USA

Citation

(2006), "USA", International Journal of Health Care Quality Assurance, Vol. 19 No. 1. https://doi.org/10.1108/ijhcqa.2006.06219aab.003

USA

Definitions of health among diverse groups of elders: implications for health promotion

Keywords: Health, Equality, Heath care values, United States of America

A report by JoAnn Damron-Rodriquez, Janet C. Frank, Vilma L. Enriquez-Haass and David B. Reuben, highlights the similarities and differences among elders in various ethnic groups.

The population-based approach of public health to addressing the health of older people emphasizes prevention of disease and disability, and, increasingly, the aging network is reaching out to diverse groups of elders to engage them in health promotion activities. The diversity of the older population is increasing, with elders of color expected to constitute 25 per cent of the older population by 2025. By 2050, some 35 per cent of elders will be from minority groups. This demographic reality raises issues that are of particular importance in Los Angeles, where 45 per cent of the current older population is composed of minority elders.

The study described here was motivated by the desire to increase the utilization in Los Angeles of a successful community health promotion project, Prevention for the Elderly Program (PEP). To that end, the study was designed to answer a group of questions of particular relevance to service: How do individual older people define health? How does the definition of health vary among groups of ethnic elders? How can an understanding of elders’ definitions of health be of use in design of health promotion programs?

The problem. Comparisons of how people rate their own health in diverse age and ethnic populations raise questions about the criteria people are using and show that definitions of personal health can vary considerably and that perceptions of one’s own health are not necessarily related to other measures of health status. A better understanding of these definitions and perceptions among minority elders could be used in outreach and health promotion, particularly to improve communication among elders and providers.

The research focuses on late-life definitions of health and explores the similarities and differences in the meaning of health for elders from several different ethnic groups.

Methods. The initial research activity was conduct of discussions in ten standardized focus groups to explore what being healthy means, what participants did to stay healthy, and their views on specific prevention activities. Participants were matched in ethnicity and language; two groups were composed of African American elders, two of Hispanic-American Spanish speakers, two of Mandarin-speaking Chinese, two of Cantonese-speaking Chinese, and two of Eastern European ethnicity and language. All focus groups were held in senior centers or senior housing recreation rooms.

The ages of the group members ranged from 59 to eight years. All African American participants except one were born in the USA. In contrast, all of the Chinese American participants were immigrants and were the most recent immigrants among these groups, with several having been in the USA for five years or less. The Eastern European elders, while all immigrants, had come to the USA at fairly young ages. The members of the Spanish-speaking groups had lived in the USA a minimum of 20 years, but for many, Spanish was still their primary language. The Eastern European and Mandarin-speaking Chinese elders had the highest educational levels, while the Cantonese-speaking and Hispanic groups (both men and women) had the lowest educational levels.

Findings. The first question within each focus group was, “What does being healthy mean to you?” After exhaustive analysis of the transcripts from all groups, a holistic and interlocking diagram of late-life health was constructed based on elders’ statements.

One older adult would identity an aspect of health as “not being sick”, for example, and another person would add “feeling no pain”, and yet another would include “being content”. No single definition of health emerged for an individual or group. The meaning of health in late life that emerged from the responses of older adults was multifaceted. All ethnic groups described elements ot health that encompassed physical, psychological, social, and spiritual domains.

The domain of physical health. This domain consisted of two major categories of responses, one, somatic, was related to the body and it’s functioning. The responses related to basic body functioning and the absence of physical illness. Somatic characterizations of physical health included responses such as “not being sick”, or “not needing to go to a doctor”. Respondents noted presence of specific illnesses, such as stroke, as examples of a person not being healthy. The respondents attributed the absence of symptoms to physical health, particularly “no pain”. Bodily functioning, “being able to sleep” was another characteristic of somatic health.

The second category of definitions of health within the domain of physical health related to functioning and activity. First and foremost, most older adults in the study defined health as the ability to maintain one’s activities. The statements ranged from “being able to get up in the morning” to “being at the peak of what you can do or be” would constitute good health. Other responses were “I get dressed in the morning, I can feed and bathe myself?” and “being healthy means I can take part in the activities that I have scheduled for myself?” Another aspect of this domain includes the ability to do activities that promote health. Examples of these more prescriptive responses are “to go out, walk around, do some exercises and just keep going”, and “just go dance, dance, dance”.

Psychological and spiritual domains. Descriptions of health for all ethnic groups also clustered into the psychological and spiritual domains. A broad range of qualities were attributed to the psychological health subcategory of this domain, including a positive attitude, happiness, not worrying, having an active mind, and creativity. The respondents recognized the relationship of mind and body as exemplified in the comment: “A person should smile a couple times a day and that will mean a long, healthy life.”

Closely related was the spiritual component of the elders’ perception of health. In this domain, religious activities were related to health, as in the observation that elders “go to church and socialize” to stay healthy. Reading the Bible and prayer were viewed by some as a practice that contributed to them staying healthy. Other qualities of health were described as beyond human control and were “God’s gift”. Most comments in this domain related to spirituality as an approach to life rather than a formal religious practice. Many elders mentioned the importance of having an overarching sense of gratitude for life as exemplified in this maxim “Appreciate things in your life, be grateful”. Other elders commented on the importance of having a good heart, thinking spiritually rather than materially, and being charitable.

Social domain. The social domain was essential for the definition of health for all ethnic groups. This domain of health included maintaining active social contacts, receiving and giving support to family and friends, and meaningful involvement in community and cultural activities. Social activities – “being able to get out of the house and be with others” – were important. However, elders emphasized social engagement as “being in the mainstream of life” and being able to “get involved with other people”. Many of their comments related more to giving social support than to receiving it. For example, “I am healthy because I help my grand-children and others”.

