Health education and health screening in a sample of older men: a descriptive survey.
Abstract: Internationally, the number of people aged over 65 is increasing, in both absolute and relative terms. There is little doubt that a healthy lifestyle, and participation in health education and health screening activities, contribute to longevity. Gender is also considered to be a strong indicator of health and longevity, as women tend to live longer and healthier lives than men. There is abundant literature on older people's health but a significant lack of research specifically on older men.

This study involved 59 community dwelling men aged 65 years or over, living in Wanganui (a city located in the North Island of New Zealand). The aim of the study was to describe the health education and health screenings older men living in Wanganui attended, and to ascertain the barriers and/or benefits of healthy lifestyle choices. Data were collected via a self-administered questionnaire.

Findings from the study were that the majority of men reported good or excellent health. On average, men had participated in 1.6 health education programmes and attended 3.1 health screenings during the previous 12 months. Most considered there were no barriers to following a healthy lifestyle and on average identified four benefits to living a healthy lifestyle. The most common benefit reported was increased opportunities for socialisation.

While it is acknowledged that more substantive research is required with a larger heterogeneous group of older men, this study provides useful baseline data on participation in health education and health screening programmes. The study also highlights that nurses need to facilitate and provide health education and health promoting activities that support healthy lifestyle choices in older men. The findings also suggest that the Older Men's Health Program and Screening Inventory questionnaire would need significant adaptation before it could be used with a representative sample of older New Zealand men.

Key Words: Older men, health education, health screening, gerontological nursing
Subject: Health education (Research)
Health education (Usage)
Medical screening (Research)
Medical screening (Usage)
Men (Health aspects)
Men (Research)
Authors: Dallas, Janette
Neville, Stephen
Pub Date: 03/01/2012
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2012 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: March, 2012 Source Volume: 28 Source Issue: 1
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 288689506
Full Text: Introduction

A global increase in the older adult population has been documented frequently (Neville & Henrickson, 2010). For example, in New Zealand the number of people aged 65 and older has doubled in the last 50 years and is predicted to double again in the next 50 years (Statistics New Zealand, 2004). Men on average die younger than women and therefore, with advancing age, women outnumber men. The gap is narrowing however, and by the year 2021 women will make up only 51% of the 65-74 year old age group (Fletcher & Lynn, 2002). While men are active participants in research involving older adults, they commonly represent a small portion of the total participants and results tend to be generalised to the entire population, consequently data specific to men is under-reported.

Many theories have been put forward to explain the gender imbalance in health and mortality. Men are considered reluctant to seek help from health professionals because it challenges their masculinity (Courtenay, 2003; Laws, 2006). It is also reported that men when compared to women tend to seek health care later in the course of an illness and see themselves as almost being immortal (Courtenay). For example, statistics for melanoma show that despite men having a 50% lower incidence of the disease, when compared to women, they have higher rates of morbidity (Banks, 2001). Men are also considered less knowledgeable about health in general, make poorer lifestyle choices and engage in behaviours that increase the risk of disease, injury or death (McKinley, 2009; Neville & Adams, 2010).

In this article, the findings of a survey describing some of the health education and health screening activities in which older men participate are presented. In addition, recommendations are made as to the suitability of using the Older Men's Health Program and Screening Inventory questionnaire (OMHPSI) within a New Zealand context. Nurses are the largest health professional group and are also those who most frequently have contact with consumers of health services (Neville, 2008). Consequently nurses who are aware of the variety of health education and/or screening activities this group participate in are well positioned to work with and support older men to promote health and well-being.

Background

In the literature the terms health education and health promotion are often used incorrectly as if interchangeable (Whitehead & Russell, 2004). Health education is considered as either planned or opportunistic, enabling the individual to make informed decisions about their health and lifestyle (Talbot & Verrinder, 2005). More contemporary definitions of health promotion focus on empowering population groups to participate in policy making, planning and implementation of health initiatives (Robertson & Neville, 2008; Whitehead & Russell). Irvine (2007) identifies that the delivery of health education and screening programmes is integral to health promoting activities.

Promotion of healthy ageing and engaging in a healthy lifestyle has become a global priority. There is little doubt that a healthy lifestyle culminates in longevity and increased well-being in the older age group. McMurray (2007) describes a healthy lifestyle as a pattern of living involving minimal disability, minimal stress, social support and a perception of being valued. An Australian study found that motivation, a health scare, a positive attitude, having goals, good social support networks and the ability to physically access health services were factors that prompted older people to engage in a healthy lifestyle (Haralambous, Balck, Nankervis & Giummarra, 2004).

