; NI“IMMI|IIIIM|IIIJIIHI i MSU LIBRARIES w RETURNING MATERIALS: P1ace in book drop to remove this checkout from your record. FINES wi11 be charged if book is returned after the date stamped below. W LLW; m 1? ;\ I . I'M “ 34-M' -<’, - a, THE PERCEIVED HEALTH NEEDS AND STATED PERFORMANCE OF HEALTH ACTIVITIES OF OLDER ADULTS AND THEIR EXPECTATIONS OF ASSISTANCE FROM HEALTH CARE PROVIDERS BY Carol J. Garlinghouse A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE .IN NURSING College of Nursing 1982 Copyright by CAROL JOANNE GARLINGHOUSE ©19 82 ABSTRACT THE PERCEIVED HEALTH NEEDS AND STATED PERFORMANCE OF HEALTH ACTIVITIES OF OLDER ADULTS AND THEIR EXPECTATIONS OF ASSISTANCE FROM HEALTH CARE PROVIDERS BY Carol J. Garlinghouse A descriptive study was conducted to identify rela- tionships among older adults' perceptions of changing health needs, their stated performance of activities to maintain their health and overcome health needs, and their expectations of assistance with health needs and activities from health care providers. Data were collected by means of a self-administered instrument from 56 independent older adults aged 65 to 89 who perceived themselves to be in good health and resided in subsidized housing or were volunteers in the community. Frequency distributions and Pearson product-moment correla— tion coefficients were obtained for all study variables. There were no relationships between performance of health activities and health needs or expected assistance but were significant relationships between health needs and expected needs assistance (r=.60, p=.001) and expected activities assistance (r=.45, p=.001). In conclusion, nurses must assist older adults to direct health activities toward meeting health needs, thereby maximizing independence in late adulthood. To Johnny and Jack, with all my love, and in memory of my mother. ii ACKNOWLEDGMENTS As I complete this segment of my professional edu- cation I find there are so very many persons without whom I would not have reached this goal. I surprised myself that age 40 I could complete a Masters thesis and still be as enthusiastic at the end of the road as I was when I took the first step. For the personal and academic support which helped maintain my positive attitude I am especially grateful to: The Junior League of Lansing and to the 60+ Health Center for fostering my interest in primary care for older adults. Dr. Barbara Given, my program and committee chair- person, with a very special note of thanks for her continu- ing encouragement, support, guidance, and counsel through- out my graduate program. As my mentor and role model she assisted me to exceed my own personal and professional expectations. Brigid Warren, JoAnn Westrick, and Sr. Mary Honora Kroger, my committee members, for their expert guidance and advice regarding the research process and the field of gernontology. They shared my belief that gerontological nursing is exciting and vital. iii To LeAnn Slicer for all the extra assistance she gave me throughout my years in graduate school. Without her I would still be far behind in all the paperwork. The management and residents of Serenity Place, Somerset, Tamarack, and Washington Park for their assist— ance with data collection and to Kathy Jones from St. Lawrence Hospital's Health Education Department and her senior volunteers for their participation in the research project. To Rob Hymes for his patience, sense of humor, and encouragement while assisting me to interpret and analyze the data. He explained what I did not understand and made statistics comprehensible. To my neighbor and friend Pam Buehler for becoming Johnny's second mother when I could not be at home. Above all, I am especially grateful to my husband Jack, and son John who not only put up with my frustrations, disappointments, short temper, and absences from home during the past three years, but made our home a haven for me to return to through their ever—present love and patience. iv TABLE OF CONTENTS Chapter Page I THE PROBLEM . . . . . . . . 1 Introduction. . . . . . 1 Purpose . . . . 6 Statement of the Problem. . . 8 Conceptual Hypotheses . . . ll Conceptual Definitions . . . 13 Delimitation of the Problem Area . . . 15 Limitations of the Study. . . l6 Assumptions . . . . . 17 Overview of the Chapters. . . 18 II CONCEPTUAL FRAMEWORK . . . . . . 20 Introduction. . . . . . 20 AGING. . . . . . . . . 21 HEALTH . . . . . . . . 26 Preventive Health Belief Model . . . . . . 26 HEALTH AND WELLNESS . . . . . 30 Health Needs. . . . . 35 Health Activity . . . . 38 Modifying Factors . . . 38 Motivational Factors. . . 39 Expected Assistance . . . 39 SELF-CARE--NURSING HEALTH ASSISTANCE . . . . . . . 42 III LITERATURE REVIEW. . . . . . . 50 Common Changes with Aging . . 50 Biological Changes . . . SO Locomotion . . . . 51 Nutrition . . . . 51 Aeration. . . . . 53 Elimination . . . . 53 Circulation . . . . 54 V Chapter III (cont'd.) Sensation . . Rest, Relaxation and Sleep . . . . Socioeconomic Changes . . Psychological Changes . . Perceived Health Needs of Older Adults. . . . Accuracy of Self-Reports of Health. . . . Variables Affecting Per- ceived Health Needs . . Perceived Health Needs of Older Adults . . . . Performance of Health Activities. Exercise. . . . . . Nutrition . . . . . Health Screening. . . . Socialization Activity . . Medication Usage. . . . Expectations of Assistance by Older Adults . . The Preventive Health Belief Model and the Older Adult . Summary of the Literature Review. . . . . . IV METHODOLOGY AND PROCEDURE. . . . . Overview. . . . . . . Sample . . . . . . Older Adult . . . . English-Speaking. . . Independent Living Situations. . Perceived Good Health . Willingness to Partici- pate . . . . Completion of the Questionnaire . . . Settings. . Site #1 Site #2 Site #3 Site #4 Site #5 vi Page 55 56 58 59 63 63 64 67 74 81 84 87 88 90 91 100 106 108 108 109 110 110 110 110 110 111 111 112 113 114 114 115 Chapter IV (cont'd.) V DATA PRESENTATION AND ANALYSIS vii Page Instrument . . . . . 117 Operational Definitions of the Study Variables . . 119 Perceived Health Needs . . 119 Performance of Health Activities (Total). . . 120 Expected Assistance . . . 122 Health Care Provider. . . 123 Older Adult . . . 123 Modifying and Motivational Variables-—Socio- demo- graphic Data Modifying Factors . . . 124 Age . . . . . . 124 Sex . . . . . 124 Marital Status . . . 124 Occupational Status . . 125 Years of Retirement . 125 Type of Dwelling. . . 125 Household Members . . 126 Income . . . . . 126 Native Language . . . 126 Perceived Health. . . 127 Motivational Factors. . 127 Reliability of the Instru- ment . . 127 Validity of the Instrument . 129 Pretest of the Study Instrument . 130 Data Collection Procedure . . 131 Human Rights Protection . . 137 Scoring . . . . . 137 Socio-demographic Data . . 137 Major Study Variables . . 139 Procedures for Data Analysis. . 141 Summary . . . . . . . 144 . . . 145 Overview. . . . . . . 145 Research Question 1 . . . 146 Research Question 2 . . . 146 Research Question 3 . . . 146 Research Question 4 . . . 147 Research Question 5 . . . 147 Research Question 6 . . . 148 Hypotheses . . . . . 149 Chapter V (cont'd.) Descriptive Findings of the Study Sample . . . . . Modifying Factors . . . Demographic Variables . Age . . . . . . Sex . . . Sociopsychological Variables. Marital Status . . . Occupational Status . . Years of Retirement . . Type of Dwelling. . . Household Members . . Income . . . . Structural Variables. . . Perceived Good Health . Native Language . . . Motivational Factors. . . Regular Doctor . . . Physical Checkup. . . Health Care Visits . . Summary . . . . . . . Data Presentation for Research Questions and Hypotheses . Research Question 1 . . Perceived Health Needs of Older Adults . . . Statistical Technique for Obtaining Per- ceived Health Needs . Results of Perceived Health Needs (total) . Results of Physical Health Needs . . . Results of Socioeconomic Health Needs . . . Results of Perceived Psychological Health Needs . . . . . Research Question 2 . . Stated Performance of Health Activities by Older Adults. Statistical Technique for Obtaining Performance of Health Activities . Results of Stated Per- formance of Health Activities. . . viii Page 151 151 151 151 152 152 152 153 153 154 155 155 156 156 156 156 157 157 157 158 158 158 159 159 159 160 161 162 162 164 164 164 Chapter V (cont'd.) Results of Stated Per- formance of Physical Health Activities . . Results of Stated Per- formance of Socio- economic Health Activities. . . . Results of Stated Per- formance of Psycho- logical Health Activities. . . . Comparison of Perceived Health Needs and Stated Performance of Health Activities . . Research Question 3 . . . Expected Assistance from Health Care Providers . . Statistical Technique for Obtaining Expected Assistance. . . . Results of Expected Assistance with Health Needs from Health Care Providers . . . . Results of Expected Assistance with Health Activities from Health Care Providers. . . Persons Most Likely to Help . . . . Reliability of the Instrument . Relationships Among the Study Variables . . . Statistical Technique for Obtaining Correla- tions Among Study Variables . . . . Research Question 4 . . . Hypothesis 1. . . . Research Question 4a. . . Hypothesis la . . . Research Question 4b. . . Hypothesis lb . . . Research Question 4c. . . Hypothesis 1c . . . ix Page 164 166 167 167 168 168 168 168 168 170 172 175 175 175 175 176 176 176 176 177 177 Chapter Page V (cont'd.) Research Question 5 . . . 177 Hypothesis 2. . . . 177 Research Question 5a. . . 178 Hypothesis 2a . . . 178 Research Question 5b. . . 178 Hypothesis 2b . . . 179 Research Question 5c. . . 179 Hypothesis 2C . . . 179 Research Question 6 . . . 180 Hypothesis 3. . . . 180 Research Question 6a. . . 180 Hypothesis 3a . . . 180 Research Question 6b. . . 181 Hypothesis 3b . . . 181 Research Question 6c. . . 181 Hypothesis 3c . . . 182 EXTRANEOUS VARIABLES: MODIFYING AND MOTIVATIONAL FACTORS . . . . 185 Results of Correlations Be- tween Modifying Factors and Study Variables . . 185 Age . . . . . . 185 Sex . . . . . . 185 Marital Status . . . 185 Occupational Status . . 185 Length of Retirement. . 187 Type of Dwelling. . . 187 Own or Rent . . . . 187 Household Members . . 188 Income . . . 188 Results of Correlations Be- tween Motivational Factors and Study Variables . . 189 Regular Doctor . . . 189 Physical Exam . . . 189 Health Care Visits . . 189 OTHER FINDINGS . . . . . . 190 Summary . . . . . . . 192 VI SUMMARY, INTERPRETATIONS, AND RECOMMENDATIONS . . . . . . . 193 Overview. . . . . . . 193 Summary and Interpretation of Findings . . . . . . 193 Chapter VI (cont'd.) Descriptive Findings of Study Sample . Modifying Factors Age . . . Sex . . Marital Status Occupational Status Years of Retirement Type of Dwelling. Household Members Income . Perceived Health and. Native Language Motivational Factors. Regular Doctor Physical Checkup. Health Care Visits Descriptive Findings Posed by Research Questions and Hypotheses. . Research Question 1 Perceived Health Needs (total) . . Perceived Physical Health Needs . . Perceived Socioeconomic Health Needs . Perceived Psychological Health Needs . Research Question 2 Stated Performance of Health Activities (total). Stated Performance of Health Activities to Maintain Physical Health Stated Performance of Health Activities to Maintain Socioeconomic Health Stated Performance of Health Activities to Maintain Psychological Health Research Question 3 Expected Assistance from Health Care Providers to Meet Health Needs Expected Assistance from Health Care Providers with Health Activities xi Page the . . 193 . . 194 . . 194 . . 195 . . 195 . . 195 . . 195 . . 196 . . 196 . 197 . . 197 . . 197 . . 198 . . 198 . . 198 . . 199 . . 200 . 200 . . 201 . . 203 . . 204 . . 205 . 206 O O 206 . . 209 . . 210 . . 213 . . 213 . . 218 Chapter VI (cont'd.) Expected Assistance from Health Care Providers with Health Activities. Relationships Among Study Variables Hypothesis 1. Hypothesis la Hypothesis 1b Hypothesis 1c Hypothesis 2. Hypothesis 2a Hypothesis 2b Hypothesis 2c Hypothesis 3. Hypothesis 3a Hypothesis 3b Hypothesis 3c Other Findings the Modifying and Motivational Factors . Marital Status Occupational Sta tus Years of Retirement Type of Dwelling Household Members Income . Contact with Hea Providers . Limitations of the Study 1th Recommendations for Study Replication . Relationship of Resu Conceptual Model 1ts Implications for Nursing. Nursing Assistance Nursing Practice. Nursing Education Nursing Research. APPENDICES O O O O O 0 APPENDIX A: INTRODUCTORY LETTER TO THE SITES . . . B: INSTRUMENT xii Page 218 220 220 220 220 220 222 222 222 222 223 223 223 224 225 227 228 228 228 228 229 230 230 235 236 238 239 239 243 246 249 253 253 254 APPENDICES (cont'd.) Page APPENDIX C: INFORMATIONAL PACKET. . . . 270 D: HUMAN SUBJECTS REVIEW COMMITTEE APPLICATION . . . 274 E: FREQUENCY DISTRIBUTIONS . . . 282 F: PERSONS MOST LIKELY TO HELP . . 301 REFERENCES . . . . . . . . . . 310 xiii Table 10. 11. 12. 13. 14. 15. 16. 17. LIST OF TABLES Age . . . . . . . . . Sex . . . . . . . . . Marital Status . . . . . Occupational Status . . . . . Years of Retirement . Type of Dwelling . . . . . Owned or Rented Dwelling . . Household Members. . . . . . Income . . . . . . Health Care Visits Within Past Year Perceived Total Health Needs of Older Adults and N . . . . . . Perceived Physical Health Needs (in decending order) . . . . . Perceived Socioeconomic Health Needs (in decending order) . . . . . Perceived Psychological Health Needs (in decending order) . . . . . Stated Performance of Health Activities (Total) . . . . . Performance of Activities to Maintain Physical Function . . Stated Performance of Activities to Maintain Socioeconomic Health. . xiv Page 152 152 153 153 154 154 155 155 156 157 160 161 162 163 165 166 166 Table 18. 19. Page Stated Performance of Activities to Maintain Psychological Health. . . . 167 Health Needs Assistance Expected from Health Care Providers . . . . 169 Health Activity Assistance Expected from Health Care Providers . . . . 170 Perceived Total Health Needs of Older Adults . . . . . . . . 301 Comparison of Perceived Health Needs and Performance of Health Activities . . 302 Persons Most Likely to Help with Health Needs . . . . . . . . 303 Persons Most Likely to Help with Health Activities. . . . . . . 307 Health Needs and Health Activities for which No Assistance is Expected . . 309 XV LIST OF FIGURES Figure Page 1. The Preventive Health Belief Model (Becker, 1974) . . . . . . . 28 2. The Health Continuum . . . . . . 32 3. Modified Health Belief Model . . . . 37 4. Orem's Model of Supportive-Educative . Nursing System (1980). . . . . . 45 5. Correlational Model of Relationships . . 232 6. Revised Model of Nursing Assistance to Older Adults . . . . . . . 241 xvi CHAPTER I THE PROBLEM Introduction The elderly population is the fastest growing seg- ment of the population in the United States. As of July 1, 1978, 11% of American citizens (24.1 million persons) were over 65 years of age. Women outnumbered men in 1978 by 4.5 million (U.S. Department of Commerce, 1979). By the year 2020 it is projected that the percentage of older adults could increase to 25%. In 1977, one of every 10 couples where the head of the household was a husband over age 65 had an annual in- come less than $4,000. The median income for all such fam- ilies was $9,110. The median income of single older adults living alone or with non-relatives was $3,829. Persons over age 65 living below the poverty level numbered 3.2 million or 14.1%. Of these persons, 27% were living alone or with non-relatives as compared to only 8% living in families. About 80% of unrelated persons over age 65 reported no income from earnings and were primarily dependent on Social Security income, either exclusively or in combination with sources of income other than earnings (U.S. Department of Commerce, 1979). 2 In 1977 the older adult accounted for 29% ($41 billion) of all personal health care expenditures. Their average health bill was $1,745 compared to $661 for younger adults. Medicare and Medicaid accounted for two-thirds of the health expenditures. Individuals paid 26% directly (U.S. Department of Health and Human Services, 1979). The elderly consume 25% of all prescription drugs. While 5% of older adults live in institutions, 95% live in the community and 81% are physically capable of being inde- pendent. It is estimated that 86% of persons 65 and older and 72% between ages 45 and 65 have one or more chronic con- ditions. Acute illnesses are more serious in older persons because they may not have the physical reserve to counteract them. Untreated these acute illnesses may lead to chronic disability or unnecessary death (Butler, 1975). Society in general places a low social value on being aged as compared to being in other age groups (Butler, 1975; deBeauvoir, 1972; Kalish, 1977). Kalish (1977) reports this is not so much that we have a youth-oriented society but that Americans value productivity, independence and the con- cept of futurity, all attributes the older adult seems to have in lessening amounts. In 1975 the National Council on the Aging (NCOA) commissioned the Harris organization to poll Americans in an attempt to determine attitudes toward aging. Some of the relevant results of this study were, first, while 25% of older persons felt their life was worse 3 now than what they had expected, 75% felt it was better. Secondly, while 51% of the public thought "good health" was a problem for the aged person, only 15% of the older adults surveyed found this a personal problem. Of the total public, 67% believed that older persons spent a lot of time watching television but only 36% of older persons reported they did. A fourth finding revealed that the general public felt only 41% of older persons were very physically active but 48% of persons over 65 reported they were. Lastly, 80% of the older persons polled expressed satisfac- tion with their past life, 75% felt their present life was as interesting as ever, and over 50% were making plans for the future. One of the conclusions made by the NCOA as a result of this study was that most older adults in the United States have the desire and the potential to be pro— ductive, contributing members of society (Kalish, 1977). Unfortunately, most health care providers share society's negative attitude toward older persons and do not recognize the potential for growth possessed by the majority of older adults. Various authors (Butler, 1975; Kalish, 1977; Lenzer, 1977) have cited surveys of health professionals and have concluded that generally, these health care providers feel they have little to learn from the old and that most dis- eases older persons develop are untreatable. The health care system is oriented toward acute illnesses. Often older 4 adults have a multiple set of chronic conditions and treat- ment regimens for one condition may be contra—indicated for another. While there is a shortage of health care agencies in the inner-city, rural areas, and small towns, most com- munities have a health care system with the potential to aid the older person. In general, few agencies and/or pro- viders assess individual and family needs, determine how best they can be met, and help persons obtain appropriate services. For the older adult, this can hasten loss of independence. Most agencies are independently administered and linkages between them are fragile or non-existant. Individual health care providers are often not aware of the services available to older adults through other community agencies. This results in fragmentation of information and services and inadequate provision of care to many older adults who might retain their independence with additional assistance in one aspect of their lives. Economic programs (such as Medicare) aimed at assisting the older adult to obtain health care assistance are often inadequate. Pre- ventive services are not often covered by third-party payers and therefore older adults only seek services when ill at which time treatment may be lengthy and expensive. Depending on the older adult's perceptions of health needs and benefits of health activities, he will seek to maximize his capacity to function. Kalish (1977) states however, that gerontologists have observed that negative 5 attitudes and even a sense of resignation may decrease an individual's willingness to follow prescribed health care regimens. An older adult may ignore medications, not eat properly, become careless, or get insufficient exercise. Mental attitudes may also affect body processes such as digestion, elimination, respiration, and cardiovascular function. Lenzer states that many older persons feel their symptoms are normal results of aging and do not seek assist- ance (Kalish, 1977). Gerontologists report, however, that much of what has long been called "aging" is now known to be disease and is possibly preventable or able to be retarded but certainly is treatable (Butler, 1975). Other older adults are aware they need help but have no knowledge or energy required to reach health care services. Some older persons lack the skills needed to manipulate the system to their advantage in order to meet their needs. In addition to the factors mentioned above (econom- ics, complexity of health problems, attitudes, knowledge, and health care system structure and organization) transpor- tation is often difficult. Those individuals with a limited fixed income find it increasingly economically unfeasible to maintain a personal car. Older adults unable to drive often find it difficult to obtain and/or negotiate public transportation. In the investigator's professional practice with older adults in primary care settings it has been observed 6 that these clients are usually aware of decreasing function- al status, would like to do something about it but frequent- ly do not think anything can be done or do not have the resources to obtain assistance. Maintenance of independence is dependent on the ability to function in all areas of daily activities. Adaptation to changing functional status is necessary as aging progresses. All of these factors underscore the need to increase and support effective self—care activities of older adults to maintain health and functional ability. From a nursing orientation, Ebersole and Hess (1980) recommend that the first step is to survey the health needs of older adults from their perspective and assess their reactions to the care they are receiving. Moses (1981) proposes since most older persons are eager for knowledge about their health, nurses can be effective in assisting them to assume more responsibility for their health. Therefore, there is a need to study the combined issues of perceptions of older adults regarding their health needs which might affect functional status, their performance of health activities to maximize functional capability, and the extent of assistance older adults expect to receive from health care providers. Purpose A review of the literature reveals that much research has been done regarding health needs of the elderly (Belloc 7 & Breslow, 1972; Mancini & Orthner, 1980; Parkerson, Gelbach, Wagner, James, Clapp, & Muhlbauer, 1981; Haney, Stephens, COOper, Oser, & Blau, 1981; Moore & Fillenbaum, 1981; Fuller & Larson, 1980; Denniston & Jette, 1980; Jette & Branch, 1981; and Katz, 1970). Aho (1979) studied the ability of older adults to perform the preventive self-care activity of innoculation against influenza. Data exist re- garding the use of various health care facilities by older adults (Archer, 1968; Sivertson, 1978; Brody & Kleban, 1981; Snider, 1981; Haug, 1981). Hain and Chen investigated health condition, physical functioning and access to medical care among older adults (Hain & Chen, 1976). In order to understand the capability of older adults to actively par- ticipate in their own health care it appears there is a need for a descriptive study exploring the relationships between the three areas perceived health needs (present and future), stated performance of health promoting activities, and expectations of assistance with health needs and activities. The purpose of this research is to identify and describe the relationships among the perceived health needs and stated performance of health activities of independent older adults, and the extent of health care assistance expected from health care providers. 8 Statement of the Problem In this study the researcher will address the following questions: 1. What are the perceived health needs of older adults? 1a. What are needs of lb. What are needs of 1c. What are needs of the perceived physical health older adults? the perceived socioeconomic health older adults? the perceived psychological health older adults? What health activities do older adults state they perform to maintain their health and overcome health problems? 2a. What health activities do older adults state they perform to maintain physical health? 2b. What health activities do older adults state they perform to maintain socioeconomic health? 2c. What health activities do older adults state they perform to maintain psychological health? What is the extent of assistance older adults expect to receive from health care providers to meet these health needs or perform these health activities? What is the relationship between perceived 9 health needs of older adults and stated perform- ance of health activities? 4a. 4b. 4c. What is the relationship between perceived physical health needs of older adults and stated performance of health activities to maintain physical health? What is the relationship between perceived socioeconomic health needs of older adults and stated performance of health activities to maintain socioeconomic health? What is the relationship between perceived psychological health needs of older adults and stated performance of health activities to maintain psychological health? What is the relationship between perceived health needs of older adults and the extent of assistance expected from health care providers? 5a. 5b. So. What is the relationship between physical health needs of older adults and the extent of assistance expected from health care providers? What is the relationship between socio- economic health needs of older adults and the extent of assistance expected from health care providers? What is the relationship between 10 psychological health needs of older adults and the extent of assistance expected from health care providers? 6. What is the relationship between stated perform- ance of health activities of older adults and the extent of assistance expected from health care providers? 6a. What is the relationship between stated performance of activities of older adults to maintain physical health and the extent of assistance expected from health care providers? 6b. What is the relationship between stated performance of activities of older adults to maintain socioeconomic health and the extent of assistance expected from health care providers? 6c. What is the relationship between stated performance of health activities of older adults to maintain psychological health and the extent of assistance expected from health care providers? The answers to these questions will provide a basis for further studies and interventions directed toward im- proving the health status of older adults. From these ques- tions hypotheses are generated depicting the concepts in the study. 11 Conceptual Hypotheses There is a positive relationship between per- ceived total health needs and stated perform- ance of health activities of older adults. la. There is a positive relationship between perceived physical health needs of older adults and stated performance of health activities to maintain physical health. lb. There is a positive relationship between perceived socioeconomic health needs of older adults and stated performance of health activities to maintain socio- economic health. lc. There is a positive relationship between perceived psychological health needs of older adults and stated performance of health activities to maintain psycho— logical health. There is a positive relationship between per- ceived health needs of older adults and the extent of assistance expected from health care providers. 2a. There is a positive relationship between perceived physical health needs of older adults and the extent of assistance expected from health care providers. 12 2b. There is a relationship between perceived socioeconomic health needs and the extent of assistance expected from health care providers. 2c. There is a relationship between perceived psychological health needs and the extent of assistance expected from health care providers. There is a negative relationship between the stated performance of health activities of older adults and the extent of assistance expected from health care providers. 3a. There is a negative relationship between the stated performance of health activities of older adults to maintain physical health and the extent of assistance expected from health care providers. 3b. There is a negative relationship between the stated performance of health activities of older adults to maintain socioeconomic health and the extent of assistance expected from health care providers. 3c. There is a negative relationship between the stated performance of health activities of older adults to maintain psychological health and the extent of assistance expected 13 from health care providers. Conceptual Definitions 1. Older adult is defined in many different ways in the literature. For purposes of this study an older adult is defined by age and includes all persons who have attained the age of 65 years or older, are ambulatory, reside in independent living quarters, are oriented to time, place and person, can communicate either verbally or by writing in the English language, and consider themselves healthy in response to a question relative to health. 2. Health needs (Total) are defined as those spe- cific requirements of the individual older adult which might be experienced as aging progresses and must be met if he is to function at his maximum physical, socioeconomic, and psychological potential. a. Physical health needs are defined as past or expected future changes in locomotion; nutrition; aeration; elimination; circu- lation; sensation; and rest. b. Socioeconomic health needs are defined as past or future changes in ability to afford food, housing, clothing, utilities, health care, and social activities. 0. Psychological health needs are defined as past or expected future changes in roles, 14 intimacy, family relationships, self-esteem, memory, desire to reminisce, ability to learn and problem-solving ability. 3. Health activities (Total) are defined as any self-care activity practiced by the older adult and directed toward maintaining physical, socioeconomic, and psycholog- ical health. a. Activities to maintain physical health are defined as exercise; nutrition; use of tobacco, alcohol, and caffeine; dental care; preventive health screening; adequate rest; use of health care services for illness; and knowledge of medication action and regimens. Activities to maintain socioeconomic health are defined as utilization of Medicare, Medicaid, nutrition programs, and free health screening programs. Activities to maintain psychological health are defined as participation in hobbies, social activities, reminiscing, family rela- tionships; and educational programs; attention to personal appearance; management of stress; and finding ways to be useful to others. 15 4. Health assistance is defined as performing, guiding, supporting, providing a developmental environment, and teaching of self-care activities necessary for an indi- vidual to reach and maintain maximum physical, socioeconomic and psychological health. For purposes of this study, expected health assistance is indicated by agreement that the individual older adult expects to receive assistance from a health care provider with a specific health need or health activity. 5. Health care provider is defined as that profes- sional person who provides health assistance with health needs and health activities of older adults directed toward maximizing physical, socioeconomic, and psychological health. For purposes of this study health care providers will be divided into the categories physician, nurse and social worker. Additional categories (relative or friend, myself, other, and no one) are provided to clarify if the older adult expects assistance but from persons outside the formal health care system. Delimitation of the Problem Area The problem area is delimited to the following extent: the pOpulation researched are all English speaking, ambulatory, self-perceived "healthy" older adults. No attempt was made to obtain access to medical records to validate these perceptions. There was no attempt to assess 16 functional status other than self-report. There was no attempt to assess performance of health activities other than self-report. In this study the researcher did not identify barriers to recipt of health assistance or actual services received. Limitations of the Study The limitations of the study are: 1. Self-perceptions of health needs may not be accurate. Reporting of health activities may not be an accurate account of performance of these activities. Expectations of health assistance from health care providers are affected by economic status, accessibility, availability of providers, past experience, and knowledge of resources. There was no control in this study for these variables nor was there validation that these services had or had not been received. The subjects who agreed to participate in this study may have been different from those who chose not to participate. Therefore, it is possible that the research findings are not representative of the total older adult population. 17 5. The subjects were all ambulatory, independent older adults. Therefore it is possible the research findings may not apply to older adults who are not ambulatory or who are in dependent living situations. 6. The subjects were all English speaking and literate. Therefore, the research findings may not apply to other ethnic groups or those who cannot read, write, or speak the English language. 7. The sample was drawn from a limited geographic area. 8. The sample was a voluntary rather than a random sample. All persons from each site who wished to participate and met the criteria were allowed to do so. 9. The instrument was administered in a group setting. Persons who participate in groups may have different characteristics than those who do not. Assumptions In this study the researcher is making the following assumptions: 1. It is assumed that all older adults experience some functional disability as they grow older. 18 2. It is assumed that most ambulatory, independent older adults wish to maintain or improve their present health status. 3. It is assumed that most older adults have had some contact with health care providers from which they have formulated present expectations of how providers can assist them to meet their personal health needs. 4. It is assumed that answers to the questions on the instrument reflect honestly and accurately the individual's perceptions of their perceived health needs and expectations of assistance at a point in time. 5. It is assumed that perceived health needs of older adults relating to functional capabilities can be identified. 6. It is assumed that health activities performed by older adults to meet these health needs can be identified. 7. It is assumed that the extent of assistance expected from health care providers to meet these health needs or perform these health activities can be identified. Overview of the Chapters The description of the study has been organized into six chapters. In Chapter I is provided an introduction, 19 statement of the problem, hypotheses, limitations, conceptu- al definitions, and the assumptions underlying this study. In Chapter II the conceptual framework is presented drawing on related gerontological, health, and nursing concepts and theories. In Chapter III the pertinent literature and research in the problem area are reviewed. In Chapter IV methodology and procedures of the research are described. In Chapter V data are presented and analysis of the results of the research are given and discussed. In Chapter VI the research findings are summarized and conclusions and recommendations are presented. CHAPTER II CONCEPTUAL FRAMEWORK Introduction In this chapter, a research framework is presented based on Rosenstock's Preventive Health Belief Model inte- grating the concepts of aging, health, and self-care. The ,__._._1.... framework presentation includes a brief overview of selected aging theories, an explanation of the preventive Health Belief Model followed by a description of health and well- ness as applied to older adults, a description of the con— cept of health beliefs in relation to perceived health needs and performance of health activities by older adults, a discussion of the concept of expected assistance; and, though nursing interventions are not a part of the present study, an explanation of the manner in which nurses could intervene as self-care agents to enhance performance of pre- ventive health activities. This conceptual framework provides the basis for examining the problem addressed by the researcher in this study: are there relationships amongpperceived health needs and health activities of older adults and their expectations of assistance from health carepproviders? 20 21 AGING Neugarten (1981) maintains that age is a poor pre- dictor of physical, intellectual, or social competence in the second half of life and, because of this, is becoming a less relevant characteristic than previously thought. This author proposes distinguishing between the young-old and the old-old based on social and health characteristics and not chronological age and describes the old—old as those older persons who suffer major physical or mental impairments. This group of older adults only comprise a minority of the present and future population of older per- sons. The young-old are the large majority of men and women over age 65 and are vigorous, competent, relatively healthy, and relatively comfortable financially. In general, they may not spend as much time working or doing household tasks but remain integrated members of their fam- ilies and communities. Most persons 65 years old and older live in their own households and play active roles in their churches, clubs, and organization. It is this population of older adults the researcher will address in the present study. Adults choose and follow courses of action which they believe will be beneficial to their own functioning (Orem, 1971, p. 13). Age and health generally determine the scope of activities a person can perform. The older adult has a lifetime of experiences from which have evolved 22 perceptions about health and established response patterns to both external and internal stimuli. Health needs and the performance of health activities of older adults may differ from those of younger persons because of changes in physical functioning, socioeconomic status, and psycho- logical stressors. Age may be described in three ways: biological age, psychological age, and chronological age. Chronological age is the method most often used to describe the age of an individual. Kalish (1977) states that the practice of utilizing the age of 65 as a boundary for "old age" had its origins when Chancellor Bismark was trying to develop a pension plan for railroad workers. Realizing that few workers survived to the age of 65 at that time he decided age 65 would be a good age at which to initiate the pension benefits. Policies of many employers at the present time fix that age of mandatory retirement at age 65. Because retirement presents the individual adult with many new life— changes, in this study the older adult will be defined as any individual who has attained the age of 65 or older. Many theories have been postulated to explain the aging process but it is still difficult to distinguish between age—related changes and trauma, stress, or sub— clinical disease processes. Furthermore, aging theories prOposed by one discipline view the process of aging from a different perspective than does another discipline. 23 Ebersole and Hess (1981) summarize the most popular theories at this time. Biologic and physiologic aging theories are concerned with cellular changes that result in metabolic error as the result of slowed repair processes, chromosomal abherations, or accumulation of waste products. Though these theories leave many questions unanswered, especially in the psychological and sociological realms, some interrelationships between the biologic theories do seem to exist. The two most prevalent sociologic theories are dis- engagement and activity theory. Disengagement theory post- ulates a mutual beneficial withdrawal between the older person and others in their social system (Murray & Zentner, 1979; Archbold, 1981; Ebersole & Hess, 1981; Vander Zyl, 1979). Disengagement theory does not consider individual variation in the need for withdrawal or past life style of older persons in their social roles. It also avoids such socioeconomic issues as decreased finances or altered mobility. Activity theory is in direct opposition to dis- engagement theory and postulates that successful aging is characterized by active social interaction. Again, this theory does not consider individual variations in life style and past patterns of interaction as well as physical or socioeconomic capability. Various authors (Vander Zyl, 1979; Murray & Zentner, 1979; Archbold, 1981; Butler, 1981; Covey, 1981; 24 Murray, Huelskoetters, & O'Driscoll, 1980) discuss the psy- chological theory of continuity which has been formulated from developmental concepts to address some of the gaps in the other aging theories. PrOponents of continuity theory conceptualize that in the process of becoming an adult, an individual develops habits, preferences and perceptions which become a part of his personality (Vander Zyl, 1979). Adaptation to aging can proceed in several directions de- pending on the individual’s past life (Murray & Zentner, 1979). Continuity of personality and one's ability to ad- just to stress and the social environment is maintained over the life span. Barring serious illness or the biological decline of the old-old, it has been postulated that patterns of aging are predictable based on the individual's behavior- al patterns in the earlier years. From this viewpoint old age is an integral part of the life cycle and not a terminal period apart from foregoing years. Vander Zyl (1979) cites several studies which support the continuity theory. Butler (1975) states the way one experiences old age is contingent upon physical health, personality, earlier life experiences, the actual circumstances of late life events (in what order, how and when they occur) and the social supports one receives (adequate finances, shelter, medical care, social rules, religious support, and recrea— tion). More longitudinal studies are necessary to test these concepts. Butler (1981) states such studies will 25 yield much in the way of understanding the process of aging. None of the other theories of aging explain why each aging individual is so personally unique in the way he interacts within his environment. Continuity theory may explain the vast amount of individual variability among the older adult population and the need to consult with indi- vidual older adults prior to planning for them about their preferences, beliefs and life-style. The goal of continu- ity theory is to facilitate growth toward a higher level of development. From a health care standpoint, continuity theory would allow a provider to build upon older adults' past and present strengths to meet health needs, thereby promoting wellness through adaptation to the continuing process of growing old. The purpose of the present study was not to test the Health Belief Model among an older adult population, however, the HBM is an apprOpriate framework for the present study because researchers testing the model have identified that relationships do exist among the variables in the model (perceived susceptibility, motivational and modifying factors, and benefits and barriers of preventive health behaviors). Rosenstock (Becker, 1974), in formulating the preventive HBM, has provided a model by which to assess the potential of older persons to achieve and maintain a state of wellness throughout the process of growing older by identifying health beliefs about possible problems which 26 might influence practice of preventive health activities, and areas of need or activity in which assistance is expect- ed from health care providers. A brief overview of the con- structs of the preventive Health Belief Model has been presented in the beginning of the next section of this chapter under the topic "Health." HEALTH Preventive Health Belief Model The health belief model (HBM) is a conceptual psycho- social formulation developed to explain and predict health- related behavior at the level of individual decision-making (Mikhail, 1981; Haefner & Kirscht, 1970). The model vari- ables were drawn from the social psychological theories of Kurt Lewin who hypothesized that behavior depends on two variables: the value of an outcome to an individual and the individual's perception of the probability that a par- ticular action will produce the desirable outcome (Mikhail, 1981). Proponents of the model assume that "good health" is a goal more or less common to all and that differences in preventive health behaviors are the result of differing perceptions, motivations to take action, and decision-making regarding selection of alternatives (Langlie, 1977). Rosenstock (Becker, 1974) proposes that five vari- ables affect health behavior (perceived susceptibility, perceived seriousness, perceived benefits of preventive 27 activity, modifying factors, and motivational factors) and that preventive health behavior has a phenomenological orientation whereby a person's perceptions determine his behavior. Health behavior is motivated by health beliefs which, in turn, are defined as a person's perception of his personal susceptibility to a disease, the seriousness of the effects of that disease upon his life, and the benefits of a particular activity toward reducing his susceptibility or decreasing the seriousness (Figure l). Cognition, dependent to some extent on knowledge, is a component of health beliefs. The health activity may be perceived as beneficial but the presence of barriers may result in avoidance of the activity. If the positive aspects of the activity are strong and the negative aspects weak, the activity will probably occur. If the negative aspects are strong and positive aspects weak the activity will probably not occur (Figure 1). When both positive and negative aspects are strong, alternative activities will be sought which will be equally beneficial. When no alternative activities are recognized or available, escape from the situation may be attempted by en- gaging in activity which does not really reduce the threat but which does temporarily alleviate the pressure of the conflict between the perceived benefits and the barriers. A second reaction when alternative activity is not found 33H .86me H802 omflmm fifimm .93:ng 99 A 356E 303.8 wfiummfle no Hmdmmmzwz pcwfium Ho H355 >353 mo mmmGHHH umflucmo no 563.13g Eoum puwo uwom pong muofio ECG 004.52 mcmflmmamo mama mum: 3.9803 HmcoUQ/flgv 20304 8 88 1 c039“ 530m fl as ommmmfla m>Hucm>wum poocQEBomm A _ mo @5013 mo poofiamfiq Hmong. cot/Hmoumm GS mmmmmwm mo ABUSE/owe mmgmsoflumm @930qu 8 2 AIIII cc mummma fi fi 8. 