S INCE 1900, there has been a ninefold increase in "o ld" Americans, or those over 65, and
their number is expected to increase to 65 million by the year 2030 (American Association of Retired Persons and Administration on Aging, 1986). It is also expected that by 2040 there will be a fivefold increase in the number of "old-old" Americans, or those over 85, bringing this segment of our pop- ulation to 13.3 million (Saldo & Manton, 1985). Many exercise and other health-promoting pro- grams are marketed to the young and middle aged; yet, considerably more attention must be paid to the health of all citizens at all ages to achieve a healthy nation.
Concepts and practices to enhance wellness, in- dependence, and quality of life among all ages have gained widespread attention. The public has become increasingly aware that one's health can be positively influenced through health-promoting be- haviors over the life span. Pender (1987) defines health-promoting behaviors as those that become an integral part of an individual's life-style, such as physical exercise and nutritional eating prac- tices.
Exercise reportedly has strong psychological,
From the University of North Dakota, College of Nursing, Grand Forks, ND.
Address reprint requests to Cecilia Volden, MS, RN, Uni- versity of North Dakota, College of Nursing, P.O. Box 8195, University Station, Grand Forks, ND 58202.
social, and physiological benefits for both young and older individuals. Exercise has resulted in "improved orientation, improved motivation to- ward self-care, responsibility and social improve- ment, higher scores in fluid intelligence and im- proved cognition" (Paillard & Nowak, 1985, p. 36), as well as increased vitality. Paillard and Nowak also found that improved activity toler- ance, range of motion, mobility, affect, and mood occurred in older adults after group exercise par- ticipation. In other research, Halfman and Hojacki (1981) suggested that "exercise helps to improve the quality of life. Many feel that this benefit alone is adequate to stimulate a personal commitment to exercise" (p. 9). Pender (1987) asserted that "a well planned physical activity program can in- crease aerobic capacity by 20 to 30 percent, im- prove cardiorespiratory endurance, enhance mus- cle strength and improve flexibility" (p. 289).
Nutrition and diet, balanced with exercise, also have been found to have a direct, positive, cumu- lative effect on general health and well-being of adults (Belloc & Breslow, 1972; DuBrey, 1982; Harris & Guten, 1979). Pender (1987) suggested that when structuring appropriate health promotion programs, age and gender, as well as exercise, nutrition, and diet must be considered.
It has been generally accepted that a healthy life-style is the way to achieve optimal health and prevent disease. With an understanding of how life-style is related to life processes, interventions that foster healthy living may be empirically planned and instituted (Payne, 1983; Pender, 1987). The impetus then for this study was to gain information that could be used to enhance the de- sign and implementation of appropriate health pro-
motion programs within the local community for older adults as well as for other age groups. Pend- er's Health Promotion Model (Figure 1) was se- lected as the framework for this study. It brings with it an extensive review of the literature on relevant topics. Pender (1987) states that the
Concepts and practices to enhance wellness,
independence, and quafity of fife among all ages have
gained widespread attention.
"model is based on a synthesis of research find- ings from studies of health promotion and wellness behavior" (p. 57).
Pender's model emphasizes seven cognitive- perceptual factors that comprise primary motiva-
Cognitive/Perceptual Factors
' Importance of Health
I Perceived Control of Health
I Perceived Self-Efficacy
I • Definition of Health
Figure 1. Health Promo- t ion Model . Note. From Health Promotion in Nursing Practice (2nd ed.) by N. Pander, 1987, Norwalk, CT: Appleton & Lange. Copy- right 1987 by Appleton & Lange. Reprinted with per- mission. For further infor- mation, contact Dr. Nole Pender, Health Promotion Research Program, Social Science Research Institute, Northern Illinois University, DeKalb, IL 60115.
" Perceived Health Status
I Perceived Benefits of Health-Promoting
Behaviors
Perceived Barriers to Health-Promoting
Behaviors
F I I
I
21
tional mechanisms for acquisition and maintenance of health-promoting behaviors, five modifying fac- tors that indirectly influence patterns of health be- havior, and cues that result in participation in health-promoting behavior. Emphasis in this study was placed on the cognitive-perceptual factors of the definition of health and perceived health status; the modifying factors of demographic and biolog- ical characteristics; interpersonal influences and behavioral factors; and cues that lead to engaging in health-promoting behaviors. Hypotheses tested were:
1. There are no differences between men and women in perceived health status, self-acceptance, meaning of health, and life-style measurements of nutrition, self-actualization, interpersonal support, stress management, health responsibility, and ex- ercise.
