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Health Education for the Elderly

Ayla Kececi and Serap Bulduk
Duzce University/ Vocational School of Health Services,
Turkey

1. Introduction
Health promotion and wellness are a great responsibility, particularly for all health care
providers who work with elderly people. Some health care providers claim that because of
their age, activities pertaining to prophylactic measures, health and wellness maintenance
will not be helpful to elderly people. On the contrary, wellbeing should not be regarded as a
concept specifically relevant to younger individuals. The wellness concept is applicable to
every age from older adults to the young (Reicherter & Greene, 2005; Tabloski, 2010).
The world population on the whole is growing older and wellness and common diseases
(infectious diseases, acute illnesses, chronic diseases and degenerative diseases, etc.) have
been changing. Although many chronic diseases cause serious defects, some studies show
that if a healthy life style is adopted and maintained, these defects can be delayed. Besides,
these illnesses generally pose risk factors for individuals and their life styles. Studies on
wellness and the prevention of diseases have been found effective, especially in providing
lifelong behavioral change. Since the elderly population is at a huge risk of major diseases
and defects, members of health care units should handle their education carefully. Through
such education, benefits are provided regarding protective and wellness development for
many elderly people (Reicherter & Greene, 2005; Tabloski, 2010).
Health education is a concept directly linked to health promotion in both clinical and
educational preparation fields. Health promotion reform has developed an increasing
interest in acute injuries and diseases from the mid-1980s. However, opportunities to
promote health have generally been neglected (Choi et al., 2010).
Health education increases individuals knowledge of health and health care and makes
them informed about their health care choices. Prophylactic health behaviors (such as
physical activities and having healthy food) keep older adults lives active, delay going to
nursing homes and increase satisfaction with life. Among the topics where elderly people
need help most, a lack of knowledge comes first (Leung et al., 2006). World Health
Organization (WHO) has emphasized the importance of health education to support health
care needs and health promotion for elderly people (Rana et al., 2010).
Health education requires a careful handling of knowledge, attitude, objective, perception,
social status, power structure, cultural practices and other social perspectives. Health
education is not a concept about individuals or their families but can profoundly affect
individuals social status (Glanz et al., 2008).

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An ageing population makes countries face many kinds of struggle in terms of health care and
education. First of all, social support and care offered by elderly peoples friends and family
members can be inadequate (Hoving et al., 2010). If elderly people can afford health-protective
and self-management behaviors in their daily lives, they can live more independently.
However, a higher prevalence of chronic diseases like diabetes, cancer, heart diseases and
dementia in this age group makes self-management of these illnesses and patient education
more complicated. Educational programs for elderly people have complicated treatment plans
because their age will increase their awareness level of medical treatment (Shen et al., 2006).
Likewise, in studies conducted in different parts of the world, it was found that there is a need
for serious educational programs related to old age (Liu&Wong, 1997; Kahn et.al., 2004;
Doucette&Andersen, 2005; Koh, 2011; Vintila et.al., 2011).
Health care personnels personal belief that elderly people have a poor understanding and
learning ability has been an important obstacle in providing elderly people with an effective
education. The myths about ageing have regarded elder people as unproductive, resistant to
change, impotent and stereotyped individuals. In addition, health care personnels lack of
knowledge and skill may often prevent them from seeing all behavioral symptoms. For
instance, behaviors of an elderly person who suffers from a mental disorder due to dementia
can be seen as manipulative, or an older person with impaired hearing may respond
intricately or inappropriately. In these situations, elderly people are considered difficult
or complicated by health service providers (Smith, 2006). Many elderly people, however,
do not experience biological, psychological and socially excessive negative effects. Instead,
for those who are physically fit and extrovert, social and psychological abilities continue. On
the other hand, experiencing some changes may disrupt learning in the health education
process. Below are the commonly seen changes that may affect the learning process in
elderly people (Tabloski, 2010; Cornett, 2011).

Physical changes: The beginning, direction and order of the ageing process of elderly
people depend physically and biologically on genetic and environmental factors.
Degenerative changes may occur in hearing, seeing, feeling and responding skills.
Spatial variability, mobility, and motor coordination may be spoilt. The working level

may affect most body systems (Tabloski, 2010; Cornett, 2011 ).

Psychological changes: The psychological aspect of ageing is related to a persons
adaptation capacity. There might be changes in perception and memory, learning and
problem solving, psychological state and attitude, sense of self and personality.
Problems with memory in particular are common. The most declining cognitive skills
are reported to be thinking with numbers and retention skills. The least decrease is seen
in interpreting ideas and events, establishing relationships between events and ideas,
generalizing, vocabulary and knowledge. Besides, regardless of a recession in their
ability to learn, memory and intelligence, the rich life experience of elderly people
makes their ideas valuable and health education should benefit from this experience.
Another factor that can psychologically affect elderly people is losses. The loss of a
former role and status, wife, friend, economical power and familiarity can be
experienced. Due to these changes, self-respect diminishes and fulfillment decreases.
Evaluating elderly people in terms of the losses they experience and the effects of these
losses on their struggle is extremely important. Also, loss of confidence suppresses the
ability or readiness to learn. However, preparing the person by strengthening self-

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esteem with personal achievements and skills is an important strategy. Safety and
safety needs are major anxiety factors for the elderly in a crisis situation. Unless these
needs are satisfied, an active elderly person cannot actively participate in health

education (Cornett, 2011).

Socio-Cultural Changes: Social change and cultural factors affect self-care of the elderly
as a personal component. Independency is a crucial purpose for most elderly people
regardless of their health conditions. This is an expression of self-respect and pride.
Elderly people seek help in gaining independency. The health education offered should
contribute to their self-management skills. As their physical power decreases, elderly
people move away from the activities that require mobility and much energy and prefer
to choose more passive life styles. Especially the ones with poor education pass their
time with limited activities. Yet, mentally and socially active elderly people face the
limitations derived from ageing at a low level (Tabloski, 2010). An older adults ability
to cope with problems is closely related to health care and education. If an elderly
person sees himself or herself as an experienced and wise individual, education can be
built on these positive experiences and ways of adapting to the occurring inevitable
changes can be sought. However, unrealistic goals and demands should be explained to
the less adaptive people before the education (Cornett, 2011). In some countries, the fact
that elderly people do not want to stay in their own houses or places specifically for
elderly people is an obstacle in providing and maintaining health care. Additionally,
physical, social and environmental liabilities cause problems regarding benefiting from
services to maintain wellness. For this reason, all the liabilities that might affect elderly
peoples learning process should be determined and minimized prior to education
(Reicherter & Greene, 2005).