31233883 69888 A coauom 935$me moanmflmk, Hoguofim B mwmfluhmmomfimoumm Adam 6.339% @586 mocmfim Immu cam Hood .mmmao H308 $8.5m ICOmHoE moanmflmkr HmoflmoHoaofloom wand: All! coflbm gauge/mum mo flammcmm Eamon?“ Touw .mfioflcfim . .momu can .093 moanmflmtr vegan—g ZOE .mO DSEHNVHA $205.“ UZHEHQQL mZOHEmE ASK—EnzH 29 might be a marked increase in fear or anxiety which, if strong enough, could reduce the capacity for objective thinking and rational activity. Several modifying factors have been proposed that might influence individual perceptions of susceptibility, seriousness, and benefits of taking action (Mikhail, 1981; Becker, 1974; Haefner & Kirscht, 1970; Langlie, 1977; Williams & Wechsler, 1973; Mechanic & Cleary, 1980). These modifying factors may be categorized as demographic vari- ables (age, sex, race, ethnicity, etc.), sociopsychological variables (personality, social status, peer and reference group pressure, income) and structural variables such as prior knowledge about problems, prior experience with the problem and perceived health (Figure l). The last variable or construct of the HBM hypothe- sized by Rosenstock is a factor which serves as an event or cue which may be necessary to motivate the performance of the preventive health activity. This (or these) cues may be internal (perception of bodily states) or external (environ- mental). The intensity of the cue needed to trigger behavior is inversely related to the level of perceived susceptibility and seriousness present. The higher the degree of acceptance of susceptibility and seriousness is in an individual the lower the intensity of the stimulus needed to initiate action (Becker, 1974). The stimuli or "cues to action" are labeled motivational factors (Figure 1) by Becker (1974). Mikhail, 30 (1981) states that motivational factors and how they influ- ence preventive health behavior are still in need of inten- sive study but cites some studies which have demonstrated that the use of mass media, exposure to health information from health care providers, postcard reminders, and the presence of symptoms have stimulated action and acted as a cue to seeking care or assistance. In the present study the preventive Health Belief Model was utilized as a framework for examination of the relationships among perceived health needs of older adults and their stated performance of health activities. In the remainder of this section of Chapter II the concept of "health" as it pertains to older adults is presented includ- ing the sub-concepts of health needs and health activities. Finally, the concept of "Expected Assistance" will be pre- sented as an addition to the preventive HBM to adapt the framework to the special needs of the older adult population. HEALTH AND WELLNES S The meaning of the work "health" often differs depend- ing on the background or orientation of the person defining the word. In medicine, health occurs in the absence of illness or disease. The World Health Organization defines "health" as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirm- ity. Using this definition it appears an individual would 31 rarely be in perfect health as these three aspects of one's person are not often in a state of complete well-being at the same time. Selzer, Corbett, and Atchley (1978) state that the meaning of the work "health" was originally defined as "to function well physically and mentally and to express the full range of one's potentialities" (Ebersole & Hess, 1981, p. 59). Dunn uses the term "high-level wellness" to describe well—being and defines this as an integrated method of func- tioning oriented toward maximizing the potential of which he is capable (Becker, 1974). Mallick (1979) states that health is relative to the ability to function despite the presence of disease. Ebersole and Hess (1981) define "well- ness" as a balance between one's environment and one's emo- tional, social, cultural, and physical processes. These authors state that even in chronic illness and dying there is an optimum level of wellness and well-being attainable for each individual. Schraff (1981) quotes President John Q. Adams on his own state of health and well-being at 80 years of age and concludes "being well has nothing to do with the presence or absence of pathology." Bruhn, Cordova, Williams, and Fuentes (1977) propose that good health is only a part of "wellness" and that well- ness is a continually changing process in which individuals may participate (Figure 2). These authors argue that health care today puts the emphasis on what 293 to do in order to prevent illness instead of focusing on what to do to remain 32 .oam .m .nema manudm .mnm Ho> .Sfiwmmm bang-:00 wo 1.5.306 .mmmooum mmocaaoz one .moucmpm w 6.53:3 .m>00u00 :Esum Eoum cowuoflmflmm mung mcfluflsaxmz 5:53:00 gamma 05H. . m mHDmHh mamum mung MO coflumoflmwpflz £03853 coflumuflflnmcmm @8003 ugmmue mmmzuqH mg] F I C < ( SHE 33 healthy or become more healthy and propose that good health is on a continuum between illness and wellness. There are several differences between good health and wellness (Bruhn, et al., 1977). Wellness is a continuing process whereas good health is a state of being at any one point in time. Wellness is active requiring effort on the individual's part while good health may exist despite one's actions or inactions. Wellness is related to the processes of learning and development while good health is a description of an individual state. The wellness process is made up of several components (personal growth, internal control, and knowledgeability about health related activities and habits), all aspects of an individual's personality and an indication of one's potential for growth and change. Bruhn, et al. (1977) refer to personality as the patterned ways one experiences and acts in life situations which are learned during the developmental process. The behaviors which are most satis- fying are retained and reinforced and thus determine the individual's potential for experiencing wellness. At each level of development certain behaviors increase and this establishes a pattern for wellness appropriate to that stage. At each stage of development the level of wellness is dependent on completion of certain wellness tasks which are, in turn, influenced by interactions between many fac- tors (environmental, physical, behavioral, and social). 34 Failure to complete all of the wellness tasks at any devel- opmental stage would indicate that an individual is not functioning at his/her maximum potential for wellness (Bruhn, et al., 1977). Each individual has a different potential for well- ness because of factors such as genetic structure and life circumstances. Individuals who develop an acute or chronic illness still have a wellness potential but that potential might be different from a person who is not experiencing a disease condition. For an individual to move from being in good health to a process of wellness one must take an active part through education, modification of life-style and maximiz- ing life satisfaction (Figure 2). Utilization of the well- ness model would allow the conceptualization that a person may experience wellness while exhibiting clinical symptoms of illness in some aspect of his life. Bruhn et al.(l977) lists five examples of minimal wellness tasks for the older adult. These are: - becoming aware of risks to health and adjust- ing life style and habits to c0pe with risks - adjusting to loss of job, income, and family and friends through death - redefining self-concept — adjusting to changes in personal time and new physical environments - adjusting of previous health habits to current physical and mental capabilities 35 Based on the above definitions and concepts, health may be considered a point from which older adults may progress in the process of achieving wellness. Rosenstock (1974) did not define the term "health" in his model and states it is difficult to give the term "positive health" any operational meaning. Health in this study will be defined as a state of physical, socioeconomic and psychological well-being in which an individual func- tions at the maximum potential of which he is capable. All older adults who participated in the present study perceived themselves to be in good health. To be in a state of health, basic health needs must be satisfied. The sub-concept health needs has been presented in the next section of this chapter. Health Needs The dictionary (Webster, 1979) defines the noun "need" as: necessary duty (obligation); a lack of some- thing requisite, desirable, or useful; a physiological or psychological requirement for the well-being of an organism; and a condition requiring supply or relief. Maslow (1970) prOposed a hierarchy of needs and theorizes that needs at one level must be satisfied before one becomes aware of needs at the next level. As awareness of needs increases, motivation toward meeting these needs increases. Levels of need fluctuate but ranked in order of priority are; 36 physiologic needs, safety and security, love and belonging, self—esteem, and self-actualization (Ebersole & Hess, 1981). Perceptions are determined through interrelationships be- tween psychological, physioloqical and socio-cultural- economic factors. The continuity theory of aging allows for consideration of individual perceptions in order to understand behavior as aging progresses. Rosenstock (Becker, 1974) states it is not known whether the improvement of health in a person who perceives himself as already healthy has a motivational force in influencing action or if the action is motivated by the desire to avoid a deleterious situation. If avoidance of a negative situation is the motivator it may be a result of the aforementioned (Bruhn et al., 1977) focus of health care on prevention of illness rather than promotion of well- ness. In the preventive Health Belief Model perceived sus- ceptibility refers to the subjective risks of contracting a condition. If an individual believes there is a possibility a particular event will occur, a "need" might be perceived to prevent or minimize that possibility. In this study health needs will be defined as those specific perceived requirements of an individual which must be met if he is to function at his maximum physical, socio- economic and psychological potential and are represented as perceived expectations of health needs in the conceptual model (Figure 3). 37 3.393% uflgwdmuwgv 39304 530: we BEE—Dung a uggcm ”.553ng 950305 mfifimfl. €896 8:33 853mg @5932 .. _ e 8 _ c 8% 3830 853mg 02 monouflmma _ _ $28.28 ofiswaflmfic 3930.4 53m: .58qu B 3332: Emcfiea 88 :38: 53 8380 a 4‘ 330:8 85mequ 5:... umummnw magnum ©0500qu mpwmz 51.00: mfiocwwuwmxm Mo me Eamouwm AmHmUIm How 039009853 3332 530: NO 85258me i Hg umflmm fiflmm “smudge: .m 85m: s moomz 53w: i no mcofimuomenm pmfimoumm 3.8838 » HMOEOHQUEOHOOm mumwuudm mug/among 5.5 umummpq 330ch Eamon?“ odfiflumofid 205 EC CREE: 922m AdZOHB¢>H§ 92¢ wZHEHDQL magma 9&8 H>HDZH 38 Health Activity To meet a need requires activity. The need becomes the motivational force directing the activity. Kasl and Cobb (1966) use the term "health behavior" to depict any activity undertaken by an individual who believes himself to be healthy for the purpose of preventing a disease or detecting disease in an asymptomatic stage. Behavior is learned throughout life and is related to the beliefs, habits, and practices of the group(s) to which an individual belongs. In the present study, the preventive Health Belief Model was utilized to determine the individual older adults stated performance of specific health activities to main- tain their health in the physical, socioeconomic and psy- chological areas of function (Figure 3). Modifying_Factors Becker (1974) proposed that a variety of modifying factors might influence individual perceptions of the threat of a problem or disease. For the purpose of this study demographic, sociopsychological and structural vari— ables relevant to the older adult population were selected (Figure 3). The demographic variables of age and sex were determined for each subject in order to identify whether there were age or sex-related differences in individual 39 perceptions of health needs or performance of health activ- ities. The sociopsychological variables of marital status, occupational status, years of retirement, type of dwelling, household members, and income were determined for each par- ticipant as each of these factors might affect an older adult's perceptions of health needs and/or performance of health activities. Perceived good health and the ability to read and/or understand the English language were cri- teria for participation in the study and therefore included as structural variables. In summary, the modifying factors investigated in this study were age, sex, marital status, occupational status, years of retirement, type of dwelling, household members, income, native language and perceived health. Motivational Factors Health care providers may provide the motivation for the older adult to perform preventive health activities, therefore utilization of health care providers was determin- ed for each subject to identify if increased contact with a health care provider was related to differences in individual perceptions of health needs or stated performance of health activities (Figure 3). Expected Assistance Expected assistance is not a component of the pre- ventive HBM, yet assistance-seeking behavior may be a 4O preventive health activity. As an individual grows older certain changes may occur in the physical, socioeconomic, and psychological areas of function. These changes are discussed in Chapter III. To adapt to these naturally occurring changes, an older adult may require assistance. In addition, pathological conditions are common among the older adult population. Though most older adults c0pe with chronic disease conditions when present, the impact of those diseases on the individual's life could be minimized if appropriate assistance is forthcoming at the proper time. Depending on individual perceptions about the per- ceived threat of a disease or aging change as well as the balance between the benefits and barriers of assistance- seeking health activity, the older adult may or may not expect to receive assistance with a health need or health activity. Several barriers to preventive health care exist for the older adult pOpulation (high cost of health care, lack of third-party payment for preventive health services, unavailability of transportation, the negative attitude of health care providers toward aging, the focus of the health care system on "cure" rather than prevention) as discussed in Chapter I. While all of these barriers may be affected by individual health beliefs, motivational and modifying factors, the "healthy" older adult may choose not to seek assistance from a health care provider. Instead, depending on individual perceptions, the older person expect to handle 41 the problem alone or seek assistance from someone outside the formal health care system. Some individuals may not expect to receive assistance from anyone or even help themselves. Because the receipt of assistance might theoritical- ly prevent loss of independence the concept of "Expected Assistance" has been added to the preventive HBM (Figure 3) to adapt Rosenstock's framework for use with the independ- ent older adult. In summary, though chronic disease is prevalent among the older adult population, wellness is still attain- able. The potential for wellness may be assessed using the preventive Health Belief Model (Becker, 1974) to identify the older adult's perceived health needs, performance of health activities, the modifying and motivational factors which influence the individual's perceptions and decisions to take action (Figure 3), and the extent of assistance expected from health care providers. Proponents of the continuity theory of aging, the preventive Health Belief Model, and the concepts of the wellness process all recognize that health behaviors can be modified or changed. They also all agree that to change a life-long pattern of behavior may require assistance from someone specifically trained and educated to do so. Though this study was not designed to test specific interventions, the same framework can be utilized to assess the need for 42 intervention among the older adult pOpulation. That inter- vention may be to provide assistance as expected and/or requested by individual older adults themselves or by alter- ing their perceptions of health needs and/or benefits of health activities, providing the motivation for the health activity, or by reducing barriers which might prevent an activity from being performed. In the next section of this chapter the concepts of self-care and self-care assistance will be explored with emphasis on the profession of nursing as the discipline whose members are uniquely educated to provide the needed interventions among the older adult population. SELF- CARE--NURSI NG HEALTH ASS I STANCE Variables in the Health Belief Model may be modified through specific interventions. Since use of the continu- ity theory of aging allows for individual variation among older adults, Rosenstock's model can be utilized as a frame- work for describing individual perceptions of health needs (susceptibility), identifying perceived beneficial health activities (benefits), including areas in which older adults expect to receive assistance from health care providers and ultimately, assessing the need for intervention (see Figure 3). Rosenstock's "preventive health action" is a similar concept to that of "self-care." Self-care is a term used 43 to describe what an individual does to stay healthy. Butler (1979-80) defines self-care as an individual's deliberate action on behalf of his own, his family's or his neighbor's well-being. The end-point of self-care is the individual. It encompasses formal consumer health educa- tion programs and patient education efforts designed to teach self-care knowledge and skills. Butler differentiates between self-care and self-help in that self-help refers to clusters of individuals with common concerns who share experiences and offer each other mutual support and aid and states further that self-care programs and self-help groups are particularly appropriate for the needs of the elderly, although few exist specifically for this popula- tion. Self-care measures help reduce costly professional health services. Self-help groups can provide social out- lets for those whose social lives are restricted. Butler's concept of self-care consists of a series of three concen- tric circles. The inner circle includes regular activities of daily living. Levin (Butler, 1979-80) reports that self- care practices account for 85% of all health care in the world. The second ring of self-care encompasses consciously acquired health knowledge and awareness and appropriately altered follow-up behaviors (Butler, 1974) which correspond to the activities of education and modification of life- style on the Health Continuum (Figure 2). Butler includes 44 in this category most preventive health care and lists some of the same "cues to action" or motivational factors as in Rosenstock's Health Belief Model (Figure 1). In the outermost ring of self-care are persons who assume tasks formerly in the realm of the professional health care provider. This third ring involves a formal educational component in which individuals learn health care skills such as taking blood pressure or monitoring a pulse. Performance of all three types of self-care is schematically represented by "performance of health activity (therapeutic self-care)" in the last column of Figure 3. In addition, the older adult may (or may not) expect assistance with self-care as represented by "Assistance Expected" and "No Assistance Expected" in the last column of Figure 3. Nurses can assist older adults with all three types of self—care activities (Figures 3 and 4). Traditionally, nursing as a profession has been con- cerned with health and patient education. The revised Michigan State Public Health Code defines nursing as: The systematic application of substantial specialized knowledge and skill, derived from the biological, physical, and behav- ioral sciences, to the care, treatment, counsel, and health teaching of individuals who are experiencing changes in the normal health processes or who require assistance in the maintenance of health and the pre— vention or management of illness, injury, or disability. (1978) 45 8mm: 53mm @5992 9fl82©mum>nuom9m no H80: 958 .q 83E .maawxm Em macflg mafia“. cam .Honucoo HOH>mnwn .mcaxmalcoflmflomp ou mumamu mocmumflmmm Mom mucmswuflsvmm .mocmumflmmm usonufi3.om op poccmo usn mnmolmawm pmnwsvmn Enouumm on :mea canonm can coo no ou wand "moflumflumuomnmnu ucwfiumm ZOHBU BZMHBGQ wuzmu<,mm¢UIMAwm m0 Bzmzqum>mQ 32¢ mmHummxm_mmB mmHmADDmm mmdUImumm mmmmHAmSOOU¢ .mcflnvmmu pom .ucme Iconfi>cm Hmucmsmoam>mp m mo coflmfi>oum .mocmcflsm .uuommom mo soapmcfloapu "mocmumfimmm mesz ZOHBUG .A WmMDZ 46 Orem (1980) states that "self-care is the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well being" (Orem, 1980, p. 35). The provider of self-care is the self- care agent. Nurses may act as a self-care agent for another individual. Self-care as conceptualized by Orem (1980) is purposeful and consists of three types of actions which are termed self-care requisites. Universal self-care requisites are associated with life processes and with the maintenance of the structural and functional integrity of the human being and are common to all persons throughout the life cycle adjusted to age, deve10pmental state, and environ- mental factors. Developmental self-care requisites are associated with developmental processes and life cycle events (i.e., pregnancy). Health deviation self-care requi- sites are concerned with genetic, constitutional, structural and functional deficits and with their effects, medical diagnosis and treatment. For purposes of the present study, self-care is defined as deliberate health behavior requiring valid per- ceptions of health needs and benefits of performing the health activity (Figure 3). Nursing assistance will be de- fined as performing, guiding, supporting, providing a devel- opmental environment for, and teaching of self-care activities necessary for an individual to reach and maintain physical, socioeconomic, and psychological function 47 (Figure 4--Nursing Assistance). Within Orem's framework, self—care requires learning, use of knowledge, and enduring motivation and skill. These same requisites are necessary (according to Bruhn et a1. 1977) to move from health toward wellness. The self-care agent performs actions which are either internally or externally oriented. Internally oriented actions include those to control internal factors using available resources and those actions to control one's thoughts, feelings, and/ or orientation, thereby regulating internal factors or external orientations. The four types of externally oriented self-care actions include knowledge-seeking actions, assist- ance and resource seeking actions, expressive interpersonal actions and actions to control external factors. There are five ways in which a self-care agent may assist someone. These are by acting for or doing for, guiding, or physically or psychologically supporting another, providing a develop- mental environment, and/or teaching another (Figure 4). Nurses may act as self-care agents only after assessing the abilities of an individual to engage in self-care demand. Then nurses may make judgments about actual or potential self-care deficits and their cause, select valid and reli- able methods of helping, and prescribe and design appropri- ate nursing systems. Individuals who may not think of themselves as self-care agents may need assistance to do so in order to understand the values their habits are based on 48 and to appraise the adequacy of their self-care practices. Orem's concepts are based on the principle that either nurses or patients or both can act as self-care agents to meet self-care requisites. On this basis she has designed three various nursing systems. The wholly compen- satory nursing system requires the nurse to act for and do for the patient. The partly compensatory system is used in situations where both nurse and patient perform care or health activities. The supportive-educative system is for situations where the patient is able to perform required therapeutic self—care but cannot do so without assistance (Figure 4). Assisting techniques used in this system are support, guidance, provision of a developmental environment, and teaching. This system is used when a person's "require- ments for assistance relate to decision making, behavior control, and acquiring knowledge and skills" (Orem, 1981, p. 101). In summary, the continuity theory of aging allows consideration of older adults' individual differences to assist them to achieve wellness. Using the framework pro- vided by the preventive Health Belief Model, perceptions of health needs, stated performance of specific health activi— ties, and expectations of assistance may be identified. Using the supportive-educative nursing system, professional nurses as self-care agents could intervene by manipulating appropriate variables within the Health Belief Model to 49 assist the older adult to regulate the exercise and develop- ment of his own self-care agency. This would include assist- ing the young-old person to work from health toward wellness by achieving the minimal wellness tasks as well as meeting all self-care requisites (see Figure 3). CHAPTER III LITERATURE REVIEW The literature review discussed in this chapter was focused on the three major constructs of the study: per- ceived health needs of older adults; performance of health activities (self—care) by older adults; and assistance expected by older adults from health care providers. As with all of the other stages of human growth and development (infancy, early childhood, adolescence, middle- age, etc.) the period of old age is accompanied by changes in biologic, socioeconomic and psychological function. Since the major concepts of the present study were health and wellness of older persons an additional section of the literature review is presented at the beginning of the chapter in which the investigator explored research iden- tifying non-pathological changes which might be expected universally among the older adult population as aging pro- gresses. The instrument utilized in this study was pri- marily developed from this review of the literature. Common Changes with Aging Biological Changes Research in the area of physiological and biological changes as opposed to pathological changes that occur with 50 51 the aging process is relatively recent. Experts in the area agree that only by means of longitudinal studies of large samples of the population can a definitive body of scientific knowledge be established. To date there have been few such studies. What research has been done seems to be very specific to organ systems and will be reviewed here organized into the functional changes: locomotion, nutrition, aeration, elimination, circulation, sensation, and rest and relaxation. Locomotion. The bulk of the skeleton atrophies but hypertrophy of bone at sites of attachments of tendons, lig- aments and muscles has been demonstrated radiologically in asymptomatic older adults. Most of these hypertrophic changes are not pathological (Rossman, 1971). Finch and Hay- flick (1977) report, however, that not enough clinical ex— perimentation has been done to identify specifically which conditions of the skeletal system represent normal aging and which are widely occurring diseases. Kale and Jones (1981) state that osteroarthritis affects 90% of the elderly though all but 70% are asymptomatic. Grob (Reichel, 1978) agrees with these percentages but differentiates between sexes; he reports 15% of men and 25% of women are symptomatic after age 60. All sources list the common symptoms of joint pain on motion and weight-bearing which is relieved by rest. Nutrition. There is erosion of chewing surfaces, re- cession of gum tissue, atrophy of alveolar bone (Ebersole & 52 Hess, 1980) and loss of muscle strength (Carnevali & Patrick, 1979) which make chewing more difficult. Gift (1979) cited studies conducted in 1975 for the American Dental Association in which researchers found that 44% of persons over 60 years old had full dentures, 16% had all their natural teeth and 38% had partial dentures or some missing teeth. Because, in part, of the atrophy of alveolar bone, excellent dentures properly fitted may become loose and inefficient over time (Gift, 1979). Feldman, Kapur, Alman, and Chauncey (1980) studied age-related changes in masticatory performance in healthy adult males ages 25-75. All participants had at least ten teeth on each side of their mouth or a fixed (non- removable) replacement for their missing teeth and the con- clusion was that masticatory function does not alter with aging in persons with complete or partially compromised den- tition. There was an increase with aging in the number of strokes used to prepare the food for swallowing but the significance of this finding was not determined. Both Finch and Hayflick (1977) and Rossman (1971) discuss the widespread belief that absorption of vitamins and minerals may be hampered in old age but conclude no con- crete evidence exists demonstrating this fact. Ebersole and Hess (1980) state minimal nutritional requirements remain the same in later years but total caloric intake should decline to compensate for changes in metabolic rate and a decrease in physical activity. Gambert & Guansing (1980) 53 discuss the prevalence of protein-caloric malnutrition in elderly persons and consider socioeconomic factors of prime importance as a cause but concur that despite the decrease in caloric requirements, the dietary protein requirement is not altered by age. Aeration. With increased age there is a change in the shape of the thorax due to calcification of costal car- tilage, a decrease in the elasticity of lung tissue, and a decrease in vital capacity with a resulting increase in re- sidual volume since total lung capacity remains constant. There is a decrease in maximal breathing capacity but seems to be adequate alveolar ventilation (Rossman, 1971; Finch & Hayflick, 1977; Reichel, 1978). All sources agree with Ebersole and Hess (1980) that it is hard to measure pulmon- ary function in older adults and that the major functional problem is decreased adaptation to stress, a decreased ability to cough, and decreased efficiency of ciliary activ- ity in the bronchial tree (Rossman, 1971; Finch & Hayflick, 1977; Reichel, 1978; Bowles, Portnoi, & Kenney, 1981). Elimination. After extensive review of research in the area both Rossman (1971) and Finch and Hayflick (1977) conclude that there are minimal functional changes in gastro- intestinal organs. Though both sources admit constipation in the elderly is a common problem, no research was found that adequately demonstrated decreased mobility of the lower 54 intestine. Brocklehurst (1980) includes constipation in a discussion of diseases of the lower bowel. Bowles, et al. (1981) state constipation may result from poor hydration, decreased activity, depression, and/or poor eating habits. Several studies have been conducted using aging men and women to determine bladder changes with age (Finch & Hayflick, 1977; Ebersole & Hess, 1980; Rossman, 1971; Reichel, 1978). It is unclear to this researcher if the subjects were asymptomatic at the time of the investigations but all sources conclude there are some bladder changes as a result of the aging process. These changes are nocturnal frequency, decrease in bladder capacity, increase in resid- ual urine, increased precipitancy, and an increased inci— dence of urinary tract infections with age. Whitmore (1981) describes benign prostatic hyperplasia as a nearly uni- versal consequence of the aging process in men but states only a small proportion of aging men will develop clinical symptoms. Circulation. With age there is a decrease in the acceleration of heart rate in response to stress, a decrease in cardiac output and a prolonged contraction and relaxation time. Elasticity of vessels decreases and the vessels be- come stiff which results in increased peripheral resistance. Perfusion of organs generally decreases (Rossman, 1971; Bowles, et al., 1981; Rockstein & Sussman, 1979; Ebersole & Hess, 1980). Both Rossman and Finch and Hayflick cite 55 studies purporting to demonstrate differences in perfusion decreases to various organs and conclude this may be an adaptive response. Sensation. Taste buds atrophy (Ebersole & Hess, 1980) and decrease in number as aging progresses (Rossman, 1971) and there is an impaired response threshold to stimuli (Ebersole & Hess, 1980; Rossman, 1971). Though wide vari- ability exists, three-fourths of the olfactory fibers are gone by the eighth and ninth decades (Rossman, 1971). PresbyOpia, the decrease in the ability of the eyes to accommodate to distance, begins in the fourth decade (Ebersole & Hess, 1980) but only 15-18% of the elderly have poor vision, 20/100 or below (Rossman, 1971). There is a decrease in the visual field resulting in impaired periph- eral vision and poor accommodation to dark due to moderate impairment of cone function resulting in a need for more illumination for reading (Bowels, et al., 1981). Older persons have altered perception of blue, green, and violet colors due to yellow pigment accumulation in the aqueous humour (Bowles, et al., 1981; Ebersole & Hess, 1980). Though wide variability exists, presbycusis, result- ing in a decrease in hearing acuity, speech intelligibility, level of auditory threshold, and pitch discrimination does occur as a result of the aging process (Ebersole & Hess, 1980; Rossman, 1971), especially in the high frequencies (Rossman, 1971). By the age of 70 loss of hearing above 56 12,000 cycles per second affects nearly everyone (Bowles, et al., 1981). Ventura (1978) reports impaired hearing significantly restricts 30-50% of persons over the age of 65 but Norris and Cunningham (1981) found that hearing loss due to presbycusis does not affect the social involvement of the affected older person. There is decreased speed responsiveness and altered proprioception with aging (Ebersole & Hess, 1980). The posture of older persons becomes more stoOped and the gait broader based (Bowles, et al., 1981; Carnevalli & Patrick, 1979) and this change, along with the decrease in visual field, makes it hard for the older person to prevent him- her-self from falling when loss of balance occurs. There is a decrease in muscle mass of the lower extremity which results in decreased vascular tone and an increased venous pooling in the lower extremities. Quick rising can result in an orthostatic drop in blood pressure and fainting (Chipman, 1981). Rest, Relaxation and Sleep. The total amount of sleep time is not usually reduced as aging progresses but older persons spend more waking time in bed. Stage IV sleep decreases steadily throughout life and occurs earlier in a given sleep period in later adulthood with over 50% occurring before the first REM cycle. There is less Stage IV sleep and an earlier REM cycle among older persons. The significance of this finding is not known but it may 57 increase daytime tiredness resulting in the need for 30-60 minute rest periods during the day (Ebersole & Hess, 1980; Gambert & Duthie, 1981; Reynolds, Coble, Black, Holzer, Carroll, & Kupfer, 1980). Coleman, Miles, Guilleminault, Zarcone, van den Hoed and Dement (1981) studied insomniacs aged 60 and older and found a much higher proportion of male subjects presented at their clinic than did females and found a high prevalence of clinically significant sleep apnea and periodic movements in sleep among the elderly subjects. Coleman, et a1. (1981) concluded decreases in Stage IV sleep were so pervasive in all the elderly subjects it was probably not due to pathologic changes. There was no data comparing this group of older adults to "normal" sub- jects available yet but reportedly will be published soon. Research in the area of sleep and aging was found to be deficient by one group of researchers (Dement, Miles & Carskadon, 1982) who strongly recommended six sleep research areas for immediate investigation: breathing during sleep; 24 hour sleep studies; sleeping pill studies; biologic rhythms; chronopathology in the elderly; diagnosis and treatment of sleep disorders in elderly patients; and sleep in the nursing home environment. In summary, physical health needs may arise in the older adult population as a result of these common biologic changes of aging: hypertrOphy of bone at joints; decreased sensory perception in each of the five senses; increased 58 frequency and precipitancy of urination; and less restful sleep. Socioeconomic Changes Kalish (1975) lists the decrease in direct income with retirement as the prime reason for limited financial resources of older adults. In preparation for the 1971 White House Conference on Aging questionnaires were distrib- uted to all older persons attending regional and state meet- ings. Results indicated that over 50% of the polled older persons received and spent less than $200.00 a month; over one-third had trouble paying housing costs and over 50% stated they did not always have enough money to make ends meet. While Medicare has helped decrease the older adult's health care costs, inflation has counteracted those cost reductions. Kalish states decreased self-esteem results from living in poverty but concludes, that the majority of older persons have the ability to live with their difficulties and enjoy life as much or more than younger persons. Kalish hypothesizes further that older persons can be free at last to be themselves and do what is important to them. This hypothesis was corroborated by Helen Hayes as she became 80 years old (1980). Ebersole and Hess (1980) examined the economic status of older persons and found that in 1977, 3,177,000 persons over age 65 (14.1%) lived below the poverty level. Of these persons, 1,176,000 lived in families. Other pertinent 59 statistics cited in this source are the rising costs since 1975: an increase in food costs of 60%; an increase in cost of utilities so rapid no figures were available; a rise of 35% in home furnishing prices; an increase of 55% in phy- sicians' fees; and an increase in hospital costs of 75%. Chen (Kalish, 1977) poses the question "What is adequate income?" and postulates there is substantial variation. This author states sex, marital status, race, and years of retirement all affect income adequacy. With advancing years Chen lists several factors which cause expenditures to decrease: no more dependent children to support; a decrease in space needs; eligibility to receive Medicare to help defray health care costs; decreased car, transportation and clothing expenses after leaving the job market; added income tax deductions; eligibility for subsidized housing; and a decrease in property taxes. Kalish (1975) states however, that expenses may diminish somewhat but not as much as most older persons anticipate. In summary, from the broad literature review of socioeconomic changes with the aging process, it appears that socioeconomic needs may vary widely and depend to a great extent on past financial status and expenditures. Psychological Changes Butler and Lewis (1977) reviewed studies on intel- lectual changes with aging and conclude there is no decline in intellectual ability with age providing the older adult 60 is in good physical and mental health, has an adequate edu- cational level, and is provided intellectual stimulation. Butler and Lewis (1977) discuss the many role changes which may occur in later life. Among these are the social roles lost as a result of mandatory retirement. This may result in a loss of meaning in life for the former worker and may result in depression. Women lose the role of wife and mother with the onset of widowhood and egress of dependent children from the household. When the male spouse retires he may wish to assume some of the household tasks previously performed by the woman. This may result in marital conflict and onset of depression within the wife. On the more posi- tive side, Butler and Lewis have found that older persons can develop new roles, one important one being that of grandparent. Butler and Lewis (1977) propose that older adults need to leave a legacy and, in conjunction with this need, must share their knowledge and experience with younger persons. Butler and Lewis (1977), Kalish (1977), and Ebersole and Hess (1980) all discuss the current trend in the mass media to blame adult children for "abandoning" their older parents. Butler and Lewis admit mobility of nuclear fami- lies may lead to geographic isolation of older adults but all sources cite recent research demonstrating though older adults may live in separate homes there remains a complex 61 pattern of family relationships which is very functional and supportive (Butler & Lewis, 1977; Kalish, 1975; Kalish, 1977; Ebersole & Hess, 1980). Various authors (deBeauvior, 1972; Butler & Lewis, 1977) discuss the ability of older adults to become creative with the addition of more leisure time in their lives. All sources accept Butler's research demonstrating the universal need for reminiscence as part of the normal life review process. Life review is necessary for one to age successfully (Kalish, 1977; Burnside, 1981; Ebersole & Hess, 1980; Butler & Lewis, 1977). All authors support the research done by Masters and Johnson in the area of sexuality in late adulthood and con- clude there remains a universal need for sexual expression and intimacy throughout life (Butler & Lewis, 1977; Ebersole & Hess, 1980; Masters & Johnson, 1981). Because developmental tasks are widely discussed in the literature as one way to assess psychological adaptation it is relevant to include a review in this chapter. Ebersole and Hess (1980) have consolidated developmental tasks as perceived by several authors (Peck, 1968; Havig- hurst, 1972; Ebersole, 1976; Butler & Lewis, 1977) and labeled them Intrinsic (requiring intrapersonal activity) or Extrinsic (requiring interpersonal activity) tasks as follows: 62 Intrinsic Extrinsic -Continue to develop curiosity -Share wisdom -Transcend ego -Teach others to live -Achieve inner peace and self- and die uniquely acceptance -Develop latent abilities -Separate identity from work that may be dormant role -Develop flexible social -Cu1tivate feminine and mascu- roles line identity -Serve as a historian for -Accept one's share of respon- younger persons sibility for the past -Maintain significant -Accept death of spouse relationships -Identify a legacy and a plan -Relate to age peers of dispersal -Develop new, less -Learn to tolerate losses and intense relationships, depressive episodes particularly with -Accept help when needed younger persons -Monitor body function —Plan for death -Adapt to physical limita- -Budget income and energy tions to meet important needs —Transcend body -Find a suitable living situation allowing maximum independence -Seek adequate health maintenance services Accomplishment of apprOpriate developmental tasks is associated with life-satisfaction (Kurtz & Wolk, 1975) which is necessary if an older person is to progress toward a state of wellness (Bruhn, et al., 1977). In summary, psychologically, older persons may expect to retain intellectual ability, may experience role changes, a need to leave a personal legacy, continuing supportive family relationships, a need for sexual expression and intimacy, and a need to accomplish appropriate developmental tasks as they grow older. In the next section of the literature review the per- ceived health needs of older adults will be presented. 