Health promoHon and illness prevention programs are important for addressing lifestyle behaviors that can contribute to illness. Usually these programs target the younger adult and emphasize preventing disabilities or chronic diseases later in life. Health care services funded by Medicare typically focus on treatment, cure, or both, rather than on illness prevention. With escalating health care costs, the focus has shifted toward health promotion and illness prevention for older adults. This shift has produced programs that include education about healthy living and methods to change health behaviors specifically for older adult participants. Such programs promote healthier lifestyles for older adults, emphasizing the quality of one's older years (Lederman & Forrar, 1986; Wagner, Gromaus, Hecht, & LaCroix, 1 991 ).
Reports of the effeciveness of health promotion programs for older adults show a variety of results. Not all reports are based on empirical data, and those that are frequently do not use standard instrumentation to measure results. This study assessed health risk behaviors using a health risk appraisal (HRA), an instrument that identifies risky lifestyle behaviors. This study sought to identify specific risky health behaviors of older adults and determine any changes over time in these health behaviors after the older adults participated in health promotion, health education, and illness prevention programs. The desired outcome of health promotion and illness prevention activities was to assist the older adults in sustaining or increasing functions deemed necessary for them to live independently and optimally in the community.
The HRAs use an individual's selfreported health behaviors, age, sex, certain physiological measures, and health risk history to estimate a person's risk of dying within a given period of time. Estimates are based on the Framingham (Ivanyi; 1971) and other epidemiological studies. Several different types of HRAs exist. Robbins and Hall (I960) developed one of the first HRAs entitled the "Health Hazard Appraisal" as part of the emerging emphasis on prevention in medical practice. While working on a prospective study on heart disease, Robbins observed characteristics, which he called hazards, that cause disease. Robbins and Hall advocated using the health hazard appraisal to help practitioners focus on disease prevention as well as cure (1960).
In the 1970s, the HRA became popular with private industry and business. Employees would complete HRAs and get feedback regarding their major health risks. Corporations frequently offered exercise or fitness programs in conjunction with the HRA programs. Employers liked the HRA because they inferred that it stimulated employees to engage in healthier behaviors that could decrease absenteeism and save the company money. Some programs have demonstrated cost savings in the company's health care plan for employees (Pilon & Renfroe, 1990; Sherman, 1990).
In the 1980s, several senior citizen programs designed health promotion activities specifically for older adults. Dychtwald compiled reports of these programs in Wellness and Health Promotion far the Elderly (1986). Most of these programs focused on group sessions of exercise, nutrition information, smoking cessation, and some aspect of mental health, often stress reduction. Evaluation of the programs seldom involved a pre-participation measure of the participant's health behaviors making an evaluation of changes to healthier behaviors difficult to accomplish.
Few researchers have reported studies that focused on health risk behaviors along with health promotion and education interventions. In one study that did, Bamberg, Acton, Goodson, Go, Struempler, and Roseman (1989) found statistically significant improvement in the health behaviors of 55 subjects ages 21 to 68 years. After a 13-month period, subjects scored lower on saturated fat in their diets and blood cholesterol levels. They scored higher on exercise, seat belt use and colorectal examinations. The authors concluded that the HRA provided instructions and stimulus for people to incorporate positive health behaviors thereby reducing their risk for disease and illness.
Ellis, Joo, and Gross (1991) suggested that the HRA may motivate older adults more than it motivates younger adults to change behavior. They used an HRA with 247 adult subjects divided into one group age 60 and older and one group for those younger than 60. The older group rated the HRA as more helpful than did the younger group. Older subjects in both groups, especially older women, reported a higher intent to change health behaviors in response to the HRA.
Other studies have indicated that behaviors are more likely to change if health professionals use counseling and interventions along with the HRA (Doerr & Hutchins, 1981; Fultz, 1977; Pilon & Renfroe, 1990; Whetstone & Reid, 1991).
In this quasiexperimental study, the investigators monitored the health behaviors of subjects who attended a community-based clinic for 1 year. Clinic clients completed the HRA as part of their initial clinic assessment (baseline). Clients who volunteered to participate in the study completed the HRA again at 6 months post baseline (Test 1) and 12 months post baseline (Test 2). The investigators compared the data obtained from baseline with the responses obtained during Test 1 and Test 2. The Human Research Advisory Committee approved the study, and the investigators assured all clients that their willingness or unwillingness to participate in the study would in no way affect their care at the clinic.
Of the 68 subjects, 55 were women; 46 African Americans and 22 Caucasians. Most subjects were black females. Subjects' ages ranged from 65 to 98 years. Most subjects were between the ages of 74 and 85 (41%), with a mean age of 79.
