The aging of the America population and the monumental restructuring that our health care system has undergone have served to intensify the need for reliable methods to reach older adults with health promotion information. Research and other literature were reviewed for this project to provide (a) evidence of the need for health promotion programs for older adults, (b) models for health promotion programs, (c) health-related topics of the most value to older adults, (d) methodology for health education of older adults, and (e) indicators of success for evaluation of health promotion programs.

Another misconception that affects the availability of health promotion programs for older adults is the belief that a positive change in health behavior will not result in a change in health status, because older adults are too set in their ways to change their health behavior. Behavioral studies related to exercise and smoking cessation provide abundant evidence that education can promote behavioral change. These studies have further demonstrated that regular exercise and smoking cessation can result in a slowing or reversal of disease processes. Kirwan, Kohrt, Wojto, Bourey, & Holloszy (1993) conducted a study involving the effect of endurance exercise training on glucose stimulated insulin levels in 12 volunteers aged 60 to 70. The results of this study provide evidence that regular exercise is effective in reducing hyperinsulinemia and in improving insulin action in older adults to levels typical of young people (Kirwan et al., 1993).

The American Heart Association (1994) has reported that older adults who quit smoking and abstain from smoking during a six-year follow-up period, have a greater survival rate than older adults who continued to smoke. The relative benefit for those who quit smoking compared to those who continued to smoke was comparable to that reported for younger subjects in other studies (Vliestra, Kronmal, Oberman, Frye, & Killip, 1986). Immediate benefits of smoking cessation include (a) lower blood pressure, reducing the risk of stroke, (b) improved respiratory function, and (c) improved taste sensation. While the survival of quitters was not as good as those who never smoked, it was indistinguishable from that of former smokers who quit earlier in life. These authors conclude that smoking cessation is beneficial for older adults.

Arthritis is the most common disease among older adults and it also causes the most pain and suffering (Davies, 1996). It is estimated that almost 37 million Americans suffer from arthritis (Daltroy & Liang, 1993). These authors have found that osteoarthritis of the hands, weight-bearing joints, and the back affects 15.8 million adults and is most common as people age. Although arthritis is not a deadly disease it is a leading cause of disability and pain; unfortunately most forms of this disease are not preventable (Daltroy & Liang, 1993). These authors list the many forms of arthritis as the leading cause of mobility limitation and the second leading cause of activity limitation in this country. They estimate the direct and indirect economic costs of arthritis to be between $6 and $14 billion a year. Behaviors found to improve the health and psychological status of arthritis patients include exercise, relaxation, joint protection, and careful compliance with medication regimens. At least three controlled studies of health education programs have demonstrated an increase in desired behaviors and improvements in health in experimental over the control groups (Daltroy & Liang).

In 1987, 12% of the population was over 65 years old, but this group accounted for 36% of the total health care expenditures (American Association of Retired Persons (AARP), 1992). These expenditures totaled $162 billion and averaged $5,360 per year for each older person as reported by the AARP (1992). The effects of a health education program on reducing health care costs in the California Public Employees’ retirement system were analyzed by Fries, Harrington, Edwards, Kent, & Richardson (1994). They reported that in one year, claims were $3.2 million less than expected.

Stewart, King, & Haskell (1993) have proposed that participation by older adults in three, one-hour exercise classes per week could reduce costs for health care and extended residential care by over $600 for each senior per year. Presently there are approximately 30.4 million seniors in America (U.S. Bureau of the Census, 1992). This would result in an estimated savings of 18.24 billion health care dollars per year.

In summary, these studies demonstrate that a positive change in health behavior can result in a slowing of the disease process. The mental acuity required to learn is present until very advanced age and even then diminishes slowly over time. Improved health and decreased disability allow older adults to live independently longer and have a higher quality of life. Therefore, the concept of prevention needs to be expanded to include the older adult population. Goals of health education programs for older adults are to delay the onset and slow down disease processes so that this population will experience improved health status and be able to live independently longer (Schuster, 1995). Additional studies document that preventive programs have tremendous potential for savings of health care dollars. This evidence suggests that prevention programs could help older adults maintain a relatively high level of independence and quality of life and at the same time decrease personal and public expenses.