63 Perceived Health Needs of Older Adults Accuracy of Self-Reports of Health Self-reports of health status by older adults are a reliable indicator of health. Deniston and Jette (1980) found that arthritic subjects' self-assessments of their joint conditions were valid when compared to the objective assessments of health care professionals. LaRue, Bank, Jarvik, and Hetland (1979) examined the relationships between self-reports of health and physicians' ratings in an aged sample and attempted to determine how both of these measures of health related to longevity. The health status measures were obtained from a medical history form between 1966 and 1968 which asked subjects to rate their own health as "excellent," "fair," or "poor." A physician conducted a physical exam at that time but did not rate the subject's health in those same three terms. Prior to the 1979 study another physician examined the medical records of 69 sur- vivors from the original group (ages 77-90) and, without meeting the subjects, subsequently rated their health as one of those three adjectives. The researchers found a sig- nificant correlation between the subjects' original ratings and that of the subsequent physician but did find the sub- jects' ratings were more positive. LaRue, et al.(l979) con- cluded that among persons below the age of 85 both self- reports and physician ratings were predictive of survival time. This conclusion supports the early findings of Maddox 64 (1964). Shanas (1968) found an old person's self assessment of health correlates highly with self-reported incapacity. Graney and Zimmerman (1980-81) examined the causes and consequences of health self-report variations among older people. Literature review indicated that older persons tend to overrate their health or adjust their health expec- tations downward relative to medical standards as aging progresses. The sample included 2,794 subjects 65 years old and older obtained from data collected by Harris for the National Council on Aging (1975). Analysis of the data revealed that social status, social participation-activity, and personal attitudes were significantly related to older persons' health self—reports and were as important to the subjects' health self-conception as were those factors (physiological—medical) generally used by physicians in assessing health status. Financial adequacy, education, and self-concept were sufficient to explain 28% of the var- iance in health self-reports. No effort was made to com- pare subjects' self-reports to objective medical evaluations. Variables Affecting Perceived Health Needs Plawecki and Plawecki (1981) studied perceptions of physical and mental age among a small sample (N=54) of older adults (ages 61-100) from three settings (well-adults, hos- pitalized patients, and nursing home residents) and found that among all three groups older adults perceived them- selves to be both physically and mentally younger than their 65 chronological age. No attempt was made to relate the find- ings to health status. These findings were congruent with those reported by Linn and Hunter (1979) who compared per- ceptions of age with psychological function in a sample of 150 older adults over age 65 (mean age==74 years). Data revealed that 64% of the sample felt younger than their chronological age and scored high on the psychological function (health) scale. The researchers concluded better psychological functioning is associated with younger age perceptions in older adults. Larson (1978) reviewed the literature over the last thirty years on the relationship of well-being to the life situations of older adults and concluded level of education, occupational status, marital status, availability of trans- portation, housing, and nonamourous forms of social inter- action are related to subjective well-being. Isolated studies were also found indicating physical disability and lack of a confidant to be associated with greater vulner- ability to negative emotional effects of life situations in later life. Evidence was also found that persons in higher socioeconomic levels have greater resources which enable them to avoid negative life situations. Phaneuf (1981) cites data from a study of noninsti— tutionalized persons 60 years and older (N=514) in which the researchers classified the respondents as "enjoyers," who had coped more or less successfully with the 66 difficulties of aging, and "causalties," who had been hard hit with the difficulties of aging. Enjoyers tended to report good to excellent health, had comparatively high assets with incomes exceeding $8,000 a year, had spouses of equal physical capability, and were relatively well-educated. Survivors were less apt to report good health, could not rely on economic security or the companionship of a spouse with equal physical capacity, and had less than a high school education. Casualties reported fair to poor health, had a high degree of economic stress, lacked a marital com- panion of equal physical capacity, were predominantly women and had less than a high school education. Fuller and Larson (1980) found that life events as measured by the Geriatric Schedule of Recent Experience (adapted from Holmes and Rahe's Social Readjustment Scale) affect functional health and that emotional support does not moderate that effect. There was no relationship between life events and low morale among subjects who scored low on the emotional support scale (N=24). The higher scores on the life events scales were associated with lower morale only under higher levels of emotional support. The results of this study, while not conclusive, indicate that both life events and emotional support may affect perceptions of physical and mental health by the older adult. Costello and Meacham (1980—81) assessed sex differ- ences in relation to perceptions of the impact of specific 67 events of aging among 15 males and 15 females (mean age==77) and found that change in appearance, departure of children, and decrease in time spent with children were perceived as more difficult for other women than for the subjects them- selves and increase in leisure time, decreased strength and retirement are more difficult for other men. In general the subjects perceived that life events caused more difficulty for their peers than they did for themselves. Perceived Health Needs of Older Adults Moore (1978) measured functional impairments in social, economic, mental, and physical health, and activities of daily living among 130 subjects aged 60 and older who were patients utilizing a Family Medicine clinic. Results indi— cated that 32% were socially impaired, 33% were economically impaired, 58% had some physical impairment, 48% had mental impairment, and 28% had difficulty performing routine activ- ities of daily living. Researchers at Duke University developed the Duke- UNC Health Profile (DUHP) for use in primary care to assess adult health status and evaluate the effect of health care interventions on patient outcomes (Parkerson, Gehlbach, Wagner, James, Clapp, & Muhlbaier, 1981). Out of a total sample of 395 subjects only 7 persons were over 65 years old. The researchers still concluded that, with their instrument, the younger the age the higher the health status score. Physical function had the highest (0.49) correlation, 68 followed by symptom status. Age was not found to be signif— icantly correlated with social and emotional function. In 1977 Leon, Kamp, Gillum and Gillum (1981) studied the current life adjustment and social and physical activity patterns of a group (N=96) of elderly men (70-85 years old) who had been initially studied in 1947 and every year since then as part of the Cardiovascular Disease Project. The recent findings indicated that these men on the whole were satisfied with their opportunities to pursue interests, had a talent or hobby that gave them a feeling of success, and felt others were interested in their ideas. Few men in the study (6%) indicated they currently had emotional difficul- ties. Most of the older men were physically active (walking, gardening, doing home repairs) and socially active (went shopping, dined out, visited friends and relatives, and attended religious services). Chronic physical illness was reported by 46% of the group. The 1977 MMPI group profile was within normal limits. The researchers concluded the surviving members of the CVP group were successful at adapt— ing to the stressors of aging. These findings may have limited applicability to other groups of older adults since at the time of the initial assessment the socioeconomic status of the group was in the upper middle to upper class and similar findings might not be obtained in a sample with a lower socioeconomic profile. 69 A comparison was made between older adults seen in an ambulatory clinic in urban New York City and older adults interviewed at a senior center in the same neighborhood (Auerbach, Gordon, Ullmann, & Weisel, 1977). Persons seen at the senior center considered themselves to be in better health than did those at the clinic. On a disability index only 11% of the senior center subjects reported moderate or severe disability as compared to 43% of the clinic group. Income seemed to be related to health since 18% of those in the clinic group felt their income was not enough to meet expenses as compared to 10% from the senior center. The majority (74%) of the subjects from the senior center received their income from Social Security while among the clinic subjects 49.7% received Social Security but 32.5% received additional SSI. Archer, Flesman, Carver, and Adelman (1979) surveyed 679 older adults in community settings to determine the needs, wants, and life-styles of healthy older adults in order to plan health promotion and education programs. Less than 2% of the respondents felt they were worse off than others and 21% reported they were much better off than others their age. "Health" was reported most frequently as the best thing about their lives. Other best aspects list- ed were family, leisure time, retirement, friends, and social and senior clubs and activities. The worst aspects listed were health problems and loneliness. The researchers 70 point out that since health leads the list of both the best and worst factors in the lives of these older adults, this population does perceive the importance of their health to their life satisfaction. The day-to-day symptoms of older persons were ident- ified retrospectively by means of interviews with 132 sub- jects (Brody & Kleban, 1981). The most frequent symptoms reported to have been experienced in the one month prior to the interview, in descending order of frequency, were periods of feeling blue, tiredness, forgetfulness, difficulty sleeping, nervousness, and tenseness. Though fourteen of the twenty symptoms on the instrument were physical com- plaints none appeared in the top five symptoms listed by the "healthy" participants. In 1972 a group of nurses measured the needs of older adults (N=466)in an effort to determine the extent of health care problems experienced by an elderly pOpulation and the adequacy of nursing services in meeting those needs (Managan, Wood, Heinichen, Hoffman, Hess, & Gillings, 1974). They selected five problem areas to assess: health condi- tion, as indicated by reported illness in the previous month; physical functioning in activities of daily living; accessibility of medical care; social isolation; and service needs, as indicated by the respondents ability to obtain meals or transportation. The greatest percentage of prob- lems were in the area of physical functioning. There was 71 little variation among social class but an increase in prob- lems as educational level decreased. Females identified more problems than did males. Problems in physical function showed a consistent increase by age in females whereas, for males, the increase was not apparent until age 85. Less than half of this group indicated a health condition. Frank (1979) replicated this study in 1975 with similar results. Researchers with the Heart Disease Epidemiological Study in Framingham, Massachusetts have collected data on a group of persons for almost thirty years. The Framingham Disability Study (Jette & Branch, 1981) is a recent componant of this longitudinal study and was designed to identify the nature and extent of disability among non-institutionalized older adults. Physical disability was measured using adapta- tions of three instruments (Katz' ADL scale, Rosow & Breslau's Functional Health scale, and Nagi's work) among 2,654 subjects ranging in age from 55 to 84 years old. Almost all respond— ents were able to perform all six activities of daily living without assistance including 90% of the subjects in the 75-84 year old group. A significantly larger proportion of women than of men used help with grooming. A smaller prOportion of persons were able to perform three gross mobility activities as compared to the ADL and the ability to perform them was related to age. Yet over 75% of those subjects between ages 75 and 84 reported they could climb stairs and walk one-half mile. There were substantial differences in 72 perceived difficulty in performing nine physical activities and the proportion performing them without difficulty decreased with advancing age. Women had more difficulty with the physical activities than men. Social disability, the limitation in or inability to perform social roles or obligations, was also investigated among this same Framingham sample (Branch & Jette, 1981). The researchers assessed older adults' needs for help in performing five social tasks necessary to maintain independ- ent living: housekeeping, transportation, social interaction, food preparation, and grocery shopping. Analysis of the data revealed the proportion of subjects with unmet or at risk of developing housekeeping needs significantly increased with advancing age and affected women across all three age groups more than men. Prevalence of unmet transportation needs also increased with age and affected women more often than men but only 10% of the oldest members of the sample had unmet transportation needs. Only 3% of the total sample had, or were at risk of developing, unmet social interaction needs and this factor was also related to increasing age. Social interaction needs were not sex specific. Food prep- aration needs were being met by all but one member of the group. A significantly smaller proportion of men than women were at risk for deve10ping a food preparation need but only among the 65-74 year old group. A larger number of persons in the 55-64 year old group were at risk (11%) for 73 developing food preparation needs as compared to only 5% of those between the ages of 75 and 84. Grocery shopping needs followed the same pattern with risk of developing the need increasing with age but there was no relationship to sex. Conclusions drawn by the researchers in the Framing- ham Disability Study are that the later years of life are characterized by substantial physical ability and the vast majority of older adults are self-sufficient in performing their social roles. The highest prevalence of unmet social needs were in the areas of housekeeping and transportation. Women appear to have more physical disability and more unmet housekeeping and transportation needs than men. One of the limitations in generalizing to other populations of older adults is the relatively high socioeconomic status and pre- dominance of white adults in the sample In summary of the perceived health needs of older adults, though chronic disease was common in the non-insti- tutionalized older adult populations studied, the majority of subjects in each study were able to cope with the stress- ors of aging and accurately perceive their health needs and/ or status. Physical function appears to be the most trouble- some area of limitation as aging progresses and socioeconomic status may affect adaptive capacity. In most of the research, women reported more difficulties than did men. In the next section of this chapter, the literature will be reviewed demonstrating effectiveness of relevant 74 health activities in maintaining maximum functional capabil- ity among older adults. Performance of Health Activities Ford (1981) examined the issues surrounding health promotion among the elderly population and found in the literature the proposal that more healthful life-styles and the exercise of greater personal responsibility for health by older adults will be less expensive than the present sys- tem of episodic care. While it will take some creative ideation and much hard work, the elderly may become more productive, provide services for their peers, and become more actively engaged in maintaining their own health in order to live a more interesting life. In this section of the literature review recent research relevant to perform- ance of health (self care) activities by older adults and the benefits to be obtained from the same has been examined. Tager (1981) discusses the process of achieving pro- gressively higher levels of health and states the first step is the assumption of personal responsibility for health, including the making of personal choices at decision points which, in turn, requires a significant amount of learning. A condition of wellness can at least be approached by pro— gressively limiting risk factors and increasing positive health-related behaviors. This puts a person in control of his own life in regard to his health and removes him from a state of dependence. Help is desirable in the form of 75 counseling, education, and workshop experience but the individual is responsible for selecting such programs from the alternatives available, and for following through with the recommendations, and for the eventual outcome. Individ- ual knowledge must be increased and, in many cases, atti- tudes must be changed. Pierce (1980) examined intelligence and learning in the aging adult and, after reviewing the literature, con- cluded that while there is no one method that will change or modify behavior, there are some strategies that can be utilized with older adults to facilitate learning. Use of common language, structuring content, providing Opportunity to use content shortly after learning has occurred, pacing the learning, and use of cues to facilitate recall all are useful techniques in working with older adults. The con- clusion was that elderly persons can continue to learn throughout life. Whitbourne and Sperbeck (1981) state that memory is an essential part of learning and, based on research on memory, initial acquisition of material is less efficient in the elderly. Once information is acquired by older persons, their memory for that material can be as accurate as that of younger persons. Shamansky and Hamilton (1979) list criteria for adult learning and stress that learning must be meaningful, problem centered, experience centered, and that the learner must have feedback about progress toward goals. 76 In the only study found testing the preventive Health Belief Model among older adult subjects Aho (1979) analyzed the preventive health behavior of a group of predominantly Black and Portugese-American older adults in participating in the Swine Flu Inoculation program of 1977. Results indi- cated that the behavior of senior citizens relative to obtaining preventive shots can be changed if health care providers provide them with accurate information concerning the safety of the immunizations for persons their age, the risks of side effects, and the risks of the illness for which the shot is designed to prevent. Palmore (Neugarten, 1973) used data from the Duke Longitudinal Study of Aging to determine if the health care practices of exercise, weight control, and avoidance of smoking do lower rates of illness and mortality of the aged individual enough to justify lower health and life insurance premiums for persons who practice these activities. The data were collected from a group of 268 community volunteers (ages 60-94) between 1955 and 1959. Of the three health practices, the amount of exercise was most closely related to illness and mortality than were the other two health practices (weight control and avoidance of smoking). The subjects who reported more frequent exercise had less inci- dence of illness and survived longer. Persons reporting performance of all three health practices spent less time ill in bed than those engaging in none or only one of the 77 activities. Palmore concluded that all three health prac- tices have an additive effect and each additional health practice tends to reduce the possibility of illness and early death. In a large sample of randomly selected adults (N= 6,928) Belloc and Breslow (1972) examined the relationships between physical health status and practice of health activ— ities. Physical health status was ascertained from answers to questions about disability, chronic conditions, impair- ments, symptoms, and energy level and subjects were placed into one of seven categories. Health activities included cigarette smoking, use of alcoholic beverages, sleeping habits, physical recreational activities, and nutrition as measured by regularity of meals and subject weight in rela- tion to height. Most respondents reported usually sleeping 7—8 hours a night and had the highest physical health rating. Results indicated that erratic eaters have poorer health and that eating only regular meals is associated with good health. Men with the best physical health were those less than 5% under weight or no more than 19.9% overweight. Women who were underweight or less than 10% overweight were slightly more healthy than the average. Respondents who participated often in recreational activities of any type (active sports, swimming, walking, gardening, physical exercises, weekend auto trips) had better physical health status than those who did not 78 participate. Only those subjects who reported partaking of five or more alcoholic drinks at one sitting departed signifi- cantly from the average in respect to physical health and the researchers concluded frequency of drinking was not associated with physical health. Subjects who had never smoked reported better physi- cal health than did present or past smokers. In every age group those who reported all seven health activities also reported better physical health. The average physical health status of those over age 75 who practiced all seven health activities was about the same as respondents aged 35—44 who practiced less than three. These results seem to indicate that certain health habits are positively related to physical health status and the rela- tionship of these habits was cumulative. These relation- ships were independent of economic status. The same population sample and data were used to examine the relationship between physical health status, health practices, and the mortality experience of the sub- jects in the five and one-half years following the initial survey (Belloc, 1973). The researcher found a marked and consistent relationship between mortality and number of health practices, especially among male subjects and this relationship was independent of income. A larger propor- tion of older persons reported good health practices than 79 did the younger age groups. He concluded that mortality was more strongly associated with poor health practices than it was with physical health status or income and that among the older age groups there was a marked inverse corre- lation between the number of activities practiced and the mortality level. Another study was conducted among a randomly selected pOpulation of Finnish 70 year old adults in 1973 (Stenback, Kumpulainen, & Vauhkonen, 1978). Among the 103 subjects, 31 reported no chronic illness and declared they functioned physically and socially as well as in their earlier lives. They reported the only change over the last 50 years was a mild to moderate decrease in physical strength. Only infre- quently was diet-keeping a matter of great significance. There were 49 subjects who had had a life-long interest in exercise and the prOportion of subjects with good subjec- tive health was greater in the group reporting high physical exercise. The researchers concluded there was less illness among those with an active interest in physical exercise and with a restrictive attitude toward smoking and drinking. McGlone and Kick (1978) studied 52 randomly selected persons over 80 years old to try to evaluate their state of health in relation to various factors, including health habits. Health habits examined were those identified by Belloc. Almost all the subjects slept 6-10 hours a night and few used any sedation. Most of the subjects were of 80 normal weight or slightly underweight. There were no obese individuals in the study. Of the 52 subjects, 47 were non- smokers. Most (40) subjects were active both physically and mentally. There were no heavy consumers of alcohol. The parents of all but one of the subjects had survived past the age of 70. Only five of the subjects had signifi- cant hypertension. Almost all the subjects were cheerful, optimistic, and had a good sense of humor. Whitbourne and Sperbeck (1981) discuss c0ping strate- gies which can be used to compensate for age-related changes in function and propose that the elderly do not need to be taught what to do to maintain their health but need to be given the opportunity to use and refine what they already are doing and what they already know in restructur- ing their health activities as aging progresses. Archer et a1. (1979) found that among 679 noninsti- tutionalized older adults (mean age 69.5) 87% participated in social recreation (playing cards, visiting, dancing) because it involved being with other persons. Less than 50% of the respondents reported participating in active physi- cal recreation (sports, walking) and only 3% reported no recreational activities at all. Performance of light exercise (gardening, housework, yoga) was reported by 98% of the study sample, 23% participated in strenuous exercise (jogging, swimming, tennis, calisthenics) and 15% reported moderate exercise (bicycling, health club, climbing stairs). 81 Only five participants reported no exercise activity. In summary, performance of the health activities of exercise, weight control, avoidance of smoking and limita- tion of alcohol intake, good nutrition, adequate sleep, and engaging in recreational activities cumulatively contribute to a decreased incidence of illness and mortality and an increase in psychological health. With one exception (Aho) there were no studies which identified the relationship of health beliefs (perceived future health needs) to the inci- dence of practice of health activities by older adults. The efficacy of specific health behaviors or activi- ties in maximizing function of older adults has been explored in the next portion of the literature review. Exercise Specific studies have been done on the efficacy of physical exercise for older adults. Price and Luther (1980) stress that often, sedentary persons begin an exercise pro- gram without any idea what their goals are or how to reach them. Specifically designed, slowly building exercise of moderate intensity should be used by older adults to prevent them from overstressing themselves in the beginning and discontinuing the program. Price and Luther describe nega- tive attitudes held by some older adults about exercising which include fear that activity would be too strenuous or embarrassment and list enabling factors for exercising. Among these are cost, distance to travel, and availability 82 of transportation as well as the availability of facilities at which to exercise. DeVries (Lesnoff-Caravaglia, 1980) conducted a major study in which he used an experiemntal design to determine how trainable the older person is in relation to exercise. The 112 male subjects (mean age 70) were grouped and placed on an exercise regimen after undergoing a thorough medical examination and an extensive battery of physiological tests. The exercise program was designed to accomplish mainly cardiovascular conditioning. Subjects in the experimental group demonstrated an improvement of 29% in oxygen consump- tion per heartbeat as compared to those in the control group. The researchers did not expect more improvement than that observed among younger persons. Vital capacity improved 19-20% and ventilation at maximum exercise improved by 35%. Again the controls did not change. The study was repeated with women resulting in similar data with one dramatic exception: there was no improvement in respiratory functions. The significance of this finding is not known. DeVries con- cluded after several years of refining the research that brisk walking for fifteen minutes is very good exercise for the older adult and that regular exercise has a relaxing effect. Bortz (1980) reviewed the literature in search of evidence that exercise can affect longevity and found none but did conclude as a result of his literature search that 83 a vigorous physical activity pattern has many advantages for the mind, body, and spirit. Aloia (1981) examined the literature for evidence of the benefit of physical exercise in the maintenance of skel- etal health. He concluded there is support for the concept that increased physical activity can prevent the loss of bone and muscle and the increase in fat that is usually observed with aging. He states further that this type of exercise may differ from that used to increase maximal oxygen uptake. Researchers in Sweden investigated to what extent physical training might influence age-related changes in muscle strength, muscle mass, and muscle composition and act as a preventive measure against disability (Aniansson, Grimby, Rundgren, Svanborg, & Orlander, 1980). Both an experiemntal and a control group consisted of 12 men (ages 69-74) and those in the experiemntal group trained for 45 minutes three times a week for 12 weeks with exercises using only body weight. The subjects had no locomotor or cardiovascular symptoms nor had they taken part in any phy- sical training during the previous ten years. Results demonstrated both aerobic capacity and muscle strength could be increased in 70 year-old men and the reduction in function seen with age seems to be a combined effect of inactivity and aging. 84 Exercise has been found to be beneficial in arthritis therapy. Kale and Jones (1981) recommend muscle strengthen- ing exercises as physical therapy for persons with arthritis along with hot or cold applications to decrease pain. Chapman, in a separate component of DeVries' exercise study examined joint mobility in older adults (Lesnoff- Caravaglia, 1980). Electronic instruments were used to objectively measure the torque required to passively rotate finger joints and data revealed that older adults did have much stiffer finger joints than did younger persons. An exercise program for the hands was initiated using the principles of progressive weight training and subsequent significant improvement resulted both among the older sub- jects and the young. From the research reviewed, it is apparent that a regular, planned program of exercise can increase aerobic capacity, retard muscle and bone loss, and improve joint mobility of older adults, all desirable outcomes of health promotion. Nutrition Price (1979) states that visits to dentists are strongly correlated with the ability to pay. In 1975, 93% of the costs for dental care to the elderly were paid with private funds ($502 million). The average dental expense of the elderly is higher than that of younger persons. Medi- care does not cover expenses for repair of teeth or dentures. 85 Dentures lead to changes in preferred types of food. Since meats require more chewing and are expensive some older adults substitute carbohydrates for meats. This can in— crease dental caries as well as contribute to malnutrition and obesity. Research was conducted to assess the dietary fiber intake of older women and to examine food behavior, health, and laxation factors associated with dietary fiber intake (Johnson, Kolasa, Chenoweth, & Bennink, 1980). The women (N=59) were selected from Nutrition Program meal sites in Michigan in 1977 and ranged in age from 58 to 89 years. Assessments were made of dietary intake, functional health, and laxation. The study was limited in that researchers had to estimate dietary fiber content in some foods con- sumed by subjects. The results suggest that generous amounts of any fruits, vegetables (including legumes), nuts, and whole grains will provide adequate dietary fiber for most persons. Intakes of dietary fiber ranged from 3 to 33 gm. per day (mean=l4gm.). For most of the women dietary fiber intake was adequate to maintain normal laxation al- though the women who used laxatives regularly generally had fiber intakes below 12 gm. per day. Poor health and indi- vidual food preferences were related to low fiber intakes. There was no description of factors (perceptions;beliefs) which influenced choice of foods among this pOpulation. 86 Hull, Greco, and Brooks (1980) examined the effect of a fiber-supplemented dietary regimen on constipation among 270 residents of a long term care facility. Most of the subjects (mean age = 79.6 years) had limited physical activity, suffered from poor dentition and had relied on regular use of multiple laxatives prior to admission to the facility to control bowel activity. An analysis was made of the diet at the facility and it was determined that it contained 20-25 gm. of total dietary fiber daily, depending on what type of bread was chosen by the resident. To mini- mize the use of laxatives and prevent constipation the re- searchers increased the fiber content of the diet over time by the addition of bran to the cereal. One year after im- plementation "the use of laxatives was virtually eliminated" at the facility. The regimen was reportedly effective in preventing constipation in previously laxative—dependent residents as well as in those who did not use laxatives. For 40% of the subjects the bran-supplemented cereal was not totally effective until prune juice was added to the diet at which time bowel habits approached normal for these 40 residents. The researchers concluded that a fiber-supple— mented diet can be effective in preventing constipation in an elderly, institutionalized population. Though this popu- lation sample was different from those adults residing in independent living quarters, similar results might be observed if the study were replicated elsewhere under more 87 rigid controls. Discomfort was experienced by most of the residents for the first two weeks of the program in the form of abdominal fullness and "gas" which might be a bar- rier to this form of therapeutic self—care for some older adults. Though an intake of fiber in the diet has been demon- strated to prevent or allieviate constipation only one study was found which described the activity of independent older adults in relation to dietary fiber intake patterns and that was among a very specific population. Health Screening Morrison (1980) discussed a preventive approach to geriatric health care and proposed certain screening tests should be performed on older adults. Rectal-prostate exam- inations, regular testing of the feces for occult blood, breast examination, papanicolaou smear, pelvic—rectal exam for women, screening for hypertension, diptheria-tetanus inoculation at ten-year intervals, pneumococcal vaccine at three year intervals, and influenza vaccine yearly are recommended. Morrison warned that obesity may indicate nutritional deficiency if carbohydrates have taken the place of protein in the diet and advised regularly scheduled health monitoring of medication regimes, diet, social activ- ity, neuro-sensory status, motor function and the feet. Breslow and Somers (1977) added annual dental prophylaxis to Morrison's recommendations. 88 Though health screening may be effective in early detection of disease no research was found which demonstrat- ed this to be a fact through prospective study nor were any studies identified which described the older adults' will- ingness and/or activity (behavior) in regards to participa- tion in preventive health screening except for Aho's analysis of participation in the Swine Flu inoculation program. Socialization Activity Evans (1979) discusses the need for older adults to maintain social activity in order to promote health. Main- taining social interaction is one aspect of self—care but among the elderly pOpulation previous support systems may not remain viable. This author cites studies demonstrating that the presence of an intimate relationship serves as a buffer against social losses and that there is a close association between the lack of relatedness and mental ill- ness in old age. Evans concludes little research has been done which describes how the elderly perceive their need for social interaction and how they adapt their behavior to meet this need. Relationships between morale, leisure satisfaction, leisure behavior, health, and income were examined in a sample (N=104) of noninstitutionalized older adults with a mean age of 72.5 years (Mancini & Orthner, 1980). Results indicated a significant relationship between morale and 89 leisure satisfaction. Older adults who reported more satis- faction with their leisure time tended to feel positive, emotionally stable, and content with their life in general. Health and health status were related to morale but not to leisure satisfaction. Leisure satisfaction was independent of socioeconomic status and dependent upon leisure behavior (activities) but not necessarily bound to a particular activ- ity pattern among older adults. Results did not indicate that health was a primary determinant of morale. The researchers concluded that leisure issues are important for well-being of noninstitutionalized older adults and it is not necessary that the older adult select any particular activity or activity pattern. Leisure satisfaction was sig- nificantly related to morale as was socioeconomic status, followed by leisure behavior or activity. Self-rated health, the illness index and age were much less important. Robinson (1981) states certain factors related to retirement influence the leisure time of older adults. First of all, the time they have for leisure activity is con- tinuous time and may require goal-directed activity and planning. Because of socioeconomic constraints, leisure opportunities may need to be close to home and inexpensive. Leisure activity must help older adults retain a Sense of self—worth and realign social relationships as well as to form new identity groups to replace the losses that may have occurred with retirement. Changing satisfactorily 90 from the work role to the leisure role is a major task. Robinson proposes if older adults are to achieve a high state of wellness they must recognize the value of leisure as an opportunity to develop and grow to a potential never before possible, a challenge requiring self-discipline since leisure can lead to boredom and apathy as well as creativity and satisfaction. Medication Usage Conrad and Bressler (1981) cite surveys demonstrating that 71% of persons over 75 years old receive regular medi- cation that they administer themselves and 46% take three or more drugs each day. Ebersole and Hess (1980) devote a chapter in their textbook to drug use and misuse among the elderly and cite use of over-the-counter drugs (analgesics, antihistamines, laxatives), hoarding and using old medica- tions, using discontinued medications, sharing medications with friends, making medication errors and omission of med- ications as common problems among this population. Krupka and Vener (1979) arrived at the same conclusion. From review of these sources it is clear that older persons must understand the benefits of all medications they ingest, the possible side effects, possible interaction effects, the risks of omitting medication, and how to evalu- ate if the medication they take is producing the desired effect. 91 In summary, performance of specific health activi- ties (exercise, nutrition, rest, avoidance of harmful sub- stances, early detection of disease, social activity and creative use of leisure time, and knowledge of medications) can serve to maintain and promote function and contribute to the subjective well-being and longevity of older adults. The individual older adult must assume responsibility for making personal decisions about self-care. Assistance may be necessary to enable the older adult to identify health needs, risk factors, and appropriate health activities. The next section of the literature review will address the assistance available and assistance-seeking activity of older adults. Expectations of Assistance by Older Adults Blenkner (Kalish, 1975) identifies four normal dependencies of aging (economic dependency, physical depend- ency, mental dependency, and social dependency) and three types of help utilized by older adults (self-solution, in which the individual modifies his behavior or circumstances; kinship solution; societal solution Such as social insurance, public housing and rent supplementation; and home health care). Among both male and female older adults, functional ability to maintain self-care is the area that is the most likely to fail to the point of creating a dependency situ- ation (Silberstein, Kassowsky, & Libers, 1977). The aged 92 seek assistance from their kin first (Ebersole & Hess, 1980). Ebersole and Hess rank type of assistance provided by kin as taking parent places, help with personal finances, help with household chores, errands, emotional support, and inclusion in family rituals. Archer (1968) found in planning for health mainten- ance programs for older adults that there is a strong tend- ency for persons in the lower economic group to visit a physician only when ill. She found that health is important to many older adults only as it becomes poor health and interferes with daily functioning and maintenance of inde- pendence. This finding seems to be contradictory to more recent health activity research. Archer also found that many elderly persons eligible for clinic care do not take advantage of the agencies where they might receive health supervision. A last observation Archer made was that older adults with private physicians do not have regularly sched- uled health maintenance examinations. Sivertson (1978) collected data on geriatric patients seen by office—based family physicians in Wisconsin (109 practices). Geriatric patients constituted 11.3% of all patients seen by these physicians. The average number of problems or diagnoses was 2.2 for each patient. The highest percentage of problems involved the circulatory system (33%) followed by endocrine, nutritional, and metabolic problems (9.1%). The researcher stated that socioeconomic needs, 93 preventive medicine and rehabilitation were conspicuously absent from the problem lists obtained in the study but argues that these problems are often beneath the presenting complaint of older persons. Moore and Fillenbaum (1981) measured change in func- tional disability of geriatric patients seen in a family medicine program over a time span of 13 to 27 months. The patients had been initially evaluated by Moore (1978) and 48 of those initial 130 clients were re-assessed for the follow-up study using a stratified random sampling proced- ure supplemented by random sampling. The researchers found more improvement in physical health than deterioration, that social and ADL status remained the same, but that there was deterioration in functioning in the economic and mental health areas. Visits to a physician because of physical health problems was found to be reported more frequently in the follow—up evaluation than initially but the researchers did not conclude this was because they were more ill. In the initial assessment 13% of the subjects felt no help from family or friends would be available to them should they become sick or disabled while in the follow-up study 19% so reported. Utilization of nineteen generically defined services was measured (transportation, nursing care, physical therapy, meal preparation, homemaker service, etc.) both times and found to have increased or remained stable on follow-up evaluation. While the extent of use of services 94 changed there was little change in expressed need for serv- ices. The researchers concluded that there was a need in this practice for evaluation and intervention in the areas of social, economic and mental health as well as physical health and for use of a multi-disciplinary team approach to care. Brody and Kleban (1981) studied the reporting and non-reporting of symptoms among 132 subjects aged 62 to over 80 (age range not given) and their collaterals (129 respon- sible relatives) by means of detailed interviews. A small majority of the subjects told someone (either a health pro- fessional, family member or friend) about their symptoms. Between 40 and 50 percent of the subjects did not tell any— one when they experienced dizziness, feeling blue, head— aches, leg cramps and shortness of breath. The older adult subjects were as likely to report most symptoms to a family member or to a friend as to a health professional. Three types of symptoms were more likely to be reported to a health professional by older adults: shortness of breath, chest pain on activity, and unsteadiness on feet. Only one symptom of 20, forgetfulness, was more likely to be report— ed to the older adult's family. Reasons given for not reporting their symptoms to anyone fell into six categories which were, in order of descending frequency, "no big deal," "nobody cares," "no one to tell," "normal aging," "don't want to bother people," 95 "will tell the doctor at next appointment," and "others know." The researchers caution that data do not include the frequency or severity of the symptoms, their relation- ships to pre-existing diagnoses, or information about whether the older adults were receiving treatment. The researchers conclude there is a need for health education for the elderly about normal changes that occur with aging and the importance of reporting symptoms and that this edu- cation should also be extended to significant others and family members as they are in a position to make appropriate referrals and provide much of the care needed by this population. Bloom and Soper (1980) reviewed journal publications concerning the evaluation of geriatric services and attempt- ed to identify those studies that were well-designed and executed according to an established set of criteria with the goal of examining the evidence regarding the special health and medical services for the elderly and determining their validity and reliability. From nearly 1,000 articles published between 1967 and 1979 only seven met the original criteria. None of these published studies addressed the population of ambulatory, noninstitutionalized, healthy older adults. Snider (1981) examined the relationship between age cohorts and the use of community-based health services in comparison with other enabling, predisposing, and health 96 status factors using a sample of 428 white, retired, non- institutionalized family heads 65 years of age or older. The researcher found that age differences among the elderly are unrelated to the use of health services and concluded that delivery of health services depends on the older adult's knowledge of health services, education, and month- ly family income, even among a population who received, for the most part, fully subsidized health care (as is the case in Western Canada where this study was conducted). In a national random sampling of 1509 persons aged 18 and above, Haug (1981) found that in a period of time dating from the previous Christmas persons over age 60 were less likely than younger persons to have experienced com- plaints classified as "less serious" by a panel of physi- cians but more likely to have experienced the more serious problems. Other findings were that older persons in general were more likely to get physical check-ups and over—utilize the health care system for minor complaints than younger persons but little difference existed between age groups in under-utilization of the health care system for conditions which should have received medical attention. The conclu— sion reached was that there is a need to educate the aging public on the "common complaints" in order to help them determine which symptoms require attention and which do not. Age preferences for professional helpers was invest- igated through interviews of 621 persons aged 16 to 91. 