2. Older adult learners

Knowing the learner is the key to successful teaching! Some features of adult and older
adult learners constitute the key.
Self-concept: The self-concept of an adult learner is to be able to direct himself or herself and
to be mature and positive in society. Adults want to make their own decisions and take the
responsibility for the consequences of these decisions. They expect to be respected and
regarded as unique beings (DeYoung, 2009; Cornett, 2011). Ericson mentioned some features
of adulthood in the eighth phase of the human development period which he defines as
self-integrity. According to Ericson, in this phase, maturity and unity of the personality
features gained in the previous phase are the most crucial task. Self-integrity is egos having
an order and meaning in itself. In other words, it is the acceptance of a life with all its
positive and negative aspects. This prevents welcoming the future with fear and anxiety.
However, the most important sign of lacking self-integrity is the idea that past days were
not spent well, despair and fear of death. Especially in the process of health education for
the elderly, educators must show respect for elderly peoples needs, choices and their desire
to manage their own lives. Creating an environment which makes them feel accepted,
respected and trusted will encourage them to express their feelings and thoughts away from
fear and pressure. For this reason, educators should ask elderly people how they would like
to be called and call them that way. Adults are motivated to learn when they realize that
they need to learn. Learners must be helped to express their feelings about their needs

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because they want to take the responsibility for their learning and management of their lives
in the learning process. For this purpose, educators regard every interaction with elderly
people as an opportunity to support their self-concept (Karaoz & Aksayan, 2009, Cornett,
2011).
Life Experiences: An older adult has considerable background information and life
experiences in her/his lifetime. Life experiences are rich sources for learning. When an
adults experiences are supported and approved by others, positive feelings come into being
since these experiences constitute her or his self-identity. If these experiences are not
noticed, the person might feel rejected (Tabloski , 2010). Negative past experiences should be
identified and dealt with since they might disrupt the learning process. For instance, an
elderly person who has had bad experiences with ageing and chronic diseases might
think that the education offered will not have any positive effect on him or her and because
of this he or she may not learn. Positive experiences of adults should be used as an
experimental teaching strategy. If new learning is related to a persons past experiences,
they become more appropriate and meaningful. New self-management skills become more
meaningful when a person adapts himself or herself to routine and a normal life style.
Sharing their experiences with people having similar problems contribute to the problem-
solving process among older adults (DeYoung, 2009; Cornett, 2011).
Being ready to learn: Before an effective education, adult learners should be ready for
learning. When an individual is ready to learn, he or she will make the most of it (Gokkoca,
2001). Peoples attitudes and responses to a situation that threatens their wellness are mostly
determined by an illness causing loss of control and self-confidence, disability and
perceptions and experiences related to other factors. Readiness is strongly affected by
individuals social roles and developmental tasks. Some social roles and developmental
roles after adulthood can be listed as an adaptation to decreasing physical strength and
health, retirement and a decrease in income, and the death of a spouse and other family
members (DeYoung, 2009; Cornett, 2011).
Readiness to learn and problem-solving skills can be enhanced by role-plays and group
work with adults who have the same roles (Cornett, 2011). Previous achievements of elderly
people have been an important motivating factor in the things that should be done and will
be done in the future. Prompts like you can do it, you can achieve it strengthen their
belief in self-efficacy. Individuals physical or mental conditions strengthen or weaken their
belief in performing an expected task (Bikmaz, 2006).
Problem-oriented or Goal-oriented: Adult learners are motivated when there is a problem or
crisis concerning them. In other words, they have a different point of view when compared
to the young (Cornett, 2011, Gokkoca, 2001). They see learning as a way to overcome these
problems and learn the things that are related to them and helpful to the fulfillment of
responsibilities. Adult education is behaviorist oriented (how is it done?). However, in order
to limit the education circumstances, minimum requirements such as vital or good to
know must be known. Patients should be provided with practical solutions to their
problems and should be immediately assisted with hands-on-practice and problem-solving
sessions to practice new information. Unless patients require information on this issue and
understand self-care, providing information on the illness process is not a priority. On the
other hand, urgent needs should be prioritized. If potential problems patients might face are

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not known, questions about their concerns and aiming to know how to handle the situation
should be asked. This gives an idea of the rehearsal situation or the possible response in
case a problem occurs (DeYoung, 2009; Cornett, 2011).
From another point of view, elderly peoples values and beliefs can be a facilitator or
obstacle in caring for their health. For instance, elderly adult symptoms (e.g., tiredness,
depression) are not taken seriously, requiring medical aid, and are regarded as an inevitable
part of old age. Advanced age can affect the efforts of protecting health and self-
management in a psychosocial context. For instance, due to changes in social relations (e.g.,
being divorced or losing a spouse), the amount and quality of social support might have
changed. Following a balanced diet and positive sickness should be taken into consideration
(Connell, 1999, Cornett, 2011). Since the results are related to support, elderly adults have
more problems with their health and self-management (e.g., diet, exercise) compared to
young and middle-aged adults. These examples are only a few of how health education will
be affected in the context of physical and psychosocial changes. Age-related changes should
always be taken into consideration, especially in the design, implementation and evaluation
of health education programs.

3. Possible barriers to education of the elderly

Possible barriers that need to be considered during teaching should be known so that the
learning potential of the elderly can be realized. These barriers can be mostly classified as
sensory loses, mental illnesses and chronic diseases (Tabloski, 2010; Cornett 2011).

3.1 Sensory losses

The five senses tend to decline with advancing age. Sensory losses are problems with one or
more senses (auditory, visual, tactile, olfactory, or taste). Hearing and vision changes affect
communication while the other losses can affect thinking processes in the elderly (Tabloski,
2010; Smith, 2006).

