The aging of the American population creates an increased need for health-related programs for older adults. Until now health education has primarily focused on children, adolescents, and adults (Schuster, 1995). The current growth of the older adult population makes it of utmost importance to also comprehensively address health education needs of older adults. Educational programs can be valuable in achieving behavioral, physiological, and psychological goals, which in turn may lead to lower utilization of health care services, higher quality of life and improved functional ability (Williams, Drew, Wright, Seidman, McGann, & Boulan, 1996). However, research indicates that identifying the most effective methods for transmitting information designed to achieve long-term behavioral changes among the older adult population is a complicated problem. It is essential that we work to identify those program characteristics that most effectively help to obtain the objective of behavioral change.

Health education has advanced far beyond the idea that knowledge inspires change (Haber, 1994). We now realize that to stimulate and support behavioral change, health education and promotion must not only be offered in traditional health care settings, but also be part of community life (Baldwin, 1995). Unfortunately, health care professionals have limited time, knowledge, and skills to devote to this important effort. It is vital, therefore, that they be as informed as possible about the community options that are available for improving health behaviors. The authors of the National League for Nursing publication entitled Vision for Nursing Education strongly suggest that all nursing educational programs shift their focus from illness care to a community health wellness model (National League for Nursing, 1993). A greater emphasis on being competent in marketing and facilitating health promotion activities is currently being added to graduate and baccalaureate nursing programs. Reorganizing curricula to include community health promotion is imperative to prepare nurses to meet the challenges they will face in the health care environment today (Baldwin, 1995).

1. A model was formulated for health promotion programs based on the health belief model, principles of adult learning and the concepts of transitions. The author’s experiences of planning and implementing programs for older adults in a senior center setting were also included in formulating this model.
2. A prototype medication use program was developed using this model.
3. Graduate and baccalaureate nursing students were mentored in the use of the model to develop and implement additional health promotion programs.

Health Promotion Programs place emphasis on the role of persons, groups, and organizations as active agents in shaping health practices and policies to optimize both individual wellness and collective well-being (Teague, 1987).

Compression of Morbidity is a decrease in the amount of time between morbidity and mortality that serves to improve the quality of later years (Lavizzo-Mourey, Day, Diserens, & Grisso, 1989; Waller & Bates, 1991). The term may also refer to a delay of the manifestation of the onset of chronic disease while maintaining the expected life span (Haber, 1994).

Older Adults are persons 65 years of age or older (Schuster, 1995).

Quality of Life refers to the perception of one’s own health, physical functioning, and functioning in daily activities (Schuster, 1995).

Mentor is defined as a teacher or coach. Mentoring is an intense, career building, mutually beneficial relationship between two individuals (Hamric, Spross, & Hanson, 1996).

Graduate Nursing Students who participated in this project were three students with baccalaureate degrees in nursing who were enrolled in a gerontological clinical nurse specialist or geriatric nurse practitioner program.

Baccalaureate Nursing Students who participated in this project were four undergraduates who were enrolled in Nursing 315, Determinants of Wellness.

1. Adult learners need to know why they need to know the new material. Most adults will invest energy in finding out the benefits of the learning activity. They are also interested in the negative consequences of failing to acquire the new information. Therefore, facilitators of adult health promotion programs must take time in the beginning of the program to help the learners become aware of the need to know (Knowles, 1989).

2. Adult learners are self-directed when properly motivated. Adults have a self-concept of being responsible for their own lives. Once they have arrived at this self-concept, they develop a deep psychological need to be seen and treated by others as being capable of self-direction. They resent and resist situations in which they feel others are imposing their will on them (Knowles, 1989). Programs directed at adult learners must be flexible enough to allow the participants to decide on the learning objectives. Unfortunately, when adults enter unfamiliar educational programs, they often revert to their previous school experiences and temporarily become dependent learners (Knowles, 1984). Program facilitators should use icebreakers or other strategies to help the participants become comfortable as quickly as possible.

3. Adults enter all types of educational activities with a richer variety and quality, of life experiences than the younger learner. In any group of older adults there will be a wider range of individual differences in terms of background, educational level, learning style, attention span, motivation, needs, interests, and goals than in a group of younger people. As a result, there is a great emphasis being placed in adult education on individualization of learning and teaching strategies (Knowles, 1989). Health educators need to recognize individuality and the diversity of the participants in their programs.

