Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Perspectives of Frailty Among African American Men and Women

Deborah A. Lekan, PhD, RN-BC; Evelyn Hoover, PhD, RN; Sarah Abrams, MSN, RN

Abstract

Frailty is a syndrome of impaired homeostasis and poor response to stressors leading to adverse health outcomes. The aim of the current study was to explore lay perspectives about frailty among African American adults. Thirteen men and women participated in two focus groups. Content analysis yielded six themes: (a) Physical Impairment With Loss of Independence; (b) Can Happen to Anyone, At Any Age, At Any Time; (c) Mind–Body Connection; (d) Affects All Aspects of Life; (e) Positive Attitude and Prayer Guard Against Frailty; and (f) Be In Tune and Stay Connected. Findings suggest psychological and social factors, including a positive attitude and spirituality, are linked to physical function and well-being in aging and are influential in frailty. Culturally tailored interventions that focus not only on promoting physical function but also address psychological, social, and spiritual domains may foster the resilience needed to prevent or alleviate frailty in African American individuals. [Journal of Psychosocial Nursing and Mental Health Services, 56(7), 20–29.]

Abstract

Frailty is a syndrome of impaired homeostasis and poor response to stressors leading to adverse health outcomes. The aim of the current study was to explore lay perspectives about frailty among African American adults. Thirteen men and women participated in two focus groups. Content analysis yielded six themes: (a) Physical Impairment With Loss of Independence; (b) Can Happen to Anyone, At Any Age, At Any Time; (c) Mind–Body Connection; (d) Affects All Aspects of Life; (e) Positive Attitude and Prayer Guard Against Frailty; and (f) Be In Tune and Stay Connected. Findings suggest psychological and social factors, including a positive attitude and spirituality, are linked to physical function and well-being in aging and are influential in frailty. Culturally tailored interventions that focus not only on promoting physical function but also address psychological, social, and spiritual domains may foster the resilience needed to prevent or alleviate frailty in African American individuals. [Journal of Psychosocial Nursing and Mental Health Services, 56(7), 20–29.]

Although many individuals remain healthy and resilient in their later years, some become more vulnerable and frail. Frailty is a syndrome that arises from physiological vulnerability and impaired homeostatic reserve that leads to reduced resilience and poor “bounce-back” in response to stressors (Feng et al., 2017). In a recent systematic review, the prevalence of frailty in community-dwelling older adults ranged from 4% to 59%, and an overall prevalence of 10.7% depending on the assessment tool used (Collard, Boter, Shoevers, & Oude Voshaar, 2012). Individuals who are frail are far less able to withstand even minor health threats and often experience poor outcomes or complications following treatments or surgery. These poor outcomes can include delirium, falls, pneumonia, rapid functional decline, prolonged recovery and dependency, institutionalization, and increased mortality (Collard et al., 2012). Research indicates that frailty may be prevented or alleviated; thus, efforts to identify frailty and appropriately intervene are needed to minimize its adverse consequences and improve public health (Lang, Michel, & Zekry, 2009).

Many frailty assessment tools are used in clinical practice, each reflecting different perspectives and measurement methodologies, with most having a biomedical orientation (Cigolle, Ofstedal, Tian, & Blaum, 2009; Rodríguez-Mañas et al., 2013). Frailty is increasingly recognized as a multidimensional construct that encompasses not only physical factors but also psychological and social factors (Gobbens, Luijkx, Wijnen-Sponselee, & Schols, 2010; Rodríguez-Mañas & Sinclair, 2014). However, limited research exists on the psychological and social components that should be included in the frailty assessment (Gobbens et al., 2010). Research is needed to better understand frailty to guide development of more effective tools for assessment and strategies for prevention and intervention to improve quality of care and outcomes. The purpose of the current study was to explore lay perceptions of frailty in African American men and women.

Method

Study Design

The current study used a qualitative descriptive design and cross-sectional approach. Focus group methodology was used for data collection for two reasons. First, valuable insights emerge as a result of synergistic energy and discussion of a diversity of opinions and ideas, and second, focus groups are appropriate when there is limited research and understanding of a particular concept in a population (Krueger & Casey, 2015).