3.1.1 Hearing deficiency

Individuals with hearing problems are people who either completely lost this sense or have
decreased sensitivity to sounds. Individuals experience various obstacles related to
communication in the process of patient education depending on their level of hearing loss.
Individuals with hearing loss may be unable to speak or may have a limited verbal ability
and a weak vocabulary. Just like other healthy people, these individuals will need health
care or health education throughout their lives. Although the health educator offers support
in different ways, individuals with hearing loss always have to use their other senses to get
information (Bastable, 2008; Cornett, 2011). A general hearing loss may be the result of an
illness, noise or bone changes while gradual hearing loss can bring about the loss of sounds
like S, SH and CH or high frequency sounds (Smith, 2006). There are so many different ways
of communication with individuals with hearing loss. First of all, educators should discover
the individuals preference to communicate. Sign language, written information, lip reading
and visual support are the most commonly used alternatives. In addition to these means,
facial expressions, gestures and mimics should be included in the communication process
for sharing information. During all education sessions, educators should be natural and not

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strict, speak clearly with simple sentences, adopt a way of asking for consent like a touch of
the hand before starting to talk, set up face-to-face communication and maintain a distance of
about 100 cm (6 feet). In conclusion, there is not just one way to communicate with individuals
suffering from hearing deficiency. What matters is determining whether the messages are
received correctly and if they are clear (Bastable, 2008; Tabloski, 2010; Cornett, 2011).

3.1.2 Visual deficiencies

Vision deficiencies are particularly common among older people. Most vision problems like
glaucoma, cataracts and macular degeneration occur in the retina. Changes in vision can
usually be seen in the form of a reduced ability to see distant objects, a loss of the ability to
see objects on the side, and a loss of the ability to see very close (even faces) and some colors
(peripheral vision) (Smith, 2006). Older people with reduced visual acuity may display
behaviors such as dimming eyes, needing to touch, reluctance to communicate or
withdrawal (Bastable, 2008; Cornett, 2011). The following are some recommendations for
education of the elderly with a reduced visual ability:
Education materials should be prepared in a format and size elderly people can easily

see,

Their other senses (touch, smell, hearing, taste) should be improved,

It should be considered that especially hearing and touch are significant for sharing

information,

The procedures should be explained as descriptively as possible,

Elderly individuals should be allowed to touch, hold and smell the related materials,

Materials should be prepared in larger fonts for the elderly with visual deficiencies,
Education materials should be prepared in black on a white background or in white on

a black background,
Contrasting colors should be preferred when using different colors,
Audio recording devices should also be included in the educational process, and Computers
and texts using the Braille alphabet should be preferred if possible (Bastable, 2008).

3.1.3 Deficiencies of smell and taste

Formation of papillary atrophy in the tongue with ageing brings about losses in sensing
sweet and salty tastes. Some chronic diseases (e.g., Alzheimers disease, Parkinsons disease)
can affect the sense of smell and taste. Similarly, drugs, surgical interventions and
environmental factors contribute to losses in taste and smell senses. Elderly people need the
same nutrients as young people but in different amounts. As a result of ageing due to
factors that negatively affect nutrition, a lack of nutrients in the elderly is found more often.
Elderly people need the same nutrients as young people but in different amounts. Due to
the factors that negatively affect nutrition as a result of ageing, a lack of nutrients is more
prevalent in the elderly. For this reason, one should be more careful about consuming some
nutrients in terms of energy, protein, folate, vitamin B12, calcium, vitamin D, iron, zinc, and
riboflavin. All these elements, which are necessary for elderly individuals, act as catalysts
for certain diseases that may affect their learning process. For this reason, the health
educator should evaluate the levels of these substances, especially when assessing an
individuals physical characteristics (Tabloski, 2010).

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3.1.4 Deficiencies of sense of touch

Older adults may suffer from a reduction in feeling cold or hot and have pain due to the
decrease in the thickness of the dermis of the skin in old age, vitamin D synthesis, its
protection against micro-organisms, capillaries, collagen production, and senses of touch
and pressure (Tabloski, 2010).

3.2 Mental illnesses

Individuals with mental disorders have possibly been existing in community mental health
centers, in society, in the family or workplace environments for the last 25 years. People who
work with such individuals should consider their feelings and thoughts about mental
illnesses before the start of the teaching-learning process. Although there are some basic
principles in the education of individuals with mental illnesses, there are still some specific
instructional strategies that need to be considered. One of the first steps in any educational
attempt is mental diagnostics. Firstly, in order to diagnose the anxiety level of an individual,
it is necessary to determine whether the individual has any mental incapability or
insufficiency. When there is an emotional threat depending on the mental illness, the
individuals anxiety level will increase and the level of readiness will decrease. While
working with an aged individual with a mental illness, the following points must be
considered:

Training must be organized according to their needs.

Learning desire and the joy of life should be kept alive.

Teaching should be performed by using short and simple words and information must
be repeated as often as possible. Important pieces of information should be written on
cards, certain techniques such as drawing one of the cards which is appropriate for

them should be used and plain symbols and drawings must be used.
Sessions should be kept short and frequently repeated. (Four fifteen-minute sessions

instead of a one-hour session, etc.)

All possible sources for the individual and his or her family should be used, all
appropriate learning styles for the individual must be sought and training must be
organized in this direction, and training should be supported by visual tools such as

computers and videos.

Assistance from the individuals family members, relatives, neighbors and volunteers

must be accepted.
Instead of an authoritarian attitude, a calm and understanding approach must be
adopted in communication (Smith, 2006; Bastable, 2008; Kurt, 2000).
In addition, since individuals with mental illness face stigma both in society and in the
family, it is crucial to determine appropriate instructional strategies. Motivation of
individuals with mental illness is quite an important issue. After completing the program,
giving a certificate to participants will increase the motivation of each individual. However,
it is necessary to give useful information to increase the quality of life of elderly individuals
with mental illnesses. As for healthy individuals, achieving and maintaining the
independence and self-government of such individuals are extremely important (Smith,
2006; Bastable, 2008; Cornett, 2011).

