Victoria M. Rizzo, PhD - Columbia University, School of Social Work

Jessica Seidman, MSW - Columbia University, School of Social Work.

Synopsis

Until the 1980s, no established framework for healthy aging existed. Furthermore, Rowe and Kahn (1998) remarked that a conceptual framework for effectively guiding an approach to healthy aging was missing until the 1990s. They suggested that development of such a framework was challenged by commonly held misconceptions including, but not limited to, the beliefs that illness and an inactive lifestyle were normal parts of the aging process. These misconceptions resulted in insufficient attention to the impact of life-style and psychosocial factors on the welfare of people aged 65 and older. In this section, we provide a history of the development of a framework for health promotion models in aging. We also discuss the implementation of these frameworks within communities committed to health aging.

The History of Health Promotion Models

Several significant historical events in the second half of the 20th century helped to lay the groundwork for development of a conceptual framework for the promotion of health.

• 1950-1975. A link between human behavior and chronic illness was recognized (Breslow, 1999). The relationship between individual life-style choices concerning nutrition, smoking, and alcohol consumption and the probability of chronic illness was established. The idea of health promotion was first conceived by health educators, who used the term primarily to refer to interventions aimed at modifying human behavior.

• 1979. The U.S. Public Health Service released an official document that declared a corresponding primarily behavioral view of health promotion (Breslow, 1999). The document described health promotion as a framework for establishing individual and community measures that supported the development of healthy life-styles and enhanced the quality of life. The report stressed the importance of individual motivation and responsibility to achieve wellness and referred to health as synonymous with “well-being” and referred to ill health as a consequence of individual life-style choices.

• 1984. A shift from a disease/disability framework for aging to a positive aging framework occurred. A longitudinal study supported by the John D. and Catherine T. MacArthur Foundation proved to be ground-breaking research on aging (Rowe & Kahn, 1998). Conducted by a group of physiologists, sociologists, psychologists, and physicians who specialized in the field of aging, the goal was to shift the focus from disability, disease, and chronology to the positive aspects of aging—the genetic, biomedical, behavioral, and social factors that influence a person’s capacity later in life. This shift in perspective to successful aging was subsequently discussed in many hundreds of journal articles, the first of which appeared in Science in 1987. Since its publication, the study has been the main topic of numerous national and international conferences, research groups, and annual organizational meetings such as that of the Gerontological Society of America. The study’s greatest accomplishment was providing an important framework for future initiatives dedicated to healthy aging.

• 1986. The World Health Organization introduced their health promotion framework. The first international conference on health promotion was the Ottawa Charter for Health Promotion, sponsored by the World Health Organization (WHO) (2008). During the conference, health promotion was defined as an approach that facilitates increased individual control over one’s own health to improve one’s health status. The WHO’s health promotion framework encompasses coordinated action from all levels of society. According to the charter, the framework should include national, state, and local governments; the health, social, and economic sectors; nongovernmental and voluntary organizations; local authorities; industry; and the media. In addition to macrosystems perspectives, the framework incorporates individuals and their families on the microsystems level. The following were among the conditions identified as necessary for health promotion to occur: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.

Development of a Health Promotion Framework

• In the latter half of the 20th century, the concept of health promotion progressively developed into a framework in response to the reality that people were living longer and with a better quality of life and freedom from noncommunicable diseases than ever before (Breslow, 1999).

Near the end of the century, “health promotion was defined as the process of enabling people to increase control over, and to improve, their health” (Marshall & Altpeter, 2005, p. 136). Marshall and Altpeter explained that to achieve a state of overall well-being, people should be able to realize their aspirations, meet their needs, and adapt to a changing environment.

Health promotion represents the shift from an exclusive biomedical focus that places the responsibility for the care of patients on physicians to a framework that emphasizes individuals’ ongoing participation in preventive health care practices (Hooyman & Kiyak, 2005). Because poor health interferes with a person’s capacity to live as fully as possible, the focus of health promotion is the prevention of acute and chronic illnesses (Breslow, 1999).