97 "Professional helpers" were defined as physician, nurse, policeman, lawyer, clergyman, and teacher (Furchtgott & Busemeyer, 1981). The researchers found older persons pre- ferred professional helpers that were older than those perferred by younger persons. Wright, Berg, and Creecy (1979-80) investigated the influence of social factors on the use of physician's serv- ices by the elderly with special emphasis on race. Vari— ables examined were demographic and sociopsychological pre- disposing factors, enabling factors (community health resources and insurance coverage) and need factors involved in illness level which relate to the individual's perception of symptoms (N=414). The mean age was 73.2 years, 83% were females, 24% were Black, and the mean income was $2,600 per year. Analysis by partial regression coefficients revealed age, education, sex, and marital status were unrelated to utilization of physician services. Race (Black) was nega— tively correlated and income and presence of a regular source of medical care were positively correlated to physi- cian utilization. Insurance coverage was not significantly related to use of medical services, a finding which the researchers attribute to universal use of Medicare and Medi- caid among the study population. The most important vari- ables affecting use of health care providers were current health problems, the impact of those problems on the sub- jects' functioning, and self-reported health status. 98 Wright et a1. conclude that much more emphasis should be given to preventive health care among the elderly including early screening and diagnostic services although it is not clear to this researcher how the design of the study and the results would lead to this conclusion. Auerbach et al. (1977) reported that among 100 non- institutionalized older adults (mean age = 72.1 years) 47% reported seeing a physician up to four times in the previ- ous year, 24% had five to nine visits, and 29% saw a phy- sician more than ten times. Only 12% of the sample had been hospitalized during that same period of time. Private physicians were the source of medical care for 47% of the subjects while 43% utilized local hospitals and 10% reported no usual source of care. Among the respondents not receiv- ing Medicaid 70% reported difficulty meeting the costs of health care. No data were reported on the subjects' reasons for seeking medical care or the relationship between self- perceived health status and utilization of health care, though 11% of the respondents reported that physical impair- ment interfered with their access to medical care. Archer et a1. (1979) asked older adult subjects (N=679) what health activities they would like assistance with in future health promotion programs and found that weight control had the highest priority followed by exercise, cooking for one or two persons, blood pressure checks, shop- ping for sound nutrition, getting along with peOple, posture 99 improvement, how to live with and/or help others live with a disability, and smoking control. The last priority was sex counseling (5%). Berkanovic, Telesky, and Reeder (1981) investigated the decision to seek medical care for symptoms (N=769). Variables examined were indicators of need (perceived health status, self-reported number of chronic health problems, amount of disability associated with the symptom), socio- demographic characteristics (sex, age [M=42.6], income, occupation, education, marital status, race), organization of care (access), utilization of social networks (relatives, friends), and health beliefs as defined by the Health Belief Model. Results indicated that the three major predictor variables in the decision to seek medical care were all symptom related. There were high correlations between specific health belief items but the researchers caution that since it was a retrospective study the subjects may have developed specific beliefs about susceptibility, seriousness, and benefits of assistance-seeking activity after obtaining physician services. There was no data reported on age range or numbers of persons in various sociodemographic groups. In summary, researchers who examined the assistance available to older adults in all areas of need (physical, socioeconomic, and psychological functioning) point out that few services exist for older adults experiencing difficulty except in acute illness situations. No data was found 100 describing utilization of preventive health care. Older adults appear to utilize the health care delivery system for episodic illness care and attempt to cope with other health problems by themselves, through personal support systems, or not at all. Lack of knowledge, income, and educational level may affect their use of the health care system. Researchers in one study demonstrated the desire of older adults to receive assistance with preventive health activities. In the next section of this chapter a brief review of the literature relevant to utilization of the preventive Health Belief Model has been presented. The Preventive Health Belief Model and the Older Adult The preventive Health Belief Model (HBM) has been formulated to enable health care providers to predict the likelihood of an individual to perform a specific health activity (behavior) by identifying the individual's percep- tions of susceptibility to a disease or event, the perceived severity or impact of the disease or event on personal life, the benefits and costs of the preventive health activity, and the presence of various modifying and motivational factors which have been found to interact with all of the HBM variables (Becker, Drachman & Kirscht, 1972). In the general population, the individual's percept- tion of personal susceptibility to a disease or event has 101 been found to be positively related to the performance of a variety of preventive health activities (Mikhail, 1981; Williams & Wechsler, 1973; Jette, Cummings, Brock, Phelps, & Naessen, 1981). Perceived susceptibility has a strong cognitive component whereby knowledge can influence health activities. Researchers have demonstrated that biologic changes (hypertrophy of bone at joints, decreased pulmonary and cardiac function during stress, decreased sensory per- ception, increased frequency and precipitancy of urination, and less restful sleep), socioeconomic changes, and psycho- logical changes (alterations in roles and intimacy patterns, need for reminiscence, new developmental tasks) do occur as aging progresses. The individual older adult's knowledge of these probable changes theoretically should positively influ- ence their decisions to perform therapeutic self-care health activities directed toward preventing, delaying, or mini- mizing problems created by these aging changes. People, however, can only act on what they believe to exist even though their beliefs may not be congruent with those of health care professionals (Mikhail, 1981). Tager (1981) states that attitudes and beliefs have a greater effect on behavior than does the increasing of basic knowledge. Studies have been conducted to identify perceived health needs of older adults and the results indicate that while most older adults are able to c0pe well with the changes that occur as aging progresses, declining physical function 102 was perceived to be of greatest concern. Utilizing the HBM then, the researcher might predict that if perceived suscep- ibility to physical problems was present among an older adult population there would also be a high percentage of the same population who performed specific health activities to maintain physical function and prevent disability. There should also be less evidence of health activities in psy- chological or socioeconomic areas if perceived susceptibil- ity to difficulties in these areas is not present. Several modifying and motivational factors have been identified in the research literature, however, that may affect the indi- vidual perceptions of older adults. An individual's perceived health status has been demonstrated to be positively correlated with various health behaviors (Jette, et al., 1981). Researchers have found that older adults' self-reports of health status are reli- able and valid. Age, educational level, occupational and marital status, availability of transportation, housing and sOcial interaction, physical disability, presence of sig- nificant others, income, and life events have been identi- fied as factors which affect perception of health among older adults. Researchers testing the HBM have also found that age has a modifying effect on health beliefs among the general population. In an experimental study (N=166) Haefner and Kirscht (1970) found that age was positively related to perceived susceptibility to and seriousness of 103 cancer and perceived seriousness of tuberculosis but the only age—related association to past health behavior was a positive relationship between age and restriction of caloric intake (age range 18-68 years). Jette, et al (1981) found that while there was a clear separation of condition-spe- cific and general measures of perceived susceptibility among younger subjects there was little discrimination be- tween general and specific indicators among respondents over the median age (38 years). Mechanic and Cleary (1970) found that sex and education were related to positive health behavior and that persons who perceived their health status less favorably also reported lower positive health behaviors or activities. Socioeconomic status, frequent interaction between non-kin, positive attitudes toward health care providers, internal locus-of-control, perceived benefits of preventive health activity, age, and gender were all found to be associated with preventive health be- havior among the general population (Langlie, 1977). Mikhail (1981) cites several studies testing the variables of the HBM in relation to performance of health activities. Though various motivational and modifying factors have been identified that affect self-perceptions of health by older adults and preventive health behaviors in the general population, no studies were found that identify the relationships among perceptions of health needs, moti- vational and modifying factors, and performance of health 104 activities specifically among the older adult population. Persons are more likely to undertake health activities when they believe the activity is effective in preventing or detecting the disease and therefore reduce its threat to them (Mikhail, 1981). Researchers have found that good health practices in general contribute to the longevity and life satisfaction of older adults. Performance of specific health activities (exercise, nutrition, rest, avoidance of harmful substances, early detection of disease, social activ- ity and creative use of leisure time, and proper use and knowledge of medications) have been demonstrated to be effective in maintaining and promoting function in the older adult population. Knowledge and the same motivational and modifying factors can also affect the individual's perceptions of the benefits and costs of health activities. The individual must believe the health activity is effective in promoting their personal health if they are to be likely to perform the activity. For older adults, there may be many barriers to the activity including monetary costs, pain (as with exer- cise or changing fiber intake), inaccessibility, inconven- ience, and lack of peer support. Mikhail (1981) cites one study in which the researchers found a negative relationship between perceived susceptibility and barriers but were un- able to draw any firm conclusions from the data. Mechanic and Cleary (1980) examined various factors associated with 105 positive health behavior and concluded that poor health behavior is part of a life-style reflecting inadequate an- ticipation of problems, inability to mobilize to meet prob- lems, and ineffective coping techniques. A finding common to most research conducted among the noninstitutionalized older adult population was the ability of individuals to cope with most problems adequately. It would appear that positive health practices would be common among noninstitu- tionalized older adults. Tager (1981) states that although accepting responsi- bility for self-care removes an individual from a position of dependency and reliance on others it does not mean that help is not desirable in the form of education, experience and counseling but only that the individual is responsible for seeking such assistance when appropriate. Haefner and Kirscht (1970) found that the nature of the activity was important for many persons in determining actual perform- ance and that some activities, such as seeking health screening for disease prevention, were motivated by cogni- tive factors. Other activities, such as dietary patterns and long-established habits were not influenced by inter- ventions directed at changing beliefs. The conclusion reach- ed was that habits and well-ingrained behavioral patterns involve many motives that go beyond health care and alter- ing an individual's beliefs about health may change actions largely motivated by health matters but may not alter 106 behaviors that simultaneously satisfy many different motives. For the older adult, since they become more individual as they grow older, it may be difficult for health care pro- viders to affect change. The implications of researchers who have tested the HBM are that attempts to influence an individual's health activity should be based on better knowl- edge of their motives and health beliefs (Mikhail, 1981). This assessment may reveal inappropriate health beliefs as well as actual and potential barriers. Intervenors should consider individual differences for all persons, especially older adults. Researchers have shown that few services exist for older adults at-risk or experiencing difficulty except in acute illness situations and many barriers affect their use of the health care system. There is some evidence, however, that older adults do wish assistance with preven- tive health activities. Utilization of the preventive HBM as a framework for assessment of the capability of noninsti- tutionalized older adults to perform thereapeutic self-care could identify appropriate intervention points for the edu- cation and counseling that would assist them to maintain their health and independence. Summary of the Literature Review From the review of the existing literature of per— ceived health needs of older adults, benefits and perform- ance of health activities, and expected assistance from health care providers, it appears that there is a minuscule 107 body of scientific knowledge about what might be expected as aging progresses, what benefits may be derived from certain health activities, and what services should be pro- vided for older adults by health care providers. This researcher, however, has found a lack of research identify— ing the perceived future health needs of persons over age 65 in the area of expected changes as aging progresses, self-perceptions of the benefits of life-style changes and health activities by older adults, and the eXpectations of assistance from health care providers. In this study, the researcher will attempt to identify the beliefs of a small population of older adults about their future health needs, their stated performance of preventive health activities, and the extent of assistance they expect to receive from health care providers. In the next chapter the methodology utilized in this study for collection of data has been described. CHAPTER IV METHODOLOGY AND PROCEDURE W This descriptive study was designed to identify individual older adults' perceptions about their changing health needs, their stated performance of health activities, and the assistance they expect to receive from health care providers to meet these needs and perform these activities. It was expected that the results of data analysis could specifically identify (1) the degree and direction of the relationship between perceived health needs and practice of health activities; (2) the degree and direction of the rela- tionship between perceived health needs and expected assist- ance from health care providers; and (3) the degree and direction of the relationship between the stated performance of health activities and expected assistance from health care providers. The subjects were fifty-six non-institutionalized adults aged 65 and older residing in independent living quarters in a midwestern community of approximately 200,000 persons. Perceived susceptibility to specific health prob- lems as aging progresses and stated performance of specific health activities were two study variables derived from the 108 109 preventive Health Belief Model (Rosenstock, 1974). The third study variable, expected assistance, was derived from Orem's nursing model (Orem, 1980). Modifying variables such as age, sex, marital status, income, household members, type of dwelling, occupational status, years of retirement, perceived health and ability to understand the English lan— guage were determined through collection of socio-demographic data. One possible motivational factor, contact with a health care provider, was measured by collection of data concerning the frequency of utilization of health care serv- ices during the previous twelve months. The instrument was presented to groups of participants and self-administered. The data was analyzed by means of descriptive and inferential statistical procedures. The purpose of this chapter is to present the method- ology and procedures utilized by the researcher in the pre- sent study. The sample, settings, instrument, pre-test procedure, data collection procedure, human rights protection, scoring techniques and procedures utilized for data analysis are described. Sample The participants were 56 English-speaking older adults residing in independent living situations who per- ceived themselves to be in good health, were willing to par- ticipate in the study, and who completed the instrument. 110 The voluntary sample was obtained from older adults residing in a midwestern urban-suburban-rural community of approxi- mately 200,000 persons. The subjects were either residents of subsidized senior citizen housing units or volunteer workers at a local hospital. Results of this study can only be generalized to individuals who possess the same char- acteristics as the subjects who participated in the study and may not be indicative of the entire non-institutionalized older adult population. Older Adult The older adult was defined as any individual who had attained the age of 65 years or older. English-speaking. The English-speaking older adult was defined as any individual 65 years old or older who utilized English as their primary language. Independent living situations. All of the subjects owned or rented their own home or apartment and did not require assistance with activities of daily living. Perceived good health. All subjects who participated in the study responded "Yes" to the question: "Do you feel you are generally in good health?." No attempt was made to obtain data regarding the presence of chronic illness since many older adults function and feel well despite these conditions. Willingness to_participate. The purpose, criteria, and technique of administration of the instrument were lll explained to the potential subjects by the researcher and residence manager/volunteer director prior to the date of administration of the instrument so that only persons who were willing to participate were present at the specified time, date, and place. Completion of the questionnaire. Only subjects who completed the last section of the instrument (socio-demo- graphic data) were included in the study to further insure that participants were able to read and understand the questionnaire. Settings Volunteers from five settings participated in the study. Initially, six federally subsidized senior citizen housing units were contacted. The manager of one of the units stated that the residents at that particular site had been surveyed by at least six other investigators for vari- ous reasons in the previous two months and felt that they would be reluctant to participate in another study at that particular time. This researcher decided that if that site were used it might introduce an additional bias into the study as those residents might be "test-wise." The manager of a second senior housing unit felt the instrument was too long and too complicated for the residents at that setting and declined the researcher entry. The remaining four 112 units were utilized for subject selection. Rental fees charged in each of the federally-subsidized housing units were based on 25% of annual income minus annual medical expenses. Residents had to undergo a physical examination prior to acceptance in the unit and had to be capable of independent living without the assistance of care-taking services. The fifth setting was a local metropolitan hospital which utilized retired older adults as volunteers in vari- ous departments. To insure anonymity of respondents there was no means of identification on the individual instruments to connect them with a particular site. Each of the settings will be further described and numbered in order of sequence of data collection (Site #1 = first administration date, Site #5 = last date of administration). Site #1. The first setting was a privately owned, federally subsidized, low-income housing unit containing 100 apartments. At any one time there were approximately 120 residents. For an older adult to be eligible to rent an apartment in this setting his/her income must not exceed $14,450 per year. The average income of the residents in Site #1 was about $7,000 per year. This unit is located in a small town within the greater metrOpolitan area but in a combination rural-suburban setting to the west of the urban metropolitan area. All residents were members of a govern— ing council which was responsible for setting the policies 113 of the residence unit. The executive committee of the council was elected by the entire population of residents every year. The average attendance of residents at council meetings was 25. This unit had been open three years. Each apartment had one or two bedrooms, a living room, kitchen, and bathroom. There was a large community room used for various recreational, social, and business activi- ties. The housing corporation employed a residence manager and a custodian. The apartment unit was within walking distance of a small shopping center and within one mile of the business area of the town which contained a library, two banks, two pharmacies, and a theater as well as assorted shops. Limited bus service (two times a day) was available to the larger urban area. At the time of participation in the study, the town had an active senior citizen program funded under the larger adult education umbrella which in- cluded a nutritional meal site. Site #2. The second setting utilized for selection of subjects was also a privately owned, subsidized low— income housing unit containing 100 apartments very similar to Site #1. It was completed in May of 1979. In this unit there were approximately 110 residents at any one time and a waiting list of 300 applicants. Income criteria was the same as in the first site but average income of the residents was only $4,800 per year. This housing unit was located in a more urban area of the community close to a large shopping 114 complex and a hospital. Bus service was available two times each hour during the day and evening at the door of the apartment building. There was a resident manager at the site employed by the housing corporation and a secre— tary. The custodian was an older adult and resided in the unit with his wife, free of charge. This site also served as an educational site for senior social work internes from Michigan State University. There was an active residence council at this site with average monthly attendance of 60 residents. Site #3. The third setting from which subjects were obtained was a city-owned subsidized housing unit contain- ing 189 apartments and approximately 229 residents. It was the largest and the oldest unit utilized in the study. There was a hierarchy of administrative personnel employed by the city to Operate and manage this unit and several other city-owned low-income complexes. The manager for Site #3 was also responsible for managing another senior housing unit. To be eligible to reside in Site #3 individ- ual income must not exceed $11,070 per year. This unit was located within one-half mile of Site #2 and was also an educational site for social work internes. There was a resident's council but participation was relatively low with an average of 40 residents at each meeting. Site #4. The fourth site was the Health Education department of a hospital in the urban area. The hospital 115 had 200 acute-care beds and 49 mental health beds. Over 800 persons volunteered time in various departments of the hospital performing different duties. Subjects for this study were obtained from a group of 75 retired older persons who voluntarily staff the Health Education Depart- ment. Hunter and Linn (1980-81) examined the psychosocial differences between older persons (mean age = 73, 75; n=102) who were active volunteers in the community and those who were not and found that elderly volunteer workers were more satisfied with life, had a stronger will to live, and reported fewer somatic, anxious, and depressive symptoms than did those persons in the sample that did not engage in volunteer work. The older adults working in this department were responsible for planning, implementing, and often teaching health education programs such as arthritis, stress management, nutrition, weight loss, and hypertension. These volunteers had been actively recruited from Michigan State University and local businesses and were, for the most part, highly educated, successful professional retired persons. The hours contributed by the Health Education volunteers ranged from one hour a month to twenty hours a week. The Health Education Director was employed by the hospital and was responsible for coordinating and directing volunteer activity. Site #5. The last site utilized for selection of subjects was another privately owned subsidized housing 116 unit containing 100 apartments and an average of 120 resi- dents at any one time. It was very similar in physical design to Sites 1 and 2 and located in a rural-suburban community to the south of the metrOpolitan urban area. There was a large shopping center next to the site and a branch of the Public Library on the housing unit grounds, though not within the physical boundaries of the apartment building. Bus transportation was more readily available at this site than at Site #1 but not as frequent as in the urban settings. Eligibility requirements were the same as for Sites 1 and 2. The residents' council at this setting was very active with a usual attendance rate of 80%. A unique characteristic of the residents of this setting was their involvement as a group in many community programs such as school fairs, church potlucks and bazaars, and fund- raising programs for specific causes such as a cystic fibrosis camp. In each of the housing sites the community room was utilized for instrument administration. The rooms were identical in accessibility, lighting, and equipment. Tables were arranged in rows with seating at each table for up to twelve persons. Coffee and tea were made available by the residents' council and in each setting some residents brought snacks for all the participants to eat while they were completing the questionnaire. 117 At the hospital site, the conference room was uti- lized for administration of the instrument. The room was light, newly redecorated and contained a large table seat- ing twelve with accompaning plush upholstered chairs. Coffee and tea were provided at the hospital site. Instrument The instrument was based upon the preventive Health Belief Model (Rosenstock, 1974) and Orem's Self-Care nursing model and combined items drawn from the literature review and from consultation with two gerontological specialists on the faculty at Michigan State University. From these three sources the instrument was developed and specific items selected to address common changes occurring as a result of the aging process, common health needs of older persons as identified by both health care personnel and older adults themselves, and health activities which may be beneficial to older adults in maintaining their health and/ or overcoming health problems. For each of the specific health needs or health activities items selected, the re- spondents were asked to identify if they expected to receive assistance from health care providers. To further clarify the variable, expected assistance, the respondents were asked to identify the person from whom they would be most likely to receive assistance. 118 The total instrument contained 132 items which meas— ured each of the major perceptual variables of the study: perceived susceptibility to specific health needs (39 items), stated performance of specific health activities (27 items), and assistance expected from health care providers (66 items, Appendix B). Motivational and modifying factors were assessed by means of collection of socio-demographic data (14 items, Appendix B). An additional 66 items identi- fied the type of individual (including self) most likely to help the older adult with a health need or activity (Appendix B). The instrument was printed in large type using both upper and lower case letters on uncoated paper (to eliminate glare) in an effort to enable it to be more easily read by a population in which decreasing visual acuity might be a problem. It was designed to minimize the amount of reading necessary, to avoid lengthy sentences, and to require a minimum of writing skills. The items in the instrument were not numbered in an effort to eliminate superfluous material which might confuse the participants. With the exception of the socio-demographic items age, language other than English, and years of retirement, all items were designed to be answered by a check mark. 119 Operational Definitions of the Study,Variables Perceived Health Needs (Total) Perceived health needs (Total) corresponded to per- ceived susceptibility in the Health Belief Model and were defined as those specific perceived requirements of the individual older adult which might be experienced as aging progresses and must be met if s/he is to function at his/ her maximum physical, socioeconomic, and psychological potential. The items measuring perceived health needs were drawn from the literature review and the expertise of two gerontological faculty persons were represented by the first thirty-nine items in the instrument (Appendix B, pages 254 through 257). Perceived health needs (total) were further categorized into physical health needs, socioeconomic health needs and psychological health needs. a. Physical health needs were defined as past or future changes in locomotion (pain and stiffness in joints), nutrition (need to change diet, difficulty chewing, denture problems), aeration (shortness of breath), elimination (constipation, frequency of urination, inability to hold urine) circulation (cold hands and feet, numbness of hands and/or feet, swelling of hands and/or feet), sensation (increasing deafness, a change in ability to smell odors, visual changes, loss of balance), and rest (daytime tired— ness, difficulty sleeping) and are represented by items 1 through 17 of the instrument (Appendix B, pages 259 and 260). 120 b. Socioeconomic health needs were defined as past or expected future possible difficulty paying for food, housing, clothing, health care services, utility bills, and social activities and were represented by items 18 though 23 of the instrument (Appendix B, pages 260 and 261). c. Psychological health needs were defined as past or expected future changes in roles (increased difficulty doing household tasks, changes in daily routines, changes in social activities, changes in work activities), intimacy (changes in sex and marital relations), family relation- ships (increased need for family closeness), self-esteem (positive feelings about self, ability to cope, confidence in doing things as well as others, feelings of uselessness), memory (difficulty following medication schedule, forgetful- ness), desire to reminisce, ability to learn new things, and problem—solving ability (difficulty making up mind, thinking through problems) and were represented by items 24 through 39 of the questionnaire (Appendix B, pages 261-262). Performance of Health Activities (Total) Stated performance of health activities (total) cor- responded to preventive health activity in the Health Be- lief Model and were defined as any self-care activity practiced by the older adult and directed toward maintain- ing physical, socioeconomic, and psychological health. The items which were designed to measure stated performance of health activities were also drawn from the literature 121 review and the advice of gerontological experts and were contained in pages 264 through 266 of the instrument (Appendix B). Health activities were further categorized into activities to maintain physical health, socioeconomic health, and psychological health. a. Health activities to maintain physical health were defined as exercise, nutrition (weight control, intake of fresh fruits and vegetables, intake of 6-8 glasses of fluid a day), use of tobacco, use of alcohol and caffeinated beverages, dental care (see my dentist every year), annual physical examination, adequate rest (schedule rest periods during the day, obtain 6-8 hours of uninterrupted sleep each night), use of health care services for illness, and knowledge of medications (know what each medication is supposed to do, know how to tell if each medicine is work- ing properly). Activities to maintain physical health are represented in the instrument by items 1 through 13 (Append- ix B, pages 264 and 265). b. Health activities to maintain socioeconomic health were defined as utilization of Medicare, Medicaid, nutrition programs and free health screening programs (Appendix B, items 17, 18, 19, and 20, pages 265 and 266). c. Health activities to maintain psychological health were defined as participation in a hobby, social activities with friends and/or relatives, reminiscing (have someone to share memories with), family relationships (have 122 someone with whom to share intimate thoughts and activities, keep in close contact with relatives), educational programs, attention to personal appearance (make efforts to always look my best), stress management (have develOped ways to reduce stress and tension, seek advice when upset), and finding ways to be useful. Activities to maintain psycho- logical health are represented by items 14, 15, 16, and items 21 through 27 of the instrument on pages 265 and 266 (Appendix B). Expected Assistance Expected assistance was adapted from Orem's nursing model and defined as performing, guiding, providing for a developmental environment, and teaching of self-care activ- ities necessary to reach and maintain maximum physical, socioeconomic, and psychological health. Expected assist- ance from health care providers was measured in the second column of responses in the instrument and indicated by the agreement or disagreement that the individual older adult expects to receive assistance from a health care provider with a specific health need (Appendix B, items 1-39, pages 259-262) or health activity (Appendix B, items 1-27, pages 264-266). Further clarification of expected assistance was measured in the third column of the instrument by the par- ticipant's delineation of the persons most likely to help them with a specific health need or health activity. 123 Health Care Provider Health care provider was defined as that profession- al person who may provide health assistance with health needs and health activities of older adults directed toward maximizing physical, socioeconomic, and psychological health. The item health care provider was categorized into physician, nurse, and social worker (Appendix B, column 3, pages 264- 266. Additional categories (relative or friend, myself, other, and no one) were provided to identify if the subject expected assistance but from persons other than health care providers. Older Adult Older adult was defined in many different ways in the literature. For purposes of this study older adult was defined by age and included all persons who had attained the age of 65 years or older, were ambulatory, resided in independent living quarters, were oriented to time, place, and person, could communicate verbally and by writing in the English language, and considered themselves healthy in response to such a question. Age was designated on the instrument in the socio-demographic section under Age. Because the participant had to be in a certain location outside the home all subjects were considered ambulatory. All study setting groups consisted solely of persons living independently. By virtue of their presence at the desig- nated date, place and time, all participants were considered 124 oriented to time, place and person. Primary language, English, was designated in the socio-demographic section. Persons had to be able to read the instrument in order to complete it. Modifying and Motivational Variables-- Socio-demographic Data Modifying Factors Socio—demographic data were collected in order to determine age, sex, marital status, occupational status, years of retirement, type of dwelling, household members, income, perceived health, and native language of the par- ticipants. Agg. The age of each participant was determined in an open-ended question and recorded as a continuous vari- able. For the purposes of analysis, the continuous scores were later categorized into four groups (65—70, 71-75, 76-80, 81-89). ng. The males and females who participated in the study were differentiated in order to measure possible vari- ations in perceptions of health needs, stated performance of health activities, and expectations of assistance accord— ing to gender. Marital Status. The marital status of the older adults who participated in the study was categorized into five groups: married; single, never married; separated; divorced; and widowed. 125 Occupational Status. As identified in Chapters I and III, persons on a limited fixed income may have differ- ent perceptions and resources than do persons who are gain- fully employed outside the home. To measure the possible differences among the variables which might be related to employment of older adults, occupational status was divided into 4 categories; working at a regular job outside the home for money, housewife, other, and retired. Years of Retirement. Since perceptions and resources might change over time after retirement, the number of years of retirement was measured in an open-ended question follow- ing the category "Retired" in the socio-demographic item which identified occupational status (Appendix B). Type of Dwelling. Some participants in the present study resided in age-segregated low-income subsidized hous- ing units and some did not. Lawton, Nakemaw and Yeh (1980) examined the relationships among several physical-environ- mental characteristics (size of community, age composition of housing units, active versus quiet neighborhoods, over- all quality of neighborhood, neighborhood shopping facil— ities, and neighborhood enriching facilities and six measures of well-being using a sample pOpulation of tenants residing in housing for the elderly (N=3327, Mean age = 74.9 years). Housing satisfaction, motility, higher morale, a higher level of friendship behavior, and family contact were all found to be greater among persons residing in age- 126 segregated sites located in small communities in high- quality neighborhoods where the risk of crime was low. To identify the effect of type of residence on the variables in the present study participants were asked to identify where they lived as one- or two-family house (owned or rented), apartment, or rented room. Household Members. Perceptions of older adults might be influenced by persons with whom they share living quarters. To measure the influence of this modifying fac- tor on the variables in the study participants were asked to identify with whom they lived: live alone; spouse (husband or wife); spouse and child (or children); child (or children); relatives (for example: brother, sister, or cousins); or non-relatives (friends). Income. As identified in the literature review, income could exert a strong influence on perceived health needs, performance of health activities, and assistance- seeking health behavior. Income was divided into four categories: I. Less than $5,000 II. $5,000 - $9,999 III. $10,000 - $14,999 IV. $15,000 or more Native Language. Since the instrument was written in the English language participants were requested to identify the language spoken in their home as a child. If not English, the subjects were asked to identify the language in an open-ended question (Appendix B). 127 Perceived Health. Since self—perceived good health was a criteria for inclusion in the study, participants were asked to respond "Yes" or "No" to the question: Do you feel you are generally in good health? Motivational Factors As documented in Chapters I, II, and III, older adults' perceptions of health needs and performance of health activities may be positively or negatively influenced by contact with health care providers. To measure the pos- sible effect of health care provider contact on the variables in the study three items were designed to identify if the individual participant had a regular doctor s/he tried to see first if s/he became ill; if the participant had had a physical check up within the last year; and how frequently the participant had utilized health care services in the past twelve months. Reliability of the Instrument The reliability of the instrument developed for the present study was assessed by means of the internal con- sistency approach to determine the extent to which all of the sub-parts of the instrument were measuring the same characteristics. Internal consistency best describes the condition in which there is a high degree of interrelatedness among the items of a scale or an instrument (Crano & Brewer, 1973). Internal consistency was computed using the 128 coefficient alpha method. Coefficient alpha is a statistical value represent- ing the average inter-item correlation of all of the items constituting a scale and is the best estimate of internal consistency (Crano & Brewer, 1973). Without interrelated- ness among the items of a scale any total score would not reflect an accurate measurement of the attribute under investigation. For the present study, coefficient alpha was computed for each of the ten scales in the total instrument. Factor analysis was conducted to eliminate items from each scale that were not correlated with the other items in the same scale. In this manner, only items with a high degree of interrelatedness were included in the data analysis. Since this instrument was developed specifically for the present study no prior reliability estimates were available. Com— putation of the alphacoefficient was necessary to determine if the selected items in each scale were, in fact, measuring the same concept. The reliability coefficient reflects the extent to which an instrument is free of variance due to extraneous factors. The closer a reliability coefficient is to 1.00 the more the instrument is a reflection of the true differ— ences of test subjects on the attributes the instrument is purported to measure (Borg & Gall, 1979). If the coefficient alpha is .80 or higher the instrument or scale may be 129 considered internally consistent (Crano & Brwer, 1973). A reliability coefficient of .90 would indicate that 81% of the differences in the scores were due to true differences in the study population on the specific attribute under investigation while only 19% of the variance was due to random fluctuations. In the present study the researcher was interested in comparing groups of participants on the various concepts under investigation. Every attempt was made to attain a reliability coefficient of at least .60 for each of the scales and sub-scales of the instrument. Should this level not be obtained, addition of more items positively corre— lated with the other items of the scale would increase the reliability coefficient. Validity of the Instrument Validity is more difficult to measure than reliabil- ity and refers to the degree to which the instrument meas- ures what it was designed to measure. A measuring device which is not reliable cannot be valid but an instrument can be reliable without being valid (Pollit & Hungler, 1978). Researchers recognize many different types of valid- ity such as content validity, predictive validity, concur— rent validity, and construct validity (Borg & Gall, 1978). Content validity was assessed for the instrument utilized in the present study. 