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3.3 Chronic diseases

The learning process of individuals with chronic diseases is full of difficulties. Many
diseases have many phases that may affect the educational needs of the individual patients
and their families. Therefore, there is no unique approach to provide the most appropriate
teaching-learning. What matters is the start of the disease, its progress and intensity. The
perception and the reaction of these individuals families to the learning-teaching process
are also very important. Families are in need of education and information on the limitations
related to the changes and limitations in the lives of individuals. Usually, these individuals
experience conflicts between their needs to become dependent or independent in their lives.
Maintaining energy and independence could sometimes be physically and emotionally
repressing. Living with a chronic disease often causes a loss of role and some other changes.
When a loss of role and a decrease in self-respect appear, the situation affects readiness for
learning. Thus, it will be right to take the following actions:
Prevent medical crises and problems before they happen.
Take control of symptoms.
Apply the existing treatment plan and provide the management of self-care-related
problems.
Prevent their social isolation from other people.
Help them balance their living standards and their relations with other people.
To provide changes related to illness, adjust yourself.
Provide funding for treatment if necessary.
Prevent psychological, marital and family problems from happening (Tabloski, 2010;
Cornett, 2011).

4. Health education process for the elderly

People offering health education have many responsibilities to determine the needs of the
elderly and to take actions according to their needs (Kulak & Emirolu, 2011). The main
objective of health education is to provide individuals and society with assistance so that
they can lead a healthy life through their own efforts and actions. Therefore, health
education supports and develops all kinds of individual learning processes. Similarly, it
makes changes in the beliefs and value systems of individuals, their attitudes and skill
levels; in other words, it changes their lifestyles (Tabak, 2000).
The role of health educators is to apply education to develop responsibilities for the self-care
of individuals who are incompetent, which is also what they are supposed to do. Families
increasingly become more involved in the work of self-care-incompetent individuals
rehabilitation, and individuals with poor self-care are expecting to become a part of life in
the community. In addition, health educators have responsibilities to determine the learning
needs of patients in cooperation with families, to plan appropriate educational initiatives
and to provide a supportive environment (Bastable, 2008).
At the beginning of this education, the problems of patients, short and long-term
consequences of their deficiencies, the effectiveness of coping mechanisms, and their needs
related to the sensorimotor, cognitive, perceptual and communicational inadequacies need
to be defined. Patients level of knowledge related to their inadequacies, the amount and the

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kinds of information that may affect the needed behaviors and the readiness level for
providing learning should also be determined separately. In order to determine the
readiness levels of the patients, the following questions should be asked (Bastable, 2008):
Are other individuals and family members interested in patients learning, do they ask questions
about problem solving, or do they take patients needs into consideration?
Is there insufficient information, vision or hearing problems that prevent learning?
If there are any sensory or motor changes, will the people around the patients be participative
and supportive towards instructional activities? What is the most appropriate learning style that
is applicable to the patients self-care activities?
Is there compatibility between the patients and familys goals?
Does the patient have learning values and skills for the purpose of functional development?
After determining the level of readiness of the elderly, educational activities should be
structured in accordance with the models of health education. These models are described
below.

4.1 Health behavior models

Health behavior models and theories are inherently associated with health behavior
measurements because they explain what they are to assess. The models used most in elderly
individuals in articles published in the 2000s in education, health and behavioral sciences in
the field of a theoretical framework are the Health Belief Model, the Theory of Reasoned
Action/Planned Behavior, the Social Cognitive Theory and the Transtheoretical Model.
These four health behavior models, which can be utilized in planning the health education
process for the elderly, are summarized below.

4.1.1 Health belief model

The Health Belief Model (HBM) is the oldest of all the theories examined here. The Health
Belief Model holds that people are more likely to take action to prevent disease when they
realize that

they can catch the disease themselves,

the disease can have serious consequences,

preventive behavior effectively will prevent disease, and

benefits of reducing the dangers of the situation clearly outweigh the damages of taking
action.
Affected by mediating variables, these four factors have an influence on the expectations of
the known dangers and consequences of the disease. Therefore, they indirectly affect the
possibility of exhibiting preventive health behavior.
Health Belief Model health screening is used to intervene in the disease, disease role and
protective behaviors. This model has been subject to a number of changes since its
development. Table 1 shows the four constructs model, the most common description of the
Health Belief Model. The four main constructs of the model are perceived susceptibility,
perceived severity, perceived benefits (efficacy), and perceived barriers (harms) (Champion
& Skinner, 2008).

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Constructs Explanations

Perceived susceptibility An individuals assessment of his or her risk of getting the

condition
Perceived severity An individuals assessment of the seriousness of the
condition, treatment of the condition and its potential
consequences
Perceived benefits An individuals assessment of the positive consequences of
adopting the promoted behavior

Perceived barriers An individuals assessment of the influences that facilitate or

discourage adoption of the promoted behavior or its
psychological and physical consequences
Clues to action Experiences and strategies promoting the desired behavior

Self-efficacy An individuals self-assessment of ability to successfully

adopt
the desired behavior

From Redding, C.A., Rossi, J.S., Rossi, S.R., Velicer, W.F., & Prochaska, J.O. (2000). Health Behaviour
Model. The International Electronic Journal of Health Education, Vol. 3 (Special Issue), pp. 180-193.
http://www.iejhe.siu.edu
Table 1. Health Belief Model Constructs

4.1.2 Theory of reasoned action/planned behavior

The Theory of Reasoned Action (TRA) is a socio-psychological approach aimed at
understanding and predicting the determinants of health behavior and is a widely-used
theory of prediction. The Theory of Reasoned Action has been applied to many health-
related behaviors in the elderly including weight loss, smoking, excessive alcohol
consumption, HIV risk behaviors and mammography screening, etc. According to the
Theory of Reasoned Action, the intention of adopting a behavior is closely associated with
realization of that behavior. The Theory of Reasoned Action is based on two main
assumptions: behavior is controlled by will and people are rational. The Theory of Reasoned
Action holds that individuals believe: We do something because we have chosen to do so and go
through a logical decision-making process when we choose and plan our behavior.
Designed to predict behavior by looking at the intention, the Theory of Reasoned Action
claims mathematical relationships between beliefs, attitudes, intensions and behavior. A
modified version of the Theory of Reasoned Action adds perceived behavioral control to the
theory. It is called the Theory of Planned Behavior (TPB) (Montano & Kasprzyk, 2008). Table
2 describes the main concepts of the Theory of Reasoned Action and the Theory of Planned
Behavior.

