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

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

Synopsis

The study of successful aging supported by the MacArthur Foundation provided many important findings and paved the way for future progress in the field of geriatrics and health promotion (Rowe & Kahn, 1998). Many outcomes of the study suggested that collaborative work among the various disciplines involved in health care (e.g., physicians, nurses, psychologists, and social workers) is necessary to work most effectively with people aged 65 and older. According to the study, each discipline, independently, is inadequately prepared to address the older population’s needs. In response to this finding, the foundation promoted studies involving collaboration of experts from diverse helping professions to achieve an authentic interdisciplinary science (Rowe & Kahn, 1998).

To foster the skills needed for effective team care, The John A. Hartford Foundation supported the development of programs that called for geriatric interdisciplinary team training (GITT) for students in nursing, social work, and medicine. In addition they supported the development of a national model to forge partnerships between educational institutions and providers of geriatric care for the purpose of designing curricula for use in training interdisciplinary teams and for testing new models of training for practicing professionals (Fulmer et al., 2005).

Although these programs have resulted in some changes in the attitudes and skills of team members, few changes have occurred with regard to care planning and team dynamics (Institute of Medicine [IOM], 2008, Fulmer et al., 2005). Consequently, further research is needed to determine which methods of training are most effective for imparting the knowledge and skills necessary to work effectively as members of a team and for demonstrating how such training can affect patterns of practice with older adults (Cooper & Fishman, 2003; Hall & Weaver, 2001; Remington, Foulk, & Williams, 2006).

During the 20th century, social workers increasingly became members of multidisciplinary public health teams and developed skills in promoting competent teams in health care institutions (Marshall & Altpeter, 2005). These collaborative teams drew on models of health promotion and disease prevention to meet the needs of contemporary health-related social issues throughout the life-span. In the field of gerontology, health promotion was applied to chronic illnesses, including, but not limited to, cancer and Alzheimer’s. In the 21st century, multidisciplinary teams strive to implement a broad range of health promotion programs in response to the growing older population and the inevitable increase in the health care needs of this population (Cooper, 2003; Fulmer, 2005).

Because the social work profession is fundamentally committed to individual- and community-level evidence-based interventions, such as individual and family development, community organizing, and advocacy, its interventions incorporate the skills and values necessary to implement effective health promoting practices at multiple systemic levels. For example, using education and counseling, social workers, on an individual basis, can help to address diseases, such as obesity, that are so prevalent in American society.

The Social Worker’s Role with Older Adults

• Social workers can help older persons remain mobile and independent, thus increasing the quality of life not only of the individuals but of their families as well.

In addition, social workers are uniquely positioned to promote health, good nutrition, and wellness among individuals and families on the programmatic, organizational, and community-advocacy levels. Alone or with other members of interdisciplinary teams, they can advocate for implementation of practices and programs within institutional and residential settings that promote health. Finally, they can offer their expertise and support to larger local and national community initiatives that encourage active aging.

Marshall and Altpeter (2005) recommended eight ways that social workers can take the lead in creating communities engaged in promoting health among older adults. The following represent a modification of these strategies.

• Provide assessment, counseling, and referral services regarding health promotion in clinical and multidisciplinary settings. Social workers can help to ensure that members of multidisciplinary teams engage older adults in conversations related to healthy living. Also, they can ensure that programs are adapted to fit an individual individual’s interests and inclination to modify his or her behavior (Center for the Advancement of Health, 2006) and that individuals are referred to community programs.

• Enhance information sharing and research alliances. Social workers and other health professionals (i.e., nurses and public health workers) can implement and test interventions intended to improve health and quality of life among older adults to ensure that the models are implemented effectively and that programs are meeting their goals (Centers for Disease Control and Prevention [CDC], 2008).

• Improve the competence of communities to develop strategies for helping older adults define and reach their goals. Social workers can provide mentoring for seniors individually and in groups to help them improve their health literacy and level of practicing healthy behaviors. They can review and update health care reimbursement structures for activities focused on health promotion. They can facilitate the development of volunteer opportunities and reach out to elders to participate in these programs.

• Participate in community management. Social workers can be actively involved in social planning to ensure a safe and accessible community environment by working to reduce potential barriers to the promotion of health and healthy aging in the community’s institutions, programs, and neighborhoods: e.g., inadequate outside lighting, poor maintenance of paths and roads, high fees at local community centers and other programs, nonfunctional and non-inclusive program schedules, and poorly timed traffic lights.