Participants and Recruitment

The research team recruited African American adults who were residents of a senior public housing apartment building in an urban Southeastern city in the United States and were selected according to the following inclusion criteria: (a) 55 and older, (b) self-identified as African American, (c) able to participate in one 90-minute focus group, and (d) able to clearly express views about frailty. Age criteria were determined considering the need to explore frailty initially with individuals with unknown frailty status to provide diverse perspectives about terminology and concepts that would inform future work with individuals identified as frail. Furthermore, age criteria were based on evidence that frailty develops earlier in African American individuals (Morley, Malmstrom, & Miller, 2012). The onsite social worker identified eligible participants, elicited their interest, and provided a study flyer. Individuals indicating interest were contacted by the research team (E.H., S.A.) and provided additional information.

Data Collection

After obtaining signed informed consent from 13 participants, the research team administered a brief questionnaire comprising sociodemographic and clinical information. The Timed Up & Go (TUG) test, a validated indicator of frailty, was administered (Savva et al., 2013). The TUG score is the time in seconds to stand up from a chair, walk 10 feet at usual pace, turn, walk back to the chair, and sit down. The TUG test is a clinically practical and valid test for frailty screening (Brown, Sinacore, Binder, & Kohrt, 2000; Savva et al., 2013). A cutoff point of ≥16 seconds was used to indicate frailty (Savva et al., 2013).

Focus Groups

Two focus groups were formed based on male and female gender and held on different days in a private room in the apartment building. The purpose for creating same-gender groups was to facilitate group synergy to elaborate concepts related to frailty and provide a comfortable social environment in which participants felt at ease expressing their thoughts, beliefs, and feelings about personal and potentially sensitive issues related to frailty and to minimize self-censoring of expressions that may occur in heterogeneous groups (Stewart & Shamdasani, 2015). A member of the research team, an African American nurse who received training in focus group interviewing from a qualitative researcher with expertise in this area, moderated the focus groups. She used an interview guide that included six topical questions: (a) What is the definition of frailty? (b) What are features of frailty? (c) What are causes of or contributing factors to frailty? (d) How can frailty be prevented? (e) What is the impact of frailty? and (f) What can others such as family, friends, physicians, and nurses do to help persons who are frail? In addition, the guide included prompts for additional information about ideas expressed by participants. The sessions were digitally recorded, and two note-takers (D.A.L., S.A.) diagrammed the seating arrangement and took notes on statements and observations of participant nonverbal behaviors, side comments, and laughter. Each session lasted approximately 90 minutes. The research team held debriefing sessions immediately after each focus group to share observations and submit notes that contributed to the analysis. Refreshments were provided, and $25.00 cash incentives were distributed upon completion of each focus group.

Data Analysis

A professional transcriptionist transcribed verbatim the digital audio recordings, which were then reviewed and edited by the focus group interviewer (E.H.) for accuracy. Each coauthor subsequently read the transcripts and made marginal notes using phrases, ideas, concepts, and initial impressions (Rabiee, 2004). Content analysis was used for a systematic analysis of the raw data that was pooled for the focus groups. This mechanism for coding data into content-related categories generates useful meanings with a minimal loss of information from the original data (Elo & Kyngas, 2008). Specifically, deductive content analysis was used, in which categories are structured in advance based on the six topics for the interview questions (Elo & Kyngas, 2008). All data were reviewed and coded for correspondence with or exception to the topical categories. Inductive content analysis was used to identify different topics or categories within that question (Elo & Kyngas, 2008). Data analysis using the long table as described by Krueger and Casey (2015) was also performed.

For the initial grouping of data, each transcript was read line by line and segments of text were identified that included descriptive statements or concepts. Those text segments were then cut out and taped to a large flip-chart paper and grouped according to the topical questions (e.g., definition, cause) with similar ideas placed together. To visualize the data, groups of text segments were then reorganized according to concepts and categories and synthesized into themes (Figure). The institutional review board for the university and county housing authority approved study procedures.

Data synthesis of focus group discussions.

Figure.

Data synthesis of focus group discussions.

Results

Two focus groups were conducted with 13 participants, including five men and eight women. There were no significant differences in participant responses by gender. Participant characteristics are described in the Table. Average age of participants was 71.2 years; most were single, widowed, or divorced. Most participants were high school graduates and reported at least one chronic medical condition in which the most common diagnoses were hypertension and diabetes mellitus. Eight participants, each older than 65, scored as frail according to the TUG test. Content analysis and synthesis yielded six themes: (a) Physical Impairment With Loss of Independence; (b) Can Happen to Anyone, At Any Age, At Any Time; (c) Mind–Body Connection; (d) Affects All Aspects of Life; (e) Positive Attitude and Prayer Guard Against Frailty; and (f) Be in Tune and Stay Connected.

