Society is ageing (Nakasato and Carnes, 2006). By 2050, it is estimated that at least 1 in 5 people will be 60 years or older and that between 2000 and 2050 the number of those aged 60-plus will double (World Health Organization (WHO), 2015). Living longer is recognised as bringing great opportunity, but this is dependent on the maintenance of good health and wellbeing. However, older people can experience a health trajectory that is less than what could be possible (WHO, 2017a). Multi-morbidity, frailty and cognitive impairment, while not inevitable, are associated with ageing. These can affect the person in a number of ways, including reduction in quality of life and wellbeing, polypharmacy, reduction in social networks, increased service use, and higher mortality (Woods, 2014; Eckerblad et al, 2015; National Institute for Health and Care Excellence, 2016).
Health in later life can be modifiable and there is potential for significant gains via health-promoting activities and a life course approach to health promotion (Andrews, 2001). However, the evidence indicates that older adults are often not targeted for health promotion messages (Miller, 2015; Boggatz and Meinhart, 2017). Campaigns are generally directed at other population groups, despite the contention that health promotion with older people requires a significantly different approach from that targeted at younger age cohorts (Golinowska et al, 2016).
Targeted health promotion campaigns are known to be effective in terms of cost, improving function, quality of life and achieving health gains (Rabiner, 2006; Miller, 2015). This article considers contemporary issues relevant to health promotion and older people, and the role and contribution that can be made by nurses.
Healthy ageing and wellness in later life as priorities
The WHO (2015) advocates ‘healthy ageing’ as a goal for life, describing it as a process incorporating the development and maintenance of functional ability to facilitate wellbeing in later life.
‘Health is a key determinant of quality of life and wellbeing for older people, impacting significantly the extent to which they can enjoy life and participate in the economic, social and cultural life of their community. Many chronic conditions can be prevented, deferred or mitigated through good health promotion, screening and preventative measures'
The promotion of healthy ageing is acknowledged to be inherently complex (Woods, 2014). For example, there is a need to consider health in older adults from a holistic rather than a reductionist, disease-focused perspective. A holistic orientation to the interpretation of quality of life includes objective constructs such as physical functioning, in tandem with subjective components such as psychological and social wellbeing, and successful ageing as rated by the older person (Nursing and Midwifery Board of Ireland (NMBI), 2015; Tkatch et al, 2016). This holistic approach is necessary because healthy ageing incorporates more than lifestyle modification and encompasses independence, social wellbeing, personal growth and spirituality (Hung et al, 2010).
The concepts of wellness and wellbeing also require consideration in terms of health promotion. Wellness in later life can be seen to have seven dimensions: physical, emotional, intellectual, vocational, social, environmental and spiritual (Strout and Howard, 2012). Contemporary perspectives on health promotion are inclusive of these domains. The achievement of wellbeing generally is linked to the meeting of essential needs, sense of purpose, achievement of goals, societal participation and living a valued life (Department of Health (Ireland), 2013). More specifically, in older persons wellbeing entails healthy, active, positive, productive and successful ageing (Department of Health (Ireland), 2013). Applied to older people, wellness is used in its broadest sense to include domains such as happiness, fulfilment and satisfaction (WHO, 2015). Both health and wellbeing are therefore understood to be multidimensional concepts that are affected by a number of interconnected factors (Department of Health (Ireland), 2013) relating to the person and the environment within which they live (Table 1).
| Factors relating to the person | Factors relating to the environment the person lives in |
|---|---|
|
|
|
Source: Rosso et al, 2011; World Health Organization, 2015; Slaug et al, 2017
Overview of health promotion
The terms ‘health promotion’ and ‘public health’ are frequently used interchangeably (Naidoo and Wills, 2016). Health promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health. It is a core function of public health and contributes to the work of tackling communicable and non-communicable diseases and other threats to health (WHO, 2005:1). The main ethos of health promotion is empowerment and advocacy to help reduce health inequalities, as reflected in the definition of the role of the nurse by International Council of Nurses (2019). More specifically, the role of nurses working with older people involves co-operative working to enable the person to attain their optimum state of health and wellbeing through interactions that aim to ‘establish the conditions that promote healthy living; compensate for disease-related losses and impairments [and] prevent further disease-related losses’ (NMBI, 2015: 9). The three pillars of health promotion are identified as:
These pillars are important to achieving the 17 interconnected Sustainable Development Goals (SDGs) identified by the WHO (2018), which address the determinants of health. The WHO (2018) uses the phrase ‘leaving no one behind’ to focus on health inequalities. Three of the SDGs focus on eradicating poverty, reducing inequalities within and between countries, and promoting health and wellbeing across all age groups. Naidoo and Wills (2016) further identify five approaches to health promotion as:
A recent review of health promotion interventions used by nurses (Duplaga et al, 2016) identified that most focused on health education, preventive and behavioural change approaches.