• Advocate regarding development and maintenance of community infrastructures. Social workers can promote communities that accommodate older adults safely by working to adapt the environment to their needs, mobilizing them to be more socially engaged, and eliminating social and environmental barriers. Among their efforts should be advocacy regarding efficient transportation systems, legible maps and schedules, and reduced speed limits for vehicles.

• Encourage better use of available resources. Social workers can use their own workplace to increase their older individuals’ physical activity by posting signs that encourage walking and climbing the stairs and by providing exercise facilities and time to use them.

• Develop partnerships among key players and stakeholders in the community. Social workers can engage and bring together agencies, such as housing, recreation, and disability services, that traditionally have not been engaged in such partnerships. For example, recreational activities and services for the disabled could be offered on site at senior housing complexes.

• Promote economic developments that will lead to better health practices among the general population. Social workers can help to promote health by advocating for the development of employment opportunities that will improve the socioeconomic status of all segments of society and thus their access to health and preventive services. As noted in the first section of the module, poverty and unemployment are linked to poor levels of physical activity and health throughout the life-span.

Social Work Models for Promoting Health

• Social workers play an important role in encouraging older individuals to adopt healthy behaviors and to integrate health promotion into their lives.

Examples of challenges that older adults face are lack of knowledge and motivation, insufficient support from family and peers, inaccessibility of available programs, and policies that promote unhealthy behaviors.

Educational programs have proven to be helpful in providing older adults with skills and knowledge about how to make healthier life-style choices. Person-centered programs that work one-on-one with individuals to set goals and make decisions that enhance their health and quality of life also yielded positive results. However, the information individuals receive must not only stress the importance of adopting healthy behaviors but also include information that will motivate them to change their behavior. According to the Center for the Advancement of Health (2006), physicians who counsel their older patients about health, include the patients in developing a personalized health plan, and follow-up regarding their progress have reported better outcomes. According to the center’s report, motivational techniques, including self-monitoring, personal communication with health care providers, and multiple channels of communication, are necessary to encourage healthy habits and achieve long-term results. In addition, the report mentions two key factors leading to improved use of healthy behaviors: ongoing reminders and support. Social workers’ knowledge and skills in intervening at the individual, environmental, and community levels, and their capacity to identify and build on an individual’s strengths makes them ideal professionals to design and implement health-promoting strategies that incorporate these two critical factors.

Programs focused on nutrition and physical activity are important examples of interventions that social workers can use to promote the health of older adults. Nutritional programs represent micro-level methods, whereas programs that promote physical activity often require community-level efforts to improve individuals’ health.

Nutrition Model

The nutritional health of older people is important (Johnson, 2004; Wellman, 2004). Consequently, when completing a nutritional assessment, the social worker needs to examine the individual’s food consumption, medical history, medications, financial circumstances, mobility, and accessibility to community institutions (Center for the Advancement of Health, 2006). Evidence-based support groups and educational programs provide older people with hands-on experience with how to adjust their eating habits. Other effective interventions include delivery of nutritious meals to individuals who are disabled, homebound, and economically disadvantaged.

Before developing programs on the basis of individuals’ needs, however, the social worker must take into account their readiness to change their nutritional behavior. In addition, an individual’s cultural identity is a highly relevant factor because ethnicity and tradition, including attitudes’ about what foods are appropriate and beliefs about the healing properties of foods, can heavily influence a person’s eating habits, Thus, the social worker must be culturally sensitive and seek out culturally appropriate options encouraging an individual to change dietary behavior (Center for the Advancement of Health, 2006; Johnson & Smith, 2002). Indeed, individuals may be unaware of ingredients that adversely affect their health and need information as to how they can modify the ingredients to improve the food’s nutritional value yet adhere to important cultural and social traditions.

Malnutrition in the older population increases health care costs, whereas a diet that improves health and promotes more rapid recovery from illness reduces the use of medical services and related costs to society (Wellman, 2004). Dr. Wellman proposed the following ways that families, friends, and social workers can help older adults improve their nutritional intake and overall health.