Byam-Williams and Salyer (2010) found that older women were more likely than older men to participate in a healthy lifestyle and health promoting activities. Findings from this American study identified that targeted health educational programmes and interventions for older men were needed. In contrast, a study by Stark, Chase and DeYoung (2010) found no gender differences in a group of over 65 year olds (N=141) in relation to engagement in health education. However the sample in this study was homogenous with respect to education and income. Research has identified that highly educated older people are more likely to participate in health promoting activities (Acton & Malathum, 2000).

An American study by Loeb (2003) measured participation in health education programmes, health screening attendance, and benefits and barriers to health promoting behaviours in a sample of 135 community dwelling men aged 55 years and older.

Lack of motivation, lack of time and lack of interest were common factors explaining non-attendance at education programmes and screenings. Benefits of healthy lifestyle choices, as seen by more motivated older men, included greater self-confidence and the ability to socialise (Loeb). Men who anticipated more benefits attended more education and health screenings, were more satisfied with their choices, and perceived fewer barriers to engaging in a healthy lifestyle (Loeb). The converse was true for men who anticipated few benefits. The results suggested a significant positive relationship between perceived benefits and healthy lifestyle choices (Loeb).

Currently in New Zealand the case for population screening programmes focusing on men and/or older men in particular remains controversial; for example, the move to routinely screen New Zealand men for prostate cancer. This uncertainty is mirrored and supported in the international literature as evidenced by Chapple, Ziebland, Hewitson and McPherson (2008) who highlight " ... the unreliability of the PSA test, the likelihood of false positive and false negative results, and continuing uncertainty about treatment for prostate cancer" (p.62). To date there is no formal national men's focused health screening programmes available in New Zealand.

In recent years New Zealand has seen a small but incremental increase in interest related to men's health, with some primary health care practices implementing programmes specifically designed for men, for example the 'Well Man Check' (Barwell, 2009). However the programmes currently offered are neither cohesive nor exhaustive in what they provide, and the type of screening offered is determined by the availability of appropriately qualified health professionals, or lay people available to participate in men's health initiatives. For example, the 'Well Man Check' incorporates history taking and assessment (Barwell) whereas others like the Cancer Society of New Zealand (n.d.) provide a set of health screening and related questions in a tick box format.

In New Zealand, there are limited quantifiable data available that specifically relate to older men's participation in health education and screening programmes. Consequently, the aim of this small study was to determine what health education and screenings older men were attending and what barriers or benefits to healthy lifestyle choices existed. The research goals were replicated from Loeb's (2003) American study and measured in a group of older men:

* Health education attendance and barriers to attendance

* Health screening attendance and barriers to attendance

* Benefits of and barriers to healthy lifestyle choices

* Self-rated health

Methods

Survey

The use of a quantitative survey design is appropriate for gathering information to describe a population (Wood & Ross-Kerr, 2011). Data were collected using--with permission from the authors--the OMHPSI developed by Loeb (2003). The OMHPSI is an eight item self administered questionnaire measuring key variables of interest in older men dwelling in the community. The first five items are structured as checklists and the participants were asked to tick those items that applied to them. These questions relate to health programmes and health screening attendance, barriers, current health conditions, and benefits and barriers to healthy lifestyle choices. The next three questions use a 4 point Likert scale for self evaluation of health status, health related activities, and degree of satisfaction with current health related activities. Self rated health measured using a Likert scale is consistently found in older populations to be associated with health status and measures of mortality (Benyamini, Blumstein, Lusky, & Modan, 2003). Four demographic questions on age, income, education and marital status were also included in the questionnaire.

Content validity for the OMHPSI was initially established through a group of health professionals who worked and/or undertook research with older adults, as well as pilot testing the inventory with a group of older men (Loeb, 2003). Reliability testing for the OMHPSI has yielded a Cronbach alpha of .78 (Loeb, 2004).

Prior to the collection of data, approval was sought, and granted, from the Massey University Human Ethics Northern Committee. The requirements and recommendations from this Committee were incorporated into the study. Support for the research was sought and granted by Age Concern Wanganui and Age Concern New Zealand.

Procedure

Participants were obtained via a non-probability convenience sample drawn from the support networks associated with Age Concern Wanganui. An introductory letter was sent to 102 men living independently in the community. The letter informed them of the purpose of the research and provided background information. One week later the OMHPSI and a four item demographic questionnaire was sent along with a covering letter and a return self addressed envelope. Of the 102 letters sent 59 were returned, giving a response rate of 61%. Consent to participate was assumed following completion and return of the questionnaire.