Priorities for health promotion
Health and wellbeing policies for older adults are now common, developed in response to increasing requirements for health care and support in later life (Drennan et al, 2018). Such policies incorporate a commitment to support healthy ageing and a recognition of the need for action at the level of the individual and society, as well as the need to consider issues such as ageism, inequity and rights (WHO, 2015; 2017a). As such, health promotion for older people needs to be transformative and broad focused, adopting an integrative approach across the domains within the continuum of health and wellness for this age group (Haber, 2016; Tkatch et al, 2016; WHO, 2017a). Related interventions also need to be multiprofessional, and adopt a multifactorial, targeted and person-specific approach to respect the heterogeneous nature of older people. Contemporary health promotion priorities for older adults are therefore generally focused on the following:
The last point is particularly important for all nurses engaged with older people. The WHO (2013) recognises that older people are at higher risk of experiencing mental health difficulties and identifies health promotion and prevention strategies as key objectives in its mental health action plan for 2013-2020. Mental health promotion strategies emphasise the importance of health throughout the life span, with efforts to encourage resilience as a way of adapting to changing life circumstances as people grow older. However, many physical, psychological, social and economic factors that influence mental health in older age require additional consideration from nurses. According to Lee (2006), these are:
Many older people with chronic illnesses are vulnerable to poor mental health, which has a negative effect on the symptoms of their illness. People with neurological illnesses such as Parkinson's disease and Alzheimer's disease can experience depression, but this is often underdetected and left untreated, resulting in a lower quality of life for those affected (Joint Commissioning Panel for Mental Health, 2013). Older people can experience the same mental health difficulties as people in other age groups, such as substance misuse, self-harm and suicide. However, older people are more likely to experience changes in their social relationships, brought about by bereavement or changes in living arrangements, which may heighten their risk of experiencing mental health difficulties such as depression and anxiety (PHE, 2019).
Acknowledging the importance of mental health, coupled with the ability to recognise the factors that affect mental health and the ability to identify older people who may be experiencing a mental health difficulty, is paramount in promoting mental health in this patient population. Physical health is sometimes perceived as more important than mental health; given the inter-relationship between the two this is an issue that needs to be addressed (Mental Health Taskforce, 2016; WHO, 2017b).
Principles for health promotion nursing practice with older people
Nursing interventions with older adults should recognise that they are more vulnerable to chronic illness, multimorbidity, mental health difficulties and functional impairment, all of which need to be considered in health promotion (Golinowska et al, 2016; Health Services Executive, 2017). Related nursing interventions should therefore be person oriented and not service or system focused. Recommendations for nursing health promoting activities should equally be realistic in terms of what is available and accessible. This requires informed nurses who are knowledgeable about, and have established connections with, local services and support organisations, because problems can arise when recommendations are standardised. For example, an older person could perceive these as irrelevant or they may require access to capacities or resources that are outside their reach.
Professional nursing bodies, such as the NMBI (2015), recognise that nurses care for, and with, older people in all healthcare contexts; they care for those who are well, as well as those living with one or more health-related conditions. Nurses therefore require competency in drawing on a range of health-promotion approaches in daily practice. As a first step however, there is a need for nurses to recognise when an older person may seek, or be receptive to, health promotion interventions. Boggatz and Meinhart (2017) identified the following as triggers that stimulate older people to engage with health promotion:
Nurses should therefore consider an individual's readiness to engage in health promotion. Additionally, because older adults are heterogeneous, there is a need for nurses to consider the needs of minority and harder-to-reach older people, including those from diverse cultures and those with frailty or pre-frailty (Tkatch et al, 2016; Frost et al, 2017). Liljas et al (2017), in their systematic review, identified facilitators and barriers to engagement with health promotion of such persons (building trust, family support etc), which need to be recognised when undertaking health promotion with subgroups, including the oldest old, older people living in deprived areas and those from black and minority ethnic groups.