1. Dine and interact with older relatives or other older members of the community, engage them in conversations related to their life experiences, feelings about their needs and pleasures, and their opinions about events.
2. Deliver easy-to make or ready-to-eat meals to their homes; help them to organize weekly meals by applying a label to each container that identifies the contents as breakfast, lunch, or dinner; or make friendly telephone calls to remind them about nutritional needs, provide support, and express interest in their self care.
3. Provide them with a microwave oven to simplify preparation, with gifts of food, and with help in arranging dental appointments.
4. Advocate for those admitted to acute care facilities regarding provision of effective services, checking of body mass, helping at meal times, and preparing for discharge.

Physical Activity Model

The current literature provides evidence that regular moderate exercise fosters strength, energy, and coordination; reduces the risk of falls and fractures; heightens mood; and relieves symptoms of depression. Despite the evidence regarding the virtues of physical activity, however, the percentage of older people who lead physically active lives is low (CDC, 2007). This section provides examples of community and organizational programs focused on increasing the level of physical activity among older adults. Social workers are integral members of the partnerships that design and implement these programs at the community level.

A program titled “The National Blueprint: Increasing Physical Activity Among Adults Age 50 and Older” (CDC, 2007) is an example of a collaborative effort of national foundations, government agencies, and other organizations devoted to health care and aging (Center for the Advancement of Health, 2006). Some of the organizations involved include AARP, the American College of Sports Medicine, the American Geriatrics Society, the Centers for Disease Control and Prevention, the National Council on Aging, the National Institute on Aging, and the Robert Wood Johnson Foundation.

The National Blueprint details the importance of physical activity, outlines the barriers older adults face and proposes recommendations for overcoming those barriers. In 2002, the collaborating organizations identified 18 strategies designed to increase physical activity among the population aged 65 and older and designated leading organizations as having the responsibility to implement the strategies The implementation was accomplished by developing programs targeted at both the individual and organizational levels for the clinicians who would be responsible for carrying out the programs. Programs targeted at the organizational level conduct marketing campaigns and research, whereas programs targeted at the individual level develop guides concerning effective intervention techniques, feedback, and information-sharing tools.

An example of a community-level program is the Building Healthy Communities for Active Aging (Environmental Protection Agency [EPA], 2007), which organized a steering committee assigned the job of creating a document outlining 10 strategies designed to help communities successfully adapt community techniques of encouraging older adults to become more physically active. The steering committee believes that active aging is a result of including both structured and unstructured activities in an older person’s life-style (EPA, 2007). Therefore, communities need to facilitate the availability of structured programs and devise ways to encourage self-directed activities, such as walking, biking, and using fitness trails.

The following strategies are listed in the Environmental Protection Agency’s (EPA’s) proposal for community-level interventions that promote physical activity among the older population.