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Health Education for the Elderly 163

Concepts Explanations
Behavioral intention Possibility of undertaking the perceived behavior
Attitudes The sum of beliefs about a particular behavior,
weighted by evaluations of these beliefs
Behavioral belief An individuals belief about consequences of
a particular behavior
Evaluation of behavioural belief
An individuals positive or negative evaluation of
self-performance of the particular behavior
Subjective norm The sum of normative beliefs and motivation to
comply with
Normative belief An individuals perception of the particular
behavior, which is influenced by the judgment of
others
Motivation to comply Every personal contact, an individuals drive to
engage
Perceived behavioral control The sum of control beliefs and perceived power
Control beliefs Possibility of the presence of factors that may
facilitate or impede performance of the behavior

Perceived power The effect of each situation that may facilitate or

impede performance of the behavior

From Redding, C.A., Rossi, J.S., Rossi, S.R., Velicer, W.F., & Prochaska, J.O. (2000). Health Behaviour
Model. The International Electronic Journal of Health Education, Vol. 3 (Special Issue), pp. 180-193.
http://www.iejhe.siu.edu
Table 2. Theory of Reasoned Action/Planned Behavior

The ultimate goal of the Reasoned Action Theory is to predict. The theory holds that the
intentions of the behavior affect the behavior. The three main variables that affect the
intention are subjective norms, attitudes and self-efficacy. Subjective norms involve an
individuals assessment of what significant others think of his or her ability to undertake a
behavior. For example, an elderly person with a cardiac condition tries to prevent
complications from the condition by taking his or her medication on a regular basis and has
regular medical checks. The intention of this individual is partly determined by the idea of
his or her spouse or a friend who could be a role model: What would he or she do if he or
she were me? Attitudes can be conceptualized in terms of values. In other words, a set of
values can be developed in relation to behaviors. For instance, healthy eating is a good way
to prevent heart disease and/or cancer (Redding et al. 2000; Montano & Kasprzyk, 2008).

4.1.3 Social cognitive theory

This theory goes far beyond individual factors to explain health behavior change and also
utilizes environmental and social factors. Indeed, this theory is the most comprehensive
model of human behavior proposed so far. Banduras Social Cognitive Theory (SCT) is a
behavioral theory of prediction that has a neutral approach to health behavior change. This

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theory is widely applied in health care in terms of health behaviors in prevention, health
promotion, and improving the living conditions of unhealthy behavior. The Social Cognitive
Theory emphasizes what people think and its impact on behavior. Based on triadic
reciprocality of behavior, the Social Cognitive Theory suggests that behavior can be
described using three key concepts, each of which serves as a determinant of one another.
The basic regulatory principle of the Social Cognitive Theory is reciprocal determinism. This
important concept represents a continuous and dynamic interaction between the individual,
the environment and behavior. Hence, a change in any of these factors will affect the other
two. The Social Cognitive Theory includes several auxiliary concepts for each of the three
main concepts in order to explain the theory. Table 3 explains all the key concepts of the
Social Cognitive Theory (Redding et al., 2000).

Concepts Explanations
Environmental Environmental factors other than the person
Situation Individual's perception of the environment
Behavioral Capability The knowledge and skills of an individual in
performing a behavior
Expectations The prospects of an individual performing a
behavior
Expectancies An individuals assessment of how the results
could be good or bad
Self-control Regulation of one's own behavior
Observational Learning Observing behaviors of other people to acquire
new behaviors
Reinforcements Reaction to the individuals behavior that
affects the possibility of repetition
Self-efficacy An individuals self-belief in achievement in
performing a behavior. Emotional coping
Emotional Coping Responses An individuals emotional strategies to cope
with provocative ideas, events and experiences
Reciprocal Determinism Dynamic interaction of individual, behavior,
and environment
from Redding, C.A., Rossi, J.S., Rossi, S.R., Velicer, W.F., & Prochaska, J.O. (2000). Health Behaviour
Model. The International Electronic Journal of Health Education, Vol. 3 (Special Issue), pp. 180-193.
http://www.iejhe.siu.edu
Table 3. The Concepts of Social Cognitive Theory

Bandura conceptualized the effects on human behavior including the concept of human in
terms of basic human capacities that are cognitive by their nature. Key concepts
associated with the person include: personal characteristics, emotional arousal/coping,
behavioral capacity, self-efficacy, expectation, expectancies, self-regulation,
observational/experiential learning, and reinforcement. The Social Cognitive Theory also
highlights the importance of cognitive and behavioral skills in building health behavior
changes. For this reason, smokers who want to quit smoking but lack the necessary
cognitive and behavioral skills to cope with stressful situations without smoking in the
future are less likely to be successful in changing smoking behavior, no matter how
enthusiastic they are (Redding et al., 2000).

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4.1.4 Transtheoretical model

In the last 20 years, research based on the Transtheoretical Model has revealed that there are
some common principles of behavior changes that can be applied to several health
behaviors. Examples of these behaviors are smoking cessation, exercise acquisition, sun
protection, dietary fat reduction, condom use, supporting mammography screening, the
spread of medicine use, coping with stress, and cessation of substance use. These problem
behaviors are very important in regards to both clinical and public health, as they are closely
related to an increase in the rate of illness and death and a decrease in the quality of life. The
Transtheoretical Model is a model of intentional behavior change that provides a large
volume of research and services in the field of problem behaviors. This model describes the
relationships among: stages of change; processes of change; decisional balance, or the pros
and cons of change; situational confidence, or self-efficacy in the behavior change; and
situational temptations to relapse. (Prochaska et al., 2008). Table 4 explains the concepts that
make up the Transtheoretical Model.
This model has some advantages over the other models. First of all, this model considers
behavioral change as a process rather than an event. Then, by dividing the change process
into phases and investigating which variables are associated with the improvement and
the extent of their association, it presents important clues both in research and
intervention development areas. The second advantage is that its emphasis on measuring
concepts constituted a rigid base for the model. Among different problematic behaviors,
different variables are associated with phase behaviors in each change phase. The
Transtheoretical Model studies report significant similarities among different types of
behavioral change. In the same way, it was found that phases of change had a predictable
relationship with positive and negative aspects of behavioral changes, confidence in
behavioral changes, the tendency to recur and processes of change (Redding 2000;
Prochaska et al., 2008).