To provide health education, many campaigns and outreach efforts that promote health have focused on the individual. However, Marshall and Altpeter (2005) suggested that health promotion strategies founded on the ecological approach to public health might be more successful, because this approach concentrates on activities and exchanges across all levels of society—micro, mezzo, and macro—and because health promotion is multidimensional in nature. In addition, the ecological approach addresses the consequences of the increase in life expectancy in the United States, which include a demand for an improved quality of life, a greater need for informal and formal caregiving, and greater financial stress on the health care system (Breslow, 1999). The following are terms developed and commonly used by health care organizations:

• Successful aging. According to Marshall and Altepeter (2005), Rowe and Kahn (1998) established the framework for health promotion. This framework for successful aging includes avoidance of disease, maintenance of high cognitive and physical functioning, and ongoing engagement with life. It has been used as a foundation upon which to develop other models that promote health.

• Healthy aging. The concept of healthy aging refers to the development and maintenance of physical, mental, and social abilities in the older population (Centers for Disease Control [CDC], 2008). This framework is likely to be most successful in communities that facilitate health promotion and take actions to prevent or reduce the effects of acute and chronic diseases on a person’s performance of activities of daily living (Marshall & Altpeter, 2005).

• Active aging. In the late 1990s, the WHO (2002) coined the term active aging based on the concept of healthy aging. However, active aging conveys a more inclusive definition that goes beyond the principles of health care to include the human rights of older adults and the United Nations’ principles of independence, participation, dignity, care, and self-fulfillment. The term “active” represents one’s participation in social, economic, cultural, spiritual, and civic affairs throughout life. The WHO (2002) conceptualization of active aging is based on three concepts: participation in life, meaning the family and the community; health, meaning health promotion and activities to maintain an optimal health status; and security, including financial, community, and family security.

Throughout the second half of the 20th century, expansion of health promotion frameworks was ongoing. Each successive version of health promotion frameworks was built on earlier frameworks. Generally, however, all the terms used in these frameworks applied a life-span perspective for prevention programs and practices focused on physical, social, and mental well-being. The main goal of health promotion was to reduce the incidence of disabling chronic diseases in the older population (WHO, 2002). In addition to prolonging life and preventing disease, health promotion programs gradually expanded to include enhancing the independence and general quality of life of older adults (Hooyman & Kiyak, 2005). Health promotion strategies are now applicable to all older people, including those who are frail or disabled or in need of support.

Although many frameworks for the promotion of health exist, the focus here is the framework developed most recently—the Alberta Rose model, developed in Alberta in Canada (KPMG Consulting, 2002). The model integrates elements of earlier health promotion strategies, incorporating primary and secondary prevention as part of health promotion. It might also be termed a wellness model. The model considers four main goals toward achieving health aging and wellness: (1) promoting health and preventing disease and injury, (2) optimizing mental and physical function, (3) managing chronic conditions, and (4) engaging with life. These four components of the model result in healthy aging. Table 1 summarizes the 4 models of health promotion that are used in the literature.

The Four Main Goals of the Alberta Rose Model

The goals encompassing the four main components of wellness that contribute to the promotion of health are described in more detail below (KPMG Consulting, 2002).

• Goal No. 1. Promoting health and preventing disease and injury. According to the model, this goal can be achieved by increasing a person’s control over his or her circumstances, the result of which is improved health. Helping individuals, families, and communities make healthy choices and foster healthy and supportive environments facilitates the practice of health promotion on all levels of society. The area of concentration with regard to this goal consists of prevention programs that address good dietary habits, smoking cessation, early detection of chronic illness, access to vaccinations, and avoidance of injuries from falls.   

• Goal No. 2. Optimizing mental and physical function. The model suggests that communities and experts can facilitate a person’s ability to carry out the routines of daily living and thus enable the person to remain within the community as independently as possible. The area of concentration with regard to this goal consists of self-care, support systems, and team approaches to managing chronic conditions.