There was intergroup similarity in the view of the nature of health as multifaceted. All groups described some elements of each domain as being important aspects of health. However, the emphasis did vary between ethnic groups. For each ethnic group, a particular domain emerged as either a primary or secondary foundation for the meaning of health in their lives.

Domains of health by ethnic groups. The content analysis of the focus group transcripts identified the two most important or the primary and secondary domains for each group’s definition of health. This ranking of the primary and secondary domains was based on the following criteria: immediacy of responses or being the first replies offered, responses offered from multiple members and receiving confirmation from others, and responses offered a number of times or brought up more than once by the group.

Three of the ethnic groups, the African American, the Eastern- European American, and the Hispanic American identified the domain of physical health as primary. There were, however, clear between- group distinctions for the characteristics emphasized within this domain. For example, the African Americans focused on the absence of illness or symptoms, such as pain. The Eastern-European Americans focused on activity and functional ability. The Hispanic American group was most likely to say they were healthy if they “do not have to go to the doctor”. The primary domain for the Chinese Americans was the psychological-spiritual. The Chinese American group characterized the meaning of health as a “positive spirit”, having a “good heart” and other humanitarian-focused comments.

For the groups of ethnic elders that first and most strongly identified the physical domain, they quickly added social aspects of health for the secondary domain. African Americans emphasized social interaction and being out and about in their community. European Americans highlighted the level of social activity (“being busy”) and social support. Hispanic Americans focused more on visiting with family and more close-knit contact. The social domain for all groups involved the giving and receding of family support. For Asian American elders, the physical domain complemented their first emphasis, the psychological-spiritual domain. Within the physical domain, Asian Americans emphasized the regularity of activity. Doing tai chi at the same time each morning was one example of the importance of having a pattern to daily functioning.

Perspectives of health in late life. Ethnic elders offered their overall perspectives of late-life health. The perspective of older adults across groups conveyed optimism about late-life health. For African American elders, this view was particularly comparative with previous periods in their life:

My mind has taken a different approach. I’m more content, I’m happier than I was when I was younger, but that’s all how you all look at me (African American man).

The last sentence of this quote was explained by the respondent to mean others may not sec him as healthy and content as he is.

All groups drew support from the bio psychosocial domains to support the view that they were indeed old and healthy:

I have five grandchildren in my home. For me, this means very good health (Hispanic American woman).

Other responses conveyed definitions of optimal health as the best that could be expected at this time of life. These statements, too, reflect marked differences by ethnic group. All the perspectives convey optimism for the potential for satisfaction with one’s health as an older person:

Being able to function. Being at the peak of what you can do or at the peak of what you think you should be (European American man).

I’m up there in age and my heart is content at this age. The mind and the body work together and must be in balance. Don’t be too serious about your life (Chinese American man).

Discussion and implications. It is critical for practitioners to understand how older adults define their health within the context of their longevity. These findings, in concert with other research, illuminate the biopsychosocial and spiritual dimensions of health. Late-life health is multidimensional, and all elements are integrally linked to the perception of physical health.

Elders in these focus groups defined their health with reference to their peers, typically comparing themselves to other older people when rating their health. Additionally, African American elders said their satisfaction in later life was better than it had been during the struggles of earlier stages of life. Across all groups, an acceptance was noted of “what is” and strong indications of adaptation to health problems and life circumstances. Older adults described basic components of being healthy and a perspective on a good and satisfying level of health. A key aspect of late-life health was functioning and being able to engage in activity. Diverse groups of older adults, by virtue of their variations in experiences, education, cultural upbringing, and a host of other individual factors, will have different emphases on the meaning of health, the value of health, and what they perceive to be useful to improve or maintain their health. This is congruent with the view that health is a context for activities that provide meaning for late life. Health conditions were only defined as “problems” when they interfered with important activities, and definitely when they prevented the completion of basic self-care activities.

The importance of social aspects of health and humanitarian values of reciprocity were meaningful, as was the impact of health on the ability to participate in these life transactions. In the social arena, giving social support was often described as more important than receiving it. Respondents derived a sense of value in helping others and having the stamina and abilities to do so. This research also supports the importance of culture and ethnicity in older adults’ decisions of health. Sociocultural factors that influence older adults’ perceptions must be assessed for health promotion interventions to meet individual and group needs.

The emphasis on activity, to some degree present in all groups, was most important for the group of Eastern European origin. Their activities, mostly of an organized and directional nature, were in contrast to the more interactional activities and daily functioning of the other groups. The definitions of health embraced by the Eastern-European Americans in this research may more closely reflect the values of the planners of activities at senior centers. This finding raises questions about the predominant value assumptions that may be the predominant basis of program design for older adults.

The differences in characteristics emphasized by African American and Hispanic American elders should be considered in health promotion program design and warrant additional research. For example, African American older adults in these focus groups emphasized the absence of symptoms in defining health and “silent killers”, such as hypertension, have a particularly high prevalence in the African American population. The African American orientation to defining health as an absence of symptoms presents challenges to health – promotion education related to conditions that have low-profile symptoms.

Hispanic American elders in this study, on the other hand, defined health by the extent of physician utilization for their healthcare needs. Reliance on physicians as barometers for health may present another challenge to health promotion interventions.

The most marked differences in the meaning of health were found among the Chinese American elderly in contrast to the other three major groups. An East-West contrast can be observed in the psychological and spiritual domains, overshadowing the physical domain in the meaning of health. Aspects of regularity and balance may also be important elements to incorporate into health promotion activities for these Asian elders.

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