4.2 Health education process

The health education process consists of some elements such as data collection, diagnosis,
planning and implementation.

4.2.1 Data collection/diagnosis

The data collection step is an important part of the education process. For example, in
education that targets elderly individuals, it is essential to determine the real needs in detail
at first in order to establish the needs and to meet those needs. Determination of the needs
also helps us to see whether the educational program meets the real needs or not (Demirel,
2000). In needs analysis studies, the individuals and the related groups needs have to be
determined. Determination of the needs that are peculiar to the individual or the group will
enable us to determine the goals that are appropriate to the health education program to be
prepared and will enable the individual to be more integrated with the society by showing
self-managing behaviors. What does the society expect an elderly individual to accomplish
basically? The program should be constructed with the regulations related to the answers to
this question at first (Demirel, 2000; Gokkoca 2001).

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166 Geriatrics

Concepts Explanations
Pre-contemplation The absence of any intention to take action within the
following six months
Stages of change

Contemplation Intention to begin the healthy behavior within the next

six months
Preparation Being ready to act within the next 30 days and
passing some behavioral stages
Action Having a clearly-changed behavior for less than six
months
Maintenance Individuals at this stage changed their behavior
more than six months ago
Pros The benefits of change
Decisional
Balance

Cons The losses of change

Confidence Trust in individuals ability to perform
healthy behavior in spite of temptations
Self-efficacy

Temptation Encouragement to perform unhealthy behavior

in various tempting situations

Consciousness Raising Gathering new facts, thoughts and tips that support
healthy behavior change
Dramatical Relief Having negative emotions (fear, worry, anxiety) that are
part of the unhealthy behavioral risks

Selfreevaluation Being aware of the fact that behavior change is an

Change Processes

important part of an individual's personality

Environmental Becoming aware of the negative effect of the
Reevaluation unhealthy behavior and the positive impact of healthy
behavior on their proximal social and /or physical
environment
Self-liberation Full commitment to change
Helping Relationships Searching and using social support for healthy
behavior change
Counterconditioning Replacement of unhealthy behaviors or cognition with
more healthy alternatives
Reinforcement Management Rewarding positive behavior change more and /or
reducing the award to unhealthy behaviors
Stimulus Control Eliminating clues or reminders to unhealthy behavior or
using clues or reminders to promote healthy behavior
Social Liberation Becoming aware of the fact that social norms have
changed in the direction of supporting healthy behavior
change.
From Redding, C.A., Rossi, J.S., Rossi, S.R., Velicer. W.F., & Prochaska, J.O. (2000). Health Behaviour
Model. The International Electronic Journal of Health Education, Vol. 3 (Special Issue), pp. 180-193.
http://www.iejhe.siu.edu
Table 4. The Concepts of the Transtheoretical Model

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Health Education for the Elderly 167

While determining the educational needs, and in the data collection step, the knowledge,
attitudes and behaviors that will be acquired by the target group are taken into
consideration. In order to learn this, it is necessary to live together with the target group,
establish meetings, to know them, to get information from their social leaders, to benefit
from the data of the related literature, and to examine their health records (Hacalioglu,
2009). While determining educational needs, the following questions have to be answered:
1. What is the general situation?: There should be sufficient information about the
characteristics, number and the level of success of the educational programs for the
elderly; the economic resources of these educational programs, the proficiency level of
educators, and educational materials and the technologies.
2. What is known about the participants?: The participants cognitive, affective, and physical
abilities, their previous experiences, their perceptions of themselves and the society can
be evaluated (Demirel, 2000). In order to achieve this, an examination HBDH (REALM-
Rapid Estimate of Adult Literacy) can be implemented to determine the cognitive level
of the individual and his or her knowledge level in the treatment process in a short time
like one or two minutes. In addition, individuals can be asked how they feel while
filling out the documents (Rojda & George, 2009).
3. What is the content of the educational materials like?: The material to be prepared should be
checked for their suitability and consistency with the aims of the education and for
legibility for the elderly (Demirel, 2000). In order to evaluate the material, a checklist
can be prepared and implemented to see whether the material is consistent and suitable
and can easily be read. In addition, with some tools like Fleisch-Kincaid Grade Level
and SMOG (Simple Measure of Gobbledygook), the number of the sentences and the
words can be counted and the suitable material can be decided on (Rojda & George,
2009).

4.2.2 Planning
While planning the health education plan, elderly individuals socio-economic level and
cultural background should be taken into consideration. Therefore, the material to be used
in the education should be chosen carefully. The level of instruction should be parallel to the
understanding level of the individuals. In addition, the place and the duration of the
implementation must be indicated in the plan (Hacalioglu, 2009).

Who will train?/ The trainer The trainer

The elderly individuals who cannot feed

Who will get the education? / themselves properly in a nursing and
The target group rehabilitation center

What to teach? /The subject Eating habits

Why to teach? /The aim To inform the acquisition of the

behavior

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168 Geriatrics

How to teach/ The methodology Instruction modeling- doing-

discussing, and etc.

Where to implement /The place The classroom, etc.

The time of the education/The date Month day - hour

The duration of the education E.g., twice a day, or three times a week.