Two hundred and twenty-seven graduates of the program were followed for four years to determine outcomes including its cost effectiveness. The direct and the indirect cost of the program were only $54 per person. A comparison of number of doctor visits by study participants verses non-participants yielded a savings of $647 per rheumatoid arthritis participant and $189 per osteoarthritis participant (Lorig & Holman, 1993). This study revealed that self-efficacy could be enhanced by a health education intervention and that changes in self-efficacy were more highly associated with changes in health status than were changes in behaviors. In a review of 34 studies measuring the effects of educational interventions on arthritis patients’ knowledge about disease process and treatment, Daltroy and Liang (1993) concluded that educational programs do consistently increase patient knowledge.

Other health promotion programs for older adults are being undertaken by hospitals, community and senior centers, YMCAs, colleges and universities and at work sites throughout the United States. This literature review demonstrates that many of the basic health promotion topics offered for younger persons, i.e. exercise, stress management nutrition education, hypertension control, back care, proper use of medications, health advocacy, and personal safety practices can be modified to address the problems and potentials of older adults (Teague, 1989).

Almost 11 million women and men over age 65 have hypertension. In 1980 the cost of hypertension was estimated to be $4.5 billion. Modifiable risk factors for hypertension include diet, inactivity, obesity, smoking and stress (American Heart Association, 1994). Hypertension is not only a risk factor for cardiovascular and kidney disease, but also contributes to an estimated 250,000 deaths per year in the United States (Schuster, 1995). It is also the most important risk factor for cerebrovascular disease and stroke (American Heart Association, 1994). Strokes cost Americans $5.1 billion dollars a year. Just by adding a regular exercise regime to the older adult’s lifestyle to help reduce the risk of cardiovascular disease, billions of dollars, not to mention the amount of devastating personal and family losses, could be saved (Schuster, 1995).

In 1990, over 8.5 million Americans over age 65 had heart disease. Over 14.6 billion dollars per year are spent on direct and indirect costs of this disease. Modifiable risk factors for heart disease are similar to those of hypertension and include inactivity, smoking, alcohol intake, high blood pressure, high blood cholesterol and diabetes (American Heart Association, 1994). It has been estimated that a 10% reduction in the prevalence of cardiovascular disease would have netted savings of $2.5 billion in 1982, and between four and five million persons would have avoided the morbidity or mortality that resulted from this disease (Schuster, 1995).

An increase in chronic conditions with aging results in an increase in prescription and non-prescription medication use. While medications can seemingly work miracles to alleviate pain, control hypertension and combat other types of illness, they can also cause some frightening problems when misused (Haber, 1994). Iatrogenic disease related to adverse drug reaction increases steadily after age 50, making it one of the most common preventable diseases among older adults (Pastorino & Dickey 1990). Adverse drug reactions can result from side effects of medicines, special sensitivities, drug interactions from improper dosages or impaired pharmokinetics related to aging, including drug absorption, distribution, metabolism and excretion (Pastorino & Dickey, 1990). Approximately 50% of all prescriptions are not followed as ordered. Consequently, an estimated 125,000 Americans die each year from inappropriate use of prescription medications (Haber, 1994). To avoid harmful medication reactions, older adults must learn to recognize and report physical symptoms that could be related to their medications. The most cost-effective means of providing older medication consumers with timely, relevant information regarding the proper use and precautions to use with medication therapy must be identified and then provided (Schuster, 1995). The National Council on Patient Information and Education (1992) promotes achieving this goal through health education programs that encourage older medication consumers to be advocates for themselves. The members of this organization are working to teach medication consumers the questions they should ask before taking any prescription or non-prescription medication.

The American Dietetic Association describes a nutritious diet as one that is high in fiber, low in animal fat, salt and sugar, and includes a balance of vegetables, fruits and whole-grain products (Weddle, Wellman, & Shoaf, 1996). Although the majority of American people agree that good nutrition is based on these principles, few report they actually consume this type of diet (Haber, 1994). There is evidence that nutrition plays a huge role in age-related impairment of organ system functioning, including the cardiovascular, immune, and musculoskeletal systems (Weddle et al., 1996). Eating and drinking habits have been implicated in six of the ten leading causes of death. These six causes of death are heart disease, cancer, stroke, diabetes, atherosclerosis and liver disease (Haber, 1994). Diet has also been identified as a contributing factor in other debilitating disorders such as osteoporosis and diverticulosis. Providing nutritional information in a way that stimulates behavioral change would certainly positively impact older adult’s quality of life.