Finally, ageism can result in discrimination and lead to social exclusion, loneliness and difficulties accessing health care. Consequently, nurses should be mindful of the potential effects of stigma and ageism on a person's readiness for, and receptivity to, health promotion and, specifically, the impacts of (Swift et al, 2017):
Competency is another factor for nursing consideration, with Harris (2009:275) identifying the following skills as relevant for promoting health with older people:
The way that nurses communicate health promotion messages is also important. Figure 1 illustrates the WHO (2019) principles that should be used to underpin tailored health promotion communication with older people. These identify that nurses must allow sufficient time when engaging with older adults, and include both objective professional knowledge and subjective person-centred perspectives.
Support is also required for older adults—and, where relevant, family members—in navigating the health and social care systems and seeking clarity around healthcare instructions targeted at supporting health and wellbeing. This requires a focus on interpersonal processes and listening, consideration of health literacy, cultural competence and the communication of information in an understandable and personally meaningful way. Nurses should also consider that health promotion must be an ongoing component of care with older people. Use of the Making Every Contact Count approach is one way to accomplish this (PHE et al, 2016). This is an approach to behaviour change that uses the millions of day-to-day interactions that organisations and individuals have with other people to support them in making positive changes to their physical and mental health and wellbeing’ (PHE et al, 2016:6). MECC uses the stages of change approach (Prochaska and DiClemente, 1983), motivational interviewing and the 5 As (Table 2).
| Ask | Ask about behaviour and document same |
| Advise | Advise of the need for behaviour change |
| Assess | Assess readiness to change. Assess what stage in the stages of change cycle, they are at |
| Assist | Assist with a behavioural change plan |
| Arrange | Arrange follow-up |
Source: Fiore et al, 2000
The trans-theoretical model or the stages of change model developed by Prochaska and DiClemente (1983) is widely associated with the behavioural change approach to health promotion. This model identifies an individual's progress during different stages of the change cycle when modifying their behaviour (Figure 2).
Nursing practice also requires an understanding of health promotion across the continuum of care. This entails knowledge of activities related to health promotion, while considering the social and physical environments that people reside in that may affect behaviour change (Rabiner, 2006). Empowerment, equity and social connectedness are the main principles of community-centred approaches to promoting health and wellbeing in later life. These principles are particularly important because older people are vulnerable to social exclusion (Börsch-Supan et al, 2015).
In contrast, many individuals contribute to their communities in later life in a volunteer capacity, and volunteering is an important component of the social fabric. For example, both Men's Sheds and Time-Bank initiatives are categorised as social network approaches to social participation. Men's Sheds are not-for-profit, volunteer-based, community organisations that foster social connectedness among men, in particular older men living in Ireland, the UK and Australia (Cordier and Wilson, 2014). The Time-Bank initiative is a social network approach, focused on the idea of ‘time credits’ that entails individuals within a community exchanging services. Nurses can have a role in socially prescribing locally available, personally relevant activities such as these via community referral. Social prescribing is enhanced when the local community has already mapped the available social assets, the outcomes of which must be known to nurses if they are to be used. These assets may include local services, informal groups and networks in the community (South, 2015). Raising awareness of, and enabling access to, such opportunities may enable nurses to target the domains of health and wellness outlined in this article.
Conclusion
Health and wellbeing in later life are frequently modifiable and there is potential for significant gains via health-promoting approaches and activities. Nurses across the continuum of care are caring for growing numbers of older people and so are ideally placed to promote health and wellbeing at individual and community levels. To fulfil this role nurses must have the requisite knowledge and professional competence. To this end, the overview provided in this article has outlined a range of considerations pertinent to health promotion practice with older people.