130 Content validity is a reflection of the sampling adequacy of the content to be measured, or, how representa- tive are the questions on the instrument of all the possible questions which could be asked on this tOpic? Content validity is usually utilized when the researcher is measur- ing knowledge (Pollit & Hungler, 1978). In the present study the concepts were defined as commonly occurring changes and problems which occur as aging progresses and by health activities which might be beneficial in minimizing the effects of aging changes and problems. Content validity, therefore, was deemed appropriate by the researcher. Con- tent validity was estimated by the judgment of the researcher, review of the literature, and by consultation with two geron- tological experts from the Michigan State University faculty. Pretest of the Study Instrument The total instrument (Appendix B) was pretested for readability, clarity of directions, and time required for completion by four older adults residing in the greater metropolitan area. The present sample was similar to the study sample in that all four subjects were over age 65, resided in independent living quarters, spoke English as their primary language, considered themselves to be in good health, and represented both sexes (1 male and 3 females). None of the pretest subjects resided in low-income housing units and were probably more characteristic of the study 131 subjects obtained from the group of hospital volunteers than the subjects recruited from subsidized housing units. The pretest subjects were requested to provide feed- back to the researcher about the readability, both in rela- tion to the print size, style, and instrument format, and to the terminology utilized in the wording of the test items. Feedback was also requested about the clarity of the direc- tions and the length of time it took for completion of the instrument. Pretest subjects were also requested to make any additional suggestions to improve the instrument which would make it easier for their peers to complete. All of the pretest subjects found the instrument "interesting" and easy to complete. They each reported it took them one-half hour to complete. Two pretest subjects requested additional information about changing health needs and beneficial health activities for older adults. As a result of these requests, the researcher prepared a summary statement describing most of the items on the instrument and identifying some service agencies for older adults in the local area (Appendix C). Data Collection Procedure Data were collected from groups of older adults in the months of October, November, and December, 1981 and the first week of January, 1982. Permission to utilize each of the five sites for recruiting volunteer older persons to 132 participate in the present study was granted by the residence managers responsible for the housing units and the director of the Health Education Department of the hospital. Each of these managers and the hospital department head were first contacted by means of a letter (Appendix A) introducing the researcher, the purpose of the study, the criteria for sub- ject participation, and assuring subject anonymity. The letter was followed within seven to ten days by a telephone call from the researcher to the identified responsible party at each site. During the telephone contact, arrangements were made for the researcher to meet with the contact person so that the instrument might be reviewed, to answer any questions, and to establish protocols for meeting with pro- spective participant groups. In each of the housing units, once permission was obtained from the residence manager, the researcher was invited to attend a resident's council meeting to explain the study to the prospective volunteer subjects. At each council meeting the researcher introduced herself, explained the purpose of the study, the criteria necessary for an individual to participate (age, independ- ence, health, English—speaking, willingness to participate), the anonymity and confidentiality of the information col- lected, and the time expected for completion of the instru— ment. The researcher also answered questions from prospective participants at that time. In each setting, the council 133 president asked the residents to decide by a show of hands if they would be willing to allow the researcher to recruit volunteers from their respective residential unit. When that permission was granted the residents decided on the date and the time for the researcher to return to administer the instrument. That date and time, along with the research- er's name, the purpose of the study, and assurance of anonym- ity was included in the minutes of the council meeting. At the first site the residents decided that the researcher could collect data immediately following the meeting that same morning. Only a few residents were present at the council meeting and only three participants completed the instrument. At the other three housing units a different date was requested by the residents and the time was established to coincide with a regularly scheduled social hour. The "social hours" were times set aside for the residents to congregate for coffee, tea, and snacks on a "drop-in" basis. At the hospital site permission was obtained from the Health Education director to recruit volunteers in the same manner as in the housing unit sites. Since the older adult volunteers met regularly at the hospital the director made the request for participation at a regular meeting when the researcher was not present. Prospective subjects were told the background of the researcher, the purpose of the study, the criteria for participation, the nature of the anonymity 134 and confidentiality, and the expected length of time for completion of the instrument. Both volunteer committees approached by the director agreed to participate in the study and the date of administration was scheduled for the next regularly scheduled committee meeting. The researcher was asked to arrive at the expected time of adjournment and the director requested that any committee members who did not wish to participate leave immediately after the scheduled committee meeting. All committee members of both committees completed the questionnaire. At the time of administration of the instrument the researcher again introduced herself and reiterated the infor- mation on the purpose, criteria, anonymity and time commit- ment. The subjects were informed that they could leave at any time whether the instrument was completed or not. The researcher emphasized that there were no "right" or "wrong" answers and that the answers were expected to vary from one individual to another since each participant had different expectations and health practices depending on their own particular life circumstances. Conversation was not re- stricted by the researcher but the participants were asked to answer the items based on their own opinions rather than the opinions of their neighbor or friends. The instruments were distributed, the instructions verbally explained, and the researcher informed the par- ticipants that individual questions would be answered if 135 necessary. Participants were provided with pens and/or pencils placed on each table and instructed to place the questionnaire in a cardboard container located on a table by the door when they left. They were also invited to pick up an informational packet describing most of the items addressed in the questionnaire as they left and to discuss any questions they had with the researcher after they turned in the instrument. At site number three a senior social work student was present to assist the researcher and observe the admin- istration procedure. The student had been placed at the housing unit for three months prior to the data collection date at that site as part of her required community place- ment internship. Since that administration date was very near Christmas many residents were not able to be present but still wished to participate. The researcher agreed to allow those residents who wished to participate but who could not attend on the scheduled date to complete the instrument the first week in January. At that time the instrument was readministered by the social work student. The researcher was available by telephone on that date to answer any questions which might arise regarding the data collection procedure and/or the instrument itself. The student received one credit for independent study for her assistance in the research project. The researcher requested that if the student observed a participant completing the 136 instrument for the second time the student was to mark the instrument in some manner so it would not be included in the data analysis: this did not occur. The length of time required for completion of the instrument varied among both the sites and the individuals and ranged from fifteen minutes (one individual at the hos- pital setting) to one hour and ten minutes. In general, the hospital volunteers completed the instrument in less time than did the resident volunteers from the housing units. The atmosphere at the hospital setting was business-like whereas in the residential units the mood was more social. The researcher was asked very few questions about the instrument or procedure by participants. The most frequent question was if more than one person could be listed as most likely to help. The researcher explained that the answer should reflect the gag person mggt likely to help each individual with a particular health need or health activity. Upon completion of the instrument the participants deposited them in the appropriate repository and availed themselves of the informational packet. The completed instru- ments were not handled by the researcher at the site and were stored in the researchers home in a metal file. Data from the instruments were recorded with no attempt made to identify the setting site from which the data were obtained. 137 Human Rights Protection No personal identification data were obtained from any individual participant in the present study. Partici- pation was voluntary and the contact person at each site did in no manner attempt to influence the individual's decision to or not to participate in the study. The re- searcher had no contact prior to administration of the instrument with any of the individual subjects other than that which might have occurred at the council meeting. The completed instrument was placed in a common depository with no handling by the researcher until after leaving the premises. The complete procedures involved in Human Rights Protection are detailed in Appendix D. Scoring In the following paragraphs the scoring procedures for the instrument are described. Socio-demographic Data In the socio-demographic section of the instrument (Appendix B) data were collected to describe age, sex, marital status, native language, occupational status, years of retirement, type of dwelling, ownership or rental of dwelling, household members, income, perceived health, presence of a regular physician, receipt of a physical examination in the last year, and frequency of health care visits. 138 Information of age and years of retirement were recorded as continuous variables and sex was recorded as male or female. Marital status was indicated as follows: Married Single, never married Separated Divorced Widowed AAAAA lUflbHdkflH vvvvv Respondents were requested to indicate the first language they learned as a child; the language spoken in their home by their parents. If other than English the participants were asked to name the language (Appendix B). There were four categories of occupational status which were recorded as: working at a regular job outside the home for money (1), housewife (2), other (3), or retired (4). Type of dwelling was recorded as: one-family house (1), owned (1) or rented (2); two-family house (2), owned (1) or rented (2); apartment (3); or rented room (4). Household members were recorded as one of the fol- lowing six categories: live alone (l), spouse (2), spouse and child (3), child (4), relatives (5), or non—relatives (6) . Income was recorded in four categories: less than $5,000 (1); $5,000 to $9,999 (2); $10,000 to $14,999 (3); or $15,000 or more (4). Perceived health was indicated by a response of "yes" (1) or "no" (2) to the question "Do you feel you are 139 generally in good health?" The motivational factors "presence of a regular phy- sician" and "physical examination in the last year" were recorded as "yes" (1) or "no" (2). Frequency of health care visits were recorded as never (1); one time (2); two or three times (3); four or five times (4); or six or more times (6). Major Study Variables The 39 items measuring perceived health needs (in- cluding the sub-variables physical health needs, socioeco- nomic health needs, and psychological health needs) were scored using a modified five-point Likert scale. The stem at the top of the left-hand column of each page (AS I GROW OLDER I EXPECT TO EXPERIENCE:) was followed by the key: 1. Strongly Agree 2. Agree 3. Undecided 4 Disagree 5 Strongly Disagree For each of the 39 health needs listed the respondent was asked to circle the number (1 2 3 4 5) which best de- scribed the extent to which they agreed or disagreed that they would expect to experience the problem. Use of the response "Undecided" is controversial among researchers (Polit & Hungler, 1978). Some researchers propose that inclusion of this response makes it easier for the individ- ual who has no strong feelings about an item to complete 140 the questionnaire. Other researchers feel that inclusion of the neutral term encourages persons to not take sides. "Undecided" was included in the present study as in the researcher's opinion, some older adults might genuinely be undecided whether they would or would not experience a par- ticular health need at some future point in time. Signifi- cant frequency of the "undecided" response to any one item or by any one individual or group of individuals might be an indication to health care personnel that a need might exist for health education and/or counseling about that issue or among that individual or group. A five-point scale was utilized to decrease the length of the questionnaire and to avoid possible confusion of the participants. A response indicating agreement (1 or 2) that the individual expected to experience a particular problem was considered evidence of a perceived health need for all but three items. A response indicating disagreement (4 or 5) with the state- ments "As I grow older I expect to experience positive feelings about myself; confidence in my ability to c0pe with most situations; and confidence I can do things as well as most others my age" were considered evidence of a perceived health need. Scoring for these three items only was re- versed (Strongly Agree : 5; Agree = 4; Disagree = 2; Strongly Disagree = l). The 27 items measuring stated performance of health activities (including the sub-variables physical, socio- economic, and psychological activities) and the 66 items 141 measuring expected assistance from health care providers were scored in the same manner (1 = Strongly Agree; 5 = Strongly Disagree). The response categories designed to identify the person most likely to help the individual older adult with a particular health need or health activity were physician (P), nurse (N), social worker (S), relative or friend (R), myself (M), other (O), or no one (NO). In the third column of each page of the instrument the participant was instruct- ed to indicate by appropriate letter (P, N, S, R, M, O, NO) the person most likely to help in the blank space provided. Procedures for Data Analysis Both descriptive and inferential statistical tech- niques were utilized in the present study. The descriptive statistics computed included frequencies, percentages, means, modes, ranges, and standard deviations. Descriptive sta- tistics are utilized to describe phenomena occurring naturally in the environment rather than to explain them. The inferential statistical procedures utilized in the pre- sent study were correlation and Chi-square. A correlation is an index of the extent to which the variables are interrelated. Correlation does not prove causation. Correlation can be used to demonstrate function- al but not causal relationships among variables. To infer causal relationships the researcher must be able to manipu— late the independent variables (Borg & Gall, 1979; Polit & 142 Hungler, 1978). The present study was designed to identify and describe the degree and direction of the relationships among the perceived health needs and stated performance of health activities of older adults, and their expectations of assistance with specific health needs and health activi- ties from health care providers. Correlation is the most common method of describing the relationship between two variables. In the present study Pearson Product-Moment correlations and point bi- serial correlations (a type of product-moment correlation) were computed to determine the relationships between the major variables and among the sub-variables of the study. The modifying factors age, sex, native language, years of retirement, type of language, years of retirement, type of dwelling (owned or rented), household members, income, and perceived health were also correlated with each of the major study variables and each sub-variable. Correlations were also computed between the motivational factors (regular phy- sical examination, and frequency of health care visits) and the study variables. Correlation coefficients (r) range from —l.00 to 1.00. A minus (-) sign preceding the correlation coeffi— cient indicates that as scores on one variable increase, scores on the other variable decrease (a negative correla- tion). When a minus sign is not present the relationship is positive indicating that when scores on one variable 143 increase the scores on the other variable also increase. The magnitude of the relationship is also indicated by the correlation coefficient. Correlations among the variables in the present study were interpreted as: Value of (r) Strength of relationship 0.00 to 0.20 No significant relationship 0.20 to 0.35 Very slight 0.35 to 0.65 Moderate to fair 0.65 to 0.85 Marked to fairly high 0.85 to 1.00 High to very high (Borg & Gall, 1979, pp. 513-514) Correlation coefficients are also described as being statistically significant. In the present study the mini- mum level of significance which was acceptable was the .05 level. Any differences between the study variables that exceeded the significance level of .05 resulted in rejec- tion of the null hypothesis. Utilizing the .05 level of significance the researcher accepted the risk that out of 100 samples a null hypothesis that was true would be rejected five times. The Chi-square test is utilized to identify relation- ships when the research data are in the form of frequency counts and can be placed into discrete categories. Chi- square tests were conducted on data in the present study to determine whether there were relationships between marital or occupational status and the major study variables. 144 Summary In Chapter IV an overview of the methodology and procedures utilized by the researcher to collect and analyze data in the present study was presented. The sample, the settings utilized for collection of data, the development and pretesting of the instrument, the actual data collection procedure and human rights protection, the scoring and the data analysis techniques were presented. In Chapter V, the data describing the subjects and the analysis of the research questions are presented. CHAPTER V DATA PRESENTATION AND ANALYSIS Overview The data presented in this chapter describe the study population, the perceived health needs and stated performance of health activities of older adults, and the extent of assistance expected with health needs and/or health activities from health care providers. Additional data are presented describing the type(s) of person(s) most likely to help with specific health needs and health activ— ities. Data describing the relationships among the three major study variables (health needs, health activities, and expected assistance) and their sub-variables (physical, socioeconomic, and psychological scales) are also presented. Finally, data are presented describing the relationships among the study variables and the extraneous variables (modifying and motivational factors). A volunteer sample of 56 independent, English—speaking older adults aged 65 years and older who perceived themselves to be in good health comprised the study pOpulation. In Chapter V a description of the findings of the study and data presentation for the following questions are included: 145 146 Research Question 1 What are the perceived health needs of older adults? a. What are the perceived physical health needs of older adults? b. What are the perceived socioeconomic health needs of older adults? c. What are the perceived psychological health needs of older adults? Research Question 2 What health activities do older adults state they perform to maintain their health and overcome health problems? a. What health activities do older adults state they perform to maintain physical health? b. What health activities do older adults state they perform to maintain socioeconomic health? c. What health activities do older adults state they perform to maintain psychological health? Research Question 3 What is the extent of assistance older adults expect to receive from health care providers to meet these health needs or perform these health activities? 147 Research Question 4 What is the relationship between perceived health needs of older adults and stated performance of health activities? a. What is the relationship between perceived physical health needs of older adults and stated performance of health activities to maintain physical health? What is the relationship between perceived socioeconomic health needs of older adults and stated performance of health activities to maintain socioeconomic health? What is the relationship between perceived psychological health needs of older adults and stated performance of health activities to maintain psychological health? Research Question 5 What is the relationship between perceiVed health needs of older adults and the extent of assistance expected from health care providers? a. What is the relationship between physical health needs of older adults and the extent of assistance expected from health care providers? What is the relationship between socioeco- nomic health needs of older adults and the 148 extent of assistance eXpected from health care providers? What is the relationship between psycho- logical health needs of older adults and the extent of assistance expected from health care providers? Research Question 6 What is the relationship between stated performance of health activities of older adults and the extent of assistance expected from health care providers? a. What is the relationship between stated per- formance of health activities of older adults to maintain physical health and the extent of assistance expected from health care providers? What is the relationship between stated per- formance of activities of older adults to maintain socioeconomic health and the extent of assistance expected from health care providers? What is the relationship between stated per- formance of activities of older adults to maintain psychological health and the extent of assistance expected from health care providers? 149 Hypotheses The following hypotheses were developed for Research Questions 4, 5, and 6: 1. There is a positive relationship between perceived total health needs and stated performance of health activities of older adults. la. There is a positive relationship between perceived physical health needs of older adults and their stated performance of health activities to maintain physical health. lb. There is a positive relationship between perceived socioeconomic health needs of older adults and their stated performance of health activities to maintain socio- economic health. lc. There is a positive relationship between perceived psychological health needs of older adults and their stated performance of health activities to maintain psycho- logical health. 2. There is a positive relationship between perceived health needs and the extent of assistance expected from health care providers. 2a. There is a positive relationship between perceived physical health needs of older 2b. 2c. 150 adults and the extent of assistance expected from health care providers. There is a relationship between per- ceived socioeconomic health needs of older adults and the extent of assist- ance expected from health care providers. There is a relationship between per- ceived psychological health needs of older adults and the extent of assist- J ance expected from health care providers. There is a negative relationship between the stated performance of health activities of older adults and the extent of assistance expected from health care providers. 3a. 3b. 3c. There is a negative relationship between the stated performance of health activ- ities of older adults to maintain phy- sical health and the extent of assistance expected from health care providers. There is a negative relationship between the stated performance of health activ- ities of older adults to maintain socio- economic health and the extent of assist- ance expected from health care providers. There is a negative relationship between the stated performance of health 151 activities of older adults to maintain psychological health and the extent of assistance expected from health care providers. Descriptive Findings of the Study Sample The study sample consisted of 56 independent, English- speaking adults, aged 65 and older, who perceived themselves to be in good health. The sample population was obtained from four high-rise, low-income, subsidized housing complexes for older adults and from the Health Education Department of a local hospital. Modifying Factors As outlined in the conceptual model presented in Chapter II, several factors may modify individual health perceptions. In the present study the modifying factors which might influence the health perceptions of older adults were categorized into 3 groups: demographic, sociopsycholog- ical, and structural. Data were collected on variables with- in each group and were utilized to describe the study sample. Demographic Variables The demographic variables utilized in the present study were age and sex. Age. The age of the study participants ranged from 65 to 89. The mean age was 72.5 years. The age distribution and percentages can be seen in Table 1. 152 Table 1. Age (n=55) Age Number of Participants Percentage 65-70 27 49.1 71-75 11 20.0 76-80 11 20.0 81-89 6 10.9 TOTAL 55 100.0 Sex. Both males and females participated in the study. The distribution and percentage of males and females may be seen in Table 2. Table 2. Sex (n=56) Sex Number of Participants Percentage Males 12 21.4 Females 44 78.6 TOTAL 56 100.0 Sociopsychological Variables The sociopsychological variables measured in the present study were marital status, occupational status, years of retirement, type of dwelling (owned or rented), household members, and income. Marital Status. The marital status was obtained from each participant in the study. The distribution and percent of older adults by marital status can be seen in Table 3. The majority of older adults in the study were widowed (n=31; 55.4%). 153 Table 3. Marital Status (n=56) Marital Status Number of Participants Percentage Married 15 26.8 Single, Never married 4 7.1 Separated 1 1.8 Divorced 5 8.9 Widowed _31 55.4 TOTAL 56 100.0 Occupational Status. The occupational status was obtained from each participant in the study. The distribu- tion and percent of older adults according to occupational status can be seen in Table 4. The majority of participants in the study were retired (n=46; 82.1%). Table 4. Occupational Status (n=56) Occupational Status Number of Participants Percentage Working outside the home for money 1 1.8 Housewife 9 16.1 Retired 46 82.1 TOTAL 6 100 . 0 Years of Retirement. The number of years of retire— ment was ascertained for each participant. The number of years ranged from 3 to 25 years. The mean number of years of retirement was 8.53. The distribution for years of retirement and distribution may be seen in Table 5. 154 Table 5. Years of Retirement (n=45) Years of Retirement Number of Participants Percentage -5 14 31.3 6-10 18 40.1 11-15 6 13.2 16-20 5 11 0 21-25 2 4.4 TOTAL 5 100.0 Type of Dwelling. The type of dwelling and whether the dwelling was owned or rented was determined for each of the participants in the study. The majority of older adults in the study resided in an apartment (n=56; 82.1%) and rented their home (n=46; 83.6%). The distribution and per— cent of persons according to type of dwelling and whether the dwelling was owned or rented can be seen in Tables 6 and 7. Table 6. Type of Dwelling (n=56) Type of Dwelling Number of Participants Percentage One family 10 17.9 Apartment 46 82.1 TOTAL 6 100.0 155 Table 7. Owned or Rented Dwelling (n=55) Owned or Rented Number of Participants Percentage Owned 9 16.4 Rented 46 83.6 TOTAL 55 100.0 Household Members. Data to identify the presence of other persons in the household was obtained from each par- ticipant. The majority of participants lived alone (n=38; 69.1%). The distribution and percent of participants accord- ing to household members can be seen in Table 8. Table 8. Household Members (n=55) Household Members Number of Participants Percentage Live Alone 38 69.1 Spouse 16 29.1 Child (or children) 1 1.8 TOTAL 55 100.0 Income. The mean total annual income for the par- ticipants in the study was between $5,000 and $9,000 with the mode below $5,000. The frequency distribution of level of income can be seen in Table 9. Table 9. Income (n=48) Income Number of Participants Percentage Below $5,000 20 41.7 $5,000 - $9,999 13 27.1 $10,000 - $14,999 6 12.5 $15,000+ __9 18.8 TOTAL 48 100.0 Structural Variables In the conceptual model (Chapter II) structural variables relevant to the present study were perceived health, and the ability to read and understand the English language. Perceived Good Health. All participants answered "Yes" to the question "Do you feel you are generally in good health?." Native Language. Each participant was asked to identify the language spoken in their home when they were a child. The majority of the participants identified "English" as that language (n=51; 92.7%). Only 4 participants of the 55 who responded to the question identified another language (n=4; 7.3%). Motivational Factors As represented in the research model (Chapter II), contact with health care providers may motivate persons to perform preventive health activities. Motivational factors 157 measured in the present study were presence of a regular doctor, recent physical exam, and frequency of health care visits in the past 12 months. Regular Doctor. The majority of the participants responded "Yes" to the question "Do you have a regular doctor you try to see first if you get sick?" (n=51; 94.4%). Only 3 of the 54 respondents indicated "No" to that question (5.6%). Physical Checkup. Each participant was asked "Have you had a physical checkup within the last year?" The fre- quency of the "Yes" response was 77.4% (n=4l). "No" was indicated by 12 subjects (22.6%). There was a total of 53 subjects that responded to the item "Physical Checkup." Health Care Visits. Each participant was asked to identify how many times they had been to a doctor or health clinic within the previous 12 months. The frequency distri- bution for health care visits can be seen in Table 10. Table 10. Health Care Visits Within Past Year (n=54) Health Care Visits Number of Participants Percentage Never 8 14.8 One time 7 13.0 2-3 times 15 27.8 4-5 times 12 22.2 6+ times _12 22.2 TOTAL 54 100.0 158 m The descriptive findings of the study population were presented in the previous section. The specific descriptors of the sample were presented in the following manner, according to the conceptual model outlined in Chapter II. 1. Modifying Factors a. Demographic variables: age and sex; b. Sociopsychological variables: marital status, occupational status, years of retirement, type of dwelling (owned or rented), household members, income; c. Structural Variables: perceived good health, native language; 2. Motivational Factors: regular doctor, physical checkup, health care visits. Descriptive data for perceived health needs are presented in the following section. Data Presentation for Research Questions and Hypotheses In this section each research question will be pre- sented with its associated data as well as an explanation of the statistical analysis utilized. Research Question 1 What are the perceived health needs of older adults? a. What are the perceived physical health 159 needs of older adults? b. What are the perceived socioeconomic health needs of older adults? c. What are the perceived psychological health needs of older adults? Perceived Health Needs of Older Adults Statistical technique for obtaining perceived health peede. In order to obtain descriptive information regarding perceived health needs of older adults frequency distribu- tions were calculated for perceived health needs (total), physical health needs, socioeconomic health needs, and psy- chological health needs. For descriptive purposes the re- sponses "Strongly Agree" and "Agree" were collapsed into one "Agree" category. Data are presented as percentages of the total respondents to each item along with the number of par- ticipants responding to each item. Results of perceived health needs (total). The per- ceived health needs that at least 50% of the older adult subjects eXpected to experience are presented in Table 11 in descending order. The total frequency distribution is presented in Appendix F, Table laF. More of the participants expected to experience pain and stiffness of joints than any other health need followed by changes in work activities, vision changes, need to reminisce, increased difficulty doing household tasks, and increased need for family closeness. Less than 10% of the participants expected to experience 160 Table 11. Perceived Total Health Needs of Older Adults and N Total Number of Participants Percent— Health Needs N Agreeing to Statement age Pain and Stiff- ness of Joints 55 45 81.8 Change in Work Activities 53 42 79.2 Visual Changes 52 41 78.8 Need to Reminisce 47 35 74.5 Difficulty Doing Household Tasks 55 39 70.9 Increased Need for Family Closeness 50 35 70.0 Daytime Tiredness 53 37 69.8 Change in Social Activities 52 36 69.2 Denture Problems 50 34 68.0 Change in Daily Routines 50 34 68.0 Increasing Deafness 55 33 60.0 Cold hands and/or feet 54 32 59.3 Shortness of Breath 56 33 58.9 Forgetfulness 52 30 57.7 Change in Sexual Relations 45 23 51.1 difficulty affording housing, COping, negative feelings, and lack of confidence in ability to do things as well as others their own age. Results of physical health needs. The perceived physical health needs of older adults are presented in Table 12. More than 50% of the participants eXpected to 161 eXperience pain and stiffness of joints, visual changes, daytime tiredness, denture problems, increasing deafness, cold hands and/or feet, and shortness of breath. Table 12. Perceived Physical Health Needs (in decending order) Number of Number of Participants Participants Responding to Agreeing with Percent- Physical Needs Item Statement age Pain and Stiffness of Joints 55 45 81.8 Visual Changes 52 41 78.8 Daytime Tiredness 53 37 69.8 Denture Problems 50 34 68.0 Increasing Deafness 55 33 60.0 Cold hand and/or feet 54 32 59.3 Shortness of Breath 56 33 58.9 Change in Diet 51 24 47.1 Frequency of Urination 52 24 46.2 Swelling of hands and/ or feet 52 22 42.3 Numbness of hands and/ or feet 52 21 40.4 Loss of Balance 52 21 40.4 Difficulty Sleeping 51 20 39.2 Difficulty Chewing 51 18 35.3 Incontinence 52 14 26.9 Results of socioeconomic health needs. The fre- quency and percentages of agreement for the six items meas- uring perceived socioeconomic health needs are presented in Table 13. Less than 30% of the participants expected to experience any of the socioeconomic health needs. 162 Table 13. Perceived Socioeconomic Health Needs (in descending order) Number of Number of Socioeconomic Participants Participants Health Responding to Agreeing with Percent- Needs Item Statement age Difficulty Paying for Health Care 53 15 28.3 Difficulty Paying for Social Activities 52 11 21.2 Difficulty Paying for Utilities 52 9 17.3 Difficulty Paying for Clothing 51 8 15.7 Difficulty Paying for Food 51 7 13.7 Difficulty Paying for Housing 51 5 9.8 Results of perceived psychological health needs. The perceived psychological health needs of older adults are presented in Table 14. More than 50% of the participants expected to experience a change in work activity (79.2%), a desire to reminisce (74.5%), difficulty with household tasks (70.9%), a need for family closeness (70.0%), a change in social activity (69.2%), and a change in daily routines (68.0%). Less than 10% of the participants expected to experience difficulty c0ping, negative feelings, and lack of confidence in their ability to do things as well as others their own age. Research Question 2 What health activities do older adults state they perform to maintain their health and overcome health 163 Table 14. Perceived PsycholOgical Health Needs (in descending order) Number of Number of Participants Participants Psychological Responding to Agreeing with Percent- Health Needs Item Statement age Change in Work Activity 53 42 79.2 Desire to Reminisce 47 35 74.5 Difficulty with Household Tasks 55 39 70.9 Need for Family Closeness 50 35 70.0 Change in Social Activity 52 36 69.2 Change in Daily Routines 50 34 68.0 Forgetfulness 52 30 57.7 Change in Sexual Relations 45 23 51.1 Decreased Ability to Learn 51 18 35.3 Difficulty Following Medication Schedule 51 12 23.5 Difficulty Problem- Solving 52 10 19.2 Difficulty Decision- Making 52 9 17.3 Uselessness 50 8 16.0 Difficulty Coping 51 4 7.9 No Positive Feelings 51 3 5.9 Lack of Confidence in Ability to Perform 54 3 5.6 problems? a. What health activities do older adults state they perform to maintain physical health? b. What health activities do older adults state they perform to maintain socioeconomic health? c. What health activities do older adults state they perform to maintain psychological health? 164 Stated Performance of Health Activities by Older Adults Statistical technique for obtainingeperformance of health activities. In order to obtain descriptive informa- tion regarding stated performance of health activities by older adults frequency distributions were calculated for perceived health needs (total), activities to maintain phy- sical health, activities to maintain socioeconomic health, and activities to maintain psychological health. For de- scriptive purposes the responses "Strongly Agree" and "Agree" were combined into one "Agree" category. Data are presented as percentages of the total respondents to each item and the number of participants who agreed with the statement. Results of stated performance of health activities (total). The stated performance of health activities (total) are presented in Table 15. More than 50% of the respondents stated they performed each of the health activ- ities. Results of stated performance of physical health activities. The stated performance of activities to main- tain physical health are presented in Table 16. Over 75% of the respondents reported performance of all but three health activities (resting during daytime (73.6%), drinking 6-8 glasses of fluid a day (69.2%), and obtaining adequate sleep (63.6%). 165 Table 15. Stated Performance of Health Activities (Total) Number Total in Agreement Health Activity N with Statement Percentage Social Activity 53 53 100.0 Finding Ways to be Useful 52 52 98.1 Contact with Relatives 55 53 96.4 Share Memories 50 48 96.0 Weight Control 53 50 94.3 Know Medication Purpose 53 50 94.3 Use Medicare 52 48 92.3 Care About Appearance 55 50 90.9 Eat Fresh Fruits and Vegetables 55 50 90.9 Seek Illness Care 53 47 88.7 Limit Alcohol and Caffeine 51 45 88.2 Annual Physical Exam 52 45 86.5 Hobby 51 44 86.3 Daily Exercise 52 44 84.6 Annual Dental Exam 50 42 84.0 Share Intimate Activities 53 44 83.0 Know Medication Effects 51 42 82.4 Do not Smoke 50 39 78.0 Seek Advice 52 40 76.9 Stress Management 51 39 76.5 Educational Programs 52 39 75.0 Would Use Medicaid 48 36 75.0 Daytime Rest 53 29 73.6 Adequate Fluid Intake 52 36 69.2 Nutrition Program 52 35 67.3 Adequate Sleep 55 35 63.6 Free Health Screening 51 31 60.8 166 Table 16. Performance of Activities to Maintain Physical Function Number of Subjects Percent- Activity . N in Agreement age Weight Control 53 50 94.3 Know Purpose of Medications 53 50 94.3 Consume Fresh Fruits and Vegetables 55 50 90.9 Seek Care for Illness 53 47 88.7 Limit Alcohol and Caffeine 51 45 88.2 Annual Physical Exam 52 45 86.5 Daily Exercise 52 44 84.6 Annual Dental Exam 50 42 84.0 Know if Medication is Working 51 42 82.4 Do not Smoke 50 39 78.0 Rest During Daytime 53 29 73.6 Drink Adequate Fluids 52 36 69.2 Adequate Sleep 55 35 63.6 Results of stated performance of socioeconomic health activities. Data are presented in Table 17 describ- ing stated performance of activities to maintain socio- economic health. For each of the four items more than 50% of the participants stated they performed the health activity. Table 17. Stated Performance of Activities to Maintain Socioeconomic Health Health Activity Total N Agree N Percentage Use Medicare 52 48 92.3 Would Use Medicaid 48 36 75.0 Use Nutrition Program 52 35 67.3 Use Free Health Screening 51 31 60.8 167 Results of statedyperformance of_psychological health activities. The stated performance of activities to maintain psychological health are presented in Table 18. More than 50% of the participants responding to each item agreed they performed the activity. All 100% of the par- ticipants agreed they regularly enjoyed social activities with friends and/or relatives. Table 18. Stated Performance of Activities to Maintain Psychological Health Health Activity Total N Agree N Percentage Social Activity 53 53 100.0 Find ways to be Useful 53 52 98.1 Contact with Relatives 55 53 96.4 Share Memories 50 48 96.0 Care about Appearance 55 50 90.9 Have Hobby 51 44 86.3 Share Intimate Activities 53 44 83.0 Seek Advice 52 40 76.9 Stress Management 51 39 76.5 Educational Programs 52 39 75.0 Comparison of Perceived Health Needs and Stated Performance of Health Activities. For descriptive purposes, data is presented in Appendix F, Table 2-F displaying per- centages of agreement with perceived health needs and stated performance of health activities in each of the three areas: physical, socioeconomic, and psychological. 