1. Create a community goal statement designed to improve levels of physical activity among seniors (EPA, 2007). The necessary steps are to identify, clarify, set targets for, and measure the community goals. On its Web site (www.healthyagingprograms.com), the National Council on Aging (2004) identifies safe, effective fitness programs for people aged 50 and older.
2. Form a community coalition or advisory unit composed of representatives from different community organizations to develop programs focused on increasing older adults’ opportunities for physical activity (EPA, 2007). Funded by the Robert Wood Johnson Foundation, the Community Partnerships for Older Adults Web site (www.partnershipsforolderadults.org) provides excellent information regarding the development of community coalitions to promote healthy aging programs.
3. Assess the community’s needs regarding physical activity programs for older adults and the opportunities available to establish a program that meets those needs (EPA, 2007). Accurate information about physical activity among the older members of a community lays the foundation for strategies for meeting the community’s goals. The EPA’s Building Healthy Communities for Active Aging program suggests using health indicators, such as rates of morbidity, mortality, falls, obesity; activity level; participation in activity programs; and outdoor and organizational community resources.
4. Evaluate the accessibility and availability of the community’s physical activity programs for older adults. To determine programs’ effectiveness, the EPA’s Building Healthy Communities program inquires about the programs’ characteristics: number of activities designed for older adults, location (concentrated in certain districts or more widely distributed), accessibility, and quality of transportation. The American Society on Aging (ASA) (2002) has developed evaluation questions, indicators, and data sources that can be used for community-based physical activity programs. These are available on the ASA Web site at: www.asaging.org/CDC/module5/phase5/phase5_3.cfm. ASA’s Blueprint for Health Promotion, of which the evaluation materials are a component, is a comprehensive report that includes chapters about changing behavior, creating health promotion campaigns, working with mass media, creating culturally sensitive and effective health promotion materials, and evaluating programs.
5. Establish a community plan for dealing with barriers to seniors’ participation in physical activities and improvements needed to boost the participation of older adults in physical activities. The plan should be detailed and, according to the Building Healthy Communities program, include the following information: action steps, people involved, timeline, necessary resources, potential challenges, and possible partners. The Healthy People 2010 Toolkit (Public Health Foundation, 2002) provides excellent information about strategic community planning.
6. Publish a resource tool that lists all physical activity programs in the community. This list should include both outdoor and indoor programs and detailed information about each one. The Healthy People in Healthy Communities Planning Guide (Office of Disease Prevention & Health Promotion, 2001) provides excellent examples of the ways communities can create lists of opportunities for physical activity in the aging population.
7. Design a community campaign to inform older members about how to achieve the suggested amounts of physical activity. The campaign can involve the participation of different institutions in the community, the publication of handbooks, the creation of clubs, the offering of special promotions and incentives, and so on.
8. Offer older members of the community a variety of physical activity programs. The offerings should include both formal programs and more informal opportunities for self-directed physical activities. The Center for Healthy Aging at the National Council on Aging lists and describes many evidence-based physical activity and health promotion programs that they endorse on their Web site: www.healthyagingprograms.org.
9. Initiate physical activity programs and other opportunities that are appropriate, both culturally and in terms of physical location, for the entire community. To ensure equal access and inclusion, programs must address the diverse needs and desires of the community’s older population. According to the American Society on Aging, as stated in the EPA’s Building Healthy Communities program, the process of inclusion incorporates the strengths-based approach of engagement, cultural competency, and use of the community’s strengths and available resources. A chapter of the report, “A Blueprint for Health Promotion” focuses specifically on the topic of cultural competence and health promotion programs (American Society on Aging, 2002).
10. Remain committed to ongoing development of programs and policies and to the involvement of people who represent different segments of the community. As well as developing coalitions of community partners to develop and implement health promotion in communities, the coalitions should be committed to ongoing evaluation of the collations and their connection to the community to ensure further development and implementation of new programs as well as the maintenance of existing programs.

Models that Combine Nutrition and Physical Activity

The Administration on Aging has created a national campaign called “You Can! Steps to Healthier Aging,” which is intended to increase the level of physical activity among older adults and enhance their dietary intake. According to Loughrey (2004), the campaign is a good example of how public health officials and medical experts are becoming increasingly aware and supportive of the belief that positive change, even if it occurs in moderate increments, helps to improve the older population’s health and quality of life. The goal of the campaign is to enlist organizations with a variety of relevant interests from across the United States. Among the diverse organizations enlisted in the plan are hospitals, state and local agencies on aging, park departments, and faith-based groups. Their mission is to provide older members of the community with information, activities, and/or programs that promote physical activity and better nutritional decisions. In 2004, the Administration on Aging successfully engaged more than 1,000 organizations across the country. However, its overall objective was to enlist more than 2,000 organizations and reach at least 2 million older adults by 2006 (Loughrey, 2004).

Effects of Health Disparities and Cultural Diversity

• The social worker’s ability to promote individual and community level health promotion is limited by the reality that older members of minority groups experience poorer health, are less likely to be adequately insured, and often receive disparate access to health care compared with older members of the majority group (Johnson & Smith, 2002).

The failure to meet the health care needs of all members of society is challenged further by poorly understood and inadequately defined health care outcomes among older members of minority groups. In addition, as Johnson and Smith pointed out, members of minority groups are underrepresented among health care professionals in the American health care system. To begin to address these disparities, Johnson and Smith suggested that interventions designed to reduce currently existing disparities must address multiple interrelated systemic issues, in the form of questions, such as the following.

• What knowledge and attitudes prompt individuals’ requests for services?
• What preconceptions of both individuals and providers affect communication and influence the provision of services?
• What structure and financing of the health care system would improve their access?
• What is the impact of social and community factors on the delivery of health care services?