Data analysis

Data were coded and entered into a Microsoft Office Excel (2007) spreadsheet for analysis. Before analysis all data were screened for data accuracy, missing values, coding errors and errors in participant responses. Some participants did not complete every question therefore sample sizes varied for each question. Frequency distributions and univariate descriptive statistics were calculated

Results

Sample description

This was a homogenous sample with all participants identifying as Pakeha New Zealanders (i.e., not of Maori or other descent) and consequently does not reflect the ethnic diversity of older people living in Wanganui (Statistics New Zealand, 2006). Ages ranged from 91 to 65 years with a mean of 74.8 years. Of the 59 participants, 82% (n=46) were married, 2% (n=1) divorced, 11% (n=6) widowed and 2% (n=1) were in a de-facto relationship. This make-up correlated well with 2006 national census data which reported 88% of older adults were married, 2% were in de-facto relationships and 9% were widowed (Statistics New Zealand).

Participants reported varying levels of education: 7% (n=4) had a primary school education, 66% (n=38) received secondary school education and 28% (n=16) had attended university. No participants reported study at a doctoral level. The total yearly income of participants was comparable to the 2006 national census data (Statistics New Zealand, 2006). Forty percent (n=21) had a personal income of $20,000 or less and the majority (51% [n=27]) received a total yearly income of $20,000-$39,999. The Wanganui District census data show 54% of older adults received an annual income of $10,001-20,000 and 64% of older adults had a personal income of $20,000 or less (Statistics New Zealand).

Health education programmes

The types of health education programmes attended during the previous 12 months are presented in Table 1.

The most frequently attended programmes were immunisation (56%), taking medications (19%) and exercising (19%). The mean number of health education programmes attended was 1.6 per participant. However, 44% of participants had not participated in any health education programme. Reasons for this included: they didn't know where these were held (24%) or that they had not made the time to attend (14%).

Health screening programmes

The number of health screening programmes attended, during the previous 12 months, ranged from 0 to 7 with an average of 3.1 screenings attended (Table 2.0). The most common health screening programmes attended were; blood pressure screenings (76%), eye examinations (55%) and prostate specific antigen testing (50%).

Seventeen percent (n=10) of participants reported that they had not participated in any health screening in the previous 12 months and the reasons for this included: not knowing where to go (12%), no time (3%) and no need (5%).

Health problems

Participants reported having anything from 0 to 8 health problems with an average of approximately 3 (Table 3.0). A small number (n=5) of participants reported no health problems at the time. The three most common health problems were heart problems (56%), trouble hearing (43%), and visual problems (38%). (Table 3)

Barriers to healthy lifestyle choices

The majority of participants (66%) reported no barriers to making a healthy lifestyle choice. Of those participants who reported barriers, the most common barrier was lack of motivation (12%), followed by lack of knowledge, and where to access education or screening (8%). The number of barriers reported ranged from 0-3 with the average being less than 1.0 (see Table 4.0). External barriers such as lack of programs, cost, or transportation were reported by 16% of participants. Barriers to healthy lifestyle choices were reported by only a small number of participants whereas benefits were reported by the majority.

Benefits of healthy lifestyle choices

The number of benefits when making healthy lifestyle choices ranged from 0 to 9 with an average of 3.6 noted. The most common were socialisation (62%), having fun (56%) and feeling healthier (54%). Other benefits reported included spending more time with the family and supporting motivation generally. A small number of participants (13%) reported that they knew of no potential benefits associated with a healthy lifestyle (see Table 5.0).

Self-Rated Health, Lifestyle and Satisfaction with Healthy Lifestyle Choices

As is commonly reported in self evaluations of health, the majority (see Table 6) of participants reported their health as good (67%), and their lifestyles were either always healthy (43%) or frequently healthy (43%). The majority of participants were frequently satisfied with their present level of health related activities (54%). Only a small number of participants rated their health as fair (17%) or poor (2%), were occasionally healthy (11%) or never healthy (4%) and only occasionally satisfied with their health related activities (13%).

Discussion

Men's health is reported to be better when they are married, and being married is associated with healthier behaviours in men (Ministry of Health, 2004). Income is also associated with health, in that the higher the income the better the health of a population or individual (Mitchell, Chang, & Hirini, 2001). The majority of men in this study were married and had a higher income than average for the older population of Wanganui. This is significant when you consider that 50.6 percent of people aged 15 years and over in Wanganui District have an annual income of $20,000 or less which is low when compared to the rest of New Zealand (Statistics New Zealand, 2006). This would suggest that respondents in this study may have better health than the non-respondents due to greater than average income and marital status.