168 Research Question 3 What is the extent of assistance older adults expect to receive from health care providers to meet these health needs or perform these health activities? Expected Assistance from Health Care Providers Statistical technique for obtaining expected assistance. Descriptive information regarding expected assistance from health care providers was obtained by cal- culating frequency distributions for expected assistance with health needs and expected assistance with health activ- ities. For descriptive purposes data are reported as per- centages of the total respondents to an item. Results of expected assistance with health needs from health care_providers. The extent of assistance ex- pected by older adults with health needs is presented in Table 19. More than 50% of the participants expected to receive assistance from health care providers for denture problems, visual changes, pain and stiffness of joints, and increased deafness. Less than 10% of the participants ex- pected to receive assistance from health care providers with difficulty paying for housing, clothing, and social activi- ties, decision-making, and feelings of uselessness. Results of expected assistance with health activities from health care providers. Data are presented in Table 20 ranking percentages of participants expecting to receive 169 Table 19. Health Needs Assistance Expected from Health Care Providers HEALTH NEEDS ASSISTANCE EXPECTED FROM HEALTH CARE PROVIDERS (percentage in descending order) Percentage N Denture Problems 73.3 33 Visual Changes 68.1 32 Pain and Stiffness of Joints 61.2 30 Increasing Deafness 55.1 27 Swelling of Hands and/or Feet 43.5 20 Shortness of Breath 42.6 20 Loss of Balance 39.1 18 Medication Regime 38.3 18 Difficulty Chewing 34.1 15 Change in Diet 33.3 16 Difficulty Doing Things 31.8 14 Numbness of Hands and/or Feet 30.4 14 Daytime Tiredness 28.3 13 Incontinence 27.7 13 Change Work Activities 26.1 12 Difficulty with Household Tasks 22.4 11 Change in Social Activities 21.7 10 Frequency of Urination 21.3 10 Cold Hands and/or Feet 20.4 10 Constipation 20.0 9 Negative Feelings 19.6 9 Coping Ability 18.2 8 Forgetfulness 18.2 8 Family Closeness 17.8 8 Decreased Ability to Smell 17.4 8 Difficulty in Sleeping 16.7 7 Change in Daily Routines 15.6 7 Paying for Health Care 14.3 7 Paying for Utilities 12.5 6 Change in Sexual Relations 12.2 5 Reminiscence 11.6 5 Paying for Food 11.4 5 Learning Ability 11.1 5 Difficulty Problem-Solving 11.1 5 Paying for Housing 9.5 4 Paying for Clothing 6.8 3 Decision-Making 6.7 3 Uselessness 4.3 2 Change in Social Activities 4.3 2 assistance with performance of health activities from health care providers. More than 50% of the participants expected 170 to receive assistance from health care providers with knowl- edge of medication purpose and effect, illness care, dental exam, and annual physical examination. Table 20. Health Activity Assistance Expected from Health Care Providers HEALTH ACTIVITY ASSISTANCE EXPECTED FROM HEALTH CARE PROVIDERS (percentage in descending order) Percentage N Know Medicine Effect 76.7 33 Illness Care 76.1 35 Know Medicine Purpose 76.1 35 Annual Dental Exam 71.7 33 Annual Physical Exam 71.1 32 Using Medicare 59.1 26 Using Medicaid 53.3 24 Health Screening 48.9 22 Weight Control 47.8 22 Nutrition Program 41.3 19 Ways to be Useful 27.9 12 Stress Management 26.8 11 Education Programs 25.6 11 Regular Social Activities 25.6 11 Limit Alcohol and Caffeine 25.6 11 Seek Advice 23.8 10 Daily Exercise 23.4 11 Intake of Fruit and Vegetables 22.2 10 Hobby 18.6 8 Contact with Relatives 18.2 8 Daytime Rest 17.8 8 Sleep 17.8 8 Sharing Memories 17.5 7 Smoking 17.1 7 Fluid Intake 16.7 7 Sharing Intimate Activities 16.3 7 Care about Appearance 15.9 7 Persons Most Likely to Help. Data are presented in Appendix F, Table 3-F (in descending order) which describe the person(s) most likely to help with specific health needs. For example: 95.7% of the participants listed the physician as the person most likely to help with visual changes should 171 they occur. Data are presented in Appendix F, Table 4-F (in descending order),which describe the person(s) most likely to help with specific health activities. For example: 84.8% of the participants expected the physician would be most likely to help them when they sought care for illness. In Appendix F, Table 5-F, data are presented in descending order which list the specific health needs and health activities for which the listed percentages of older adults expected no one to help. In summary, data was presented in this section of Chapter V describing the study sample, the perceived health needs, the stated performance of health activities, the assistance expected from health care providers with health needs and/or health activities, and the types of persons most likely to help with specific health needs and health activities. In the next section of Chapter V data will be pre- sented describing the relationships among the three major study variables (health needs, health activities, and expected assistance), and their sub-variables (physical, socioeconomic, and psychological). This data will be preceded by a presentation of the reliability coefficients of each of the scales. 172 Reliability of the Instrument The reliability of the instrument was measured through the computation of the coefficient alpha. Coeffi- cient alpha was computed individually for each of the scales: perceived health needs (total), stated performance of health activities (total), and expected assistance from health care providers. Coefficient alpha was also computed on each of the sub-scales; physical, socioeconomic, and psy- chological needs and activities. The reliability coefficient for perceived health needs (total) was .91. This alpha coefficient represented a high internal consistency among the items of perceived health needs. Four items were deleted from the total health needs scale to obtain the reliability coefficient (Appendix B, items 2, 32, 33, and 34). The reliability coefficient for perceived physical health needs was .86 which represented a high internal con- sistency among the items of perceived physical health needs. One item (item 2) was deleted from the physical health needs scale to obtain the alpha coefficient (Appendix B). The reliability coefficient for perceived socioeco- nomic health needs was .94 which represented a high internal consistency among the items of perceived socioeconomic health needs. There were no items deleted from the socio- economic health needs scale. 173 The alpha coefficient for perceived psychological health needs was .86. This reliability coefficient repre- sented a high internal consistency for items in the psycho- logical health needs scale. Three items were deleted from the psychological health needs scale to obtain the reli- ability coefficient (Appendix B, items 32, 33, and 34). The reliability coefficient for stated performance of health activities (total) was .83 which represented a high internal consistency among the items of the scale. Six items were deleted from the total health activities scale to obtain the alpha coefficient (Appendix B, items 2, 4, 5, 14, 18, and 22). The alpha coefficient for stated performance of activities to maintain physical health was .78 which repre— sented a moderate internal consistency among the items of the physical health activities scale. Three items were deleted from the scale to obtain the reliability coefficient for physical health activities (Appendix B, items 2, 4, and 5). The reliability coefficient for stated performance of activities to maintain socioeconomic health was .57. This alpha coefficient represented a fair to moderate internal consistency among the items of the socioeconomic health activities scale. One item was deleted from the scale to obtain the reliability coefficient (Appendix B, item 18). 174 The alpha coefficient for stated performance of activities to maintain psychological function was .72 which represented a moderate internal consistency among the items of the scale. Two items were deleted from the scale to obtain the reliability coefficient for psychological health activities (Appendix B, items 14 and 22). The reliability coefficient for expected assistance from health care providers with health needs was .96. This alpha coefficient represented a very high internal con- sistency among the items of the health needs assistance scale. There were no items deleted from the scale in order to obtain this alpha coefficient. The reliability coefficient for expected assistance from health care providers with health activities was .96 which represented a very high internal consistency among the items of the scale. No items were deleted from the scale to obtain the alpha coefficient. In summary, the reliability coefficients computed for the various scales of the instrument using the coeffi- cient alpha method were: Perceived Health Needs (Total) .91 Perceived Physical Health Needs .86 Perceived Socioeconomic Health Needs .94 Perceived Psychological Health Needs .86 Performance of Health Activities (Total) .83 Physical Health Activities .78 Socioeconomic Health Activities .57 Psychological Health Activities .72 Expected Assistance with Health Needs .96 Expected Assistance with Health Activities .96 175 In the next section of Chapter V data will be pre- sented describing the relationships among the variables and sub-variables of the study. Relationships Among the Studerariables Statistical technique for obtaining correlations among study variables. The Pearson Product Moment correla- tional technique was utilized to calculate the degree and direction of the relationships among all of the variables and sub-variables of the study. The complete correlation matrix is presented at the conclusion of this section in Table 21. Research Question 4 What is the relationship between perceived health needs of older adults and stated performance of health activities? Hypothesis 1: There is a positive relationship between perceived total health needs and stated performance of health activities of older adults. The correlation (5) between perceived total health needs of older adults and stated performance of health activities (total) was —.1239 with a significance level (P) of .184. The null hypothesis was not rejected. There was no significant relationship between perceived total health needs of older adults and stated performance of health activities. Research Question 4a 176 What is the relationship between perceived physical health needs of older adults and stated performance of health activities to maintain physical health? Hypothesis 1a: There is a positive relationship between perceived physical health needs of older adults and their stated performance of health activ- ities to maintain physical health. The correlation between perceived physical health needs of older adults and their stated performance of health activities to maintain physical health was -.0738 (P=.296). The null hypothesis was not rejected. There was no signif- icant relationship between perceived physical needs and performance of health activities to maintain physical health. Research Question 4b What is the relationship between perceived socio- economic health needs of older adults and stated performance of health activities to maintain socio- economic health? Hypothesis 1b: There is a positive relationship between perceived socioeconomic health needs of older adults and their stated performance of health activities to maintain socioeconomic health. The correlation between perceived socioeconomic health needs and performance of socioeconomic health activ- ities was r= .910 (P=.088). There was no significant rela- tionship between socioeconomic health needs of older adults 177 and performance of socioeconomic health activities. The null hypothesis was not rejected. Research Question 4c What is the relationship between perceived psy- chological health needs of older adults and stated performance of health activities to maintain psychological health? Hypothesis lc: There is a positive relationship between perceived psychological health needs of older adults and their stated performance of health activities to maintain psycholog- ical health. The correlation between perceived psychological health needs of older adults and their stated performance of psychological health activities was r=.0186 (P=.447). The null hypothesis was not rejected. There was no signif- icant relationship between perceived psychological health needs and psychological health activities. Research Question 5 What is the relationship between perceived health needs of older adults and the extent of assistance expected from health care providers? Hypothesis 2: There is a positive relationship between perceived health needs (total) and the extent of assist- ance expected from health care providers. 178 The correlation between perceived total health needs and expected assistance from health care providers was r=.6028 at a significance level of .001. The null hypothesis was rejected. There was a moderate to strong positive rela— tionship between perceived total health needs and the extent of assistance expected from health care providers. Research Question 5a What is the relationship between physical health needs of older adults and the extent of assistance expected from health care providers? Hypothesis 2a: There is a positive relationship between perceived physical health needs of older adults and the extent of assistance expected from health care providers. There was a correlation of r=.4744 (P=.001) between perceived physical health needs and expected assistance from health care providers. There was a significant posi- tive relationship between physical health needs and expected assistance from health care providers. The null hypothesis was rejected. Research Question 5b What is the relationship between socioeconomic health needs of older adults and the extent of assistance expected from health care providers? 179 Hypothesis 2b: There is a relationship between perceived socioeconomic health needs of older adults and the extent of assistance expected from health care providers. There was a correlation of r=.3022 (P=.016) between perceived socioeconomic health needs of older adults and expected assistance from health care providers. The null hypothesis was rejected. There was a slight positive rela- tionship between perceived socioeconomic health needs of older adults and the extent of assistance expected from health care providers. Research Question 5c What is the relationship between psychological health needs of older adults and the extent of assistance expected from health care providers? Phypothesis 2c: There is a relationship between perceived psychological health needs of older adults and the extent of assistance expected from health care providers. The correlation between psychological health needs and expected assistance was r=.5768 (P=.001). There was a moderate positive relationship between perceived psycholog- ical health needs and the extent of assistance expected from health care providers. The null hypothesis was rejected. 180 Research Question 6 What is the relationship between stated performance of health activities of older adults and the extent of assistance expected from health care providers? Hypothesis 3: There is a negative relationship between the stated performance of health activities of older adults and the extent of assistance ex— pected from health care providers. There was a correlation of r=.1506 (P=.146) between performance of health activities (total) of older adults and the extent of assistance expected from health care providers. The null hypothesis was not rejected. There was no significant relationship between stated performance of total health activities of older adults and the extent of assistance expected from health care providers. Research Question 6a What is the relationship between stated performance of health activities of older adults to maintain physical health and the extent of assistance expected from health care providers? Hypothesis 3a: There is a negative relationship between the stated performance of health activities of older adults to maintain physical health and the extent of assistance expected from health care providers. The correlation between these two variables was r=.2812 (P=.023). The null hypothesis was rejected. There 181 was a very slight positive relationship between the stated performance of health activities of older adults to maintain physical health and the extent of assistance expected from health care providers. Research Question 6b What is the relationship between stated performance of activities of older adults to maintain socioeco- nomic health and the extent of assistance expected from health care providers? Hypothesis 3b: There is a negative relationship between the stated performance of health activities of older adults to maintain socioeconomic health and the extent of assistance ex- pected from health care providers. There was a correlation of r=.2179 (P=.062) between socioeconomic activities and the extent of assistance ex- pected from health care providers. There was no significant relationship between these two variables. The null hypothe- sis was not rejected. Research Question 60 What is the relationship between stated performance of activities of older adults to maintain psycholog- ical health and the extent of assistance expected from health care providers? 182 Hypothesis 3c: There is a negative relationship between the stated performance of health activities of older adults to maintain psychological health and the extent of assistance ex- pected from health care providers. The correlation between these two variables was r=.0571 (P=.345). The null hypothesis was not rejected. There was no significant relationship between the stated performance of health activities of older adults to maintain psychological health and the extent of assistance expected from health care providers. In summary, the relationships among the study vari- ables were identified and presented in this section. Hy- potheses 1, 1a, lb, 1c, 3, 3b, and 3c were rejected indi- cating that there were no significant relationships between hypotheses: l. Perceived health needs (total) and stated performance of health activities. 1a. Perceived physical health needs and per- formance of health activities to maintain physical health. 1b. Perceived socioeconomic health needs and stated performance of activities to main- tain socioeconomic health. 1c. Perceived psychological health needs and stated performance of health activities to maintain psychological health. 3. Stated performance of health activities of older adults and the extent of assistance expected from health care providers. 3b. Stated performance of health activities of older adults to maintain socioeconomic health and the extent and assistance expected from health care providers. 183 3c. Stated performance of health activities of older adults to maintain psychological health and the extent of assistance expected from health care providers. Hypotheses 2, 2a, 2b, 2c, and 3a were accepted. There were significant relationships between hypothesis: 2. Perceived health needs (total) and the extent of assistance expected from health care pro- viders (r =.6028, P=.001). 2a. Perceived physical health needs of older adults and the extent of assistance expected from health care providers (r=.4744, P=.001) 2b. Perceived socioeconomic health needs of older adults and the extent of assistance expected from health care providers (r=.3022, P=.016). 2c. Perceived psychological health needs of older adults and the extent of assistance expected from health care providers (r=.5768, P=.001). 3a. Stated performance of health activities of older adults to maintain physical health and the extent of assistance expected from health care providers (r=.2812, P=.023). The relationships among the extraneous variables (modifying and motivational factors) and the study variables will be presented in the next section. 184 85H So. Bu um €831.88 u .2... H93 8. mfi um ucBEBmH u .2. H93 mo. mfi um ucmoflflcmflm n .. 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The total correlation matrix may be seen in Table 22. Results of Correlations Between Modifying Factors and Study Variables Age. There were significant negative relationships between age and: total health needs (r=-.3740, p=.002); physical health needs (r=-.3802, p=.002); psychological health needs (r=-.3037, p=.013); socioeconomic health activ- ities (r=-.3l43, p=.014); health needs assistance (r=-.3435, p=.006); and health activities assistance (r=—.3009, p=.017). All of these correlations were slight to moderate. There were no significant relationships between age and socioeco- nomic health needs, total health activities, physical health activities and psychological health activities. Sex. There were no significant relationships be- tween sex and any of the study variables. Marital Status. There were no significant relation- ships between marital status and any of the study variables. Occupational Status. 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Hm. mm.: mm.: mm.: 8.: 8.: 5.: 3303 a. « a. a. k as. mmommz gamma Bandy c0365 Houooo 9505 96952 pcmm @5395 vow: xmm odd mHmo 1.me Hmdpmmm macs no 850 no one? Imuflumm £86: 83 mag 680: mo mo 80.52 flog Apcmbglggm COmHmmmv moanmflmxw madam Sufi» 380mm Hmcoflmtwflug can @533 “xflnums GOEMHNHHOU . mm magma 187 variables. Length of Retirement. There was a moderate positive relationship between length of retirement and stated per- formance of health activities (total) (r=.3832, P=.005). There were slight positive relationships between length of retirement and stated performance of activities to maintain physical health (r=.297l, P=.025) and stated performance of activities to maintain psychological health (r=.2705, P=.038). There was a slight negative relationship between length of retirement and stated performance of activities to maintain socioeconomic health (r=-.2557, P=.047). Type of Dwelling. There were very slight negative relationships between type of dwelling and total health needs (r=-.2192, P=.052) and perceived physical health needs (r=-.2472, P=.O33). There was a slight positive relation— ship between type of dwelling and stated performance of activities to maintain physical health (r=.2878, P=.Ol7). There was a moderate positive relationship between type of dwelling and stated performance of health activities (total) (r=.3594, P=.004). There was a moderate negative relation- ship between type of dwelling and stated performance of activities to maintain socioeconomic health (r=—.4834, P=.001). Own or Rent. There were slight negative relationships between own or rent of dwelling and total health needs (r=-.2469, P=.O35) and perceived physical needs (r=-.2447, P=.036). There was a slight positive relationship between own or rent of dwelling and stated performance of activities 188 to maintain physical health (r=.2686, P=.025). There was a moderate positive relationship between own or rent of dwelling and stated performance to total health activities (r=.3594, P=.004). There was a moderate negative relation- ship between own or rent of dwelling and performance of socioeconomic health activities (r=-.49l7, P=.001). Household Members. The variable "household members" was significantly related to total health needs (r=-.2530, P=.030); perceived socioeconomic health need (r=-.3163, P=.Oll); total health activities (r=-.2504, P=.033); activ- ities to maintain psychological health (r=-.2866, P=.Ol7); and health needs assistance (r=-.2552, P=.033). Income. There were significant positive relation- ships between income and total perceived health needs (r=.3084, P=.016); perceived physical health needs (r=.3250, P=.012); perceived socioeconomic health needs (r=.2690, P=.034); and performance of socioeconomic health activities (r=.5462, P=.001). There were significant negative rela- tionships between income and performance of health activi- ties (total) (r=-.5995, P=.001); physical health activities (r=-.5023, P=.001); and psychological health activities (r=-.2894, P=.024). There were no relationships between income and perceived psychological health needs, health needs assistance, and health activities assistance. 189 Results of Correlations Between Motivational Factors and Study Variables Regular Doctor. There were slight positive relation- ships between having a regular doctor and perceived total health needs (r=.2718, P=.023); Perceived physical health needs (r=.2848, P=.018); and perceived psychological health needs (r=.3220, P=.009). There were no significant relation- ships between having a regular doctor and the other study variables and sub-variables (health activities, expected assistance, and perceived socioeconomic health needs). Physical Exam. There were significant positive rela- tionships between having had a physical examination in the past year and perceived psychological health needs (r=.2352, P;.047); performance of total health activities (r=.3610, P:.004); and performance of activities to maintain physical health (r=.4213, p=.001). There were no significant rela- tionships between having had a physical exam in the past year and the other needs scales (total, physical, and socioeconomic), activity scales (socioeconomic and psycho- logical), and either expected assistance scale (needs and activities). Health Care Visits. There were significant negative relationships between number of health care visits and socioeconomic health activities (r=-.30ll, P=.Ol4) and health needs assistance (r=-.2904, P=.Ol9). Number of health care visits was not significantly related to any of the other variables of the study. 190 Significant other findings will be presented in the next section. OTHER FINDINGS Other significant findings among the variables of the study which were obtained by means of product-moment corre- lation but not included in the research questions or hypoth- eses are presented in this final section of Chapter V. There was a significant moderate positive relation- ship between perceived total health needs and stated per- formance of activities to maintain socioeconomic health (r=.4700, Pé.001). There was a moderate positive relationship between perceived total health needs and expected assistance with health activities from health care providers (r=.4474, Pg .001). There was a slight positive relationship between per- ceived physical health needs and perceived socioeconomic health needs (r=.2513, p§.035). There was a moderate positive relationship between perceived physical health needs and perceived psychological health needs (r=.5469, pé.001). There was a moderate positive relationship between perceived physical health needs and stated performance of activities to maintain socioeconomic health (r=.4906, Pé .001). 191 There was a moderate positive relationship between physical health needs and expected assistance with health activities from health care providers (r=.4132, P§.001). There was a fair positive relationship between per- ceived socioeconomic health needs and perceived psycholog- ical health needs (r=3623, pé.004). There was a slight positive relationship between perceived psychological health needs and stated perform- ance of activities to maintain socioeconomic health (r=.3490, Pé.005). There was a moderate positive relationship between perceived psychological health needs and expected assist- ance with health activities from health care providers (r=.4l42, Pé.001). There was a moderate positive relationship between stated performance of activities to maintain physical health and activities to maintain psychological health (r=.4735, pé.001). There was a slight positive relationship between stated performance of activities to maintain socioeconomic health and expected assistance with health needs from health care providers (r=.3l39, P§.012). There was a high positive relationship between expected assistance with health needs and expected assist— ance with health activities from health care providers (r=.8458, pé.001). 192 There was a moderate negative relationship between stated performance of health activities (total) and stated performance of activities to maintain socioeconomic health (r=-.4329, P=.001). Summary In Chapter V data were presented that described the study sample, the perceived health needs of older adults, the stated performance by older adults of health activities, and the assistance expected from health care providers by older adults with health needs and health activities. Additional descriptive data were presented which identified the person most likely to help the older adult with health needs or health activities. The Pearson Product-Moment correlation was utilized to identify the degree and direction of the relationships among the study variables. The extran- eous variables (modifying and motivational factors) were correlated with the study variables. Reliability analyses were reported on the scales and sub-scales of the instrument. In Chapter VI the research study and the data described in Chapter V will be interpreted and summarized. Conclusions will be discussed in relation to the research framework, and to the implications for nursing education, service and research. CHAPTER VI SUMMARY, INTERPRETATIONS, AND RECOMMENDATIONS Overview In Chapter VI a summary and interpretation of the research findings are presented. In addition, conclusions are made with implications and further recommendations for nursing research, education and practice. Summary and Interpretation of Findings Descriptive Findings of the Study Sample As discussed in the Literature Review chapter, certain changes occur as aging progresses in the physical, socioeconomic, and psychOIOgical areas of function. Addi- tionally, pathophysiological conditions are prevalent among the aged population. Despite these changes and conditions only 5% of the older adult population are institutionalized at any one time. Recent data from longitudinal studies (Leon, et al., 1981; Jette & Branch, 1981) have led research- ers to the observation that non-institutionalized older persons can cope with aging quite well in all areas of func- tion. Phaneuf (1981), on the other hand, reported that there are differences among the older adult population in coping ability. 193 194 Health is related to life satisfaction and coping ability (Phaneuf, 1981; Archer, et al., 1979). Preventive health activities can be effective in the older adult pOp- ulation (Neugarten, 1968; Belloc & Breslow, 1972; Belloc, 1973). Rosenstock (Becker, 1974) proposed that several factors may affect performance of preventive health activ- ities as discussed in Chapter II. For the older adult pop- ulation age; occupational status, marital status, housing, presence of a significant other, social interaction, and income have been demonstrated to affect health perceptions and activities. In the present study these factors were labeled modifying factors. A summary of descriptive infor- mation of the participants in the study in relation to these modifying factors will be presented in this section. Modifying Factors Age. The mean age of participants in the study was 72.5 years with a range from 65 to 89. The majority (49.1%) of participants were in the age group 65-70 and only six persons were over 80. There was a range of 24 years between the youngest participant in the study and the oldest, more years than it usually takes for a newborn to progress from birth through four years of college. As in any other seg- ment of the population an age range of 24 years would account for multiple differences between individuals in all areas of function. 195 Sex. There were almost four times as many females (78.6%) as males (21.4%) who participated in the study. There are more women in the older adult population as a whole than there are men. Marital Status. Only fifteen participants were married (26.8%). The remaining 73.2% of the study popula- tion were either widowed (55.4%), had never been married (7.1%) or were separated (1.8%) or divorced (8.9%). In the United States in 1975 the most common marital status of men was to be married and living with the wife (76%) but the most common marital status of women was widowhood (51%) (Kovar, 1977). The highest percentage of single older adults were from the lowest socioeconomic group (Cassels; Eckstein; and Fortinash, 1981). Occupational Status. Only one participant was work- ing outside the home for money. Most of the sample popula- tion was retired (82.1%) while nine persons (16.1%) listed their occupation as housewife. These data would indicate that all but one older adult in the sample population were living on a fixed income though it is possible some of the participants had income from investments. Years of Retirement. There were 45 persons who listed the number of years of retirement corresponding to 46 participants who listed their occupational status as retired. Of those 45 participants listing the number of years of retirement, 40% had been retired between six and 196 ten years, 14 (13.3%) had been retired for three to five years, six persons had been retired for eight to fifteen years, five persons had been retired for 16 to 20 years and two persons had been retired for 21 to 25 years. Persons who retired as recently as five years ago have experienced a rapid escalation of inflation. What might have been a very comfortable retirement income five years ago may have become a basic subsistence level in 1982. The persons who retired many years ago could be in severe finan- cial difficulty now. Type of Dwelling. The majority of the older adults resided in rented apartments. Only 10 persons (17.9%) lived in one-family homes. This is not a representative sample of all older adults in the community but a function of the types of settings from which the sample population was drawn. All of the participants who resided in one-family homes and owned their homes came from the volunteer group at the hospital setting since the other four settings were all apartment units. Household Members. One participant in the study lived with a child (or children). The number of partici- pants listing a spouse as the person with whom they lived was 16 in contrast to the 15 persons who stated they were married in the item measuring marital status. Assuming the responses were accurate, the additional person who was living with a spouse must have been that person who was separated 197 or one of the persons who were divorced. The majority of the participants lived alone (69.1%). Nationally, in 1975, 37% of women aged 65 and over and 43% of those women 75 years and over were living alone in contrast to 14% and 19% respectively for men (Kovar, 1977). Income. The income of 20 of the 48 persons (47.1%) responding to the item was below $5,000 a year. There were 9 (18.8%) older adults with an annual income above $15,000. The mean income group was between $5,000 and $9,999. Since the maximum allowable income for the subsidized housing units was $14,500 it would appear that all of the partici- pants in the highest income group were obtained from the hospital setting. Since this same group of hospital volun- teers also were the only participants not residing in apart- ments it would be difficult to draw conclusions about the effect of income alone on the research findings. Perceived Health and Native Language. Because they were criteria for inclusion in the study, all participants perceived themselves to be in good health and were able to read and understand the English language. Motivational Factors In addition to the modifying factors discussed above, contact with health care providers could provide the motiva- tion for health activity (see Conceptual Framework). A description of the findings regarding contact with health care providers will be presented in this section. 198 Regular Doctor. Most of the participants had a regular doctor they went to see if they became ill (94.4%). Only three participants did not. Physical Checkup. While the majority of partici- pants had undergone a physical checkup in the past year (77.4%), twelve persons had not (22.6%). A physical check— up could be an effective preventive health activity and even though all but one older participant in the sample pOp- ulation utilized a regular doctor for illness care only about three-fourths of the participants had utilized a doctor for a preventive examination. Health Care Visits. Eight participants (14.8%) had not had contact with a doctor or health clinic within the previous twelve months and seven had only been once (13.0%). Fifteen participants had been to a clinic or doctor two or three times but twelve persons (22.2%) had utilized these services four to five times and another twelve persons had had more than six visits. If these reported data are accurate 39 older persons (72.2%) accounted for 150 to more than 177 (95.3%) health care Visits in a one-year period of time. Lipsitt (in Kalish, 1977) states that there are some older persons who seek visits with physicians to support dependency needs. In the future it might be beneficial to determine the reason for and the nature and outcome of the health care visits to determine if they were either appro- priate or of benefit to the older adult. 199 In summary, the sample population covered an age range of 24 years, included both males and females in a 1:4 proportion, included both married and unmarried older adults who resided in rented apartments as well as owned houses either with a spouse, a child, or by themselves. The par- ticipants had been retired from three to twenty-five years and their annual income ranged from below $5,000 to more than $15,000. All of the participants perceived themselves to be in good health, most had a regular doctor, and the majority of the study population had undergone a physical checkup and had visited a doctor or health clinic two or more times in the past twelve months. In the next section descriptive data of the study variables will be interpreted. Descriptive Findings Posed by Research Questions and Hypotheses An instrument was developed based on Rosenstock's Health Belief Model to assess the perceptions of older adults regarding expected health needs, stated performance of activities to maintain their health, and the extent of assistance they expect to receive from health care providers. The instrument was also utilized to describe the relation- ships, if any, which existed among these three variables. All scales had a moderate to high reliability (Chapter V). 200 Research Question 1 What are the perceived health needs of older adults? a. What are the perceived physical health needs of older adults? b. What are the perceived socioeconomic health needs of older adults? 0. What are the perceived psychological health needs of older adults? Perceived Health Needs (total) Over 75% of the participants expected to experience (or had already experienced) pain and stiffness of joints (81.8%), a change in work activities (79.2%) and visual changes (78.8%). Six of the top ten perceived health needs (change in work activities, need to reminisce, difficulty doing household tasks, increased need for family closeness, change in social activities, and change in daily routines) were in the psychological area of function (Table 11). Less than 25% of the older adults in the study sample expected to experience difficulty coping (7.9%), making decisions (17.3%), problem-solving (19.2%), feeling useful (16.0%) or affording necessities (see Table 11). Most of the physical changes ranked in the middle of the total list of health needs. In the literature physical needs are most often mentioned as causing the greatest concern to older adults. One possible reason for this apparent discrepancy is that all studies reviewed in Chapter III focused on the past or present while 201 the participants were asked in this study to identify what they expected to experience in the future, as they grew older. In the present investigation participants were not asked to identify the perceived impact of the health need on their lives. It could be that though the older adults expect to eXperience these problems they also expect they will be able to cope quite adequately as evidenced by the low ranking of difficulty coping (Appendix F, Table l-F). One other possible interpretation would be that older adults perceive themselves more positively than they perceive their peers or than others perceive them. This interpretation would support the findings of Archer, et al. (1979), LaRue, et al. (1979), Grakey and Zimmerman (1980-81), and Costello and Meacham (1980-81). Perceived Physical Health Needs The rank order of perceived physical health needs was presented in Table 12. More than three-fourths of the participants expected to experience pain and stiffness of joints (N=45, 81.8%) and vision changes (N=4l, 78.8%), both expected as a result of the aging process. Daytime tired- ness, expected by 69.8% (n=37) of the participants might be a result of changes in sleep patterns though only twenty (39.2%) participants expected to experience difficulty sleeping. Denture problems were expected by 68.0% (n=34) of the study participants though only slightly more than half that many persons (n=18, 35.3%) expected to experience 202 difficulty chewing. Problems with dentures may result with aging from atrophy of alveolar bone (Gift, 1979) but chewing function should not be altered in the absence of pathology (Feldman et al., 1980). Increasing deafness was expected by 60% (n=33) of the participants which corresponds with Ventura's findings (1978) that impaired hearing significant- ly affects 30-50% of persons over the age of 65. (Hearing loss may have been responsible, in part, for the expected change in social activities by 69.2% of the participants as presented in Table 14.) More than 50% of the older adults in the study expected to experience cold hands and feet (N=32, 59.3%) and shortness of Breath (N=33, 58.9%), both symptoms of a pathological chronic disease. Less than half of the sample population (N=24, 47.1%) expected to experi- ence a need to change their diet. Even in the absence of chronic disease a reduction of calories is usually necessary as aging progresses due to decreasing activity levels if an older adult is to maximize health. Frequency of urination may result from a pathogen or changes in the aging bladder (Finch & Hayflick, 1977; Rossman, 1971; Reichel, 1978; Whitmore, 1981). Frequency was expected by 24 participants (46.2%) but incontinence, a symptom of pathology, was expected by only 14 persons (26.9%). Less than half of the older adult participants expected to experience edema and numbness of hands and/or feet or loss of balance which are all symptoms of chronic disease. All of the top five 203 physical health needs expected by the participants in the study can result from normal aging changes but could hasten loss of independence in the absence of successful adapta- tion (Table 12). This sample of older adults, in general, did not expect to experience many pathological conditions. Perceived Socioeconomic Health Needs Less than 30% of the participants expected to experi- ence any of the socioeconomic health needs (Table 13). Difficulty paying for health care was an expected need for only 15 participants (28.3%) and ranked highest of all the socioeconomic items. Another 24.3% (N=13) of the study pop- ulation were undecided if they expected to experience dif- ficulty paying for health care and 25 persons (47.2%) dis- agreed with the statement (Appendix E, Table l-E). Cassels et a1. (1981) found older adults (ages 64-75 years) in all income brackets were able to adjust their expenses adequate- ly to their available income. The majority of the partici- pants resided in subsidized housing. Since rental fees (which include heat and electricity) are assigned according to ability to pay in these units, it was not totally un- expected that difficulty paying for housing and utilities was ranked low on the list of expected health needs. This population of persons survived the Great Depression in their younger years and that experience may benefit them in the present inflationary situation. It is surprising, how- ever, that so few participants (13.7%, N=7) expected to 204 experience difficulty paying for food. Though past experi- ence with a depressed economy may have given them beneficial coping skills, with the price of foodstuffs in the market in 1981-82 so high one can only wonder if a person with an annual income less than $5,000 who is not having difficulty paying for food has an adequate nutritional intake. Perceived Psychological Health Needs More than 50% of the participants expected to experi- ence the normal developmental changes which occur as aging progresses (Table 14). A change in work activity (N=42, 79.2%), desire to reminisce (N=35, 74.5%), difficulty with household tasks (N=39, 70.9%), the need for family closeness (N=35, 70.0%), a change in social activities (N=36, 69.2%), daily routines (N=34, 68.0%), and sexual relations (N=23, 51.1%) all require adaptation if health in late life is to be maximized. Evidence that this group of older adults expected to adapt successfully is represented by the sharp decline in percentages of persons who expected to experience the more pathological changes (decreased ability to learn: N=18, 35.3%; difficulty following medication schedule: N=12, 23.5%; difficulty problem-solving: N=10, 19.2%; difficulty decision-making: N=9, 17.3%; feelings of uselessness: N=8, 16.0%; difficulty coping: N=4, 7.9%; negative feelings: N=3, 5.9%; and lack of confidence in the ability to do things as well as their peers: N=3, 5.6%). Though this instrument is not a diagnostic tool for determining 205 psychological function, the profile of the study population in relation to attitude, coping ability, and self-esteem appears to be very positive. Again, this older adult popu- lation has experienced and survived many changes. Within a lifetime they have witnessed four wars, the discovery of the speed of wheels, flight faster than sound, and the landing of man on the moon. They have adjusted to rapidly advancing communication techniques from radio and the telephone to television by sattelite and computers that communicate. Apparently these experiences have prepared most of the older adult participants to cope quite well despite adversity. Research Question 2 What health activities do older adults state they perform to maintain their health and overcome health problems? a. What health activities do older adults state they perform to maintain physical health? b. What health activities do older adults state they perform to maintain socio- economic health? c. What health activities do older adults state they perform to maintain psycholog- ical health? 