The investigators used the Healthier People Health Risk Appraisal developed by the Centers for Disease Control and Prevention in Atlanta (1988). This HRA identifies risky health behaviors and provides suggestions for correcting those behaviors and incorporating healthy behaviors into one's lifestyle. Healthier People, a 45-item self-administered questionnaire, consists of openended and multiple choice questions, along with physiologic measurements such as blood pressure, weight, height, and cholesterol level.
Foxman and Edington (1987) found that the Healthier People HRA could accurately identify risky health behaviors in younger adults. An assessment of the reliability of the findings, found that only the category related to physical activity fell below the desired .80 correlation (.65) (Smith, McKinlay, & McKinlay, 1989). Test-retest reliability (4-week interval) with a sample of 51 older adults ages 65 to 91 indicated that older adults responded to the instrument consistently on repeat testing (r = .87) (Thatcher-Winger & Leath, unpublished data). Others have established initial validity of the Healthier People HRA for coronary heart disease and heart attack risk (Smith, McKinlay, & McKinlay, 1991).
Healthier People identifies controllable factors that can contribute to the development of chronic illness and provides information that will encourage the respondent to work on changeable lifestyle habits. Some Healthier People items ask for health history information to calculate the subject's overall risk level. The investigators excluded these items from the data analysis. They analyzed data only from items that measured health behaviors the subjects could feasibly change. Those items were rectal/prostate examination, last mammogram, breast selfexamination, professional breast exam, high fiber diet, dietary fat, exercise, seat belt use, and perceived physical health.
All subjects were enrolled in the North Little Rock Community Seniors Health Services (NLRCSHS) project. Health care sources included health maintenance, promotion, education, and prevention using a multidisciplinary team managed care model (Leath & Thatcher, 1991). Upon enrolling in the project, clients completed the HRA as part of their initial assessment to assist in identifying lifestyle and health behaviors. Along with health history and other examination data, the team used the computerized HRA results to design individualized care plans for clients. In addition to the individualized health maintenance/promotion interventions, the team offered a health promotion program with a different topic and activity each month. The team encouraged clients to participate in these programs along with their individual activities.
Monthly Self Breast Exams
Approximately 6 months after completing the initial HRA (baseline), those clients who volunteered for this study completed the HRA again (Test 1). At approximately 12 months after baseline, subjects again completed the HRA (Test 2).
For both Tests 1 and 2, the investigators contacted the subjects by phone and made appointments to visit them at home to complete the HRA. The questionnaire took 30 to 45 minutes to complete depending on the amount of assistance needed. Poor eyesight or reading skills accounted for most of the assistance required. During the visit, the investigator measured the subject's weight and blood pressure. Previous studies have concluded that measuring the values rather than relying on self-reports increased reliability of these physical indicators (Smith, McKinlay, & McKinlay, 1989). After the home interview, the investigators reviewed the subject's medical record to verify the accuracy of demographic data.
The investigators used the paired t test to compare subjects' HRA responses on the nine selected health behaviors at baseline with responses at Test 1 and Test 2. Results showed no significant changes from baseline to Test 1 on any of the nine health behaviors. However, analyses revealed statistically significant changes (p = .0001) in six of the nine health behaviors from baseline to Test 2, indicating positive changes in health behaviors of the subjects.
The one item to which only men responded asked about the length of time since they had last had a rectal or prostate exam. At baseline, 25% of them reported never having had a prostate exam. At Test 2, that percentage decreased to 16% (p = .0001), with more of the men reporting having had a prostate exam within the previous year.
Only women responded to two items. One asked about their use of mammograms. Results revealed that the percentage of women who had never had a mammogram decreased from 53% at baseline to 31% at Test 2 (p = .0001). On the other item, women were asked about the frequency of breast examinations. Monthly breast self -examinations increased 5% from baseline to Test 2 (p = .0001), and the percentage of women reporting "rarely or never" performing breast self-exams decreased by 9% over the same time period (Figure 1). The percentage of female subjects reporting breast exams by a professional within the year increased from 32% at baseline to 48% at Test 1 and remained the same at Test 2 (p = .0001) (Figure 2)
When asked about daily consumption of some food high in fiber, most subjects reported already eating foods high in fiber (90%) at baseline. Nevertheless, this behavior increased to 97% at Test 2 (p = .18) (Figure 3). The frequency of eating foods high in fat decreased from 83% at baseline to 70% at Test 2. The percentage of subjects eating a diet low in fat stood at nearly 30% at Test 2 (p = .04) (Figure 4).
Professional Breast Exams
Fiber in Diet
In an average week, the number of times subjects reported engaging in 20 minutes of non-stop physical exercise "at least three times a week" increased from 38% at baseline to 69% at Test 1, but decreased to 58% at Test 2. The lower frequency of engaging in physical exercise "one to two times a week" increased from 20% at baseline to 25% at Test 2 (p= .002) (Figure 5). The subjects who reported fastening their seat belts 100% of the time increased from 38% at baseline to 70% at Test 2 (p - .0001) (Figure 6).
