The Healthy Ageing Model: Health behaviour change for older adults
Article Outline
- Summary
- Theoretical and practice background
- The Healthy Ageing Model
- Clinical applications and summary
- References
- Copyright
Summary
Proposed is a model of primary care for older adults with chronic health conditions that focuses on active engagement in health care. The Healthy Ageing Model is anchored in established theory on motivation and health behaviour change. The model draws on empirical and applied clinical underpinnings in such diverse areas as health promotion and education, treatment of addictions or obesity, management of chronic diseases, goal-setting, and coaching techniques. The conceptual foundation for the Healthy Ageing Model is described first, followed by a brief description of the key characteristics of the model. In conclusion, suggestions are offered for the clinical application and for further developing the model.
Keywords: Health coaching, Nurse coaching, Healthy ageing, Motivational Interviewing, Disease management, Self-care, Self-efficacy, Goal-setting, Behaviour change, Lifestyle management
Theoretical and practice background
It is well established that the health of older adults, especially those with chronic health conditions, is heavily dependent upon behavioural choices (CDP, n.d., Healthy people, 2010). However such changes are not always easily accomplished or sustained. The challenge to clinicians is how best to support clients in adopting healthy behaviours.
There has been intense scientific and clinical interest in health behaviour change over the past few decades (Bandura, 1977, Bandura, 2004, Gollwitzer, 1999, Green et al., 1994, Hibbard et al., 2007, Lorig, 1996, Prochaska et al., 1992, Prochaska, 2008, Rollnick et al., 2007). Recurring themes in this literature include: self-efficacy, perceived control, and decisional balance, and perceived benefits. The majority of interventions that used these theories also emphasised a client centered, and goal-setting approach.
Self-efficacy (the belief that one is capable of performing in a certain manner to attain certain goals) (Bandura, 2004) and perceived control (a belief that someone has the ability to make a difference) (Jerant, Moore, Lorig, & Franks, 2008) are two related concepts that are dynamic in nature—beliefs that are shaped by behaviour and that in turn affect behaviour (Leventhal, Weinman, Leventhal, & Phillips, 2008). In a review of the literature on perceived control and older adults, although Jacelon (2007) found a lack of consensus on the theoretical underpinnings, her findings indicate that there is general agreement that high perceived control is important for wellbeing in older adults and effective disease self-management.
There is also a strong relationship between decisional balance (the individual's weighing of the pros and cons of changing a behaviour) (Prochaska, 2008) and perceived benefits (an individual's assessment of the positive consequences of adopting the behaviour) (Green et al., 1994). After examining the pros and cons of a behaviour change, if the benefits are perceived as being advantageous, the person is more likely to follow through with the change or adhere to the treatment plan (De Smet, Erickson, & Kirking, 2006).
A client-centered approach is exemplified by methods of reflective listening, eliciting solutions from the patient, and supporting autonomy (Rollnick et al., 2007), the principles of self-care or self-as-healer (Lorig, 1996), and matching programs to the state of readiness of clients (Prochaska, 2008). Goal setting, not just establishing targets but how targets are established, also appears to be important to success. Multiple researchers and practitioners stress setting small achievable targets based on the patient's readiness and activation level (Hibbard et al., 2007, Rollnick et al., 2007). Individualizing goals and making them specific for times and places also appears to be essential (Gollwitzer, 1999, Prochaska, 2008).
As promising as these concepts and approaches are, their application has so far been limited to relatively narrow groups of clients, such as participants in cardiac rehabilitation programs, those with other chronic diseases, or those with problems with alcohol, tobacco or obesity. They have not been widely applied to general health behaviours and multiple methods have only rarely been purposefully applied in concert. In addition, the application of these methods to an ageing population has only begun. Jacelon's work (2007) underscores the importance of addressing perceived control with older adults. Lifestyle factors, including exercise, dietary behaviour and stress management have been established as major contributors to healthy ageing (Staner, 2009). There remains a need, however, for better understanding of the application of these approaches in health promotion for older adults.
Personal patterns are central to improving sustained health in a manner that limits disability to only a small amount of time immediately before death. Because older individuals have not been systematically included in behaviour change research there is little agreement about what health promotion and disability prevention or “compression of disability” (Dychtwald, 1999) specifically means for the over fifty population (Berg & Cassells, 1990).
Beyond prevention of morbidity, older adults and families also seek better quality of life in the later years (Healthy people, 2010: Understanding and improving health, 2000). For most, in addition to physical health, “quality of life” includes a general sense of happiness and satisfaction, meaningful activity, and the ability to express culture, beliefs, values and relationships (Healthy people, 2010: Understanding and improving health, 2000).
The Healthy Ageing Model
It is in response to the literature and the need to systematically study the effects of the application of theory, the Healthy Ageing Model was developed to guide ongoing research and practice (see Fig. 1). The concept described here represents a model of health promotion for an ageing population, a model focused on supporting positive health behaviour changes in ageing adults. The model combines tested methodologies and applies established theoretical models of health behaviour change in a population of ageing individuals in varying states of health and illness. The purpose of this paper is to describe the conceptual framework of the Healthy Ageing Model, and lay the foundation for a concerted research effort to evaluate its effectiveness.