The Americans most likely to die as a result of cigarette smoking-related diseases are those over the age of 60 (Haber, 1994). Cigarette smoking accounts for more than 60,000 of the 80,000 deaths each year that are due to chronic obstructive pulmonary disease. Equally unfortunate is that death from chronic obstructive pulmonary disease usually is preceded by an extended period of disability due to chronic bronchitis or emphysema (Haber, 1994). Despite public awareness of these hazards, smoking remains prevalent among individuals over age 65. Health promotion counseling specifically directed at smoking cessation has been demonstrated to be effective (Pastorino & Dickey, 1990). This type of counseling is especially effective during a smoking-related acute illness (Forciea, 1989). Forciea concludes that smokers who are able to stop, can eventually reduce their risks of diseases such as coronary heart disease, lung cancer, and stroke to levels seen in non-smokers.

The transfer of knowledge, while frequently insufficient by itself to achieve behavioral and health outcomes, is nevertheless fundamental to all patient education interventions. Patient understanding of treatment options and their implications is also necessary to fulfill an ethical and legal obligation of treatment, obtaining informed consent, which may be most effectively achieved by application of educational principles.

The concept of andragogy is also important to consider when evaluating the usefulness of health care programs. Andragogy is the art and science of teaching adults based on a set of assumptions about learning that are different from traditional pedagogy (Haber, 1994). Knowles’ principles of adult learning summarized in chapter one are an example of andragogy. Haber (1994) summarized the assumptions of andragogy as follows:

1. Active involvement on the part of the older student is preferable to the more traditional, passive student role. Older adults learn best when actively participating in an experience (Haber, 1994).
2. Participation of older adults is encouraged by peer support, information, and assistance. Community health education programs that allow for peer interaction are more effective than those that rely primarily on didactic educational techniques (Haber, 1994).
3. Community health education programs with self-selected, doable, and measurable objectives are more effective at accomplishing changes in health behavior or health status than those that rely on instructor selected objectives, unrealistic expectations, and vague goals (Haber, 1994).

Williams et al. (1996) completed a study to determine predictors of attendance and behavioral outcomes of health promotion programs for seniors. The workshops selected were developed by HealthWise, Inc., of Boise, Idaho, and consisted of two packages of written material, Growing Younger and Growing Wiser (Kemper, 1986; Kemper, 1988). Their findings revealed that less standardized health promotion workshops, allowing for more individual variability of the participant’s needs and life situation, were more effective. Joint goal setting by patient and provider proved to be an effective motivator to produce behavioral changes. This demonstrates that health promotion participants do, in fact, prefer programs designed to meet their individual needs.

The ability to predict which Medicare enrollees are most likely to participate in health promotion workshops is also critical, especially if more preventive health services are to be added to the Medicare benefits package. Williams et al. (1996) have found that those greater than 75 years of age are less likely to participate in health promotion and disease prevention programs despite their higher health risk and thus their greater potential for health improvement and cost savings. Older adults with little interest in reading articles about improving their health are more difficult to motivate to attend health promotion program. Special efforts must be taken during program planning to attract the member of these at-risk groups (Williams et al., 1996).

Facilitators of health promotion programs should develop insight into their own assumptions concerning aging. Many health care providers believe that illness and disability are normal unavoidable parts of aging, making health promotion programs unnecessary. If this underlying belief is present, it will also be in the message that is conveyed to the audience (Pastorino & Dickey, 1990). Similarly, the belief that personal habits can not be changed after the age of 55 can be equally damaging. Cultural values of education as a way to better oneself and to have a better life are not isolated to the young. Worn out cliches such as, "you can't teach an old dog new tricks" are simply wrong. These authors strongly believe that education is no less valuable as people age.