2. There are no differences among various age groups in life-style measures, perceived health sta- tus, self-acceptance, and meaning of health.
3. There are no differences among nonexercis-
Modifying Participation in Factors Health-Promoting
Behavior
I * Demographic I Characteristics
• Blologlc I Characteristics
I * Interpersonal I Influences
I Situational Factors
• Behavioral Factors
It J
I
|
* Likelihood of I Engaging In
I Health-Promoting Behaviors
Cuee to Action
22 VOLDEN ET AL.
ers, acquisition phase, or maintenance phase exer- cisers in life-style measures,perceived health sta- tus, self-acceptance, and meaning of health.
METHOD
Sample
Participation was solicited through exercise classes and various community and church groups. Five hundred twenty-four individuals consented to participate. Four hundred seventy-eight question- naires were returned with the complete data nec- essary for inclusion in this study.
This convenience sample of 478 consisted of 291 men and 187 women, aged 18 to 74. Men comprised 60% (291) of the total sample. Women made up 53% (n = 129) of the two exercise groups (see Table 1). The mean age of the sample was 40 years, with exercisers averaging 2 years younger than nonexercisers. While the median family income range was $25,000 to $29,999, an income of over $40,000 was reported by 31% (n = 148) of the respondents. This is consistent with the mean income for the total population in this rural-urban community. Over 95% (n = 444) of the participants had completed high school and over 55% (n = 263) had completed college course work.
Instruments
Laffrey Health Conception Scale (LHCS)
The LHCS measures individual perceptions of the meaning of health using four dimensions based on Smith's (1982) description of four ideas of health. The four dimensions are as follows: clini- cal (the absence of disease or illness); the role
Table 1. Exercise/Nonexercise Groups by Age and Gender
performance/functional component; adaptiveness (flexibility in adjusting to changing circum- stances); and eudaemonism (exuberant well-being and self-actualization). Content as well as con- struct validity were established through factor analysis. The scale alpha coefficient for internal consistency was .88, and test-retest reliability after 1 week was .78 (Laffrey, 1986).
Philadelphia Geriatric Center Multilevel Assessment Inventory (MAI)
The MAPs subscale of self-rated health in the physical health domain was used based on its abil- ity to measure self-rated health of young to old adults. The tool contained four items with an alpha reliability of .76 and a retest of .92 after 2 weeks (Lawton, Moss, Fulcomer, & Kleban, 1982).
Rosenberg Self-Esteem Scale
This easily administered, unidimensional tool measures the self-acceptance component of self- esteem (Rosenberg, 1965). The scale's reported stability reliability over a 2-week period was .85 (Silber & Tippett, 1965). The Guttman reproduc- ibility coefficient was .92, and the scale correlated from .56 to .83 with several similar measures to substantiate convergent validity (Rosenberg, 1965).
Health-Promoting Life-Style Profile (HPLP)
The HPLP is a 70-item questionnaire designed to measure health-promoting behavior conceptual- ized as perceptions, attitudes, and actions that serve to maintain or increase the level of wellness, self-actualization, and fulfillment of the individ- ual. The instrument has a high internal consistency with a standardized item alpha of .94. The six subscales (nutrition, self-actualization, interper- sonal support, exercise, stress management, and health responsibility) have standardized item al- phas ranging from .76 to .91. The test-retest r was .85 over a 2-week period (N.J. Pender& S.N. Walker, personal communication, December 18, 1985).
Procedure
A cover letter described the purpose of the study and guaranteed anonymity. Questionnaire packets consisted of demographic questions and the four previously described tools, as well as stamped, ad- dressed return envelopes.
HEALTH AND LIFE-STYLE MEASURES
DATA ANALYSIS
Quantitative information was reported through the use of descriptive statistics in summarizing nu- merical data. A three-way analysis of variance (6.2.3) was used to examine groups that differed from each other along three dimensions: age, gen- der, and length of time in regular exercise (Huck, Cormier, &Bounds, 1974). Health-related vari- ables tested were self-rated perception Of health, self-acceptance, meaning of health, and various health-promoting life-style measures.