• Goal No. 3. Managing chronic conditions. The model suggests that by providing guidance regarding self-care and using collaborative approaches, people with chronic conditions related to injuries or diseases can effectively manage those conditions. The area of concentration with regard to this goal consists of programs focused on the physical and mental functioning of members of the community by addressing depression, addictions, and incorporation of active living practices.

• Goal No. 4. Engaging with life. The model promotes the development of meaningful relationships and involvement in rewarding and meaningful activities. The area of concentration with regard to this goal consists of relationship-building to improve social interaction and participation in the community.

This conceptual model incorporates the different levels of society and encompasses macro, mezzo, and micro perspectives. It focuses on the health of the population, the health care systems, and the availability of partnerships that are capable of developing health strategies. Furthermore, it connects with the individual by incorporating some of social work’s core values, including dignity, autonomy, participation, fairness, security, and recognizing and building on strengths and capacities (KMPG, 2002). The strategic framework for healthy aging proposed by the Alberta Rose model, which targets people 35 years of age and older and stresses the importance of their lifelong involvement in and commitment to practicing healthy aging, takes into account health determinants, health strategies, and partnerships. Several determinants of well-being relate to factors discussed earlier: a person’s income, social and educational status, social support networks, employment, work environment, gender, and culture. The model indicates that all these factors have an impact on a population’s health status. The population health strategies represent five crucial methods of promoting health: developing policy, building supportive environments, enriching community action, expanding individual skills, and enhancing awareness of the framework among health services (KPMG, 2002). Finally, to overcome the challenges resulting from the determinants of health, partnerships must be developed among all levels of the community. Because the model includes both the determinants of health and the health care system, it incorporates Marshall and Altpeter’s ecological perspective (Marshall & Altpeter, 2005).

Implementation of the Health Promotion Framework

The application of health promotion to the older population is a relatively recent endeavor. The latest attempt to apply this framework at the national level in the United States was through the Healthy People 2010 initiative (U.S. Department of Health and Human Services [USDHHS], 2000), a successor of the Healthy People 2000 initiative (National Center on Health Statistics, 2001). That initiative implemented the health promotion model by targeting healthy behaviors, such as the following, for the American population:

• Physical activity. The target set by Healthy People 2010 is for 80% of the population older than 64 years of age to spend their leisure time being physically active. If carried out regularly, physical activity is a major contributor to healthy aging because it helps to prevent or control many health problems. Such activity is commonly recommended to manage high blood pressure, depression, obesity, and diabetes, and strength training can aid in decreasing the pain of arthritis, improving balance, and reducing the risk of falls (CDC & The Merck Company Foundation [Merck], 2007). 
•  Nutrition. According to a report on the health of the nation’s older population (CDC & Merck, 2007), the nutritional targets for the year 2010 are divided into different goals for the consumption of fruits and vegetables. Diets rich in vitamins and fiber reduce the risk for certain cancers and chronic diseases. In relation to other age groups, older adults eat, on average, more than five fruits and vegetables daily, which bodes well for this age group because diets rich in fruits and vegetables can reduce the risk for some chronic diseases (i.e., diabetes) and some forms of cancer (CDC & Merck, 2007). The current national consumption of fruits and vegetables is 30% below the objectives for 2010 which are 1) at least 75% of people aged 2 years and older will consume two daily servings of fruit, and 2) at least 50% of all people aged 2 years and older will consume three servings of vegetables.
• Obesity. One aim of Healthy People 2010 is to reduce the percentage of obese people older than 64 years of age to 15% by the year 2010 (USDHHS, 2000). A body mass index of 30 or more increases health risks and threatens a person’s quality of life. The health risks associated with obesity include chronic conditions, arthritis, and cancers that are more common among older adults. In addition, obesity can result in limited activity, depression, or feelings of hopelessness (CDC & Merck, 2007).

