Achieving Health Promotion Behaviour Change Among Older Victorians

1. Achieving Health Promotion Behaviour Change Among Older Victorians Betty Haralambous, Kirsten Black, Melita Guimmara, Joan Nankervis National Ageing Research Institute

2. Today’s presentation • Background and aims of study • Methodology and participants • Participant’s concept of health • Summary of barriers and enablers to health promoting behaviour • Quotes to illustrate barriers and enablers • Preliminary recommendations

3. Project aim To identify the enablers, barriers and structural supports that affect an older person’s ability to comply with health promoting behaviours. Strategies will be recommended to further facilitate health-promoting behaviour

4. World Health Organisation’s definition of health promotion “the process of enabling people to increase control over, and to improve their health. To reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life..” (1986, p2)

5. Methodology • Literature review • Scoping exercise • Focus groups • Falls Clinic MDS data analysis

6. Focus Groups • 10 focus groups • 5 with service providers (3 PCP & 2 F&BC) • 5 with service users (3 PCP & 2 F&BC) • 3 PCP catchments (1 inner metro, one outer metro & 1 rural)

7. Primary Care Partnerships • Victorian Government initiative • Alliances of primary care providers • HACC, community health, General Practice, ACAS, psychiatric disability support & dental health • Usually 2-3 Local Government Areas • BATS initiative aims to meet needs in a “timely, cohesive and consistent” way (DHS, 2000, p1)

8. Focus group topics • What does health mean to you? • What affects your sense of health and well-being? • Do you believe that you (personally) can improve your health? • Is there anything that you don’t think you can change? • What motivates you to take action to improve or look after your health? What prevents/constrains you from looking after your health? • Are there any groups or individuals you may listen to who influence you taking action to improve or look after your health?

9. Profile of service user participants • 36 participants (19 PCP and 17 F&BC) • 75% female • Mean age 76 years (range=62-90) • Falls Clinic participants significantly older (79.3) than PCP participants (73.7) • 44% lived alone • 86% born in Australia • Comorbidities: F&BC=3.5; PCP=2.9

11. Participants’ Self Rated Health

12. Profile of service provider participants • 41 participants (30 PCP & 11 F&BC) • 18 allied health, 6 medical, 5 assessment officers, 9 managers, 3 ‘other’

13. Participants’ concept of health

14. Concept of Health • Similarities between service users’ and providers’ definition of health • Both talked about social, physical, mental and spiritual health • Maintaining independence: “Get out and about, maintain independence, keep contact with friends and family, socialise, be able to participate in the things you want to do”.PCP service user

15. Social health • Service provider and service user participants discussed the role of socialisation and social activity in relation to maintaining their health “Socialising is very important otherwise you become a hermit in your own environment. … It makes you happier and if you’re happier you’re healthier”.PCP Service user [Social activity] “helps your health. Makes you get out and not sit at home…I’m in a senior citizens club mixing with people”.F&BC Service user

16. Physical health: Service providers • Service providers talked about function and absence of disease: “Having a ‘normal’ level of functioning”.F&BC Service provider “Being able to communicate”PCP Service provider “Absence of disease”.F&BC Service provider

17. Physical health: Service users • Service users related physical health with function but also the extent that they could undertake physical exercise: “Health means going to the gym 2-3 times a week. I do pump, aerobics. If I can’t do this, I’m devastated. Don’t know what to do with myself”.PCP service user “Being able to do your garden”.F&BC Service user

18. Mental health • Service users identified mental wellbeing as very important to their overall health. This included having a positive outlook and the use of services that support mental wellbeing (e.g. psychology). “Mental health is very important. It’s the main thing really – mental attitude – it’s all upstairs really”.F&BC service user “I think its when you get out of bed in the morning and think ‘well I’ll make sure I’m going to have a good day today’ and you have it. If you’re going to get up and think ‘oh God I’m down today’, you’re going to get around like that”.F&BC service user

19. Spiritual health • Faith and spirituality were reported as significant aspects of health and wellbeing: “A personal thing. For me I have a faith I believe in and I probably need to maintain that. I’d like to maintain that throughout my whole life and that gives me a sense of peace, of tranquillity in my life”.PCP service provider “I believe in a lot of the Eastern philosophies… I believe that if you change your thought-set that you’ll probably be healthier than what you are now”PCP service user

20. Summary of key findings of barriers and enablers to promoting health behaviours amongst older people

21. Summary of findings: Barriers(client level) • Loss of physical function • Social isolation/loss of spouse and social networks • Lifestyles / Behaviours throughout life (SES and education)

22. Summary of findings: Barriers(organisation and macro levels) • Negative attitudes about ageing • Lack of access and knowledge about services • Lack of transport • Structural barriers such as lack of footpaths, poor lighting and accessing public transport • Cost of services • Demand on services

23. Summary of findings: Enablers (client level) • Motivation to maintain independence • A positive attitude • Having goals and social roles • Support from family/carers; ‘buddy’ • Able to drive/use public transport • Health scare- perceived benefits of treatment • Links between self-esteem and physical appearance

24. Summary of findings: Enablers (organisation & macro levels) • Relevant and flexible services that adapt to the client’s needs • Health professionals respecting clients and actively listening to achieve client’s goals • Culture: respecting elders, shift promoting exercise as OK for older people • Media’s role in promotion positive ageing • Physical activity programs fostering social interaction

25. Illustrating barriers and enablers Quotes from study participants

26. Barrier: Loss of physical function • Clients reported difficulties associated with getting older and the impact on function “I don’t have good health because of arthritis and my husband cares for me. Can’t travel as much, can’t go for long walks, hip op hasn’t come up to standard - would love to go and dance again but can’t. Products you can’t open, milk bottles, pill bottles... They don’t put things out for people with arthritis”. PCP Service user

