The literature review for model development revealed that programs designed to match the needs of various groups will be more effective in meeting the goal of stimulating behavioral changes (Caserta, 1995). With this in mind prior to the medication use program, a Medication Use Assessment (Appendix D) was conducted to determine what types of medication the potential participants were taking and what information they needed about those medications. A questionnaire interview assessment strategy was chosen for a number of reasons: (a) ensure understanding of the questions, (b) remove barriers to completion of a written survey due to physical or sensory impairments, and (c) increase the undergraduate students' comfort level with talking to older adults about health-related issues. Clinical time permitted only thirty-six potential participant interviews. Obtaining the membership list of the Newark Senior Center and mailing the questionnaires to that membership would have potentially resulted in a larger sample size.

These thirty-six interviews did demonstrate that this population is taking many and varied medications. The undergraduate nursing students completing the questionnaires stated this opportunity along with their long-term care clinical experience has helped them become very comfortable talking with older adults about health-related issues. Furthermore, the nursing students also related that they now feel more comfortable communicating with and assessing older adults with disabilities related to chronic conditions. The broad use of medication therapy demonstrated by the questionnaires was interpreted as an indicator of readiness for this program. Programs that associate specific medication therapies and the conditions for which they are used, e.g. medications used for hypertension, may prove to be more effective in meeting the goal of behavioral change, as such a program could be designed to meet the individualized needs of the participants.

Helping at risk populations gain access to health promotion programs is a step towards reducing health disparities. The health promotion activity developed as part of this model was presented in a senior center environment. The older adults who attended this program were those who had transportation to the senior center or those that attended the adult day care program in that building. However, health promotion programs do not only benefit more able, socially well-connected seniors. For future programs, special efforts must be taken during program planning to attract the members of at risk groups such as those greater than age 75, with multiple chronic conditions, who are socially isolated due to lack of transportation, or who suffer from physical or sensory impairments.

A barrier to successfully conveying a health-related message may be firmly established in the program facilitator's personal beliefs about the aging process. Prior to presenting a program directed at older adults, facilitators of health promotion programs should explore their personal assumptions concerning aging. Many health care providers believe that illness and disability are normal unavoidable parts of aging, making health promotion programs unnecessary (Pastorino & Dickey, 1990). If this is the underlying belief of the presenters it will also be in the message that is conveyed to the audience. The interdepartmental team that worked on this medication use program spent time exploring those feelings and reviewing the literature as it relates to health promotion programs for older adults and the impact aging has on the ability to learn. This review enabled this team to proceed with confidence that time and energy devoted to health promotion activities for older adults was well spent. Confidence on the part of the facilitator in the ability of the participants be successful in achieving the desired health related behavior is of utmost importance to the success of the program.

There are numerous generic, pre-packaged, scripted health promotion programs. The HealthWise for Life, Growing Younger, Growing Wiser (Kemper, 1986; Kemper 1988) series discussed earlier is an excellent example of this type of program. Although, undoubtedly a timesaver for the facilitator, these programs may not include participant selected objectives and thus are potentially unable to convey a meaningful message to the older adult health promotion program consumer. Facilitators using generic programs must find ways to add participant selected objectives and interactive strategies thereby increasing the value of these programs.

Another possible limitation of increasing individual control through an educational intervention 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. 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 (Waller & Bates, 1991). One of the program participants felt as if the suggested tactic of talking to a health care provider about suspected adverse medication reactions was meaningless because he had difficulty reaching his provider. The advice offered was to file a complaint with his provider. This participant was encouraged to be an advocate for his own health. If his complaint goes unanswered, this participant's feeling of powerlessness to have his needs met by the health care system are bound to escalate. He will need further support and possibly assistance to pursue adequate health care services.

Written materials were provided to support this stage of the transition. Instructions that are provided on non-glare paper in a large easily interpreted font can serve to enhance the health promotion topic (Williams et al., 1996). Printed medication information and other written instructions should be designed specifically for use by the older populations. Questions submitted to the program facilitators were answered using MICROMEDEX AfterCare (1994) instruction sheets. The primary limitation of using this patient education material is that the format and font styles are dependent on the computer system from which they are printed. The font size is often small and thin making this material difficult to read. Suppliers of computerized medication resources should be made aware of the special needs of older adults and different options of printed educational materials should be made available.