Other approaches to promoting health in older adults from culturally diverse populations include the following.

• To tackle the lack of diversity among health care professionals, Johnson and Smith (2002) suggest beginning with the educational system. Parents and community leaders can encourage cultural diversity among these professionals by becoming more involved in advocating for it in the educational and health care systems. Academic Medical Centers should include outreach and community service as part of their role (IOM 2008).

• Medical professionals recognize that increasing the cultural competency of practitioners is important because one’s culture affects not only the practitioner’s diagnosis and treatment but his or her responsiveness to the patient as well. Therefore, cross-cultural awareness needs to be integrated into training in all health care and professional educational settings. In addition, minority communities need to become involved in research initiatives to achieve results that are effective for their situation.

• Building partnerships between health care centers and communities enhances health outcomes and standards of care (Johnson & Smith, 2002). Indeed, some studies on health disparities suggest the need for totally new research models to test dynamic multidimensional interventions that use continuous feedback from patients, providers, and communities to make interventions effective and improve community-wide outcomes (Rust & Cooper, 2007).

• Ultimately, increased knowledge and collaborative work between community organizations and research institutes can help to transform decisions made at the policy level. For example, the SHARE Awards Program, a joint effort between GlaxoSmithKline and the University of Pennsylvania’s Institute on Aging provides funding to small organizations that are committed to improving the lives of older members of minority groups. (For more information about the SHARE awards program, visit http://www.gsk.com/press_archive/press_11172001.htm)

Implications for Health Policy

The World Health Organization (WHO) has developed a policy framework for active aging that is generalizable to aging populations in all. In the organization’s report entitled, Active Ageing: A Policy Framework countries (World Health Organization [WHO], 2002), key policy proposals for the three pillars (health, security, and participation) are outlined. The key proposals in the health arena include developing and implementing policies and programs that:

1. Prevent and reduce the prevalence of chronic illnesses and disabilities—areas of policy focus include, but are not limited to, policies that address the economic influences on health, such as poverty; the development and implementation of effective prevention programs; the barriers to active aging that communities present; as well as the mental health, quality of life, and social supports necessary for successful active aging among older adults.
2. Increase protective factors for health and reduce risk factors for disease—areas of policy focus include, but are not limited to, policies that address tobacco, alcohol, and substance use; access to health care for oral health as well as vision and hearing loss; nutrition; access to medication; and adherence to prescribed medical treatment.
3. Develop age-friendly health care and social services that are designed to meet the unique needs of older adults—areas of policy focus include, but are not limited to, access to affordable health insurance, health care that is delivered across a continuum rather than the delivery that is provided in our current fragmented system, provision of adequate training, salaries and working conditions for formal caregivers, and support for informal caregivers, who are mainly women caring for their older parents.
4. Provide training for the workforce that will deliver services to older adults—areas of policy focus include, but are not limited to, providing basic training as well as opportunities for lifelong learning to improve skills, development of volunteer opportunities for work with aging individuals, and policies to improve the economic situation of formal caregivers in the aging services arena.

As we begin to develop new policies to address the needs of the growing population of older adults worldwide, the WHO policy framework can be used as a guide to developing sound policies that can address the multiple factors that impact the health of older adults.

Conclusion

As the tsunami wave of older adults approaches between now and the year 2020, health promotion has become a topic of great importance in the United States and globally. In this chapter, we presented:

1. An overview of the epidemiology of aging and the need for health promotion to ensure that older adults maintain the highest level of health and quality of life possible. We identified myths of aging that make the development and implementation of health promotion initiatives and programs difficult and dispelled these myths.
2. A framework for health promotion in aging that includes a summary of the history of health promotion models as well as the models that are currently being used to guide the development and implementation of health promotion initiatives in the United States. The frameworks include the Successful Aging Model, the Health Aging Model, the Active Ageing Model, and the Alberta Rose Model. Each of these models has been used to develop successful health promotion programs.
3. Possible roles for social workers in promotion health. Social workers can play critical roles as members of public health teams in promoting community-wide health promotion programs. Furthermore, they can engage older to clients to promote the adoption of healthy behaviors and lifestyle changes in order to prevent and/or diminish the impact of chronic diseases on older adults’ quality of life and health status. In this section, we also identified policy issues that social workers can highlight in order to promote health among older adults.

References

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