Characteristics of Focus Group Participants (N = 13)

Table:

Characteristics of Focus Group Participants (N = 13)

Physical Impairment With Loss of Independence

Participants defined frailty as physical limitations resulting in loss of independence and not being able to perform physical activities as usual. The need to slow down and adjust lifestyle habits was also posited as an aspect of frailty. A change in function was a signal for potential frailty, where localized impairments are noted: “I feel like my hands, sometimes, be locking because, you know, it hurts sometimes. Like knocking on the door, something like that, they hurt sometimes. I feel like they're getting fragile.” A more all-encompassing view of frailty was exemplified by multiple, compounding deficits and dependency, as expressed by one participant:

Well I guess…[I] won't be able to dress myself, prepare me some food by myself, and live by myself without having help…when I can't move, can't get up out of my bed every morning by myself. That's when I think I'll be frail.

Frailty also existed on a continuum of function and could mean not being able to travel alone with the need for some accommodation to physical demands that may challenge one's capacity, to being “extremely handicapped” or completely dependent on others and living in a nursing home.

Can Happen to Anyone, At Any Age, At Any Time

Frailty is not restricted by person, status, age, or time, as illustrated by one participant: “A frail person can be anybody, can be doctor, or a lawyer, whatever.” Although frailty was a realistic issue to be faced with aging, as reflected in the statement, “As you get older you know you're getting frail,” participants also provided descriptions of younger individuals who were frail, especially where compounding stressors take their toll:

You have a situation where maybe a young lady perhaps have two or three children and don't have any support, maybe working a job, and then coming home and taking care of children. She don't eat properly, don't rest properly and so she becomes frail. Perhaps you can even see in the face, it's like the life is being taken away from this person.

Frailty at younger ages was typically associated with physical disability due to neuromuscular conditions, such as cerebral palsy or traumatic injury.

Objective descriptions of physical frailty included physical alterations and slowness: “...an old, old man, hump in the back, walk real slow.” Although a frail person would typically appear thin and weak, individuals who were heavy could also be frail. An appearance of imbalance was also a feature of frailty, as stated by one individual: “I had a bad fall...twisted my back…I lost weight. When I looked in the mirror, I looked frail. I looked thin...I was feeling frail then because I wasn't walking steady, and I wasn't feeling that great either.” However, participants stated that the objective appearance of physical frailty could be deceiving, as hidden psychological factors could be an underlying operative in frailty that conferred vulnerability: “...I don't think you can just look at a person and tell because you don't know what's inside of them.”

Participants indicated that frailty is dynamic; it “come[s] and goes” and manifests in stages with potential movement across stages. Frailty level is influenced by health-promoting behaviors, and nutrition was especially important, as reflected in these quotes: “…getting a better diet; that would change their stages of frailty because usually they would progress, maybe gain weight...they would begin to move about better and feel better,” and “…I see people that's thin, and if they're fed and taken care of properly, it revives that person; is revived to do things they thought they never could do.” The possibility of descending into frailty and recovering from it was frequently discussed by participants:

…I don't think it's permanent because if a person gets to a point that they cannot walk or stand alone, and they graduate from standing and from not standing to being able to use help, like a walker or a cane. And then they graduate from the walker to the cane, and then from that be able to walk without anything. That's improving…frailty.

Internal and external factors can influence dynamic frailty.

Mind–Body Connection

Participants defined frailty as physical limitations that affect independence, but they also discussed a mind–body connection in which an interconnectedness and ongoing interaction existed among the physical, psychological, social, and spiritual domains that influence frailty: “You could...become frail by not eating. You got to eat and nourish your body physically, spiritually, and mentally.” In addition, an underlying emotional state can provoke vulnerability to frailty: “If you aren't feeling uplifted, naturally, you're going to be in a down situation, even if you have an illness, you know what I mean. It's basically psychological really until you get some help. It's mind over matter, you know.” However, this vulnerability was not always noticeable; much discussion highlighted the impact of stress and worry on vulnerability to frailty. Focus group discussion revealed that one could be emotionally frail as well as physically frail: “It works both ways. It's all, like I say, in the mind…” Negative emotional states adversely impact one's ability to consistently engage in self-care so that the body does not “get weak.” For example, worry may have deleterious consequences that could increase risk for frailty: “...worrying...you get it on your mind and nothing else and you're just thinking about that and that's all in your mind. You just don't really… care.” This spiral of a negative emotional state, social isolation, and self-neglect with deterioration in self-care was also cited as a concern:

...when you're frail, you don't feel good; you don't feel well. And so there's quite a number of things you just don't do. You may get up or not feel like brushing your teeth or washing your face. Or you may not feel like taking the trash out or dishes in the sink may be building up...