Adults from 55 to 70 can have very different learning styles and needs than those 75 and older (Caserta, 1995). Programs designed to match the needs of various groups will be more effective in meeting the goal of stimulating behavioral changes. Enthusiasm and energy on the part of the presenter can help to keep the participants’ interest. However, it has been noted that excessive cheeriness may cause older adult audiences to feel annoyed and suspicious (Pastorino & Dickey, 1990). Likewise, excessive energy levels on the part of the instructor during fitness routines may cause older adults to feel inferior and subsequently reduce their willingness to participate.

Written instructions that are provided on non-glare paper in a large easily interpreted font can serve to enhance the health promotion topic. Educational materials with the name of the disease or disability on a section of the handout that cannot be concealed (Williams et al., 1996) may embarrass the consumer and be quickly discarded. The key to successfully using printed materials to support health promotion activities is providing personal positive feedback (Lange, 1989). This author believes that a program facilitator immediately available to discuss questions and expand on the content will help to convey the value of the message contained in the written material. Finally, it is extremely important that health promotion facilitators practice the health behaviors that they wish to instill in others. Personal beliefs and physical presentation can potentially convey as important a message as the verbal content of the program (Smith, 1984).

Older audiences may need time to assimilate new material. Speaking slowly and clearly as well as using audio and visual aids have been found to be helpful (Caserta, 1995). Information conveyed in a meaningful, interpretive way as opposed to the usual lecture format will be more readily retrieved later. This author believes that the mechanisms the brain uses to retrieve information may decline with aging. Developing presentations and workshops that are interactive serves to improve recall as the participants relate the program content to their own life situation. Including some type of interactive technique in every presentation such as role-play, reminiscences, group discussion, or gaming will help older adult audiences retain and recall the intended information (Caserta, 1995).

Identifying the most effective methods for transmitting information designed to achieve long-term behavioral changes among this population is a complex issue. It is essential to identify those program characteristics which will result in successful outcomes. Relationships between program attendance, health status and social support have been identified (Williams et al., 1996). Generic, pre-packaged, scripted programs for older adults may not contain specific enough information for this population. These programs often lack an interactive component that encourages mental engagement with the subject matter.

Programs that include a component of goal setting by the participant and provider and individualized counseling most reliably produce the desired behavioral changes. Less standardized health promotion workshops allowing for more individual variability of participants’ unique needs and situations are more effective (Williams et al., 1996).

In social psychology literature, control is defined as the intentional manipulation of a situation in order to produce desired outcomes, or the belief in one’s ability to produce behaviors. One possible limitation of individual control is that many who live in poverty or face discrimination, such as ageism, may have an accurate assessment of the extent of their control in the environment (Wallerstein, 1992). Interventions which attempt to increase internal locus of control without changing the environmental conditions may increase frustration and lead to greater perceived powerlessness and ill-health (Wallerstein, 1992). For example, providing health promotion information that encourages walking to increase activity tolerance in a neighborhood that is known to have a high crime rate would lead the individual to believe that it is hopeless to attempt to increase their level of fitness.

People with enough resources in their lives, such as decision-making power, finances, or system access, can adequately cope with the psychological and actual demands in their lives (Mullen et al., 1995). People in low socio-economic positions have greater structural constraints and fewer opportunities to gain access to resources. Community center organizers have the potential to impact health outcomes through enhancing community empowerment variables of social supports including information and networks. Setting influences the choice of indicator of success for health promotion and education programs. The values of the participants who attend a particular setting must be considered when program evaluators wish to produce the type of evidence that will help assure that a program is maintained and disseminated in that setting (Mullen et al., 1995).

There is preliminary support cited in the literature that demonstrates that loci of control and self-efficacy are associated with lifestyle behaviors and health. If this assertion is true, health education practitioners and researchers should measure locus of control and self-efficacy in subjects to determine if compliance and success of health education interventions are related to these sociological variables (Waller & Bates, 1991).

REVIEW OF THE LITERATURE
Evidence of the Need for Health Promotion Programs for Older Adults		Model Health Promotion Programs for Older Adults		Health-Related Topics that Are of the Most Value to Older Adults		Methodology for Health Education for Older Adults		Indicators of Success for Evaluation of Health Promotion Interventions

Comments, suggestions, or requests to ud-geriteach@udel.edu. "http://www.udel.edu/geriteach/project/watson-chap2.html" Last updated July 12, 1998. Copyright Norine Watson, 1998.