Community center organizers have the potential to impact health outcomes through enhancing community empowerment variables including support and networks (Mullen et al., 1995). As we begin to look at community models, further comparisons could be made between communities that embrace activities that promote positive health behaviors and those that do not. Questions such as (a) how do specific health related behaviors of the participants of health promotion programs differ from the behaviors of non-participants, (b) do the members of senior centers use fewer illness-care dollars than non-members, or (c) do health promotion program participants experience more healthy years of their life span than non-participants, could then be answered.

An area that requires further investigation is determining the types of programs and promotion techniques that most reliably result in attendance. The contact person at the Newark Senior Center suggested that a routine schedule of programs would encourage attendance. Her belief was that older people like to plan and have predictable monthly activities. Based on this assumption, this series of health promotion programs was scheduled for the second Wednesday of each month. Unfortunately this plan did not allow the undergraduates promoting the programs to attend the health promotion program. Their class schedules were firmly fixed by the beginning of September. Most of the graduate nursing students offering these programs were employed. Providing them with pre-planned dates for programs did not allow them the flexibility they needed to juggle the many aspects of their busy lives. A recommendation for further programs would be to include as many members of the team as early in the planning period as possible.

One of the most beneficial things about this model is the potential for the graduate nursing students to become mentors for the undergraduates. The graduate students who were involved in the health promotion programs this semester have been practicing nurses for some time with a rich history of experiences to share. The undergraduates supporting these programs reported benefiting from relationships established in this course. Working together toward a common goal is one way that nurses develop lasting relationships. A recommendation would be to encourage more frequent interactions between the graduate and undergraduate students working on the health promotion program.

The health promotion programs in this model were directed towards older adults. The students who experienced the greatest level of satisfaction during this clinical rotation were those with some experience working with this population. This is especially important with this model because much of the clinical time is completed independently. Other students and faculty members are not at the clinical site to offer support and guidance. A recommendation would be to place the community health experience after a health assessment clinical rotation in the undergraduate curriculum.

For nursing to assume a leadership role in community health promotion, the belief that these programs are a nursing responsibility equally as important as illness care in the acute care setting must be further embraced by the faculty members of the Department Nursing. Having this belief reinforced in all components of their educational experience will facilitate undergraduate students shifting their focus from individual and disease-oriented arenas to include community health promotion processes (Baldwin, 1995). A recommendation is to add a component of community health promotion to other undergraduate clinical rotations. A further recommendation is that the nursing students who participated in this model be contacted at different points during their nursing careers to determine if they were more attuned to the importance of patient education and health promotion activities than nurses who did not have this experience in their educational programs.

The evaluation process is an important component of any health promotion program. Unfortunately, there can be barriers associated with the evaluation process in programs directed towards older adult audiences. Evaluation tools should be adapted to the audience attending the program. For example, the questions should be simplified for ease of understanding and the font enlarged to increase readability. Sensory impairments or difficulty writing due to the complication of arthritis sometimes prevent these participants from evaluating the health promotion activity. One solution to overcome this obstacle is to have the undergraduate nursing students assist the older participants with disabilities in interpreting and completing the evaluation tool. The participants' comments must then be carefully evaluated and used to clarify the next program.

At risk populations should not be excluded from the benefits of health- related information. Further work must be done to determine the best methods of reaching older adults who are socially isolated due to sensory impairment, depression or simply lack of transportation. Longitudinal studies are indicated to determine the statistical significance of the health promotion activities on lifestyle changes and how long these changes last without further intervention. Then, program characteristics that most consistently produce the desired outcome should be communicated to all health educators.

When chronic illness exists, tertiary prevention should be implemented to prevent further decline and maximize functional capacity. Health promotion programs must be constantly modified and redesigned to successfully function as an important means to transmit vital information. Only then can health education intervention programs for older adults reach their stated goals of not only reducing health care spending by billions of dollars but also increasing every older adult's enjoyment of life.

Comments, suggestions, or requests to ud-geriteach@udel.edu. "http://www.udel.edu/geriteach/project/watson-chap4.html" Last updated July 12, 1998. Copyright Norine Watson, 1998.