Participants also talked about changes in memory in frailty, such as being forgetful and feeling “discombobulated,” which suggested a temporary psychological instability that affected physical and psychological function.

Affects All Aspects of Life

Frailty affects all aspects of life and prevents an individual from enjoying life to the fullest. There was broad agreement among participants of the negative impact of frailty: “I think frailness would impact the rest of the things in your life, how you take care of yourself and how you perceive things…” The magnitude of the impact of frailty in the physical, psychological, and social domains of function was regarded as considerable: “You can't do like you used to do. You don't think like you used to think, or get forgetful…everything come along with frailty.” Frailty was also portrayed as a socially disconnected life space, in which the individuals is sidelined from the mainstream and unable to keep up with the social flow: “...not in the race.”

Positive Attitude and Prayer Guard Against Frailty

Participants identified a range of health-promoting behaviors to prevent frailty, including proper nutrition and getting sufficient rest and exercise. A positive attitude was important to engaging in those behaviors to prevent frailty: “...you have to have a willing mind to do what you want to do. If you don't want to do it, you sit and get frail. If you don't, you have to get up and go.” Participants talked about the importance of staying as physically active as possible: “You have to keep moving. If you don't move it, you lose it,” and certain social behaviors helped individuals avoid becoming frail, such as “clean living,” “do what you're supposed to do,” and “...treating everybody as you want to be treated and you don't have any problem getting frail.” Participants also thought that cognitive activities, such as reading and doing puzzles, and emotional self-regulation kept the mind active and frailty at bay, and these activities required a positive attitude.

Spirituality and religious practices were powerful forces for prevention of frailty. Prayer and “having a personal relationship with Jesus Christ” buttressed one's inner strength to prevent frailty. Citations from scripture often elaborated this perspective:

...there are things in the book of Proverbs, and in the Psalms, and even in Jesus' teaching that could help a person have an uplifting attitude about things in life and the value of their life in such a way that they would not become frail or stay frail.

The importance of drawing on spiritual and religious resources to sustain a positive attitude and hope was often emphasized: “The word says, whatever you ask the father in my name, says Jesus, he will do it. And then you pray and ask God not to let you be frail in the name of Jesus.”

Be in Tune and Stay Connected

Participants discussed the importance of a positive, proactive, and accepting attitude when interacting with individuals who are frail. This meant that others should not judge them, and should get to know them and respect their independence, but also know when and how to get involved. Providing material assistance, such as housekeeping and bringing a meal, was most important, and churches and neighbors are typically prepared to provide these things and would be expected to follow through without asking. When asked what physicians or nurses could do to help frail individuals, some participants noted that physicians are “kind of rude” and abrupt; one participant stated, “They give you the medicine…they walk right off.” Participants expressed the importance of providers developing a relationship with the individual and spending time learning about his/her needs: “I think they can maybe sit down with the person and talk to them about what's causing or contributing to their frailness and then maybe suggest a nutrition program that would help them.” Male participants' opinions differed in this regard; men spoke about not having the life skills to manage housekeeping, cooking, and self-care as women, and would “let themselves go.”

Participants also emphasized keeping in touch and being socially engaged with individuals who are frail: “...bring them gifts on their birthday…take them out. Go to dinner, movies...keep them active. Don't let them sit back and think about their frailty.” Health care providers can be supportive by listening, asking the right questions about needs and preferences, and mobilizing resources. Personal care providers were identified as the most important resource in the support network in providing for a multitude of needs, and the role of the health care provider is to facilitate that resource: “...that's what the doctors do, they sign that paper.... Then they send the person out to help me.”

Discussion

Frailty was defined by focus group participants as physical impairment that impacts independence in self-care, and these impairments could be mediated by an individual's emotional state, such as a positive attitude, “a willing mind,” motivation, and a spiritual grounding. Participants believed that these behaviors would sustain an individual's highest level of function and well-being to prevent frailty or alleviate or reverse its effects. The importance of a positive outlook that bolsters efforts to cope and carry on despite physical challenges from frailty has similarly been noted in a Swedish study of frail older adults (Ebrahimi, Wilhelmson, Eklund, Moore, & Jakobsson, 2013). Impaired physical function has also been identified as a dimension of frailty in a study of frail older adults in the Netherlands, in which this dimension included physical appearance, physical decline due to chronic diseases, and mobility impairments (Puts, Shekary, Widdershoven, Heldens, & Deeg, 2009).