27. Barrier: Social isolation “Loneliness is the worst. If you live on your own, ... you see I’ve always had a family, always had children around. Now they’ve all left … I live in a court but everybody goes to work. I live next door to my son, but he and his wife go to work and I don’t see them. They’re gone by the time I get up and sometimes I see them at night …”. PCP Service user

28. Barrier: Ageist attitudes “...It’s just that perception amongst a lot of our clients that part of getting older is slowing down and you expect to start falling over and you expect to start being sick and you cant do everything you used to do ten years ago”.F&BC Service Provider “You give grandma the weights and before you know it she’s bench pressing tractors, but everybody is anxious about the fact that this doesn’t fit the myth. Doesn’t fit how things should be”.PCP Service Provider

29. Attitudes changing “Ten years ago it wouldn’t have been OK for a 70 or 80 year old lady to be doing Tai Chi, but now it is happening all over the place. So ‘I might give it a try’ because it is more acceptable. Even from the point of view of old ladies feeling ok to go out in public wearing a tracksuit and pair of runners. They’re used to wearing high heels, pantyhose and a dress all of the time”. PCP Service provider

30. Barrier: Access and knowledge • Difficulties accessing services such as GPs in rural areas and getting on transport. • Service providers not knowing about services such as Falls Clinics. “There are good cheap programs in the region, e.g. tai chi, strength training, gentle exercise, but they are difficult to access and there is lack of promotion”.F&BC Service provider

31. Barrier: Impact of demand • Not providing services in a timely manner was recognised as detrimental to health (eg physical deterioration waiting for an operation/ deterioration in self esteem when community services weren’t available): “Once they loose their self esteem they view themselves as being very old...Well you may be old but you’re still valuable, still worth something. And if the services are interrupted they often personalise it and think ‘they don’t worry about me, I’m forgotten’, and it snowballs on.”PCP Service provider

32. Enabler: Motivated to be independent “Have always been a strong man and go to the gym now to make myself stronger (following stroke). It makes me self-reliant, don’t have to rely on anyone to push me around or look after me. That’s the motivation”.PCP Service user “I dread the thought that I would have to go into care”.PCP Service user

33. Enabler: Goals/social roles “They [older people] will get better quickly if they have pets, people or garden who depend on them. They involve themselves in social groups, gardening groups and meaningful activity”.PCP Service provider “Having a goal is really important”.PCP Service provider “Pets are a good motivator. Reason to live. Give people a goal”.PCP Service provider

34. Enabler: Family influences • Family was valuable in providing emotional and practical support in undertaking healthy behaviours “It’s very important to have family around you. … They care about you more than anyone else”.F&BC Service user “My son helps with all things - he’s a doctor, gives me hip protector... Because if you fall on your hip and break your pelvis you may as well die fast. They (hip protectors) make you look horrible but at the same time it’s better than getting a broken pelvis”.F&BC Service user

35. Enabler: Health Scare “Back in 1983 when I had a heart attack I thought to myself I’m not going to have one of those again. I’ll listen to the people, to the medical profession, do everything they tell me, medical, physiotherapists or anything, I did it. And I’m still alive and I’m still going well”.F&BC Service user

36. Enabler: Flexible service delivery Importance of health professionals providing a flexible service that met the needs of individuals: “I care for a 96 year old who’s still at home and refuses to go out to day centres or anything organised but wants to go for a walk. So we take her for a little walk- not a big walk but a little walk- and she gets out in the sunshine, looks at the garden. It just gets her out of the four walls and I think that improves her state of health and mind”.PCP Service provider

37. Enabler: Health professionals respecting clients • Also need to respect clients and actively listen to their point of view and goals: “I nearly drive my doctor mad asking him questions..but I like my doctor because he listens. Get an answer in a round about sort of way. They are good for recommending you to go to somewhere else that can help - like the [Falls] Clinic. That’s a sign of a good doctor - or if they ask you if you would like a second opinion”.F&BC Service user

38. There were concerns raised by service providers that older people tended to not question their GP: “Some people believe everything their doctor has said. ‘It’s gospel’.”PCP Service provider “I know my grandparents are very passive ‘this is what the doctor says, we just go, we listen, we don’t ask questions’. I think they need to be educated to take a more active role and find out what is going on with them”.F&BC Service provider

39. Enabler: Services promoting independence “(When providing home care to someone we ask:) ‘What can you do for yourself? What do you need to be helped with?’ Not ‘they’re going to come in and do everything for you’. … You’re saying to these people ‘we still think you’re valuable”.PCP Service provider

40. Enabler: Learning from cultures that value older people “To think that the older person has something to offer back to society. It’s a mutually beneficial thing, not a burden. Same applies to Aboriginal community, elders have respect. Juvenile Justice in Shepparton use Aboriginal elders to deal with it because they have such status in the community, young people respond to them rather than a rap over the knuckles from the system. We can learn a lot from that example”.PCP Service provider

41. Enabler: Exercise & Socialising “I do water aerobics twice a week and after swimming we have a cup of coffee. I look forward to the aerobics and the cuppa afterwards - get a chat”.F&BC Service user “I am a big walker, I walk everyday, I’m a fanatic for walking. Niddrie walking group on a Friday for 1.5 hour, then I walk everyday with my next door neighbour, so that’s an important part of my life, and the socialising”.PCP Service user

42. Recommendations • For service providers: • Flexible, client centred approach, • Listening to clients • Goal setting with client and carer • Including social interaction in exercise programs • Educating health professionals about services • More broadly • Media promotion of positive ageing • Improved transport • Learning from other cultures-respecting elders • Services more adequately resourced