A health education plan must be designed based on some principles. These principles are:

Functionality: The plan must have the qualities and the content to achieve the
educational goal or goals. And it must consist of the goals that can be measured,
beneficial, action-based, and valid for real life.
Flexibility: The plan must be creative and flexible, be able to answer the individuals
changing needs and be open to new developments.
Realistic: The health education plan must not include over-idealistic and utopic aims.
Practicability: Not only the people who prepared the plan but also other people can use
the health education plan easily at different times.
Being Scientific: The health education plan should include scientific qualities in terms of
the knowledge and the behavior to be gained.
Suitability to the social values: The plan shouldnt contradict the life philosophy, ideals,
beliefs and the values of the society where it is implemented.
Being Economical: The costs of the implementation steps of the health education plan
and the behaviors to be acquired should be affordable (Tabak, 2000).
Another factor to be considered in the planning is the determination of learner-centered
objectives. The objectives are defined as the changes in the behaviors of the individual or the
group. The objectives have priority in the determination of the target group and the content
of the educational program. Besides, the objectives should be determined first in order to
decide on the methodology and the techniques to be used in the program. The goals can be
determined as the short and long-term (Demirel, 2000; Tabak, 2000). For example, teaching
an elderly individual with type II diabetics how to inject insulin is a short-term objective. On
the other hand, it is a long-term objective for the same individual to manage the illness
effectively.
The objectives to be determined in health education can be developed for individuals
cognitive, affective and psychomotor skills. The cognitive field is related to the knowledge
and the mental abilities that are derived from knowledge (Demirel, 2000; Tabak, 2000). The
cognitive domain objectives related to an elderly individuals health education can be
written as follows:
While preparing an educational program, the trainer, the target group, the aim of the
education, the methodology to be used in the education, and the place and time of the
education should be clearly determined (Demirel, 2000; Hacalioglu, 2009). For example, a
health education plan for the elderly individuals who cannot feed themselves properly can
be as follows.

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Health Education for the Elderly 169

Knows the complications of Type II Tells the normal blood pressure values.
diabetics. Interprets the relation between
Knows the normal blood glucose level. hypertension and salt.
Plans his/her dietary program. Tells the associations related to the
hypertension.
Evaluates his/her diets effects on the type Evaluates the effects of regular health
II diabetics. controls for the effective management of
hypertension.
Knows the complications of Type II Tells the normal blood pressure values.
diabetics Interprets the relation between
Knows the normal blood glucose level. hypertension and salt.

The affective domain target behaviors are related to the emotion and value systems. Interest,
attitude, appreciation, belief, etc. include behaviors that are difficult to measure (Demirel,
2000; Tabak, 2000). Affective domain objectives can be written as follows:

Believes in the importance of measuring Is careful about keeping the blood pressure
the blood glucose at regular intervals. at correct levels.

Is willing to participate in the scientific and Is willing to follow the up-to-date

social activities related to diabetics. resources about hypertension.
Accepts the new diet special to him or her. Accepts being an active member of the
associations related to hypertension.
Cares about the continuation of the regular Believes in the importance of regular health
physical exercises. controls for the effective management of
hypertension.
Believes in the importance of measuring Is careful about keeping the blood pressure
the blood glucose at regular intervals. at correct levels.

Is willing to participate in the scientific and Is willing to follow the up-to-date

social activities related to diabetics. resources about hypertension.

Finally, the psychomotor domain includes skills that require the individuals muscle and
mind coordination (Demirel, 2000, Tabak, 2000). Psychomotor domain objectives can be
written as follows:

Follows the stages of the measurement in Follows the stages of blood pressure
the blood glucose meter. measurement.
Measures the blood sugar level alone. Measures blood pressure properly.
Performs a proper physical preparation for Takes a proper position when blood
the measurement of blood sugar. pressure rises.
Applies a self-insulin injection. Prepares hypertension drugs properly.

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170 Geriatrics

Some programming approaches should be utilized so that the content can be managed
consistent with the objectives. These can be summarized as linear, spiral and modular
programming approaches. The linear programming approach is used to arrange the topics,
which consist mainly of learning that is successive, closely related or a prerequisite for each
other. Spiral approach programming involves addressing issues over and over when
necessary. Finally, in the modular programming approach, the subjects to be learnt are
divided into modules, modules are connected to each other and each module gains meaning
within itself. The content should be offered after determining the most appropriate
programming approach for the elderly. What programming approach to choose should be
decided by considering factors such as learning preferences, cognitive-affective and
psychomotor skill levels of the target elderly population, qualifications of the educator and
available sources (Demirel, 2000). After organizing the content based on the appropriate
programming approach, the next step is to decide with which method, technique, material,
etc. to present that content. The groups characteristics, size, target learning domains,
duration of education, funds, available educational resources, the educators qualities and so
on have to be taken into account when choosing educational methods tailored for the
elderly (Demirel, 2000; Tabak 2000).
Methods such as lectures, discussions, questions and answers, demonstrations, role-plays,
etc. can be used according to the goals and objectives in the process of education. However,
no matter what method is used, there should be active participation of the elderly, feedback
and a supportive communication style (Tabak, 2000). Therefore, educational environments
should be designed in a way that allows everyone to see each other easily, have eye contact
with each other comfortably, and should be free of hierarchy. Common seating
arrangements are U-type, team style, circle, and work units seating orders; arrangements
can be shaped according to the educational method chosen.
In order to determine the location and time for health education, educators and the target
group should take the decision jointly. It would be appropriate to choose convenient times
and places (Tabak, 2000). In addition, the place of education must have efficient acoustic
features; enough space for writing activities and tools like wheelchairs, sticks and walkers; a
suitable temperature; non-slip stairs and a floor, and comfortable chairs with back support
on which individuals of different physical sizes can comfortably sit (Grandal, 2008).

Fig. 1. U Seating Order

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Health Education for the Elderly 171

Fig. 2. Team Seating Order

Fig. 3. Circle Seating Order

From Demirel, (2000). Learning Art. Ankara, Turkey: Pegem A Publishing.

Fig. 4. Working Units

Another component of this educational process is materials; the answer to the following
question is important when choosing educational materials: Are the font of these materials
large enough for the elderly to read easily? The font of educational materials should be large
enough and the background should contain white areas because it is easier to read when the
background largely consists of white areas. Also, images and graphics should be preferred
as they make the message clearer. Words and posters should be used instead of long

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172 Geriatrics

paragraphs (Rojda & George, 2009). In addition, medical/health terminology (i.e., medical
jargon) should be avoided in the educational materials designed specifically for the elderly
(Figure 5 a, b). Finally, another focus point in the health promotion for the elderly is
encouraging health promotion experts to acquire the necessary skills so that they can
develop culturally and linguistically appropriate health education materials (Wallace, 2004).

a. b.