Although no participant self-identified as frail, several acknowledged having physical limitations they associated with frailty, but stated they would not become frail until something happened that resulted in significant dependence in self-care. Qualitative research also finds that frail older adults actively resist self-identifying as frail due to negative stereotypes (Ebrahimi, Wilhelmson, Moore, & Jakobsson, 2012; Nicholson, Meyer, Flatley, Holman, & Lowton, 2012). Participants emphasized observable features of frailty, which include appearing thin and weak; observations that were similarly identified in surveys of physicians (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004; Rodríguez-Mañas et al., 2013). However, frailty could also be detected by observing subtle changes in facial expressions and body posture indicating problems “beyond the surface,” a perspective that is strikingly similar to clinician appraisals of frail older adults, indicating a general impression, “known when seen” (Nicholson, Gordon, & Tinker, 2017, p. 350).

Participants articulated causes and contributing factors to frailty that spanned the physical, psychological, social, and spiritual domains. These findings concur with research indicating that frailty comprises multiple domains of functioning (Ebrahimi et al., 2012; Gobbens et al., 2010; Nicholson et al., 2012; Puts et al., 2009); however, the current study findings emphasized the interactions between these domains and highlighted their importance. Although participants discussed the physical aspects of frailty as most visible and tangible, psychological and social factors were overall more salient in the frailty life cycle. Depression and worry could impact self-care and healthy behaviors (e.g., nutrition, physical activity, sleep), and lead to frailty, and spiritual resources could mitigate or prevent frailty by motivating health-promoting behaviors. Conversely, decline in function and self-care ability could adversely impact mood and motivation and lead to self-neglect, further decline, and frailty. Psychological aspects such as being forgetful or “discombobulated” were also discussed as a more innocuous or temporary aspect of frailty rather than frailty that may be accompanied by cognitive deficits (Kelaiditi et al., 2013). The quality of social support (more than the number and frequency of contacts) and a responsive network are important for the well-being of African American older adults (Nguyen, Chatters, Taylor, & Mouzon, 2016). In qualitative research on lay perspectives of frailty, physical conditions such as medical problems and functional impairments were interrelated with psychological and social problems such as depression, fear, loneliness, and isolation in descriptions of frailty (Puts et al., 2009). Indeed, links between cognitive and psychological issues such as depression and dementia are now more broadly recognized; however, there is insufficient understanding of these domains (Rodríguez-Mañas & Sinclair, 2014). Collectively, the current findings agree with literature that advocates for a more holistic approach to frailty assessment, with particular attention to psychological and social factors (Andreasen, Lund, Aadahl, Gobbens, & Sorensen, 2015; Gobbens et al., 2010; Rodríguez-Mañas & Sinclair, 2014).

Spirituality and religious practices were emphasized throughout the focus group discussions as primary sources of inspiration that helped sustain an uplifting attitude, which motivate efforts to promote health and prevent frailty. The importance of spirituality and religious practices in fostering positivity, mental health, and resilience in African American individuals has been reported in the literature (Subramaniam, Camacho, Carolan, & López-Zerón, 2017), but has not been previously studied in relation to frailty. Spirituality and religious practices help African American individuals preserve health and independence (Jett, 2002; Waites, 2012) and promote psychological and social hardiness for positive coping (Lewis, Hankin, Reynolds, & Ogedegbe, 2007). There is limited research on these factors in frailty or how spirituality and religious practices can be assessed in clinical practice. In a study to elicit feedback from Caucasian frail older adults about the adequacy of a frailty assessment tool, spirituality and psychosocial issues were identified as missing elements (Andreasen et al., 2015). Frailty could be a threat to psychological well-being, but spirituality and religious practices were cited by participants as important in preventing and alleviating frailty.

The appreciation of frailty as both age-related and age-neutral by participants suggests that frailty is impacted by a myriad physical, psychological, social, and spiritual factors, and not solely driven by increasing age. This perspective concurs with literature that finds that chronological age alone is a poor determinant of health status and that biological age, which reflects factors such as lifestyle, medical conditions, socioeconomic status, psychosocial well-being, and the environment, is a more salient measure of overall health (Yoo, Kim, Cho, & Jee, 2017). These factors are especially important to consider in the African American population as life course stressors, systemic disadvantages, and health disparities confer excess vulnerability to frailty (Cigolle et al., 2009; Morley et al., 2012).