RESULTS
The sample was separated into three groups ac- cording to Dishman's (1982) criteria: nonexercis- ers were those who reported that they were not currently exercising regularly or had been exercis- ing for less than 1 month (n = 234); acquisition phase exercisers had been exercising regularly for 1 to 6 months (n = 66); and maintenance phase exercisers had exercised regularly for 7 months or longer (n = 178) (see Table I). Sixty percent of the nonexercisers reported that they had previously exercised regularly, while 40% had never exer- cised regularly for a period greater than 6 months.
Hypothesis 1
This was rejected as there were significant gen- der differences on several measures. Men scored higher than women in self-acceptance, whereas women scored higher on measures related to mean- ing of health, overall health-promoting life-style profile, and the HPLP subscales of nutrition, in- terpersonal support, exercise, and health responsi- bility. There was no significant gender difference with perceived health status, or with the HPLP subscales of self-actualization and stress manage- ment.
Hypothesis 2
No significant differences were found with per- ceived health status, self-acceptance, and meaning of health among various age groups. However, there were significant differences on three of the HPLP subscales. There was a gradual increase in concern with nutritional health with increasing age. Results indicated a steady decline in partici- pation in exercise until the age group of 55 to 64, when there was a resurgence. This was followed by a continued decline in the 65 to 74 age group.
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Data indicated that assumption of health responsi- bility practices steadily increased with age.
Hypothesis 3
Several significant differences related to exer- cise practices were found. Scores on the MAI and LHCS were greatest for the maintenance exercise group. Exercisers scored higher on the overall HPLP than nonexercisers, with those in the acqui- sition phase scoring higher than the maintenance exercisers.
The HPLP subscales also indicated differences between the exercise groups. Nutrition measures were significantly higher for exercisers, with those who had been exercising longer having the highest scores. Self-actualization scores were highest for those who had exercised regularly between 1 and 6 months, and lowest among those who did not reg- ularly exercise. The differences among the three groups were significant. There were significant differences on the HPLP interpersonal support scores; the mean for the nonexercise group was the lowest and the mean for acquisition exercisers was the highest. The HPLP exercise subscale discrim- inated between the three exercise groups (p < .001); nonexercisers had the lowest mean, the ac- quiSition exercisers had the next highest, and the maintenance group had the highest mean. Stress management scores were higher for exercisers than for nonexercisers. Little difference was noted be- tween those in the acquisition phase and those in the maintenance phase, who had a longer history of regular exercise. There were no significant dif- ferences among the exercise groups on measures related to self-acceptance and health responsibil- ity.
DISCUSSION
The development of quality health-promoting programs relevant to this rural-urban population was to be an outcome of this study. The aim of each program would be self-activation or "a for- mula that stimulates patients into action to better the state of their own health" (DuBrey, 1982, p. 27). Rural, as well as urban, communities have special kinds of challenges associated with acces- sibility, usefulness, and perceived value of specific health promotion/maintenance programs (DuBrey, 1982). Enhancing cost-effective planning and im- plementation of such programs in terms of age, gender, and exercise practice needs is paramount.
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The study results, therefore, will be related to their application to developing potential health- promoting programs.
Age Age was a significant variable with only three
HPLP subscales: nutrition, exercise, and health re- sponsibility. This reinforces the conclusions of Smith and Serfass (1981) and Brower (1985) that stereotyping older people as inactive in the area of health promotion is inaccurate. These conclusions support the finding of Wan, Odell, and Lewis (1982) that many elderly people report their health as excellent or good. Planning and implementing a variety of programs, some that cut across age and others that focus on specific age groups and their unique needs, should be helpful in meeting the health-promoting needs of all participants regard- less of age.
Differences in age were found in the area of exercise involvement. Exercise involvement de- creased for each decade except for the 55 to 64 age group, suggesting that maintenance of physical ex- ercise throughout the life span must be stressed by health care providers so that a high level of in- volvement may become a norm of all age groups. The largest numbers of nonexercisers were noted in the three decades from 25 to 54; this may indi- cate that a concerted focus to stimulate initiation and maintenance of regular daily exercise could be a critical need.
The data indicate a gradual increase in assump- tion of responsibility for personal health and in initiation of healthy nutritional practices as indi- viduals age. Nutritional programs might do well to focus on the intricate interrelationship of nutrition and exercise and vice versa to foster motivation and adherence.
Gender
Self-acceptance mean scores for both men and women were high in this study. This may be ex- pected, considering the educational levels of this sample. However, women's scores indicated sig- nificantly less self-acceptance than men's scores. Stanwyck (1983) hypothesized that male involve- ment in community organizations and recreational practices that focus on competition, both of which reinforce feelings of success, or from progress in career development, may influence their self- acceptance.
