The prevalence of hypercholesterolemia in the elderly, combined with the knowledge that high serum cholesterol levels are a major risk factor for cardiovascular disease, makes health promotion regarding reduction of fat and cholesterol intake critical. While costly medical interventions, such as pharmacologie treatment, have not effectively reduced hypercholesterolemia in elderly persons, health promotional efforts, which are relatively inexpensive, have proven successful (Higgins, 1988).
Programs, such as the Wisdom Project of the American Red Cross in Greater New York and the Healthwise Program: Growing Younger (Dychtwald, 1986), demonstrate that American elders are receptive to organized health promotion programs, and can receive numerous benefits from them. A study of health seeking behaviors, which compared older adults to younger adults, demonstrated that elders were significantly more conscientious in complying with recommendations than were their younger counterparts (Baiiseli, 1986). Unfortunately, most health promotion programs developed for the elderly focus on urban dwellers (Bender & Hart, 1987).
Elderly individuals residing in rural settings typically are isolated both geographically and financially from health care facilities and health promotion programs. Forced closings of small rural hospitals and difficulty recruiting health care providers further exacerbates problems of access. Because difficulty obtaining resources leads elderly rural residents to be more independent and self-reliant in health matters (Bigbee, 1991), health education efforts are of special importance for them.
Health promotion programs specifically designed for this group and more active involvement by health professionals are needed. In order to develop appropriate programs, the interest of rural elderly persons in health promotion education and their knowledge concerning nutritional health promotion must be determined.
It was the purpose of this study to answer the following questions:
* Are elderly persons in rural settings able to access cholesterol screening programs?
* Are elderly persons in rural settings knowledgeable about methods for promoting nutritional health?
* What types of information about cholesterol do elderly persons prefer?
A research proposal was submitted for use of human subjects, following its approval, the proposal was described to the coordinator of an Area Agency of Aging located in a rural area of Central Pennsylvania. Consent to proceed was granted by the coordinator, who then contacted the directors of the four busiest senior citizen centers in the area to ascertain whether they were interested in participating. All four directors agreed to be involved. Each center's director then was approached directly by one of the investigators and a date and time was arranged for data collection. On the prearranged date, the investigator visited the center, explained the purpose of the study to those in attendance, and answered any questions potential participants had. At that time, senior citizens were asked to voluntarily and anonymously complete the Cholesterol Awareness Instrument, a 24-item instrument designed to answer the questions of interest to this study (Dellasega & Brown, 1990). Completion of the instrument took approximately 20 minutes. One investigator and an undergraduate nursing student were available to assist those subjects requiring help with reading and filling out the instrument.
The Cholesterol Awareness Instrument was developed by the investigators. The basic format involved 24 simple questions with enlarged printing requiring minimal time to read, understand, and answer. Readability level, as analyzed by Right Writer (Rightsoft, 1989), was at the sixth grade level.
Forced choice questions were used to obtain information germane to the study questions. In order to measure access, subjects were asked if they had had a cholesterol screening. The subject's knowledge of and motivation for nutritional health promotion was assessed by asking about dietary changes, and awareness of high and low cholesterol food sources. Subjects also were asked about their concern over cholesterol, and what type(s) of information, if any, they preferred to receive on cholesterol reduction. Content for the questions was obtained from a review of the research literature, information from the American Heart Association, and expert opinion.
The study population was obtained from four rural senior citizen centers located in two different counties in Central Pennsylvania, the state with the largest U.S. rural population (Center for Rural Pennsylvania, 1990). For the purposes of the study, Juniata County has been designated as 100% rural and Mifflin County as 79% rural (Mifflin County Industrial Development Council, 1991). (Pennsylvania Department of Health criteria for rurality were used. These criteria are based on population density and status as a medically underserved area.) Response rates ranged from 58% to 98% at the four centers used for data collection, and were judged to be acceptable. The most frequent reason for non-participation in the study was lack of interest.
The sample of 116 subjects were all within the age category of old-old (mean age 75), with most subjects educated at the grade school or high school level. The most frequent marital status was widow(er), indicating that this sample was similar to elderly rural populations described elsewhere (Brown & Stokes, 1990; Johnson & Moore, 1988; and Krout, 1983). Overall, the sample rated their health as "good" or "excellent," with only a small percent (6%) considering themselves in a "poor" state of health (Table 1).
Description of Study Sample
Frequency analysis of responses to the study questions provided a picture of the sample's nutritional health habits. Sixty-six percent of respondents (M = 77) said they were concerned about their cholesterol level. While most people (n = 82) had had their cholesterol checked at least once in the past year, about one-fourth (31) had not. Of those who had not been checked, 74.2% or 23 people had no plans to pursue a screening in the future. Of those persons who did have their cholesterol checked, 60% had an elevated cholesterol reading.
Among the 60% of persons who had an elevated cholesterol reading (n = 27), there were nearly equal numbers who did (46.4%) and did not (53.5%) change their diets as a consequence of the elevated reading. The majority of subjects (91.4%) could not correctly identify the desirable cholesterol level, and although most (82%) could identify foods that were high in cholesterol, the majority (57%) were unable to identify sources low in cholesterol (Table 2).