The Re-Aim Framework

Once health promotion programs are developed, implemented, and tested for efficacy and efficiency in rigorous scientific studies, targeting the areas outlined in the healthy promotion framework discussed above, the next task is to translate these programs into formats appropriate for various communities. The Re-Aim framework can be used to consider the strengths and weaknesses of health promotion programs to guide their implementation in specific communities (Glasgow, Vogt, & Boles, 1999). This framework includes the following dimensions:

1. Reach refers to the rate of participation in programs in the community and the characteristics of people who participate in health promotion programs versus non-participants.
2. Efficacy relates to the impact that an intervention has on the specified health outcomes that the community has identified for improvement.
3. Adoption refers to the number of, and level of commitment of, agencies and the community to provide health promotion programs targeted to the specified outcomes.
4. Implementation refers to the quality and integrity of the programs that are provided in the real world setting.
5. Maintenance occurs at the individual and systems level. At the individual level, it refers to how committed individuals are to making behavior changes to promote health. At the systems level, it refers to how committed communities and agencies are to providing programs to attain the health outcomes they have identified as important for them.

The Re-Aim framework is a powerful tool for program planners and macro-level social workers to utilize when identifying health promotion programs for their communities to adopt for implementation. The framework allows for evaluation of the multiple dimensions that can influence the success of health promotion programs for aging individuals (Glasgow, Vogt, & Boles, 1999).

References

Breslow, L. (1999). From disease prevention to health promotion. Journal of the American Medical Association 281, 1030-1033. Retrieved on March 18, 2008, from www.jama.com

Centers for Disease Control (CDC). (2008). Healthy aging: Preserving function & improving quality of life among older adults. Atlanta, GA: Author. Retrieved on December 17, 2008, from http://www.cdc.gov?nccdphp/publications/aag/pdf/healthy_aging.pdf

CDC & The Merck Company Foundation. (2007). The state of aging and health in America. Whitehouse Station, NJ: The Merck Company Foundation. Retrieved February 8, 2008, from http://www.cdc.gov/aging

Glasgow, R., Vogt, T., & Boles, S. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89(9), 1322-1327.

Hooyman, N. R., & Kiyak, H. A. (2005). Social gerontology: A multi-disciplinary perspective (7th ed.). New York: Pearson Education, Inc.

KPMG Consulting. (2002). Alberta’s health aging & seniors wellness strategic framework 2002-2012. Edmonton, AB: Alberta Health and Wellness. Retrieved March 18, 2008, from http://www.gov.ab.ca/acn/images/2002/702/12861.pdf

Marshall, V. W., & Altpeter, M. (2005). Cultivating social work leadership in health promotion and aging: Strategies for active aging interventions. Health & Social Work, 30(2), 135-144.

National Center on Health Statistics, U.S. Public Health Service. (2001). Healthy People 2000 Final Review. Hyattsville, MD: Author. Retrieved January 5, 2009, fromwww.cdc.gov/nchs/data/hp2000/hp2k01.pdf

Rowe, J. W., & Kahn, R. L. (1998). Successful aging. New York: Pantheon Books.

U.S. Department of Health and Human Services. (2000). Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 volumes. Washington D.C.: U.S. Government Printing Office Retrieved January 5, 2009, from http://www.healthypeople.gov/Document/tableof contents.htm#volume1 and http://www.healthypeople.gov/document/tableofcontents.htm#Volume2

World Health organization (WHO). (2002). Active ageing: A policy framework. Geneva, Switzerland: Author. Retrieved February 5, 2008, from http://whqlibdoc.who.int/hq/2002/WHO_NMH_NPH_02.8.pdf

WHO. (2008). The Ottawa Charter for Health Promotion. Geneva, Switzerland: Author. Retrieved February 20, 2008, from http://www.who.int/healthpromotion/conferences/previous/ottawa/en/