In other studies, participants described frailty as dynamic and transitional, where movement between different levels of frailty is possible, and that frailty can be reversed, a perspective that mirrors current understandings of frailty (Frost et al., 2017; Lang et al., 2009). Participants in the current study described a feature of frailty as not being able to “snap back” from a stressor; this perspective has been similarly characterized in the literature as poor “bounce-back,” which is attributed to impaired homeostasis and resilience (Rodríguez-Mañas et al., 2013). Resilience has also been characterized as a state of robust physiological reserve and capacity to maintain or regain well-being during or after adversity (Whitson et al., 2016). Resilience not only refers to response to an immediate stressor, but is ongoing. Participants also indicated that frailty required making adaptations to declining physical abilities and resetting expectations, which is similarly framed in resilience, which is characterized as a dynamic process that involves adaptation and adjustment (Aburn, Gott, & Hoare, 2016). Coping with changes helps foster a sense of competence that is important in frailty, and has been similarly noted by Ebrahimi et al. (2012), in which frail older adults expressed that adaptations to mobility deficits allowed them to experience themselves as fully functioning. Adaptation also means acknowledging one's abilities and recognizing deficits requiring compensation. This perspective was emphasized by focus group participants; it is important for individuals to focus on what they can do now, and not on what they could do in the past as a part of the aging experience and way to prevent frailty. Overall, these perspectives agree with the concept of response shift, in which the value of an individual's expectations may change over time as circumstances change, which helps preserve one's identity, self-esteem, and self-efficacy (Carr, Gibson, & Robinson, 2001). However, findings from a longitudinal qualitative study of Swedish frail older adults indicated that the need to manage an array of incomprehensible symptoms often led to uncertainty and mistrust about the body and its functioning (Ebrahimi et al., 2013). In this regard, focus group participants also reflected on the precariousness and uncertainty of frailty, and the possibility of movement between levels of frailty (Lang et al., 2009).

Psychological distress leading to worry, depressive reactions, and “being mean” were cited by participants as indications of not adapting to the demands required to maintain one's health to prevent or alleviate frailty. The literature reports that reactions to failing health and increasing dependence due to depression may be manifested as denial, anger, and recalcitrant behaviors, especially in men (Smith, Braunack-Mayer, Wittert, & Warin, 2007). These behaviors may be influenced by social norms and expectations for masculinity where men are expected to be independent and in control (Smith et al., 2007). To counteract potential negative reactions that could influence frailty, participants advocated to maintain a positive attitude and optimism, a finding that is in agreement with other research in which maintaining a positive attitude was an important coping mechanism in frailty (Ebrahimi et al., 2013; Jett, 2002).

Frailty has a detrimental impact on social function and creates a social distance. Frailty as an ambiguous social space that displaces the individual outside of the social network has been similarly described, in which older adults are sequestered with little guidance about norms and roles (Nicholson et al., 2012). Such social isolation also underscores the risk for self-neglect as well as neglect by others (Heath & Phair, 2009), as was also expressed by focus group participants. Although social support was necessary in preventing and alleviating frailty, participants also emphasized that the responsiveness of a support network was important, which involved other individuals knowing others' needs and providing help without asking. The quality of the social network to buoy spirits and sustain motivation in addition to providing material forms of support has been found to be of great importance for African American older adults (Nguyen et al., 2016). The importance of being around individuals who motivate and nourish each other is essential because social support helps individuals stay active, which helps preserve strength and maintain a positive spirit (Rush, Watts, & Janke, 2013). However, although motivation to engage in healthy behaviors and attitudes is highly valued by African American older adults, maintaining motivation may be difficult (Waites, 2012) and requires ongoing efforts.

The current study found that providing support required knowing the individual and anticipating his/her needs. Help-seeking behavior among African American older adults may follow social norms and expectations. For example, in a study of African American older adults living in the Southeastern United States, asking for help was unnecessary because individuals close to the older adult would be able to identify needs and respond accordingly as an expression of duty and affection (Jett, 2002). This perspective also aligns with evidence that some older adults may be reluctant to acknowledge deficits and needs and strive for independence that comes at a cost (Puts et al., 2009). Gender roles may be influential in help-seeking. Smith et al. (2007) found that African American men may not ask directly for assistance due to perceived threats to their masculinity and independence and may be at greater risk for self-neglect, as noted in the current study. Support in health care encounters may also be important, as participants described these encounters unnecessarily negative and unhelpful. Other research in African American older adults also found that communication with providers is often frustrating and recommendations seldom contained practical solutions (Griffith, Ober, & Gunter, 2011).