206 Stated Performance of Health Activities (total) More than 50% (N=56) of the participants stated they performed each of the twenty-seven physical, socioeconomic, and psychological health activities listed (Table 15). Since all of the respondents also perceived themselves to be in good health, this finding supports the works of Belloc and Breslow (1972) who found a cumulative positive relation- ship between practice of health activities and physical health status, and Graney and Zimmerman (1980-81) who found a substantial significant relationship between social par- ticipation activity and health self report among older adults. This congruence among past research findings and those found in the present study indicates that the present sample was similar in performance of positve health activ- ities in general. Stated Performance of Health Activities to Maintain Physical Health Almost all (N=50, 94.3%) of the participants stated they controlled their weight, consumed fresh fruits and vegetables (N=50, 90.9%) and limited their intake of alco- hol and caffeine (N=45, 88.2%). A lesser percentage (N=36, 69.2%) of the participants reported they drank at least six to eight glasses of fluid a day (Table 16). These findings correspond to those of Belloc and Breslow (1972) and McGlone and Kick (1978) who found that the individuals with the best perceived physical health were slightly 207 underweight or within 10-20% of normal weight and were not heavy consumers of alcohol. Adequate intake of fluid is necessary to maintain maximum physical function. Though only five participants (9.6%) disagreed they had an intake of at least six to eight glasses of fluid a day, eleven (21.2%) were undecided. Health care providers working with older adults must not only stress the importance of fluid intake but explain that such an intake can include items such as soups, jellos, and ice cream as well as water and juices. Forty—four participants (84.6%) reported participat- ing in daily exercise but only ten persons (19.2%) strongly agreed with the statement (Appendix E, Table l-E), four persons (7.7%) were undecided, and four reported they dis- agreed they exercised daily. These findings support those of Archer et a1. (1979) who found that older adults were more apt to participate in social rather than physical recreation. Since exercise has been found to be highly cor- related with general health status (Belloc & Breslow, 1972; McGlone & Kick, 1978) and beneficial in maintaining maximum function (DeVries, 1980; Aniansson, et al., 1980; Kale & Jones, 1981; Chapman, 1980) further research is recommended on the types of exercise acceptable to older adults, barriers to performing regular exercise, and availability and efficacy of alternative exercise activities for older adults. 208 Though 63.6% (N=35) of the participants reported six to eight hours of uninterrupted sleep at night 36.3% (N=20) disagreed with the statement or were undecided (Appendix B, Table l-E). This finding reinforces the need for further research in the area of sleep and aging as recommended by Dement, et a1. (1982) since adequate sleep was also posi- tively correlated with health status (Belloc & Breslow, 1972; McGlone & Kick, 1978). Only 73.6% (29 persons) reported scheduling rest periods during the daytime. Be- cause of the prevalence of sleep disturbances among the older adult population (Coleman, et al., 1981) health care providers must assist older persons to accept and adopt a program of rest and relaxation during the daytime hours and examine the type of sleep problems these 36.3% of older adults had. The majority of participants stated they sought care for illness (N=47, 88.7%) and knew what each medication they took was supposed to do for them (N=50, 94.3%) but a lesser percentage stated they knew how to tell if each medication was working properly (N=42, 82.4%). Such knowledge is essential if older adults are to be active participants in therapeutic self-care. Forty-five participants (86.5%) stated they had an annual physical examination which in- cluded vision and hearing tests while only one person dis- agreed with the statement. Six older adults (11.5%), however, were undecided. The nature of the term "complete 209 physical examinatiofl'might not have been understood by some of the participants. This information should be included in health education programs for older adults as well as an explanation of the rationale for including various diagnos— tic and screening procedures. The percentage of participants who reported yearly dental examination (N=42, 84.0%) was high considering Price's (1979) findings regarding the relationship of dental care to ability to pay. The finding in the present study that despite low income status participants obtained dental care is a further indication that individuals in the present study practiced general positive health behaviors. Stated Performance of Health Activities to Maintain Socioeconomic Health Most of the participants (N=48, 92.3%) stated they used Medicare to pay for health care services. Since all of the older adults in the study were eligible for Medicare the finding that one person disagreed with the statement and three were undecided (Appendix E, Table l-E) may have been a factor of the confusion which exists among some older persons about what services are covered by Medicare and what are not, or if they needed them. Another item related to Medicare assessed willingness to use Medicaid to help pay for health care services. The adjacent location of these two items may have further confused some of the participants. Eligibility for Medicaid is based on low 210 income and only 75% (N=36) of the participants stated they would use Medicaid to pay for health care. Only 67.3% (N=35) of the participants stated they participated in the senior citizen nutrition programs and only 60.8% (N=31) utilized free health screening programs. Each of the four socioeconomic health activities were devel- oped to meet the special needs of persons with restricted income, including older persons. Only Medicare was utilized by most of the participants. Further study is recommended to determine why older adults in need of special services do or do not choose to participate in the programs. In addition, health care providers with an older adult clien~ tele must establish and utilize a collaborative network among community agencies to disseminate information about available community resources among the older adult pOpula- tion and assist older persons to accept and participate in such programs. Stated Performance of Health Activities to Maintain Psychological Health All of the participants agreed they regularly enjoyed social activities with friends and/or relatives. In addi— tion, 98.1% (N=52) of the respondents found ways to be use- ful to others, 96.4% (N=53) kept in close contact with rela- tives, and 96.0% (N=48) had someone to share memories with. These findings support those of Archer et al.-(l979) who observed that the majority of nonninstitutionalized older 211 adults participated in social activity because it involved being with other persons. Seelbach and Hansen (1980) found that 80% of the non-institutionalized older adults they interviewed (N=208) were satisfied with their family rela- tionships. Since the ages of the participants in the pre- sent study ranged from 65 to 89 these findings also support the proposal by Neugarten (1981) that the older adult popu- lation be distinguished between the young-old and old—old based on social and health characteristics rather than chronological age. Most (N=50, 90.9%) of the participants stated they made efforts to always look their best and (N=44, 86.3%) had a hobby they enjoyed. Both of these activities are positively related to life satisfaction and well-being (Ebersole & Hess, 1980; Butler & Lewis, 1977). A smaller percentage of participants (N=44, 83.0%) agreed they had someone with whom to share intimate thoughts and activities though there is a life-long uni- versal need for sexual expression and intimacy (Masters & Johnson, 1981). Loss of a spouse or intimate friend through death affects intimacy activities of many older adults at some point in time. In addition, some older adults equate intimacy solely with sexual intercourse. Changing sexual response patterns resulting from physiologic aging or medi- cation may be a source of embarrassment causing loss of self-esteem thereby inhibiting sexual expression. 212 For whatever reason, intimacy is necessary and health care providers must help older adults find an acceptable activ— ity to meet this need. This item on the instrument as well as the corresponding health needs item (expect to experience changes in sexual and marital relations) were the two items which created the most comment among the participants during administration of the instrument. Reactions ranged from laughter to anger ("That's no one's business!"). This response of the elderly regarding sexuality was also found by Brower and Tanner (1979). Upon initial examination of the data it would appear that, of all the psychological health activities, partici- pants were less likely to agree they sought advice when necessary (N=40, 76.9%), were able to reduce stress and tension (N=39, 76.5%), and participated in educational pro- grams (N=39, 75.0%). ~For each of these three items, how- ever, there was a sizeable number of persons who were unde- cided (Appendix E, Table l-E). Lack of understanding of what constitutes stress reducing measures, educational pro- grams, or advice-seeking behavior might account for the number of undecided responses. Only two persons disagreed they had found a way to reduce stress but six older adults (11.5%) disagreed they participated in educational programs and sought advice when upset. In summary, the majority of the older adults who participated in the study stated they performed specific 213 physical, socioeconomic, and psychological activities to maintain their health and overcome health problems. Accord- ing to Bruhn et al. (1977), health behaviors (or activities) determine the individual's potential for experiencing well- ness. It would appear that, in addition to perceiving them- selves to be in good health at the time of the study, most of the older adult participants had the potential to eXperi- ence wellness in the future in each area of function. Research Question 3 What is the extent of assistance older adults expect to receive from health care providers to meet these health needs or perform these health activities? Expected Assistance from Health Care Providers to Meet Health Needs Over half of the participants expected to receive assistance from health care providers if they were to ex- perience denture problems (N=33, 73.3%), visual changes (N=32, 68.1%), pain and stiffness of joints (N=30, 61.2%), and increasing deafness (N=l7, 55.1%) (Table 19). The physician was the person most likely to help with visual changes (N=44, 95.7%), deafness (N=36, 81.8%), pain and stiffness (N=39, 75.0%), and denture problems (N=26, 59.1%) with "other" listed as the person most likely to help with denture problems by 34.1% (N=15) of the participants. Since the dentist could be considered as either "physician" 214 or "other" the researcher would recommend including the category "dentist" in the list of possible responses to "persons most likely to help" in the future. Less than half of the participants expected to receive help from health care providers for the remaining thirty-five listed health needs (Table 19). These included such pathological needs as edema of hand and/or feet (N=20, 43.5%), shortness of breath (N=20, 42.6%), loss of balance (N=18, 39.1%), difficulty chewing (N=15, 34.1%), numbness of hands and/or feet (N=l4, 30.4%), incontinence (N=13, 27.7%), cold hands and/or feet (N=lO, 20.4%), having nega- tive feelings about self (N=9, 19.6%), difficulty coping (N=8, 18.2%), and difficulty sleeping (N=7, 16.7%). The physician was most likely to help with edema (N=27, 65.9%), shortness of breath (N=29, 60.4%), loss of balance (N=32, 69.6%), chewing (N=l6, 42.1% - other N=10, 26.3%), and numbness (N=25, 58.1%). Though the physician was listed as the person most likely to help with incontinence (N=19, 42.2%), another 37.8% (N=ll) of the participants expected no one to help (Appendix F, Table S-F). The person listed as most likely to help with cold hands and/or feet was "myself" (N=23, 48.9%) though 34.0% (N=l6) of the participants again listed the physician and 14.9% (N=9) expected no one to help. Most of the partici- pants expected to help themselves maintain positive feelings (N=26, 66.7%) or receive help from relatives (N=7, 17.9%). 215 Again, the person most likely to help the older adult cope was "myself" (N=26, 68.4%) although an equal percentage of the participants (N=7, 18.4%) expected help from the physi- cian and from relatives with coping problems. An additional 13.2% (N=5) expected to receive no help with coping (Append- ix F, Table 5-F). While 39.5% (N=15) of the older adults expected the physician to help should they experience dif- ficulty sleeping, 30.2% (N=13) expected they would help themselves and 30.2% (N=13) did not expect assistance from anyone. Most older adult participants expected to help them- selves to do things as well as others (N=32, 84.2%), to cope (N=26, 68.4%), to adapt to changing work (N=29, 72.5%) and social activities (N=21, 50.0%), to change daily routines (N=22, 55.0%), to overcome constipation (N=17, 35.4%), day- time tiredness (N=21, 44.7%), difficulty paying for food (N=18, 42.9%), housing (N=15, 37.5%), health care (N=13, 28.3%), and utilities (N=15, 35.7%), to cope with forgetful- ness (N=17, 43.6%), and to solve problems (N=l6, 41.0%) and make decisions (N=18, 46.2%). An equal number of partici- pants (N=15, 31.9%) expected to help themselves or be helped by relatives should they experience difficulty doing house- hold tasks. Relatives or friends were the persons most likely to help with an increased need for family closeness (N=29, 70.7%) and reminiscence (N=22, 56.4%). 216 The majority of participants did not expect help from anyone with decreased ability to smell odors (N=19, 44.2%), difficulty purchasing clothing (N=l4, 34.1%), or paying for social activities (N=15, 30.6%). No one was listed as most likely to help with chang- ing sexual and marital relations by 39.5% (N=15) of the participants while 36.8% (N=l4) felt they would help them- selves. The findings relating to expected assistance from health care providers with health needs support those of Brody and Kleban (1981); Sivertson (1978); Wright et a1. (1979-80); and Berkanovic, et al. (1981) in that older adults utilize health care providers for episodic illness care and attempt to cope with other health care problems themselves, through personal support systems (relatives or friends), or not at all (no one). O'Brien and Wagner (1980) state that the strongest potential for aid to the elderly may be from older adult peers rather than younger persons. Less than half of the participants expected to receive help with many pathological health needs. This finding supports that of Haug (1981) who found that the aged under-utilize physician services for more serious conditions. This researcher concurs with Haug's recommendation that a need exists to educate the public on the common problems and changes which often occur as aging progresses to help older adults and their families sort out the symptoms requiring 217 attention from those symptoms which do not. Kovar (1977) found by analyzing national health statistics that more than 90% of the older adults seen in ambulatory care settings had been seen by the physician previously and 80% had been seen for the current problems before. The bulk of ambulatory care was for follow-up and continuing care. Nurse clinicians have been educated to provide health maintenance services to clients yet none of the participants in the present study identified a nurse as the person most likely to help with any of the thirty-nine health needs. One reason for the lack of utilization of nurses as health care providers by older adults is the un- availability of nurses in expanded roles in primary care settings. Another reason may be that, as Haug pointed out (1981), older adults View the physician as an authority figure and have been socialized to do so and accept phy— sician authority both in attitude and behavior. Salkever, Skinner, Steinwacks and Katz (1982) found while nurse prac- titioners' care was less costly it was not less effective in a pediatric clinic. Research must be conducted to ident- ify the efficacy of nurse clinician service in providing health care to older adults in ambulatory settings. Such research would identify if older adults would accept nurse services instead of the more costly medical service as well as evaluating the outcomes of such nursing care on health Status . 218 Expected Assistance from Health Care Providers with Health Activities More than half of the participants expected to re- ceive assistance from health care providers with knowledge of the effect of medications (N=33, 76.7%), the purpose of medications (N=35, 76.1%), illness care (N=35, 76.1%), annu- al dental (N=33, 71.7%) and physical (N=32, 71.1%) examina- tions, using Medicare (N=26, 59.1%) and Medicaid (N=24, 53.3%). The physician was most likely to help with the first five activities and the social worker was most likely to help the older adult utilize Medicare and Medicaid. Less than half of the older adult participants expected health care providers to assist them with the other twenty preventive health activities (Table 20). Older adults expected to help themselves establish a daily exercise program (N=16, 74.5%), control their weight (N=30, 61.2%), control smoking (N=35, 79.5%), limit alcohol and caffeine (N=38, 84.4%), schedule daytime rest periods (N=37, 88.1%), obtain adequate sleep (N=3l, 72.1%), and fluid intake (N=34, 79.1%), pursue a hbbby (N=33, 78.6%), obtain free health screenings (N=10, 26.3%), main- tain physical appearance (N=38, 92.7%), manage stress (N=22, 55%), participate in educational programs (N=19, 48.7%), and find ways to be useful (N=28, 70.0%). Relatives or friends were most likely to help with sharing memories (N=29, 70.7%), enjoyment of social activ- ities (N=30, 71.4%), sharing intimacy (N=28, 63.3%), main- taining family contact (N=27, 65.9%), and necessary advice 219 (N=l4, 33.3%). The fact that older adults in this study did not expect to receive more assistance with health activities from health care providers may be a function of the unavail- ability of primary health care services addressing socio- economic needs, preventive medicine, rehabilitation, and social and mental health of older adults as found by Moore and Fillenbaum (1981) and Sivertson (1978). It might also be a lack of knowledge by older adults that differences exist as to the best type of activity to maintain health depending on individual health needs. On the other hand, Archer et al.(l979) found older adults stated they would like assistance with many preventive health activities if possible. Based on the descriptive findings of the present study regarding expected assistance with health activities from health care providers and Archer's findings, it is recommended that each agency with an older adult clientele include both individual and group counseling and instruc- tion in preventive health activities directed toward pro- moting socioeconomic and psychological as well as physicial health of older adults. In addition, research should be conducted to evaluate the effect of such health activity problems on future health status of the participants and their willingness to participate and assume responsibility for continuing the activity on their own. 220 Relationships Among the Study Variables In the present study, seven hypotheses regarding the relationships between the study variables were rejected and five were not rejected. In the following section, the rela— tionship findings will be discussed and conclusions drawn as to the significance of the relationships or lack of rela- tionships between the study variables. Hypothesis 1: There is a positive relationship between perceived total health needs and stated performance of health activities of older adults. Hypothesis la: There is,a positive relationship between perceived physical health needs of older adults and their stated performance of health activ- ities to maintain physical health. Hypothesis lb: There is a positive relationship between perceived socioeconomic health needs of older adults and their stated performance of health activities to maintain socioeconomic health. Hypothesis 1c: There is a positive relationship between perceived psychological health needs of older adults and their stated performance of health activities to maintain psychological health. There was no significant relationship between the perceived health needs (total) of older adults and stated performance of health activities (total) or between the phy- sical, socioeconomic, or psychological health needs and cor- responding health activities. While this finding appears to indicate that older adults do not practice preventive health 221 activities, examination of the data does not support this conclusion. The majority of older adult participants stated they performed each of the listed health activities. The lack of a relationship between these variables and sub- variables is best explained by re-examining the definition of health activity as defined in the present study and dis- cussed by Bruhn et al. (1977) and Tager (1981). Health activities are directed toward the goal of maintaining physical, socioeconomic, and psychological health. Though the older adults in the study were performing preventive health activities those activities were part of a pattern of behavior or health habits that they had developed through- out their lifetimes but not specifically directed toward preventing or overcoming a possible future health need or problem. Bruhn et a1. (1977) and Tager (1981) maintain that in order to achieve progressively higher levels of health and move toward wellness an individual must assume .responsibility for health, make effective personal choices based on knowledge among various alternatives, and continue to learn new behaviors as development progresses. As Whitbourne and Speebeck (1981) propose, the elderly do not need to be taught what health activities to perform but do need to be assisted to use and refine what they are already doing. The task of health care providers caring for non- institutionalized older adults is to develop the potential 222 for wellness that already exists, as evidenced by their practice of positive health activities, by providing instruction and knowledge and guiding them to direct those health activities toward meeting an expected future health need. The effectiveness of such an intervention would be demonstrated by a measurable change in the relationship between perceived health needs and changed stated perform- ance of health activities as a total indicator and in the relationships between physical needs and activities, socio- economic needs and activities, and psychological needs and activities. Hypothesis Hypothesis 2a: Hypothesis 2b: Hypothesis 2c: There is a positive relationship between perceived health needs (total) and the extent of assist- ance expected from health care providers. There is a positive relationship between perceived physical health needs of older adults and the extent of assistance expected from health care providers. There is a relationship between perceived socioeconomic health needs of older adults and the extent of assistance expected from health care providers. There is a relationship between perceived psychological health needs of older adults and the extent of assistance expected from health care providers. There was a moderate positive relationship between perceived health needs (total) and the assistance expected 223 by older adults with those health needs from health care providers (r=.60, P§.001). There were similar positive relationships between physical needs and assistance, psy- chological needs and assistance, and socioeconomic needs and assistance although the correlation between socioeco- nomic needs and expected assistance with health needs was weaker than the other relationships (r=.30, P=.016). Older adults expected to receive assistance from health care pro- viders when they experienced a need regardless of whether that need was in the physical, psychological or socioeco- nomic area of function. These findings were similar to those of Berkanovic, et a1. (1981) who found that among the general population, the major predictor variables in the decision to seek medical care were all symptom related. Hypothesis 3: There is a negative relationship between the stated performance of health activities of older adults and the extent of assistance ex- pected from health care providers. Hypothesis 3a: There is a negative relationship between the stated performance of health activities of older adults to maintain physical health and the extent of assistance expected from health care providers. Hypothesis 3b: There is a negative relationship between the stated performance of health activities of older adults to maintain socioeconomic health and the extent of assistance expected from health care providers. 224 Hypothesis 3c: There is a negative relationship between the stated performance of health activities of older adults to maintain psychological health and the extent of assistance ex- pected from health care providers. There were no significant relationships between stated performance of health activities (total), socioeco- nomic activities, and psychological health activities and expected assistance but there was a relationship between stated performance of physical health activities and expect- ed assistance, though not in the negative direction as hy- pothesized. The researcher had hypothesized that older adults who performed health activities to maintain physical health would expect less assistance with those activities than those who did not, assuming that those who did not practice the activities would expect assistance in order to adapt the activity. As discussed earlier, the majority of older adults did practice all health activities. The finding that phy- sical health activities had the only relationship to expect- ed assistance and in a positive, rather than a negative direction, indicates that among this older adult population, assistance with activities to maintain physical function was the only activity assistance seen as being within the realm of health care providers. This is again part of the pattern of utilization of the health care system for physical care rather than socioeconomic and psychological preventive 225 health care. An additional interpretation might be that, though there was no relationship between perceived needs and activities, older adults are partially aware that there might be activities they could perform to maintain their health, especially in the area of physical function, and they would like health care providers to help them to de- velop these behaviors more fully. This interpretation would support Archer's (1981) findings that the older adults in the community do desire assistance with health promotion activities. The interpretation of the findings regarding the hy- potheses may be further clarified by examining the other significant relationships not included in the research questions. Other Findings That there were significant moderate positive rela- tionships between perceived total, physical, and psycholog- ical health needs and performance of socioeconomic health activities may indicate that older persons are attempting to prepare financially for future health problems by taking advantage of free or inexpensive health-directed programs now. With only three items on the socioeconomic activity sub-scale and an alpha coefficient of .57 any interpretation of a relationship between another study variable and socio- economic activity must be cautious. A possible further 226 interpretation might be, as Archer et a1. (1981) found, that older adults participate in activities because of the social interaction with others. Both the free health screening clinics and the nutrition programs offer a chance for intense social interaction. A further indication that older adults wish to par— ticipate more in therapeutic self—care is evidenced by the moderate positive relationship between expected future total, physical, and psychological health needs and expected assistance with health activities from health care providers. There was a high positive relationship (r=.85, P=.001) between expected assistance with health needs and expected assistance with health activities. The implications are that older adults expecting future health needs do see health care providers as potentially valuable should prob- lems arise as they grow older, and also expect health care providers to assist them to perform self-care activities. It appears older adults would like to participate in more effective health care activities but need instruction, guidance, and/or support to do so. The modifying and motivational factors which were related to the study variables will be discussed in the next section. 227 Modifying and Motivational Factors Various modifying and motivational factors were rela- ted to the study variables as proposed in the conceptual model (Figure 3). ng. With increasing age the participants expected to experience more total, physical, and psychological health needs (Table 22). There was no relationship between age and socioeconomic health needs which might have been a function of the small number of items on the socioeconomic needs sub- scale or the fact that persons, regardless of age, did not expect to experience socioeconomic health needs (Table 13) or were already adapting to financial constraints. Age was also related to stated performance of socio- economic health activities (as the age of the participants increased they were more likely to perform socioeconomic health activities), expected assistance with health needs, and expected assistance with health activities. The older participants were more likely than the younger persons in the study to expect assistance from health care providers with both needs and activities. As Kovar (1977) pointed out, prevalence of chronic disease and disability sharply increases at about age 75. The increased assistance expec- tations of the oldest persons in the present study reflects this statistical fact. §E§° Gender was not related to any of the study vari- ables although in other studies (Branch & Jette, 1981; 228 Jette & Branch, 1981) women reported more health problems than did men. It may be that both males and females share the same expectations of future health needs and only in actual experiences do women report more symptoms and dis- ability. Marital Status. Marital status was not related to any of the study variables although the presence of a sig- nificant other to provide support has been demonstrated to affect activities (Archer, et al., 1981) as well as life- satisfaction (Larson, 1978; Phaneuf, 1981). Occupational Status. There were not significant relationships between occupational status and the study variables. Years of Retirement. Persons who had been retired the greatest length of time tended to perform less total, physical, and psychological health activities. This was not totally a function of age as there were no correlations between age and the same health activities. It would appear that differences exist between previously employed persons and those never employed and that those differences increase with the numbers of years that have passed since retirement. Such differences are unexplainable within the confines of the present study. Type of Dwelling. Persons in the subsidized apart- ments expected to experience more health needs (total and physical) than did those residing in a single-family home. 229 These persons in the apartments also stated they performed more socioeconomic health activities. The senior housing units are often the sites of nutritional programs and health screening clinics which would explain part of the difference in socioeconomic activity performance. Independence in per- forming activities of daily living is a requirement for residents of the senior housing units. When a resident is no longer able to function independently he/she must relo- cate, often to a long—term care facility. Residents of the apartment complexes have undoubtedly seen this occur among their friends and neighbors. This could account for the differences in perceived health needs based on the type of dwelling since not all of the differences are explained by income alone. Persons in single-family homes were more apt to perform total and physical health activities, perhaps because of additional resources (financial, transportation). Maybe in their own dwelling individuals sense a need for greater self responsibility. Household Members. Persons living with a spouse or a child were more apt to expect future socioeconomic and total health needs than persons living alone, perhaps a func- tion of anticipating the future loss of a spouse or ability to reside with a child or the perceived threat of loss of control. They were also more apt to practice total and psycholoqical health activities, probably because they inter- acted daily with a significant other. 230 Income. More participants in the lower income brack- ets expected to experience total, physical, and socioeconomic health needs, performed fewer total, physical, and psycho- logical health activities, but performed more socioeconomic health activities than did persons in the higher income brackets. Phaneuf (1981) and Snider (1981) reported poorer health and health perceptions among older adults in the low- est income groups. This finding reinforces the need to focus provision of health promotion, education, and mainten- ance services to older adults who are economically deprived. Contact with Health Care Providers. Persons who had a regular doctor anticipated more future health needs, both physical and psychological than those who did not. Partici— pants who had undergone a physical examination within the past year were more apt to expect future psychological health needs and more apt to practice total and physical health activities than those who had not. As the number of health care visits increased over one year's time, so did perform- ance of socioeconomic health activities and expected assist- ance with health needs. Contact with a health care provider appears to have heightened the older adult participants' awareness of possible future problems and may have increased performance of positive health activities, especially to maintain physical health. This contact did not, however, assist the older adults to direct health activities toward meeting an expected future health need. Health care providers 231 may not perceive that health activities can be effective in pmaintaining health of older adults as hypothesized by Butler (1975), or may not have the knowledge of what specif— ic health activities can be beneficial in overcoming specif- ic health needs and how to adapt those specific health activities to the life-style of the individual older adult. The increase in performance of socioeconomic activities with increasing frequency of health care visits may reflect the financial strain created by costly health care services. A revised model schematically representing the cor- relational findings from this present study is presented in Figure 5. Older adults expected to experience future health needs and stated they performed health activities but there was no relationship between their expectations and preventive health activities. The conclusion is that, in the sample, non—institutionalized older adults are notpperforming thera- peutic self-care to maintain their health and overcome problems. Since they were engaging in positive health activities, however, a second conclusion is that the poten— tial exists among thisppopulation of persons for develppment of applanned_proqram for therapeutic self-care without major life-style changes and directing them to see relationships to maintain health and overcome problems. Expectations of future health needs were greater among the oldest participants, those with a regular doctor, 232 WMHBH>HHO¢ 3% 3.5.3 gmHmmd Bommxm mUZ/meHmm/N Bmmxm mmflsmcoflmamm mo H802 Hmcoflmamnund ESE/w 35% 58mm.» E WHEHm mem HMOHmwcm u -0-.. o u. m NH v ugflmm mo 55:8 .: .I :0 wmvmm 1» filmy 0.80 53mm mo MOORE 9~8QH BZMHmmmNm OH. HDmEXM .m 95.53 233 those living with a spouse of a child in a senior apartment complex, and those persons in the lower income brackets (Figure 5). In conclusion, senior citizen housing units would be excellent settings in which to provide individual, family, and group_programs to clarify perceptions of the normal and abnormal changes which often accompany the aging process and what active role they can take to do something about it. The majority of participants resided in such housing units and may have skewed the data therefore caution must be used in concluding low income housing units would be the peep settings for such programs. The majority of participants stated they performed all of the health activities but younger participants in higher income brackets residing with a spouse or child in single family homes who had been retired for a shorter period of time and had undergone a complete physical examin- ation within the past year reported the highest frequencies of health activities (Figure 5). In conclusion, though all participants could benefit from goal-directed health activ- ity programs, theppoor elderly living alone seem to have the greatest need as well as being in higher risk of inadeqpate resources 0 As expectations of health needs increased so did expectations of assistance, not only with health needs but also assistance with health activities (Figure 5). Older retired persons living with a spouse or a child and making 234 frequent health care visits expected more health needs assistance (Figure 5). The oldest participants also expect- ed more asistance with health activities from health care providers (Figure 5). In conclusion, older persons expect assistance from health care providers should health needs arise but also expect health care providers to help them perform health activities to maintain their health and over- come their problems. In summary, a small sample (N=56) of non-institution- alized older adults (ages 65-89) did perceive future health needs and did, in general, state they performed health activities. They also expected health care providers to assistiflunn,primarily in the area of physical needs and activities. There was no relationship between expected future health needs and stated performance of health activ- ities but a strong relationship between perceived future health needs and expected assistance from health care pro- viders, both with health needs and with health activities. It would appear that these older adults, in anticipation of perceived future health needs, desired to become more in- volved in performing health activities directed toward main- taining their health and expected health care providers to help them meet future health needs as well as to assist them with health activities now. 235 Limitations of the Study In addition to the eight limitations of the study outlined in Chapter I, there were some additional limita- tions which might have affected the results. 1. The data were collected among groups of older adults. There was conversation among individual group members during administration of the instrument. It is possible that answers to the items could have been influ- enced by opinions of others beside the individual respond— ent. 2. A large majority of the sample population were in the lowest income bracket and were residents of low in- come subsidized housing units which could account for dif— ferences in addition to those measured in the study. 3. No data were obtained on educational background of the participants. Educational level could account for some of the differences among the variables. 4. There were no objective data obtained on health status of the participants. It is possible that actual health status of the participants was different from per- ceived health and might have influenced individual percep- tions of needs and/or performance of health activities and expectations of assistance. 5. There were no qualitative or quantitative data obtained of actual performance of health activities which might have accounted for differences in perceptions of 236 performance of activities. Recommendations for Study Replication It is recommended that this study be replicated among other populations of older adults such as church groups and retirement communities not limited to low-income populations. It is also suggested that use of this instrument might be a valuable tool to use in assessing groups and/or individuals in the pre-retirement ages in order to assist them to pre- pare for retirement in a manner which will best meet their needs and help them relate activities to health. The researcher can attest to the value of using a multiple contact methodology to obtain volunteers. Consist- ent with the experiences of Archer, et a1. (1979), it is be- coming increasingly difficult to gain entry into groups of older adults due to the increasing focus of attention on the needs of this population. In the present study, there was some concern expressed by the residents at the council meet— ings that the questionnaire results would be utilized to take away even more benefits than had already been eliminated in recent budget cuts. Allowing the prospective participant groups to make the decision regarding recruitment of volun- teers and to establish the date, time, place and protocol for administration of the instrument greatly facilitated recruit- ment and cooperation though the sample obtained may not have been totally representative of the older adult population in general. Additionally, allowing time between initial contact 237 with prospective participants and actual administration gave the individuals a chance to discuss the upcoming event among themselves. This researcher would also recommend that the invest- igator(s) be present during administration. It became an excellent Opportunity to conduct informal health education as the participants often stayed to discuss individual prob- lems or ask general questions of this researcher after they had completed the instrument. In replicating the study it is recommended that addi- tional socioeconomic items be added to both the health needs and the health activities scales to improve the alpha coef- ficients and, therefore, the internal consistency of the scales. In this manner results would more accurately re- flect existing relationships among the study variables and the socioeconomic variables. It is also recommended that level of education be included as a modifying factor in the sociodemographic sec- tion of the instrument. Those items which were deleted be— cause of low factor-loading values should be reworded in an attempt to increase the correlations between the deleted items and the rest of the items on the appropriate scales and sub-scales. In further studies it is recommended that more ad- vanced statistical procedures such as multiple regression be utilized to analyze the data. In this manner predictor 238 variables might be identified that would be the best indi- cator of a health need, activity, or expected assistance. Curvilinear relationships may have existed among some of the modifying and motivational factors (years of retirement) which were undetected by means of the Pearson product-moment correlational techniques. Relationship of Results to Conceptual Model Though the research was not designed to test the variables contained in the Health Belief Model, it would appear that perceived susceptibility to various physical, socioeconomic, and psychological health needs did not influ— ence the likelihood performing preventive health activities in an older adult population taking into consideration four- teen motivating and modifying factors as in Figure l (p. 28). The health activities generally performed by the older adults in this sample were more a function of a life-long pattern of development of health habits consistent with the thesis outlined by prOponents of the continuity theory of aging than a function of perceived threat of a condition or disease. For these adults to experience wellness and maximize life-satisfaction they need to understand how health behav- iors can positively affect future health, even at an old age, and need to alter, redirect and/or strengthen present health habits to better reflect eXpected health needs as proposed by Bruhn, et al. (1977), and represented in 239 Figure 2 (p. 32). Expected Assistance was an apprOpriate addition to the preventive health belief model for older adults (Figure 3). Though the older adults were not acting as self-care agents by directing specific activities to prevent future health problems, they were interested in maintaining health as demonstrated by the strong relationship between health needs and expected assistance. They also expected health care providers to provide assistance with health activities (Figure 5). Based on the revised correlational model (Figure 5) of the research findings and utilizing Orem's nursing model (Figure 4) the implications for nursing will be presented in the next section. Implications for Nursing Nursing Assistance The older adults in the study sample did expect assistance from health care providers with health needs and health activities (Figure 5). They were able to perform self-care activities as evidenced by the high percentage of participants who stated they performed each health activity. These health activities, however, were not therapeutic in that they were not directed toward meeting any particular perceived health need. The participants expressed a desire to learn to perform therapeutic self-care as evidenced by the 240 high correlation between expected assistance with present health activities and perceived health needs (Figure 5). Types of assistance needed from health care providers to enable older adults to perform therapeutic self-care are related to decision-making, behavior change and control, and acquiring knowledge and skills. All of these character- istics indicate a requirement for a supportive-educative nursing system as conceptualized by Orem (Figure 4). The nursing process consists of assessment, planning, intervention, and evaluation. Using that process, the pro- fessional nurse, practicing within a supportive-educative nursing system, can provide assistance to independent older adults through guidance, support, teaching and creating a developmental environment as represented in Figure 6. Individual older adults have differing expectations of health needs as identified by analysis of research data and presented in Table 11. Nursing assistance can be pro- vided to older adults to help them clarify their perceptions of their health needs. An understanding by both the nurse and the client of present and expected future health needs is necessary before any planning or decision-making can occur. Once needs have been identified and alternative activ- ities explored, the nurse can assist the older adult to direct those selected activities toward preventing, delaying, or adapting to the limitations of a health need (Figure 6). 