VOLDEN ET AL.
Researchers have suggested that individuals who have a higher self-concept enter into more health-promoting practices than those less self- accepting (Hallal, 1982; Lum et al., 1978). Thus, it might be expected that males would report more health-promoting behaviors than females. This is so, as women in this study reported more health- promoting practices. This is consistent with find- ings of a 1979 study by Harris and Guten. Because of these conflicting findings, further research is warranted in this area.
Women scored significantly higher than men in the areas of meaning of health and total HPLP and its subscales of nutrition, interpersonal support, exercise, and health responsibility. This suggests higher levels of commitment to and involvement with development of healthy life-styles for women. As primary care givers for family mem- bers, they are likely to have substantial influence on the development of life-styles for themselves and their families. In planning health programs, nurses might capitalize on reinforcing positive be- haviors and enhancing the likelihood that partici- pants will continue to engage in health-promoting behaviors. Planning elective practices within the programs that will enable women to successfully complete practices or compete with themselves within groups will provide feelings of achievement
in planning health programs, nurses might capitalize on
reinforcing positive behaviors and enhancing the likelihood that participants will continue to engage in health.promoting
behaviors.
leading to greater self-acceptance (Reasoner, 1983). Another primary focus in response to find- ings of this study might be on male motivation to initiate and maintain involvement in health- promoting practices, particularly up to the mid-50s and again after age 65.
Exercise
In this study, exercisers scored higher on per- ception of health, meaning of health, total HPLP,
HEALTH AND LIFE-STYLE MEASURES
and the subscales of nutrition, self-actualization, interpersonal support, exercise, and stress manage- ment. Self, acceptance and health responsibility were the only two variables not related signifi- cantly to exercise.
Exercisers in the acquisition phase of exercise scored highest on the overall HPLP; however, the impact lessened only slightly in those who con- tinue to exercise. Both exercise groups scored higher than nonexercisers. Perhaps new exercisers adhered more closely to a "new life-style," giving them greater impetus in maintaining the more health-promoting life-style. The key appears to be initiation and maintenance, as many other health- promoting behaviors appear to develop jointly with the exercise practices. Providing appropriate in- struction to those in the acquisition phase of exer- cise and encouraging nonexercisers to plan for reg- ular exercise are approaches to consider. Pender and Pender (1986) found that people who planned for health-promoting practices had more positive attitudes and "also had stronger expectations that others expected them to engage in appropriate fit- n e s s . . , behaviors than persons without plans to engage in these behaviors" (p. 18). Programs also should have a keen focus on maintenance of reg- ular exercise throughout the life span, to encourage those like the 60% of nonexercisers who reported that they had previously exercised regularly.
Interpersonal support appears to be more avaii- able when initiating a new activity than when maintaining that activity. This has implications for teaching peer support strategies to groups of indi- viduals who are concerned about the health-related practices of those close to them. With ongoing support, more individuals can be expected to con- tinue in the maintenance phase, and fewer should revert to nonexercise status. Stoedefalke (1985)
25
suggested that behavioral contracting and self- control techniques may be useful in motivating and sustaining individuals in programs.
An individual approach must, of course, be maintained for those beginning regular exercise. Nurses, in collaboration with other health profes- sionals, must take the lead in designing educa- tional programs. Being involved in these programs as an effective role model enables the nurse or other leader to understand tZtrsthand the needs of others and forsee potential problems. This personal experien.ce proves invaluable in future program de- velopment and in the improved quality of life (Halfman & Hojacki, 1981).
SUMMARY
Data provided some support for Pender's Health Promotion Model (Figure 1) and for the need of purposeful design of health-promoting classes and practices. Efforts should be made to pique interest in and increase understanding of the critical need for everyone to initiate regular physical exercise and maintain this practice. Because the largest number of nonexercisers were in the middle de- cades (25 to 54), people of these ages might be especially targeted.
Significant interest in health promotion was shown by the number of respondents willing to: participate in this study. It should bode well, then, that many men and women of all ages could be motivated to participate in health-promoting prac- tices. Programs should be designed to enhance knowledge and understanding of self-monitoring practices needed by the individual and family and to incorporate motivational and adherence factors. This should lead to the incorporation and mainte- nance of healthy life-style behaviors.
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