4. Adults are willing to put forth the effort required to learn things that they are convinced that they need to know to continue to be responsible for their own lives. Mastering the tasks associated with moving from one developmental stage to another provide an excellent demonstration of learning readiness. The critical implication of this assumption is the importance of timing learning experiences to coincide with those developmental tasks (Knowles, 1989). Common developmental tasks or transitions of the older adult include: adjusting to decreasing physical strength and health; adjusting to retirement and reduced income; adjusting to the death of a spouse or a significant other; establishing associations with others in their age group; adopting and adapting social roles in a flexible way; and establishing satisfactory physical living arrangements (Lueckenotte, 1996). Nurses frequently encounter older adults during these developmental stages or transitions (Schumacher & Meleis, 1994). Health promotion topics that help to maintain independence during the transitions associated with aging will be of the most interest to individuals in older age groups.

5. The adult orientation to learn has a life-centered or problem solving focus. Accordingly, learning experiences in adult education are increasingly organized around life tasks or problems. Health promotion programs will be more effective if the information can be readily applied to the participant's life (Knowles, 1989). For example medication regimes are followed more reliably when the medication causes an observable benefit such as decreased shortness of breath or pain control. Medication therapies that have less readily apparent benefits such as long term anticoagulants or antihypertensives are more frequently mismanaged by the consumer (Swonger & Burbank, 1995)

6. Adult learners are more responsive to intrinsic factors such as a desire for a better quality of life, increased self esteem, or job satisfaction (Knowles, 1989). Adults are generally motivated to keep growing and developing. Potential for growth can be blocked by negative experiences as a student, inaccessibility of opportunities or resources, time constraints, and past experience with programs that violate the principles of adult learning. Health educators must keep in mind that programs should not only be convenient and affordable, but they must also leave the participant feeling positive about the experience (Knowles, 1989).

The desired health behavior is contingent on perceived susceptibility to a health problem, the seriousness of the health problem, perceived benefits of taking action, perceived barriers to taking action, and perceived factors that trigger the health behavior. In addition to these variables, three other factors are included in predicting health behavior: (a) demographic factors such as age, ethnicity, and gender, (b) sociopsychological factors, such as personality and peer pressure, and (c) structural factors, such as knowledge or intellectual capacity (Haber, 1994).

Perceived susceptibility relates to the program participants' feelings about their personal vulnerability to an illness or belief in a given diagnosis. This dimension is concerned with the individual's subjective perception of the risk of incurring a health-related problem (Rosenstock et al., 1988). Older adults will attend certain types of health promotion programs because they believe they may be susceptible to the illness being presented and they may obtain information that will help them avoid this illness.

Perceived severity involves a subjective assessment of how serious the consequences will be of incurring the health-related problem. This assessment includes both physical implications as well as social implication, such as the ability to earn a living or to maintain a marital relationship (Rosenstock et al., 1988). The perceived benefits of making a lifestyle change are also seen as important. These authors also document that even individuals who have faced major illness or disability might not be motivated to incorporate the health related advice unless they feel their action is both practical and useful.

Perceived barriers are relevant to the likelihood of changing or adopting the health related behavior. In order for an older adult to engage in a health promotion activity the perceived benefit must outweigh the perceived cost, especially if a lifestyle change is to take place. The perception of benefits minus barriers is one determinant of whether or not change occurs (Rosenstock et al., 1988).

The older adult's ability to use health promotion information depends on what they believe about their life and the extent to which their actions impact their health. This belief system is referred to as locus of control (Waller & Bates, 1991). Waller & Bates (1991) report that an internal health locus of control in older adults has been associated with optimism, happiness and contentment (Waller & Bates, 1991). People with an internal locus of control are found to have better health habits and fewer illnesses than those with an external locus of control.

Older adults with an external locus of control are more likely to be unmarried, less educated, living alone and believe that health is significantly related to chance, luck, or other influences outside of their control (Wallerstein, 1992). Adults over the age of 80 tend to be more externally oriented. However, given control and knowledge about what to expect in their lives, Wallerstein (1992) believes that nursing home residents can develop better mental and physical health than older adults given the same intervention without added choice or decision-making power.

Interventional studies of people who increase their self-efficacy scores have also demonstrated better treatment compliance and choice of healthier behaviors than the comparison groups (Wallerstein, 1992). The Health Belief Model supports using an individual's beliefs about a specific health promotion activity to adapt that program to have the greatest potential to meet their specific needs.