0:500 .030 on 00500004 050.32 Mo .0099 o00fi>0m .0 983m 0.89905 0H3 530m .00 830033: Bmwumgmmdm ucg8§c0 l gsflaflomm 3553900 4 mo cofimfiwem 2 9:500? 000090 £30m @533 0031.30 0800:.“ .00 R559 gamed/30¢ 0H050m000§ A, 530m 000.30 A mag mmao A1 muzgmHmmm GZHWMHE COHMDHE / mmvmwz Sufi—”MOE \ GOHHCgHmvCH mo 0coHHE0ou0m mafia—swam @HHMHU 05000003 mmgm UZHWSZ 242 One of the findings in this study (as well as in pre— ceding research) indicated that older adults primarily expect assistance from health care providers for physical illness care. The provider seen as most likely to help was predom- inatly the physician. With increasing numbers of older adults, decreasing Medicare benefits, and the prevalence of chronic disease among this population, it has become impos- sible for one health care provider to meet all of the health care needs of all older adults. A third area of nurse assist- ance implicated by the results of this study is in facili- tating the appropriate use of health care providers, includ- ing, but not limited to, the physician. Nurses, especially those in expanded practice, can be utilized to provide much of the follow-up and continuing care accounting for the majority of physicnmivisits by older adults. Older adults, however, must View the nurse as an appropriate resource for health promotion and maintenance service. Nurse clinicians must take the initiative to establish practices in settings which would allow for greater visibility as autonomous health care providers for older adults.. Older adult clients should be utilized to help plan services based on these needs and to evaluate the effectiveness of nursing assistance in helping them meet health care needs. Alternative nursing practice settings should not be limited to medical clinics but might include apartment complexes or senior centers. 243 Utilizing the supportive-educative nursing system, the nursing process, and methods of nursing assistance described above, older adults can and should become capable of therapeutic self-care. In addition, self-care activ- ities, with nursing assistance, will be directed toward maximizing health rather than simply maintaining health or overcoming problems. Older adults should and could experi— ence wellness as aging progresses (Figure 6). This type of nursing assistance can be practiced in many settings and is appropriate for individuals, families, and small or large groups. Nursing Practice Since differences existed between individuals regard- less of socioeconomic characteristics any nurse with a clientele of older clients must assess the individual per- ceived needs of each older adult before planning a program to improve self-care activity. Any one activity is not appropriate for all older adults nor may it be acceptable to each individual depending on age, life-style or various other modifying factors. Rather than trying to substitute a new health activity for an already existing positive health activity the old method should be adapted to better meet the client's existing needs and preferences. Families should be included in planning and imple- menting self-care education and activity for older adults since they may be the first source of help when a health 244 need is experienced. The term "family" can be utilized to include any and all persons whom the older adults perceive as important in their personal lives. A "personal health history form" has been developed by Jepson-Taylor to facil- itate inclusion of significant others in self-care activ- ities of older adults (Jepson-Taylor, 1982). Small groups, as utilized in the present study, can be an effective means of providing instruction and knowl- edge about the normal changes inherent in the aging process, common problems and self-treatment of those problems, dif- ferentiation of serious and non-serious conditions and/or symptoms, and various health activities. Ward (1979) found that actual involvement in on-going group activities were more meaningful to older adults than episodic activities such as single session educational programs. Groups for older adults may be more beneficial when they provide more than a simple escape from boredom and isolation (Ward, 1979). In conjunction with the present study, nurses should implement small group health activities among pre-existing older adult groups such as in senior centers, apartment complexes, church groups, or senior clubs. Again, activ- ities should be planned based on the perceived needs and preferences of the group members. In addition, nurses should work with directors of already existing health programs (nutritional sites) to develop goals for the programs con- sistent with self-care goals of the participants. 245 Large groups such as entire residential complexes can also be utilized to foster therapeutic self-care among the older adult population. All residents of a housing unit could be surveyed by means of the instrument developed for the present study to assess general perceptions of needs, performance of activities, and expectations of assistance. This assessment would reveal priorities for program planning. A long-range program consisting of instruction, guidance, and participation in multiple health activities would assist older adults to maintain their independence and prevent or delay involuntary relocation. The implication for the nursing profession is to become assertive and creative in assisting older adults to become therapeutic self-care agents and to be aware of how nurses can help. As Stevenson stated (1981): Nursing over the past decades has moved increasingly toward optimizing the self- care of the ill and disabled through patient teaching and rehabilitation. The natural next step is a growing com- mitment toward health promotion and higher-level wellness as a goal of nursing practice. Innovative nursing programs have been initiated in a few locations. An ambulatory preventive program for the elderly was instituted in Colorado and was effective in developing an awareness and responsibility among the older adult clients for health care maintenance (Furukawa, 1981). A program was conducted in Virginia in which older adults were 246 activated and trained in self-care and, in turn, provided self-care assistance and self-care education to their home- bound peers (Kosidlak, 1980). For such programs to become practical nurses must become active politically to obtain policy changes favoring support of health promotion assistance by nurses both financially and philosophically. A second imperative is that nurses become knowledge- able about community agencies and resources for older adults and actively create a network of resource persons from other professions with whom to consult and collaborate. In this manner, older adults may be assisted to utilize the health care system for other than medical care. A third imperative is that nursing educators prepare nursing practitioners at each level to provide nursing service to older adults in any setting. Nursing Education As Stone (1982) stated, to care for older adults it is not enough to have a knowledge of nursing; one must also have a knowledge of gerontology. Though some universities have Master's programs in gerontological nursing there are not enough applicants presently to use the available fellow- ships (Stone, 1982). Other graduate programs such as crit- ical care nursing do not lack for applicants. Stone maintains nursing educators have failed to make gerontolog- ical nursing dynamic and yet it has the potential to be 247 exciting. One reason for the apparent lack of excitement in gerontological nursing may be the negative stereotype of "being old." The implications of the present research findings are that "being old" is not a depressing state of affairs. The older adults who participated in the study felt healthy, were active, and wanted to become more active in managing their own health despite age, losses, and eco- nomic restraints. Having a positive attitude toward the elderly, however, was not found to be related to the will- ingness of professional nurses to care for the elderly (Meyer, Hassanein, & Bahr, 1980). Robb and Malinzak (1981) examined knowledge levels among nurses caring for older adults and concluded that gerontological nursing should be a discrete rather than an integrated part of the nursing curriculum at each level of nursing education (Associate Degree, Baccalaureate, Masters, Doctoral) and be included in continuing education programs. Both the Meyer, et a1. and the Robb and Malinzak studies were conducted in acute and long-term health care settings. Nurses in these studies did not have adequate knowledge of gerontology, though they all had nursing knowl- edge, to meet the special needs of older adults when disabled. Great excitement exists in the areas of health education, promotion, and self-care among pediatric, matern- ity, and adult nurse practitioners. To create excitement 248 for gerontological nursing the implication for nursing edu- cation is to include in the curriculum at each level of nursing education material relating to the 85-95% of the older adults who are not seriously disabled. This material should focus on the normal changes of aging rather than the pathological conditions present in many older adult individ- uals. Education should focus on the preventable and treat- able common problems of older adults (i.e., constipation) rather than irreversible conditions such as cerebral vascu— lar disease or organic brain syndrome. Such normal aging changes and common problems exist among the aging population regardless of health status. With the knowledge of common problems nurses can assist older adults to adapt to patho- logical and irreversible conditions while maintaining adaptive self-care activity and thereby experience wellness despite a debilitating illness or condition. Thirdly, educational programs for nurses should focus on health activities beneficial in maintaining and maximizing health as appropriate for an older population. Gerontological nursing standards must be taught and incor- porated into the practice of every nurse. A fourth implication for nursing education is that the curriculum should include, at all levels, instruction on how to obtain information from and collaborate with com- munity agencies. Whether the practice setting is within an institution or in an ambulatory setting, effort must be 249 made to pool all available resources to assist older adults to maintain their independence and avoid institutionaliza- tion. In this manner nurses caring for older adults in any setting and with any type of educational background will understand the commonalities among an aging pOpulation and assist older clients to perform therapeutic self-care regard— less of the extent of ability or disability. Sensitization to the well older adults is an equally important facet of the educational process. Too often nursing students gain their only gerontological experience among the frail or ill elderly in acute- or long-term care settings. How much more apprOpriate it would be if they first gained experience with healthy, active older adults. Gerontological nursing education, as well as practice, must be based on a scientific body of knowledge. Geronto- logical nursing research must and can provide that body of knowledge. Nursing Research The American Nurses' Association (1981) identified the following six research priorities for the 19805: 1. Promoting health, well-being, and competency for personal care among all age groups. 2. Preventing health problems throughout the life span that have the potential to reduce productivity and satisfaction. 250 3. Decreasing the negative impact of health problems on coping abilities, productivity, and life satisfaction of individuals and families. 4. Ensuring that the care needs of particularly vulnerable groups are met through appropriate strategies. 5. Designing and develOping health care systems that are cost-effective in meeting the nurs— ing needs of the population. 6. Promoting health, well-being and competency for personal health in all age groups. There are implications based on the results of the present study for further nursing research in each of the priori- tized areas. The first implication for nurse researchers of the findings from this study is for replication. Not only should similar samples be surveyed but researchers should seek commonalities and differences among various other groups of older adults. Similar results from many various samples of older adults would strengthen any political effort to obtain funding for health promotion programs. Commonalities found among all groups sampled could be uti- lized to establish priorities for nursing intervention. A second implication for nurse researchers is to test the health belief model constructs among the older adult population. It would appear that different relation- ships may exist between the variables among an older pOpula- tion than exist among younger groups. If the HBM is to be eventually utilized as a basis for prediction and intervention 251 it should be applicable to all healthy persons regardless of age. Nurse researchers should direct research efforts to- ward identification of alternative health activities accept- able to older adults which would maximize physical, socio- economic, and psychological health. This would include experimental studies evaluating the subjective and objective effects of health activities in preventing, delaying, or minimizing disability from a health need. Not only should the effects of various activities be studied, but the effects of nursing intervention on the improvement of therapeutic self-care activities of older adults should be analyzed and documented. Nurse researchers in clinical practice must experiment withanuianalyze not only the subjective and objective changes as a result of nursing interventions, but the willingness of older adults to continue the health activity without assistance upon completion of the formal program. Because of the present limitation of funding re- sources and the highly competitive market for those limited funds, nurse clinicians must research and publish the cost- effectiveness of health promoting nursing service to older adults. If nurses can demonstrate that nursing care is an appropriate alternative to medical care for much of the ambulatory health care needs of the well-elderly, society in general as well as older clients and their families will be 252 willing to utilize the health care system more appropriately. Finally, the high alpha coefficients of the instru— ment developed for the study imply that effort should be directed toward further refining the instrument to improve the internal consistency of the socioeconomic scales and to evaluate the instrument for construct validity. Should the instrument prove to be both reliable and valid among a large population of older adults it might be utilized as an index of self-care potential of older adults in general in future research directed toward optimizing health. For use as a practical clinical assessment tool not requiring sophisticated statistical analysis the instrument must be simplified and tested in clinical sites. A check- list format rather than use of a Likert scale might be suf- ficient to identify individual and group needs for clinical health care interventions, thereby further incorporating nursing research into nursing practice. In summary, in Chapter VI the research results have been interpreted, conclusions have been made, recommendations have been suggested for further study, and implications for application of the study findings have been presented in respect to nursing practice, nursing education, and nursing research. APPENDIX A INTRODUCTORY LETTER TO THE SITES 2 5 3 APPENDIX A INTRODUCIORY LETIER '10 THE SITES MICHIGAN STATE UNIVERSITY CDLLEGE OF NURSING Carol J. Garlinghouse, R.N. 4583 E. St. Joseph Grand Ledge, MI 48837 October 1, 1981 Dear : I am a Registered Nurse presently completing requirements for a Master's Degree in Nursing at Michigan State University. My special area of interest is health care for ambulatory older adults, focusing on health maintenance, health pronotion, and prevention of illness and disease. During the past year I have been providing these services to residents at a local senior citizen housing unit. I am currently conducting a survey of groups of older adults in the Lansing Area for the purpose of identifying their perceptions of their personal health needs, the activities they perform to maintain their health, and the amount of assistance they expect to receive frm the health care system as it exists today. In addition to supplying data for my master's thesis, I will use the information obtained to plan care for older adult individuals and groups within the local population when I establish my practice in the future. I have developed a questionnaire by which I may obtain the information and now need volunteers from the older adult population in the commun- ity who would be willing to participate in the study. I will admin- ister the questionnaire to each group personally and the information obtained will be totally anonymous as I do not ask for any identifying data from the individual participant. I would like to obtain volunteers from your setting, but need your permission and assistance to do so. I will be contacting you by telephone for an appointment within the next two weeks to explain try study further, give you the opportunity to review my questionnaire, and explore the possibility of using your setting as a part of my research project. If you wish to contact me before then, I may be reached at the above address or by telephone (627-9232) . Thank you very much for your tine. Sincerely, Carol J. Garlinghouse, R.N., B.S.N. Family Nurse Clinician Student CJG? 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In an effort to answer some of these questions I have prepared this brief explanation of some of the problems and activities dis- cussed in the questionnaire. Though some of the problems frequently occur as a result of the aging process and NOT disease, each person is an individual and will experience different problems. Some persons never experience any of the mentioned problems and many persons do not have prob- lems until they reach a very old age. All of the problems mentioned are treatable. PAIN AND STIFFNESS IN JOINTS is a common problem and a result of the lifetime wear and tear they have been subjected to. Alternating periods of rest and exercise usually helps as does application of heat to the affected area. There are medications which can be used if the prob- lem becomes severe. As a person grows older they still need a balanced QIET but do not need as many calories. Your nurse or phy- sician can advise you if your diet is adequate and help you decide how many calories you need. Changes do occur in each of the FIVE SENSES, though they occur slowly. Any sudden changes are not to be expected. 271 With later old age it may become DIFFICULT TO CHEW food due to a decrease in muscle strength of the jaw and the fact that teeth surfaces lose their cutting edges. Cutting your food into smaller pieces usually solves the problem. DENTURES should never be a problem. They may need realignment periodically as the shape of the face changes with the aging process. DAYTIME TIREDNESS, not exhaustion, is common. Take that daytime nap you were never able to do in your younger years! Many persons have a particular television program they enjoy during the afternoon and they watch it while resting. With inflation such as we have today it may become increasingly difficult AFFORDING TO BUY food, housing, clothing, health care services, utilities, as well as pay- ing for social activities and maintaining the home. Many assistance programs are presently available but they are uncoordinated and confusing. One of the functions of a social worker is to help persons figure out which program would best meet their needs. The Tri—County Office of Aging can help put you in touch with someone to help you. DAILY ROUTINES may need to be changed as aging pro- gresses. If that seems difficult many professional nurses can help you plan a better schedule. For example, it is not necessary to take a complete bath or shower every day (in fact, daily baths may create dry skin!). 272 There may be changes in SEXUAL AND MARITAL RELATIONS but the need for love and affection never ceases. This is a subject some health-care professionls do not feel comfort- able discussing but there are many who are knowledgeable, warm and understanding. Do not be afraid to bring up the subject if this becomes a problem. If they become uncom- fortable ask them for another source of counseling. REMEMBERING THE PAST is fun and necessary. Find someone to share your memories with. Some persons who live far away from loved ones put their remembrances on a tape recording for their children and grandchildren to enjoy. It is sometimes difficult to follow a prescribed MEDICATION schedule. Talk it over with a nurse. The pro- fessional nurse should be able to help you figure out a way to follow the Doctor's orders. You should also know how to tell if the medicine you take is working. Some degree of FORGETFULNESS is expected. Usually it's the little things that happen every day that are for- gotten while memories of the past are no problem. Making check-lists sometimes helps. Older persons should have POSITIVE FEELINGS about themselves. They do not lose their ABILITY TO LEARN and many find time after retirement to learn new knowledge and skills they have always wanted to learn. The following problems are not to be expected as a result of the aging process: 273 SHORTNESS OF BREATH COLD HANDS AND/OR FEET CONSTIPATION NUMBNESS OF HANDS AND/ NEED TO URINATE MORE OR FEET OFTEN INABILITY TO HOLD URINE SWELLING OF HANDS AND/ DIFFICULTY SLEEPING OR FEET DIFFICULTY MAKING FEELINGS OF USELESSNESS DECISIONS DIFFICULTY THINKING THROUGH PROBLEMS If any of these problems occur, assistance should be sought. In the Lansing area the following agencies may help you find assistance: INGHAM COUNTY MEDICAL or OSTEOPATHIC SOCIETY - Physician services TRI—COUNTY OFFICE ON AGING - Many services (Home- bound meals, energy assistance, extensive information and referral) GREATER LANSING VISITING NURSE SERVICE - Home nursing care, physical therapy, social service, Speech therapy. INGHAM COUNTY DEPARTMENT OF SOCIAL SERVICE - financial assistance, social services, housing assistance (landlord-tenant problems, heating assistance, relocation assistance). CATHOLIC SOCIAL SERVICES - counseling and referral APPENDIX D HUMAN SUBJECTS REVIEW COMMITTEE APPLICATION II. III. 274 APPENDIX D .MICHIGAN STATE UNIVERSITY SCHOOL OF NURSING HUMAN SUBJECTS REVIEW COMMITTEE APPLICATION* Date fornlcxxmgbeted: Principal Investigator Name: Carol J. Garlinghouse Address: 4583 E. St. Joseph Grand Ledge, MI 48837 Phone: home 627-9232 office Position/Title: Graduate Student Qualifications: Completed required courses for degree of Master of Science, December, 1980. Names and Qualifications of Associates: None Names and qualifications of other persons responsible for perfbrndng or supervising procedures: Dr. Barbara Given, Assistant Director Graduate Nursing Program Brigid Warren, Instructor, Graduate Nursing Program Sr. Mary Honora Kroger, Ph.D., Community Health Sciences JoAnn Westrick, Instructor, Graduate Nursing Program Title of proposal or activity: "The Perceived Health Needs and Stated Health Activities of Older Adults and their Expecta- tions of Assistance from Health Care Providers: A Correlational Study." *Eor further information and clarification, please refer to the Human Subjects Review Committee "Policies and Procedures Guidelines. " IV. Beginning date of proposed activity: 275 January, 1981 V. Anticipated completion date: June, 1981 VI. VII. IS this activity related to a grant or contract? If yes, complete Arl. A. B. C. D. E. Is it related to a training grant? Is it related to a fellowship? Has proposal been submitted? Has award.been made? Name of Principal Investigator shown (or to be shown) on proposal: Name of agency to which proposal was (or will be) submitted: If continuation (or already awarded), what is the agency's grant or contract number? Inclusive dates of grant or contract? From , through Will activity be performed if funding is not received? Checklist to be completed by investigator: A. Will another organization or agency be involved (hospitals, Department.of Public Health, others)? Washington Square Residential Center Somerset Residential Center Serenity Place Residential Center Other senior groups to be contacted. Name and titles of person(s) in agency fnmnvdrmnpemnussion to do study must be Obtained: William Morris, Lansing Housing Commission Dr. Robert Williams, Minister Will an investigational new drug (IND) be used? Yes No x Yes No Yes NO Yes No Yes No Yes No Yes X No Plymouth Congregational Church Senior Group Yes No x If yes , name, proposed dosage, status with Food and Drug.Administration and IND number. Enclose one copy of available toxicity data. C. D. 276 Will other drugs be used? If yes, Danes and dosages. Yes No ‘Will a written consent forums) be used? Yes No (Required in most cases.) 1. If no, explain why a*written consent form will not be used. Older Adults are reluctant to sign their names to any form. The purpose of the study will be explained to prospective participants ahead of the date of administration. Attached to the questionnaire will be a letter explaining that by completing the questionnaire, the participant has agreed to participate in the study and that they are free to leave at any time whether or not the questionnaire is completed. (See attached questionnaire.) 2. If no, is a statement attached describing Yes _§__No what participants will be told? Partic— ipants must be informed of all elements of VII-E below. A written script of the verbal explanation must be attached to this request. Does (Do) the consent form(s) include: "Nfichigan State university" heading? Yes X No Name, position, department and telephone Yes _5_ No number of investigator? Project Title? Yes ___ No Date? Yes _ No Copy for subject? Yes ___ No Signature and date lines to be completed Yes ___ No by subject (and legal guardian, if sub- ject is a.minor or is legally incompetent), and investigator? The following elements of consent expressed in lay terms: Purpose-benefits to be expected or Yes _3_ No knowledge hoped to be gained? Procedures to be followed.only'fOr the Yes _5_ No [purpose of this activity, and time involved? 277 Identification of the procedures that Yes No None are experimental? Nature and amount of risk, or sub- Yes x No stantial stress or discomfort involved? ApprOpriate alternate procedures that Yes No NA might be advantageous or available to subject? (Show N/A, not applicable, when there are none.) Costs the subject may immediately or Yes No X ultimately be forced to bear and what reinbnrsenent of costs or other come pensation the sdbject‘will receive as the result of participation in this activity? Vbluntary nature of participation and Yes X No freedom.t0‘withdraw at any point.with- out penalty? Opportunity to ask questions at any Yes No X time? Assurance that subject's identity will Yes X No remain confidential? Please follow the consent form.guideline attaChed to this application fOIHL F. Describe how, by whom, and where consent will be obtained. Consent will be obtained at the time of administration of the instrument by the principal investigator as evidenced by completion of the questionnaire. Consent will be obtained from the administrator of the agency and/or senior group prior to date of adminis- tration by the principal investigator. VIII. Subjects .A. Criteria for selection (include sample size and age group). 50-100 subjects 1. 2. U14:- Age--65 years and older. Stated "yes" to question "Do you feel you are generally in good health?" Presence at designated location for administration of questionnaire at designated time. Ability to read questionnaire. Use English as their primary language. Be ambulatory and residing in independent living quarters. Completion of the questionnaire. IX. X. 278 B. Source of subjects (including patients), and how they will be approached. Subjects will be selected from residential centers and senior citizen groups from Lansing area churches after consent has been obtained from the apprOpriate authority (manager, director, clergyman, leader). This person will address prospective participants about the purpose of the study, the requirements for participation, types of questions to be asked, anonymity of answers, length of time to complete the instrument, and the date, time and location of administration. C. Will subjects be paid or otherwise compensated? NO If so, what amount? If not, how might the subject benefit? After completion of questionnaire, the subjects may pick up an information packet consisting of explanations of the various health needs, activities, and services available for older adults. D. location where procedures will be carried out, e.g. , patient's bedside, conference room, etc. Location to be designated by the apprOpriate authority; probably community rooms of residential centers and churches. Confidentiality and.Anonymdty A. Steps to ensure that participation by subject will be kept confidential. No personal identification data will be obtained from any individual participant in this study nor will any numbers be assigned to the questionnaires. The completed instru- ment will be placed by the participant in a common con- tainer with no handling by the researcher until she has left the premises. B. Provisions to ensure anonymity of documents and data (include provisions for control over access to documents and data). No means of identification with individual participants on instrument. Data accessible only to researcher and Thesis Committee. Data will be stored in metal file cabinet in researcher's home. What prlications might be helpful to the committee in con- sideration of this application? (Answer only if these might expedite review.) XI. 279 Outline of Activity. Provide answers in spaces following.ArD.below (add Sheets, when needed). A. Discuss other methods of data collection and reason for rejection. (i.e., Is there another method for collecting data whidh.would put the subject at less risk? If so, why was it rejected?) The instrument could have been distributed by the person from whom agency consent was obtained, filled out by the participant in his/her home, and mailed to researcher or returned to setting office. This method was rejected as it would increase the possibility of intervening variables affecting the data. It might also allow for coercion by the agency person distributing and/or collecting the instrument. Participants could have been approached indi- vidually but this would have greatly increased the time of the study as well as the risk of identification with a particular response. If any deception (withholding complete infbrmation) is required for the validity of this activity, explain why this is necessary; Describe the procedure for debriefing. No deception is required. Each participant will be offered an information packet at the time of completion of the instrument containing explanations of question in the instrument, i.e.: Pain and stiffness of joints due to degenerative joint dis- ease is a result of the aging changes in the joints. Obesity can make it worse. Regular exercise with frequent rest periods help reduce the pain and stiffness. Medica- tions are available if the pain becomes severe. Potential significance of the results (i.e., to patients, society, nursing). The results will begin to describe how accurately healthy older adults' perceive their changing health needs as aging progresses, how effective they perceive certain health activities are in maintaining their health, and how adequate they perceive the health care system to be in providing assistance. Any agency serving older adults can use the results to plan health care programs so as to increase awareness of changing health needs, benefits of health activities, and assist older adults to more effectively utilize the health care system. Any nurse caring for older adults can use the results to improve self-care capabilities among her client caseload. l. 2. 280 D. Nature and degree of risk (stress, discomfort, side effects). Risk refers to all risks-~physical, psy- chological, social, legal, etc. There are no physical risks. Any participant can leave at any time. Administration of the instrument in a group setting in a familiar non-threatening environment should keep any psychological stress at a minimum. Possible adverse effects. Include an assessment of the likelihood and seriousness of such effects or risks. There should be no adverse effects. What safety precautions or counteremeasures are planned to minimize risks in order to protect the rights and welfare of the individuals? Participants can leave at any time for any reason during administration of the questionnaire. The informational packet is designed to provide an expla- nation as to the normalcy of each item on the instrument. The researcher will be available after administration to answer any questions participants may have. Followeup planned for procedures. Include debriefing statement. No follow-up is planned other than the informational packet. Should any agency desire the results of the study it will be provided to them. .Arrangements for financial responsibility for adverse effects. None 281 XII . If you are a graduate student, have you informed your thesis committee that you are filing this application? Yes X No Signature of Principal Investigator Signature of 'Ihesis Committee Member Approving 'Ihis Application Form APPENDIX E FREQUENCY DISTRIBUTIONS 282 «Am 3 «.3 am Ema a at: e N a am noon mom ozoae SEES EmHmmoe ma m Yam fl Sam 2 m.m~ 2 Ema a 3 Sega Samoan we a S m 3 m 3 mm mm 2 cm mange go 92 m Tam me 93 m m.m~ 3 ma m E ozcgo EEHEQ Em m Md” a mad a Sum mm 2 a mm mmedmmfi E8 9m m mg: 3 mam 3 oém E Em m mm muzfiam mo moon ma m m.m m 9: s Tue mm mam 3 mm amazed .235 mad a Dem 2 9mm 3 mam me me mmooo Adam 8. and? E E Ezso a 93 m Ema e. Ema a. mi. mm 3: 2 mm mmmzfimc oszammozH Ema a Tom 3 TS . m Tom 3 v.3 m an E modza 82% E so ozeefizm as a. mam 2 New 3 warm 3 9: e mm Ema moEza mazes E ....o mmmzmaz Tm m 93 a S: m m.mm 3 TN 3 am Swag $58 9: e mam 3 mm . 2 92 a. Ema 5 mm mam: E3028. EEHmmzH m.m m eém a: «.3 m mam 3 Sm m mm 530 E9 mega oe camz a «.3 S mam 3 mm 2 ma m «.3 m mm zoEfiEmzoo 1s a TE 3 3: m Tam mm 92 2 mm ream so mmefimomm Tm m Yam me 93 m «Am 3 Ema .m E .53 m: 8236 B. ommz < 1m m 1m m TD. em mém 2 mm wagon m: 2H Em 92 ES m z m z m z w z w z z "moszmeE 8. monommeo ooummflo 83085 momma 8H3 38. Deg H mango 380 H me 398% 3963.0. mcoflsnwuumao Cough 68oz 53oz N a 9m m MEN 3 mém NN NA: N am mzoESFHm .89 :5: Eco 8. 33:3 E E muzfifizoo N H N.N N m.NN 3 me mN 9: a 8 Emma; .509 82% ESE N.NN N N.Nv «N N.mH m 92 3 o..m N 3 598 205689. 8358mm Nza .3ng 2H EQUHES 9m v ma w ma e «.3 2 am 3 Nu. 8322mm 8. E58 N.m m N.m m Ya m 98 cm o.NN NH mm EESHQ amoz zH mmwzsb N.N N 93 m «.2 m N.Nm mN «.ma m Nm §§< .288 5 mafia m m 3 m 3 N cm 3 8 8 om $386 52% m8 ammz 83$qu N.NH m v.3 N v.2 N m.mm 3 N.NH m mv mzoESmm a; 92 5mm zH mmwzso S m m m 3 m vm NN S N cm 82% 52a E E mfizso 9m N H5 m «.3 a N.Nm mN N.NN 3 mm mxmfi Bofimoom quoo BBCEE 62$qu méN 3 oém 3 N.NH m 92 N N.N v Nm mESEoc .268 m8 quaE E3855 SE88 N.NN fl oém 3 N.NH 3 mad N N.N N Nm dem 2.35: 353 NSBEB SE88 N.ON d «.oN 3 méN 3 N.NH N as: m mm mat/mam E6 mug mom 025$ N.N.BUHEB .3388 m.NN E N.Nm 8 0.: m N.N m m.m N am wzHEQU BEBE madman 8. 33:2 5 >55an mamHmmom N.Nm 3 m.mm 3 92 m N.N v N N am 858: m8 025E EQUEE Emma w z w z N z N z w z z "muszmBE B. magmmmflo wwnmmmfla 83085 mmuma 8&4 H38. 8mg H mac 296 H 9 395.3...“ wamcouum 284 N.Nm NH NON OH N.NH O N.N.H Nm mzfimBm 58mm. 02255. OEHBEHO N.Nm NH NON OH H.mN NH N.N.H Nm 9sz N: “5 EUR: N.N.HBEHO N.NN OH N.NN OH N.N O N.NN Hm 82mm. 3% 52$ 8. EHHHNZ N: E mmfimumn 4 N.NH N N.N m N.HN HH HON Nm NEE mo Ema mzom ON ON ON NH ON OH NH ON mmmzmmSmB mo 82% OH H N.N N O.H H N.NO E H! N: 985 982 ma 3m: ma gay 8 26 H 82858 N z N z N z N z "22mg 8. 8nmme £33 33085 83¢ 38. Bumxm H mquo 56 H mm NHmcofim >328...“ 285 O N OO ON OO ON OO EH: 829% gm 8. mzoazom m>§ N H O.m N O.N O N.Om ON H.NO ON HO Noam H #50: < HE: N H N H N.OH N HO ON O.Hm OH HO NEOQE @szng OH mzHoHoE 6am .mH E 8. 38 5Q O.H H N.O N 0.00 ON 0.00 NN NO m: mom 8 0H. ammomBO OH 82H. H 28.5689 6% ONE 292 O.N O O.m N O.HO NN N.NO ON OO .H.HH E H 2mm: 9.6ng E6 N835 MONO 0.0 O N.HN HH 0.00 OH N.NO NH NO NE NH OHQE mo mummfiw NO 995 .2 Nszo N.N O 0.0H O 0.0H O N.Nm HN 0.0N OH OO .HNGHz NOON. Em omEEmmHsz: .8 98m OIO HE N.O N N.OH N 0.0 O N.OO OH N.ON OH N.O NE NE. @228 802mm HOME 58mb O.H H O.HH O O.HO NN 0.0m OH NO ozwzmm Ba 20ng 35:65 2H um? :68 .20ng 8.3% a m>§ O N O O O O NO HN NO HN OO Nam» NOE BOOZE N2 mmm O.N O N H N H N.Om ON OO ON HO EH3 032% ozm 0388.2 BEHH OH O NH O OH O OO Om OO 85% .82 8 O.m N 0.0 m 0.00 ON OO NN OO g 92 ESE OE Ham N.O m 0.0N Om N.ON HH OO H.553 N: H858 N.N O N.N O 0.00 Om N.OH OH NO SHE mmgm N z N z N z N z N z 2 "H gm fig §m>o mmuOmmHO 8583 @8885 8H? 8H? H38. nzm 32% N: zHfisz‘ DH. aamconum mqmcouum mcofluznfluumHa xucmsvmuh "mmHuw>fluQ¢ nudmm: 286 m..: m min m mine mm v4.3 m mm 02% 98mg Emmns 24 H E "va Em min A 0.0m om mév mm mm EMBED DH. EB mm DH. mg 025 m.HH m m.mH N. m.mm mm ~.m.n OH Nm m2 8% a? mUZHmF 5.3 gm lam ..HflZOHBgm 2H BRQHUHENE m.m N v.3” OH mdm om mKH m Hm m2 m8 v39» 6H3; ZOHmZHH 92¢ mg...“ NOR—mm DH. mam; Dung EBB ad m m.om mm ov mm mm Emma MS 3 mg DH. magnum ”622 min H m4 H w.mv vm RUNm am mm 3% m2 OPE HOE mad 2H E aim H h.m m «6 m Himv mm vm ma mm ”mag E§B§HB§E EWZEHEEEHZMZQm—‘ammaa m.m m NHMH N. ©.mH OH H6O mm NHmH m am a E 2H gm quzmmmuO BEEN E OE. E4 N.O m 0.0 O N.NH O N.ON OH 0.0m ON NO g N2 5 gm onNHmSz szHaHu monmO ma. zH BEHUENO N.O O H.N H 0.0H N N.NO HN O.Hm OH OO Emma? .NH 80ng E6 52% mos NE N.Hmm 8. 355.2 mm: 338 O.H H 0.0 m N.OO ON H.NO ON NO 96ng $6 5.2m: mom NE 8. E55? mm; N.OO ON N.OO ON OO Oak/Hea N852 OOEHE EH3 BEEEN H468 Noam NE N z N z N z N z N z 2 ”H mzmqmam Ease @6990 8388 8HOONHO 8308:: m8? 8H2 H88 92 NEHOBN N2 22322 2. >Hm§m Ema—0.3m 287 0.00 ON 0.00 OH 0.0 O H.O O O.N H OO 88 28 02222 EHBEHO mHmHmOom 0.0N OH 0.00 OH N.ON HH N.OH N NO qumOmHm 25858 0.0 O 0.0H O 0.0 N 0.00 NN 0.0N HH OO 225282 MODES N.OH O H.OO OH 0.0H O 0.0N O 0.0H O OO quszO EQUEHO 0.0H O NO OH N.OH N 0.0N HH 0.0 N OO mmmzommfl. EEO OH O N.HN OH H.ON NH H.OO OH OO 82422 20 OOQH 0.0H O 0.0 O 0.0H N 0.00 OH N.ON OH NO 822,25 2239 O.NH O NO NH 0.0N OH N.OH N N.N H OO mmooo 2225 8. N.OHHHmm H2 2H 8230 4 N.NH O 0.0H O 0.0H N N.OO NH 0.0N OH OO OE wszOmmqu N.OH N O..ON OH OH O 0.00 OH N.O O OO E 20322 82% 22 mo szHmzm OH O 0.00 OH N.HN OH 0.0N HH 0.0 O OO 9222 20322 8222 2 mo mmmzesz N.OH N N.OO OH 0.0N OH 0.0H N H.O O OO E 222 8222 S8 H.OH O 0.0N OH 0.0N HH H.OH O 0.0 O NO OzHNS 22 So: 8. EHHHmOzH 0.0H O O.NO ON 0.0N NH O.NH O 0.0 O NO 2280 2292 2.2on OH. 252 2 N.NN OH 0.00 O 0.0N HH 0.0H N 0.0 N OO 20223828 0.0H N 0.0N HH H.OH O 0.0N OH O.NH O NO 5,2222 20 mmOszomm 0.0H N O.HO OH 0.0N OH O.HO OH H.N H OO EH2 N2 8225 OH. 822 2 N.OH O N.OH O 0.0H O 0.00 ON 0.0H N OO mEHoH. 2 2H NERO 022 22% N 2 N 2 N 2 N 2 N 2 2 £22. EH: 9.. flux 2. 8HOOOHO meOOOHa 8308:: 8H3 meO< H58. @8382 225 2352. 82822 H NHOcoflO NHOcofim mcoflzfluufla 2055822 "mcmwz 53mm 553 8:5mwmm4 630% 288 ON HH ON HH O.HO OH 0.0H N O.N H OO OonEHOHm H.OH: EH2 88 DH. N.OHHHOO 2 2H gaEzoo 0.0N HH N.OO OH N.HN OH O.NH O N.N H OO EOE .884 82% 23.582 NH O N.OO NH 0.0 O N.OO NH H.N H NO N.HBBUO 2055532 22328222 222 22638 2H N.N.HBEHO N.OO OH O.NO OH O.HH O O.HH O OO BOSE O2. EH82 NO NH 0.0N OH N.O O 0.0H O 0.0 O OO E35 2202 2H 82225 NO NH H.ON NH N.OH N N.OH N 0.0 O OO NEE H288 2H mafia N.NO OH O.NN OH H.HH O 0.0 O 0.0 O OO OOEHNOQU 2222.2 28 2222 22222qu OO OH OO OH 0.0 O 0.0 O O.N H HO 903482 92.222 O22 gm 2H 82245 0.00 OH 0.00 OH O.NH O H.HH O 0.0 N OO 82258 SHE 2.2 2H 82225 O.NN HH N.NO OH 0.0N HH 0.0H N N.O O OO mg 395802 u2H8 N.O.HBHEHO 288.2qu 0.00 NN 0.00 OH 0.0H N H.N H H.N H NO 82.95 2488 28 22542 N.O.HBHEHO ......HmHmOom 0.00 OH 0.00 OH 0.0H N 0.0H O H.N H OO OOHHm 23de 22922 258528 SOHOOOO 0.0N O N.OO NH O.NN HH N.NH O O.N H OO 8238 225 5.2% 28 22222 258528 3388 0.00 ON 0.00 NH H.O O O.N H 0.0 N .OO 922280 22288 285222 O2. N.OHHHOO 2H 222558 22288 H.NO ON 0.0N NH 0.0 N 0.0 N 0.0 N NO 028202 28 @2222 N.N.HBHEHHO O.HOHOOOO N 2 N 2 N 2 N 2 N 2 2 "OHS. EH2 Oz 2222 OH. 8883 8.888 EH85 8H8 882 H38. 9222622 225 22222 82% H bozouum wamconflm 289 0.00 OH OO OH 0.0H O H.HH O OO @2882 8288 OszszH. 85088 O.NO NH 0.00 OH ON O N.O O OO 222 .2 8 02822 2.8252 OO OH OO OH 0.0 O 0.0 O N.N H OO 8222. 222 2228 8. 2.822 2 2H 28268 2 O.HO OH 0.0N OH 0.0N O N.OH O OO E88 .8 888.8 0.00 ON 0.00 OH O.NH O 0.0 N OO 8828888 mo 8228.2 0.0N OH O.NN NH O.HH O ON HH 0.0 O. OO 82 .2 892.0 802 mm 2.82 mm 8222. 8 28 H 8H8 N 2 N 2 N 2 N 2 N 2 2 ”822. EH2 22 2.8 O2. 8888 $888 2888:: 882 $82 88. 8882 85 5822 8% H hachHum mecoHum 290 0.00 OH 0.00 OH 0.0 O O.NH O O N OO EH2 222922 222% 8. 220962 222 O.NO OH 0.00 OH OH O O O O.HH O OO 20222 H 22202 2 2222 0.0 N OH O 0.0 N 0.00 ON N.OO OH. OO 2222282 225202 OH 22HoHo§5222H§352292 0.0 O N.OH O N.N H 0.00 OH O.HO OH OO 9. 202 8 8. 22202222 OH 2222. H 202.5522 522 .222 522 0.0 O 0.0 O 0.0 O 0.00 OH O.HO OH OO an .222 H 2222 289222 226 222222 2222 0.0H O 0.00 ON OH O H.O O 0.0 O NO 222 2 2522 20 222252 OuO 2.223 2.2 2522 0.0N NH 0.0N OH 0.0N NH 0.0 O H.HH O OO 2.232 522 22222 _ 2252222522 20 22202 O..O 2.22 0.0N HH 0.00 ON 0.0H O 0.0 O H.HH O OO 222 222. 2528 88222 2.222 2.22202 0.0H O 0.0 O N.N H 0.00 OH 0.00 OH OO 222222 222 20ng 2253qu OH 2222 2222 255222 E5260 2 2322 0.0H O 0.0 O 0.0 O 0.00 HN H.ON NH OO 2222 222>2 2225.8 22 222 O.NO OH 0.00 OH O O 0.0H O 0.0 O OO 22.22252 28.22.26 222 025832 2.223 O.HO OH H.OO OH . 0.0 O 0.0 O 0.0 O HO 222.2 .82 8 0.0N NH N.NO OH 0.0 O 0.0 O 0.0H O OO 22.25% 222 8.522 22222 2.22 0.0H O 0.0N HH 0.0H O 0.00 ON 0.0 N OO 9622 22 282.28 O.HN OH O.NO ON O.NH O H.OH O 0.0 N OO SHE 228222 N 2 N 2 N 2 N 2 N 2 2 "OHE. EH2 O: 2222 OH. 82283 82238 28885 . 852 82% H58. 2222982 225 232.22 202222 H 395.32 >Hmconum 2203232325 20229582 22ng302 5302 :33 2022222202 02202222 291 b.mm mH o.mN NH at: m «O.HN m «O.N H Nw UZHmFMZOm g Emma. E H E 8% Em O.Nm vH N.OM MH M6 O. m.mH m m.m «2 2» $9.90 DH. g8 mm 9... ma Qth N.Om MH o.Nm vH wt: m m.MN OH m.N H mq m2 9% Ba 82HE 930mm é lam gag 2H Edmsgm véN OH véN CH véN OH v.vN OH «O.N H .3 m2 m8 v39» 6Hm3 ZOHmZH. DZ< gm "H.HH—mm DH. ma QMQQHE/B mam: e.g.. mH Hém mH m.m.H o m6 m H.m v 3N Emma N2 M8H mg DH. magma g 5.32 HN mN HH H.@ v m6 N m.m.H m 3 Egg H2 EH3 28 mg ZH E o.Nm 3n N.N.m 0.... «H o O. m m.m v mv QED—55¢ 02¢ magma. SE .582 MS gm 26 H 2033 EH3 "Hag m>§ m.m.H 0 AN m N.NH m vév ON vé N mv g a ZH 9243093 _ OZHmeEUm 553 E H.HH. Damn-H4 N.HN OH NHHN 0H N.mH 5 mm 5H m.v N mv g HS ZH gm ZOHBHMHDZ ZMNHBHU MOHZWm a 2H BflmHUHgm m.hH m H.HH m N.NH m v33 ON m.m v we Emmamz .mH magma E5 ES.— m9"..— Enu a CH. QH¢UHD§ MB O.HDQS m.ON m w.MH 0 m6 m m.mv ON v.2” w «v meHBEm E6 3% mg 2m DH. EEHQE EMS m2: mH mKN NH 2.2 N m.m w m.wH N. mv Ea mO\QZ< 82mg EH3 Egg gm $0....an fig w 2 w . Z w 2 w 2 w 2 z umHE. 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Health Needs and Health Activities for which No Assistance is Expected Health Needs % Health Activities % Decreased Ability to Snell 44.2 Adequate Sleep 18.6 Decreased Ability to Learn 42.1 Do Not Smoke 13.6 Cnanges in Sexual Relations 39.5 Free Health Screening 13.2 Difficulty Decision-Making 38.5 Nutrition Programs 12.5 Incontinence 37.8 Adequate Daytime Rest 11.9 Affording Social Activity 36.6 Adequate Fluids 11.6 Affording Housing 35.0 Participation in Medicaid 10.5 Frequency of Urination 34 . 8 Education Programs 10 . 3 Affording Clothing 34.1 Hobby 9.5 Difficulty Problem-Solving 33.3 Limit Alcohol and Caffeine 8.9 Affording Utilities 33.3 Care about Appearance 7.3 Feelings of Uselessness 32.4 Seek Advice 7.1 Affording Food 31.0 Exercise 6.4 Forgetfulness 30.8 Share Intimate Thoughts 4.9 Difficulty Sleeping 30.2 Know Medicine Effects 4.8 Constipation 27.1 Use Medicare 2.6 Numbness of Hands and/or Find Ways to be Useful 2.5 Feet 23.3 Share Ivlennries 2.4 Shortness of Breath 20.8 Annual Dental Exam 2.4 Change in Diet 20.4 Consume Fruits & Vegetables 2.1 Change in Daily Rountines 20.0 Change in Work Activity 20.0 Change in Social Activity 19.0 Difficulty Chewing 18.4 Reminiscence 17.9 Affording Health Care 17.4 loss of Balance 17.4 Oold Hands and/or Feet 14.9 Swelling of Hands and/or Feet 14.6 Difficulty Coping 13.2 Daytime Tiredness 12.8 Increasing Deafness ll 4 Family Closeness 9 8 Following Medicine Regiiren 9.1 Positive Feelings 7 7 Visual Cnanges 4 3 Difficulty with Household Tasks 4.3 Pain and Stiffness of Joints 3 8 Difficulty Doing Things 2.6 Denture Problems 2 3 REFERENCES 310 REFERENCES Aho, W.R. 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