Figure 1.
The Healthy Ageing Model: a practical model of health behaviour change for older adults.
The Healthy Ageing Model is characterised by four elements: (1) a client-centered perspective, (2) a goal-driven approach, (3) an individualised “coaching” strategy of health behaviour change, and, (4) recognition of the importance of the broader health context in which clients live, described in the model as one's “Personal Health System.” The following paragraphs briefly describe each of these elements.
Client-centered perspective
The care experience and expressed needs of the individual are of vital and primary interest in this model. We know that health and illness experiences are very personal. First-person accounts by patients are a rich resource for understanding health, illness and recovery. The Healthy Ageing Model concentrates on understanding and focusing continuous attention to the needs and perspectives of the client and their support systems. This involves approaching the client in an empathetic, non-judgmental manner, “surrendering” the provider agenda and truly listening to the client's story.
Goal-driven approach
Goal setting is central to this model. The approach is based on the assumption that goals that are (1) articulated by the client, (2) individualised, (3) specific, (4) meaningful and (5) achievable are the most effective. Goals may or may not be directly related to health, or at least health in this context is very broadly defined. It is another premise of the model that even modest progress toward a specific goal accesses clients’ desire to engage further action toward other desired behaviour change. Confidence or self-efficacy is built specific behaviour by specific behaviour.
Health professionals coaching
Behavioural coaching, an art not well understood or routinely practiced by many clinicians, is a core strategy of the model proposed here. The role of the health coach is to facilitate, through counseling methods, the client's own identification of health or health care goals and facilitate the client's behaviour change necessary to achieve these goals. One aspect of successful counseling is a methodology called Motivational Interviewing (MI). MI is “a directive, client centered counseling style for helping clients to explore and resolve ambivalence about behaviour change” (Miller & Rollnick, 2002). MI is the only health coaching technique to be fully described and consistently demonstrated as causally and independently associated with positive behavioural outcomes (Butterworth, Linden, & McClay, 2007). It is characterised by the “spirit of the counseling style, in which motivation to change is elicited from the client, not imposed from without” (Rollnick et al., 2007). The MI-based health coaching approach differs greatly from the traditional health education model used frequently in health care settings and, generally, from other health coaching approaches (Butterworth et al., 2007). It is not based on the information model, does not rely on information-sharing, advice-giving or scare tactics, and is not confrontational, forceful, guilt-ridden, or authoritarian; rather it is shaped by an understanding of what triggers change (Miller & Rollnick, 2002). In fact, a systematic review of the literature demonstrates that MI outperforms traditional advice-giving in the treatment of a broad range of behavioural problems and diseases (Rubak, Sandbaek, Lauritzen, & Christensen, 2005).
The Healthy Ageing Model goes beyond MI, however, borrowing concepts and techniques from the work of Lewis and Zahlis (1997) in their experience with the application of nurse coaching with cancer patients and their families, Lorig (1996) in her work with diabetes and other chronic conditions, Prochaska (2008) in assessing readiness to change, and Bodenheimer and Laing (2007) in their development of the patient-centered medical home model. The focus shifts from an expert giving information, advice and behaviour prescriptions to using a team-based model to help clients explore values, concerns, intention and reasons for change and then consider ideas and strategies for change.
Personal Health System
The Personal Health System is a concept that has grown out of Henry's notion of an “idiopathic health system” (Henry, 1999). The Personal Health System can be briefly defined as a constellation of relationships, activities, practices, and beliefs that bring value and meaning to clients and assist them in moving toward their goals. It may include traditional medical service elements as well as other health supportive services used or available to the client (e.g. health club, nurse coach, care giver services, faith communities, cultural rituals, alternative or complementary care) that contribute to the client being able to engage in meaningful life activities and relationships. Family and social network engagement and the ongoing creation and acknowledgement of activities, people and resources the client relies on for assistance and support is well-documented as a key contributor to positive self-care and well being (Beckingham & Watt, 1995).
Clinical applications and summary
Early applications of this model have demonstrated effectiveness particularly of the MI method of health coaching for exercise and diet (Bennet et al., 2005). While a comprehensive assessment of the model awaits further study, we think that the theoretical and empirical underpinnings of the model are compelling for clinical practice.
A key aspect of clinical application is the establishment of the ongoing relationship with a provider as coach rather than solely as an information source. This relationship can be sustained through telephone and electronic mail as well as through in-person clinic or home visits. We recognise that the role of the coach may not be the same as the role of the primary care provider. In our work, coaches have functioned in a synergistic manner with the primary care provider who may be a physician or nurse practitioner. The clients have easily recognised the distinct roles and have appropriately utilised both sources in their health care. Yet, we also recognise that efficiency in primary care is important and we also have found that the primary care provider may themselves embody the coaching role. A fundamental aspect of the model is exquisite communication between the primary care provider and the coach (if they are different individuals) as well as communication with other allied health providers as the client or patient's needs present. The important aspect is the relationship that is established that shifts the focus of the provider/coach to a client-centered, health promoting, and facilitative support with the client as partner.
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PII: S1322-7696(10)00027-2
doi:10.1016/j.colegn.2010.04.008
© 2010 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