Fig. 5. a. Appropriate educational material. b. Inappropriate educational material

4.2.3 Implementation
It is the phase that involves organizing the learning experiences that enable the individuals
to gain the targeted behaviors. Learning experiences are to be oriented to the individual, and
must be arranged in a specific order. This arrangement can be ordered as introduction or
preparation activities, development activities, and final activities (Demirel, 2000). The
individual must be informed in advance about which qualities and competences he or she
will have by the end of the educational process. Afterwards, the necessary content to
achieve these goals should be indicated. The activities planned to be implemented must be
assessed during improvement activities (Demirel, 2000).
It is crucial to pay specific attention to the language used and communication when you
apply the health education process. The essential strategies to communicate effectively with
elderly individuals can be summarized as follows:
Improving communication with an elderly individual
1. Using the principles of individual-centered care
- Knowing the person to be educated: An educator that works with elderly individuals is
required to be able to use his or her tone of voice, facial expressions, gestures, and the
words correctly, and have the ability to listen without expressing criticism, sadness,
or complaint.

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Health Education for the Elderly 173

- Applying the principles of gentle listening: The educator must listen what is being said
without interrupting the person, or "tuning out" his or her words. The educator should
understand what the real problem is.
- Allowing time to right (positive aspects of their lives) things as well as talking about
problems: The individuals positive qualities/strengths must be stressed while talking
about problems. Emphasizing wrong things can create a bad feeling. Listen to
personal stories and experiences properly. What does the person say? What is the
individual doing to improve his or her power and abilities?
- Slow down and focus on the individual: What is he saying? What is he conveying? The
educators shouldnt have a hasty or duty-based approach. Attention should be paid not
only to what they say about their health but also to other things they mention. Think
about being an old person, he or she has lived a long life. What is the meaning of the
current situation for him or her?
2. Arrange the environment and the routines
- Adjust changes in seeing: An older adult can see you better in bright light. Avoid
standing too close in order not to being seen blurred. You should stand in front of the
person to be seen easily. Yellow and red or green and blue colors should be used for
signs and markers.
- Adjust to changes in hearing: Make sure that the individual can read your lips. If it is
necessary to speak out, a low tone of voice should be used. Ear wax accumulation ought
to be checked as it can prevent hearing. Hearing aids and batteries should be checked.
- Pay attention to environmental effects: in educational environments, the noise must be
prevented. Rooms must be lit enough to see them and let them read your lips. Elderly
individuals mustnt worry about others hearing what they say (privacy respected).
- Evaluate the personal comfort level of the individual: They should be physically
comforted.
Hunger, thirst, pain, or the need for the toilet must be eliminated. What they think and feel
should be evaluated for their effects on learning.
3. Adjust your interaction with the elderly
- Think about the approach and the language: They should be given time to respond to
your questions, or ask questions (Note: The reaction time slows down). Familiar and
understandable words should be used, and medical terminology or slang should be
avoided. The educator should be clear and understandable, and should not use long
explanations or instructions.
- Adapt to changes in responses: If you need to improve participation, yes/no questions
should be used. Important points should be written in large fonts. Use physical gestures
to enhance verbal communication. Questions with only two options may be used in
order to promote success.
- Help them think by giving clues like When? or How long ago? Apologize for
misunderstandings and provide an explanation.
4. Adapt your approach to accommodate changes in EXPRESSION: Listen for meaningful
words and ideas, trying to identify the main theme or goal. Respond to the persons
emotional tone and validate feelings (e.g., understandable to feel frustrated, angry).
Accept/understand cursing or other foul language as an expression of distress and
discomfort not an insult to you. Using guessing (e.g., trying to replace words the

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174 Geriatrics

person is having difficulty saying) based on how well you know the person and the
relationship you have; guessing can been annoying to the person and may further
increase confusion (Smith, 2006; Cornett, 2011).

4.2.4 Evaluation
The success of health promotion can be evaluated by measuring to what extent the intended
objectives can be achieved. What were the individuals knowledge, attitudes and skills on
the subject before the education? What have they accomplished after the training? How
much lack of information has been fixed? Has an attitude change been provided? Have the
skills been gained? How much have they gained? What more skills should be gained? The
correct answers to these questions, etc. are obtained by measurement and evaluation
(Hacalioglu 2009).
Evaluation processes are usually performed with qualitative and quantitative assessment
techniques. The knowledge level of elderly individual/individuals participating in a health
education program can be estab;ished only through post-training tests. During the
evaluation process, qualitative methods such as observation and interviews can also be
used. Qualitative evaluation includes the views and expectations of educational program
participants and other people related to the program and provides a much broader
perspective than quantitative assessment (Tabak, 2000). In recent years, however, these two
types of assessment have been used together in a holistic approach to minimize the
disadvantages of both methods.

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 Geriatrics
Edited by Prof. Craig Atwood

ISBN 978-953-51-0080-5
Hard cover, 246 pages
Publisher InTech
Published online 24, February, 2012
Published in print edition February, 2012

With the baby boomer generation reaching 65 years of age, attention in the medical field is turning to how best
to meet the needs of this rapidly approaching, large population of geriatric individuals. Geriatric healthcare by
nature is multi-dimensional, involving medical, educational, social, cultural, religious and economic factors. The
chapters in this book illustrate the complex interplay of these factors in the development, management and
treatment of geriatric patients, and begin by examining sarcopenia, cognitive decline and dysphagia as
important factors involved in frailty syndrome. This is followed by strategies to increase healthspan and
lifespan, such as exercise, nutrition and immunization, as well as how physical, psychological and socio-
cultural changes impact learning in the elderly. The final chapters of the book examine end of life issues for
geriatric patients, including effective advocacy by patients and families for responsive care, attitudes toward
autonomy and legal instruments, and the cost effectiveness of new health care technologies and services.

How to reference
In order to correctly reference this scholarly work, feel free to copy and paste the following:

Ayla Kececi and Serap Bulduk (2012). Health Education for the Elderly, Geriatrics, Prof. Craig Atwood (Ed.),
ISBN: 978-953-51-0080-5, InTech, Available from: http://www.intechopen.com/books/geriatrics/health-
education-for-elderly-people

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Fax: +385 (51) 686 166 Fax: +86-21-62489821
www.intechopen.com