Clinical Implications and Future Research

Frailty Assessment

African American focus group participants identified physical, psychological, social, and spiritual factors associated with frailty; thus, recognizing changes in individuals' psychological status (e.g., depression, worry) and social supports network is important, as these issues were identified as risk factors for frailty that may be evident before physical manifestations. Many frailty assessment tools do not incorporate indicators for psychological, social, and spiritual domains (Fried et al., 2004; Rodríguez-Mañas & Sinclair, 2014), but when included, the indicators varied across assessment tools; thus, further research is needed to identify the most relevant indicators to include, as it is essential to address these domains in the frailty assessment (Gobbens et al., 2010; Rodríguez-Mañas et al., 2013). Research indicates that frailty assessment augments traditional risk assessments to improve risk stratification and clinical decision making (Lang et al., 2009; Rodríguez-Mañas et al., 2013). Nurses and other health care providers should consider ways to address these domains in their assessment because more holistic assessments may better identify stressors and therefore facilitate more accurate risk stratification and person-centered care planning and outcomes (Andreasen et al., 2015; Gobbens et al., 2010).

Prevention of Frailty

Participants described health-promoting behaviors to age well and prevent frailty. In quantitative research, emerging literature indicates that African American individuals develop frailty at earlier ages and experience a more severe course, and that this group is especially vulnerable to frailty due to health disparities (Cigolle et al., 2009; Morley et al., 2012); thus, the findings from the current study may help inform prevention efforts in quantitative research. Emerging research on frailty is focusing on recognizing strengths rather than deficits and building resilience through health promotion strategies for nutrition, physical activity, stress management, and chronic disease management (Whitson et al., 2016). In a scoping review of interventions to prevent frailty in community-dwelling older adults, nine of 14 studies reported improvement in level of frailty; most interventions focused on physical function, and only a few studies addressed cognitive or psychosocial well-being (Puts et al., 2017). Based on the current study findings, interventions should incorporate psychological, social, and spiritual aspects and these may be collectively addressed in tailored interventions (e.g., physical activity interventions with psychological, social, and spiritual components). Innovative, culturally appropriate, person-centered interventions hold the most promise for impacting frailty (Waites, 2012). These areas warrant further research considering the current findings.

Nurses and Other Health Care Providers

Health professionals did not emerge as a critical link in the support network of frail individuals and participants particularly cited poor communication with physicians as a source of distress. The absence of the nurse's role in these focus groups galvanizes a call to action for nurses (and other health care providers) to examine the effectiveness of communication, especially in assessment where individual needs and strengths can be identified, and to provide advocacy, education, and support. Effective client–provider communication is essential to quality care, and nurses can exert leadership by reaching out to more fully engage the individual and his/her support system to identify needs and determine an action plan (Frost et al., 2017; Ha, Anat, & Longnecker, 2010). Nurses can ask clients about their priorities for the visit and at the end of the visit determine if they have had all their questions answered, understand the plan of care, and identify remaining concerns, involving family members in these discussions. Health care providers, however, are cautioned to not only focus on problems and limitations, which may make older adults feel frail, but to recognize strengths, capacities, and health-promoting behaviors in managing daily life (Nicholson et al., 2017). Participants identified the personal care assistant as the most valuable resource in the care network; thus, efforts should be taken to facilitate training, deployment, and supervision of these caregivers. Health care providers and other carers should also be familiar with local services and resources, including transportation, as these resources may be difficult for older adults to learn about and access, but can be crucial in maintaining mobility as well as motivation for health promotion (Frost et al., 2017).