Subjects rated their own physical health as excellent, good, fair, or poor in response to the question, "Considering your age, how would you describe your overall physical health?" The percentage of subjects responding "good" increased from 42% at baseline to 47% at Test 2 (p -.0001) (Figure 7).
The investigators compared the health behaviors of older adults with baseline measurements at two testing times: 6 months and 12 months. The greatest changes occurred over the time span of 12 months. This suggests that older adults will change lifestyle behaviors, but will make the changes slowly. The length of time required for older adults to change is similar to the time it takes younger adults to change (Acquista, Wachtel, Gomes, Salzillo, & Stockman, 1988; Bamberg et al., 1989; Foxman & Edington, 1987).
This study indicates that women are more likely to perform breast selfexaminations instead of obtaining examinations from medical professionals. According to Kane, Kane, and Arnold (1985), women detect 80% to 90% of primary breast cancers themselves, and breast self-examination has been promoted as an inexpensive way to detect cancer. Moreover, the American Cancer Society recommends an annual mammogram for women over age 40. In this study, the number of women obtaining mammograms increased over time.
A legal factor may have artificially influenced the finding that seat belt use increased dramatically to 70% usage. Subjects completed the last questionnaire after the Arkansas legislature passed a mandatory seat belt use law. Another artifact related to this finding is that the senior citizens' buses, which many of the subjects rode regularly, do not have seat belts available for use.
Exercise in these older adults increased after participation in the project. Often times, the clients exercised by walking in groups. This health behavior may keep older adults out of the hospital, or decrease the length of a hospital stay (Lubbin, Weiler, & Chi, 1989).
Almost half of the subjects reported that their health was good, but this may involve the use of coping mechanisms. According to Kane, Ouslander, & Abrass (1989), older adults generally report their health as "good," although they have more chronic conditions and impairments than younger adults have. This disparity highlights older adults' use of coping mechanisms, thus adapting to problems by ignoring or denying them. Although the number of subjects was small and did not represent all older adults, the findings are consistent with other studies that used the HRA on younger adults (Bamberg et al., 1989; Ellis, Joo, & Gross, 1991).
Older adults have special needs for managing chronic health problems and psychosocial changes related to aging. Nurses must be cognizant of these needs as quality-oflife issues. They can develop strategies in nursing practice, education, and research to help older adults improve their disease prevention and health promotion behaviors.
In clinical nursing practice, nurses can apply the findings of this research study by using the HRA as an assessment tool in managing the care of their older patients. By using the HRA data, nurses can promote continuity of care as they communicate the results to other health care providers and develop multidisciplinary teams. The team can use information obtained from the HRA to develop plans of care with realistic and individualized goals. Using such plans, the team's focus would be on health, rather than just illness. Primary and secondary prevention programs would be geared to an older client's individual needs, and the outcomes would be evaluated according to health behavior and lifestyle changes. Clinical nurses can use HRA data in discharge planning by obtaining a baseline of measurable health behaviors that health care providers could monitor from setting to setting. Used in this way, the HRA would help to bridge the gap that occurs when a client moves from one health care environment to another.
Exercise Groups I, II, and III
Seat Belt Use
As health care delivery continues to move toward community-based care settings and away from institutional settings, nursing education must keep pace. Educators must emphasize the importance of older adults' lifestyle behaviors and their relationship to health promotion and disease prevention. The HRA is a vehicle that could enable nursing students to be prepared to provide individualized care to older adults living in the community. Using the HRA, students could learn nursing care techniques adapted to cultural lifestyles, customs, and individual needs of their older clients.
More clinical nursing research is needed involving community-dwelling older adults and their needs for community-based health care services. Nurse researchers can use the HRA in these endeavors, for example, they could modify the HRA to assess additional risk areas such as falls, cognitive impairment, drug interaction, nutritional deficits, and other domains in which lifestyle behavior changes would reduce risk and promote health.
Further studies using the HRA with health promotion should include a control group that does not receive the interventions. Such a design could define the effect of directed health promotion interventions on HRA changes.
The results of this study indicate that the appropriate time span for administering the HRA to detect health behavior changes is 12 months. The longer testing interval also would avoid the possible effects of test wiseness from more frequent exposure to the HRA. A longitudinal follow-up study is needed with a subject group of clients in a community-based clinic. Nurse researchers could measure the lifestyle and health behavior changes of such subjects by administering the HRA after 5 years and 10 years. The knowledge learned about long-term maintenance of lifestyle changes in older adults could prove invaluable to gerontological nursing and to improving the health care for this country's growing population of older adults.
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