Older adults are often the most open to education and other forms of support when they need help in making a change or transition in their lives. Schumacher and Meleis (1994) contend that transitions are a central concept in nursing and propose a model of transition in which education is the primary modality for preparing for transitions. The model also specifies ways to measure desirable transition outcomes.

Schumacher and Meleis (1994) categorize transitions as developmental, situational, health-illness, and organizational. It is not unusual for several of these types of transitions to occur concurrently for older adults. Categories of nursing measures suggested by Schumacher and Meleis to facilitate healthy transitions are assessment of readiness, education, role supplementation, and measurement of transition outcomes. In addition, efforts should be made to incorporate and measure subjective, behavioral, and interpersonal dimensions as part of nursing interventions.

Schumacher and Meleis believe that facilitating healthy transitions is of utmost importance because of their health consequences. Therefore, more emphasis needs to be placed on the measurement of factors that indicate healthy outcomes of transitions. Outcomes should be measured periodically as they can occur at any time in the transition process. Schumacher and Meleis suggest that three areas that should be measured are (a) subjective well being, (b) role mastery, and (c) the well being of the relationship.

Currently people 65 years of age or older represent 12.6% of the United States population. One in 35 Americans was 80 years or older in 1990 and by 2050 at least one in 13 could be 80 or older (U.S. Bureau of the Census, 1992). Healthy aging is becoming an accepted model in health care. This project has contributed to the first broad goal of Healthy People 2000 (U.S. Department of Health and Human Services, 1990, pg. 6 fig. 1.4) by providing health promotion programs that can help older adults learn ways to lengthen their healthy span of life and compress morbidity. Compressing the time between morbidity and mortality improves the quality of later years (Waller & Bates, 1991). Participants who attended health promotion programs conducted as part of this project indicated that they received specific information that will help them make healthy life-style changes or assist them with illness to health transitions. Clearly, nurses have the potential to make a significant impact by directing health promotion programs that consider the learning needs of older adults (Caserta, 1995).

Increasing an individual's healthy years can not only improve quality of life, but also has the potential to greatly impact on our nation's annual health care expenditures. Since managed care companies strive to keep their members as healthy as possible as long as possible, a priority for their systems is health promotion. Centers such as Christiana Care Health System's Preventive Medicine and Rehabilitation Institute (PMRI), for whom the author presented a program as part of the preparatory work for this project, have been developed to give health care professionals the resources required to take health promotion beyond the walls of the traditional hospital and out into the community. However, PMRI, as most preventive services, does not currently include programs tailored to meet the learning needs of older adults. The process developed in this project has the potential to assist preventive services such as PMRI to incorporate strategies to meet the learning needs of older adults into their programs. Therefore, this project can contribute to the second broad goal of Healthy People 2000 (U.S. Department of Health and Human Services, 1990, pg. 6 fig. 1.4) by increasing access to preventive services to our growing population of older adults.

This project provides guidelines in the form of a theoretical framework and a model that can help nursing educators incorporate components of health promotion into didactic and clinical practice. Nurses are the ideal healthcare professionals to plan, offer, and evaluate health promotion programs because they have responsibilities for patient care, including education, in primary, secondary, and tertiary settings. To be proficient in providing health promotion education to older adults, however, students need to learn the concepts and skills demonstrated in this project in their educational programs. Another contribution of this project to nursing education will be the guidance it will provide for graduate and undergraduate students in the Spring of 1998 in planning and giving health promotion programs for low-income members of the Wilmington Senior Center and their families. This project, therefore, has the potential to contribute to the third broad Healthy People 2000 (U.S. Department of Health and Human Services, 1990, pg. 6 fig. 1.4) goal of reducing health disparity among Americans.

The project melds concepts of transition with those of the health belief model and the principles of adult learning to delineate a model for providing health promotion programs that are meaningful and useful to older adults. These concepts and methods need to be further developed and evaluated through nursing research. Such knowledge could be used to develop future health promotion programs which are even more effective in attaining the goals of Healthy People 2000 (U.S. Department of Health and Human Services, 1990)

Comments, suggestions, or requests to ud-geriteach@udel.edu. "http://www.udel.edu/geriteach/project/watson-chap1.html" Last updated July 12, 1998. Copyright Norine Watson, 1998.