Frailty and Resilience

Focusing on resilience in aging as opposed to the frailties of aging is an area of increasing research interest (Friedman, Shah, & Hall, 2015; Whitson et al., 2016), and findings from the current study and other research support the importance of comprehensive strategies that build and sustain resilience in the physical, psychological, social, and spiritual domains to prevent frailty (Puts et al., 2017). Research on an innovative model that incorporates resilience can strengthen the frailty assessment and provide direction for nurses and other health care providers with tools for empowering clients in engaging in health-promoting behaviors (van Abbema et al., 2015). The term frailty also has negative connotations that may hinder appropriate assessment and lead to inappropriately withholding treatment (Friedman et al., 2015). Shifting perspectives from a problem-based deficit model to an approach that focuses on adaptations and actions to promote function will counteract the negative stereotypes associated with frailty held by clinicians and foster greater shared decision making that starts with what older adults can do and their desires for services and care (Nicholson et al., 2017; Whitson et al., 2016). Counteracting the label of frailty as a failure to age well and to be afflicted with numerous infirmities requires shifting to a paradigm that captures capabilities, the “glass half full,” and the ways that frail older adults proactively manage their vulnerabilities and strengths (Nicholson et al., 2017, p. 350). Efforts that focus on capabilities must especially incorporate the individual's psychological, social, and spiritual worldview (Frost et al., 2017) that fosters the optimism and motivation that was repeatedly discussed in the focus groups as central to health-promoting behaviors that could prevent or alleviate frailty.

Limitations

The current study has several limitations. Participants were recruited from congregate housing in an urban Southeastern U.S. city, and perspectives may differ from African American individuals in other geographic locations and settings in the United States and globally. The sample included a sufficient number of participants for focus groups (Krueger & Casey, 2015), and allowed for a variety of perspectives from group process synergy and facilitated data saturation, but slightly larger focus groups and multiple groups would ensure that diverse views were represented. Participants were constituted in same-sex groups to promote open dialogue about a potentially sensitive topic, and concepts and themes across both groups were remarkably similar. Findings from mixed-sex groups may differ and further exploration would be important. None of the participants self-identified as frail, although most were classified as frail based on a single measure of physical frailty (walking speed); perspectives of frailty may differ from individuals who self-identify as frail or who are in more advanced stages of frailty. Despite these limitations, the current study is the first to the authors' knowledge to explore perspectives of frailty among African American adults and offers new insights about the importance of psychological, social, and spiritual aspects of frailty.

Conclusion

With the rapidly aging population, the prevalence of frailty is expected to increase, leading to greater needs for health and social services for this group. Findings from these focus groups of African American men and women indicate that frailty can develop at any age and is manifested in physical impairments that arise from the interaction of physical, psychological, and social domains of function. Frailty impacts all aspects of life, but social support and spirituality and religious practices are important in the prevention and mitigation of frailty. Further explorations of frailty perspectives in African American individuals are needed to expand understanding of frailty that ultimately informs effective assessment, prevention, and treatment.

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Characteristics of Focus Group Participants (N = 13)

VariableWomen (n = 8)Men (n = 5)
Age (mean [range]) (years)73.8 (56 to 90)67 (58 to 80)
Partner status (n [%])
  Widowed5 (62.5)1 (20)
  Single1 (12.5)4 (80)
  Married1 (12.5)0
  Divorced1 (12.5)0
Educational level (n [%])
  Grade school01 (20)
  Some high school1 (12.5)0
  High school graduate or equivalent6 (75)1 (20)
  Some college1 (12.5)2 (40)
  College graduate01 (20)
Timed Up and Go Test score (mean [range]) (seconds)19.25 (10 to 38)15.2 (11 to 23)
  Frail (≥16 seconds)5 (62.5)3 (60)
Comorbiditya (mean [range])2.1 (0 to 3)3.2 (0 to 7)
Authors

Dr. Lekan is Assistant Professor, and Ms. Abrams is Doctoral Student, University of North Carolina at Greensboro, School of Nursing, and Dr. Hoover is Assistant Professor, North Carolina Agricultural and Technical State University, School of Nursing, Greensboro, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise. External funding for this study was provided by Sigma Theta Tau International, Gamma Zeta Chapter, 2016.

The authors acknowledge Susan Letvak, PhD, RN, FAAN, for guidance in the qualitative study design, focus group procedures, moderator training, and review of the manuscript; and Peggy Markham, MSLS, for editorial assistance in the preparation of the manuscript. The authors also thank the participants for sharing their time.

Address correspondence to Deborah A. Lekan, PhD, RN-BC, Assistant Professor, University of North Carolina at Greensboro, School of Nursing, 409 Moore Nursing Building, Greensboro, NC 27402-6107; e-mail: dalekan@uncg.edu.

Received: November 20, 2017
Accepted: December 28, 2017

10.3928/02793695-20180619-05

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