Likewise, only 47% of subjects realized that exercise was a helpful adjunct in cholesterol control. When asked about sources they preferred for information regarding cholesterol reduction, subjects chose written information. This reinforces the notion of self-reliance in rural populations because written materials allow the learner a greater measure of independence than other teaching methods (Smitherman, 1981).
Older persons in rural settings, most of whom are unmarried females in good health with less than a high school education, are concerned about issues related to nutritional health promotion and have taken action to have their cholesterol screened. Concern over an elevated reading, however, led fewer than half of the people in this study sample to change their diet. The majority of participants knew about high cholesterol food sources, but were less informed about low cholesterol food sources, the role of exercise in cholesterol reduction, and the ideal cholesterol level. Written information was the identified method that subjects preferred for learning about cholesterol.
Much attention has been focused on hypercholesterolemia and heart disease in special population groups, such as the elderly. With the risk of coronary heart disease increasing with age, attempts to prevent or retard the disease process are appropriate interventions for older persons, even though debate continues on the pros and cons of aggressively treating hypercholesterolemia in persons who are over the age of 65 (Aronow, 1990; Forette, Tortrat, & Wolmark, 1990; Goldman, Kuhn, Scheldt, & Smith, 1990). Age alone cannot be the determining criteria for intervention with older persons who are in varying states of health. Also, health promotion efforts should not be limited to those who are young and fit, because the quality, as well as the quantity of remaining years of life, must be the standard. For the rural elderly in particular, strategies for maximizing health status are critical, because traditional resources for health care likely are to be unavailable.
Health promotion for older rural populations carries with it certain implications for professional nurses. Because nurses often are an important source of health care in geographically isolated areas (Turner & Gunn, 1991), they must fill many different roles (St. Clair, Pickard, & Harlow, 1991). Identification of needs, development of plans to meet these needs and the implementation of appropriate health care strategies often are the responsibility of a single nurse. Because rural nurses are a valued component of the health care system and personally, as well as professionally, acquainted with residents of rural areas (Seavy, 1991), they are in an excellent position to promote nutritional health in elderly persons.
Screening efforts must be easily accessible, geographically, by the target population. Mobile vans and programs in churches and senior centers enhance the ability of older persons to receive services. Hospital outreach programs and visiting nurses also can facilitate testing and screening efforts for elders who are location-bound. After screening, receipt of a cholesterol number by the client is not sufficient. Trie older person must have guidance from the nurse to interpret the screening results and an explanation of the limitation of a single cholesterol value. Cholesterol screenings usually provide total cholesterol readings and not the comprehensive information needed to develop nutritional interventions. Therefore, the nurse must gather data on the client's food intake, financial status, and support systems, as well.
Individuals with elevated readings also must know how and where they can readily obtain cholesterol subtractions and ratios that provide much more information on cardiovascular risk. When providing this type of cholesterol reduction information, nurses must give careful attention to the content and format of their presentations, because little is known about program characteristics that are attractive to older adults (Carter, Elward, Malmgren, Martin, & Larson, 1991).
Dietary modification is usually the first means of intervention for hypercholesterolemia. Most studies show a cholesterol lowering benefit after two years of dietary changes (Brown, Brunton, & Denke, 1990). Therefore, overall health status rather than the arbitrary criterion of age should be used to determine whether nutritional interventions are warranted. Information on foods to use, as well as those that should be avoided, should be incorporated in nutritional health education efforts, and the benefits of exercise for improving cholesterol subfraction ratios should be discussed. Access to food stores, and the ability to purchase low cholesterol items also should be assessed. Fresh foods may be difficult to obtain in some rural areas, as well as alternatives to traditional items, such as beans and legumes. Ethnic/cultural preferences for foods also must be incorporated into nutritional education, because beliefs and values influence eating patterns, and may be of particular importance in geographically isolated areas. Teaching should involve not only the person with elevated cholesterol, but the individual responsible for food preparation, if these two are different.
Mailed information or brochures placed in critical locations, such as the local food market are likely to be successful in reaching a target audience, because written material was identified in the study as a preferred means of communication. Information in the local newspaper, provided by an informed source, such as the community health nurse, is another method for communicating with elderly individuals. Fact sheets also can be circulated at the senior center.
Follow-up and reinforcement on health promotion interventions for elderly persons in rural settings plays an important role in changing health behavior. Written materials that are understandable with large, easy to read print can be mailed as a reinforcer. Individual telephone contact by the nurse could be another beneficial reminder.
In rural settings, the family is an important source of support and should be incorporated in any health care program. Because heart disease has a genetic component and many elderly people receive nutritional help from family members, family involvement in follow-up could have an effect not only on the client, but also on their relatives.
With an estimated 24 million hypercholesterolemic Americans age 60 and older (Brown, Brunton, & Denke, 1990) and the increased risk of coronary heart disease with increasing age, the elderly are ideal candidates for screening and intervention. In rural settings, reliance on self for health care places special importance on the contribution of health promotion programs. Control of costs related to chronic illness and improved quality of life are both relevant health care goals for the elderly that can be achieved with nutritional health promotion.
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Description of Study Sample