There was a relatively low attendance by older men at health education programmes, although 58% indicated they had attended an education programme on getting immunised. This high rate of participation in being immunised may be explained by the significant amount of media coverage identifying the importance of having a "flu injection" which is free for over 65s. A large number of participants had not attended any education programmes. A common reason (24%) for not attending was not knowing where the programmes were held. This may be simply a reflection of the number of education programmes and/or the limited advertising of education programmes available. This conclusion is supported by The National Health Committee (2000) who reported there has been little investment in health promotion or education programmes for older adults and that most programmes are informal and vary in different communities.

The majority (83%) of participants reported they had participated in at least one or more health screening programmes in the previous 12 months. This is consistent with other studies that report men are more likely to participate in health screening once they are over 65 years, have a high income, are married or in a de facto relationship, and are regular users of the medical care system (Gray, 2005). The three most common screenings attended were a blood pressure check, followed by eye examination, and then by PSA blood test. This is closely in-line with Loeb's (2003) research where a blood pressure check was the most common health screening, followed by a PSA blood test and a physical exam. The high rate of attendance at eye examinations (55%) in this research may be explained by the need for an eye examination in New Zealand as part of medical certificates to enable adults over 75 years to retain their driver's license (Ministry of Transport, 2006).

Before a person chooses to assume a healthy lifestyle, perceived benefits would need to outweigh perceived barriers. It is encouraging to note that participants reported an average of 3.6 benefits in comparison to an average of 0.4 barriers. The majority (66%) of participants reported no barriers to making healthy lifestyle choices and, interestingly, no participant reported lack of knowledge. This is consistent with the literature surrounding older people's perception as to what can be done to improve their health (Kim, 2009). The most common barrier was lack of motivation followed by not being aware of screenings or education in the area. Lack of motivation as a barrier to making healthy lifestyle choices is also consistent with other studies (Haralambous et al., 2004; Loeb, 2003; Pender, Murdaugh & Parsons, 2006). Organisational barriers such as lack of knowledge and cost are also consistent with the literature (Haralambous et al.).

The four most commonly reported benefits for healthy lifestyle choices were feeling healthier, feeling better, socialising and having fun. These are consistent with the most common benefits described in Loeb's (2003) research. Socialisation, as a benefit, was also identified in Loeb, Steffensmeier and Lawernce's (2008) research which compared the benefits and barriers to maintaining a healthy lifestyle, between community dwelling and older incarcerated men. Findings from this study identified that both groups found "being with others" was positively related to making healthy lifestyle choices.

The majority of participants reported good or excellent health (81%) and identified that they were frequently or always satisfied (88%) with their lifestyle choices. This finding is supported by Loeb's (2003) research. It is evident in the present study that reports of good or excellent health co-exist with health problems.

Implications for nursing practice

Research has identified that men's engagement in health promoting and screening activities, as well as their knowledge of health issues and when to seek professional advice, requires further work (Johnson, 2009). As already discussed, nurses are frequently the first point of contact when men engage with health care providers and as such are in an ideal position to promote and support men to engage in health promotion and screening behaviours. For example, offer screening checks for older men where this group congregate such as Returned Servicemen Associations or Bowling Clubs. This suggestion is supported by Johnson, Huggard and Goodyear-Smith (2008) who assert that primary health care workers need to move outside of the confines of the Primary Healthcare Organisation to participate in wider community initiatives.

Nurses, where it is not possible to engage in wider community based health promoting and screening activities, need to be cognisant of the previously mentioned specific health issues that older men may encounter (such as cognitive screening, HbA1c prostate and bowel screening). Doing so could mean that these nurses are appropriately placed to initiate health education and screening whenever they encounter older men. Foster and Neville (2010) claim that the "development of nurse-led multi-disciplinary wellness clinics for older people could enhance quality of life and perhaps decrease the likelihood of hospital admissions and rest home care" (p.11). Specific regular drop-in clinics focused on older men's health and wellbeing, either based within the community or at a primary health care organisation, would be useful.

Nursing is also well positioned to advance the body of knowledge related to older men's health education and screening behaviours. Literature to date has clearly described the current state of men's health and the barriers to men participating in health promotion and screening (Johnson et al., 2008; McKinlay, 2009). Nurses could lead future research agendas focusing on the development and testing of interventions designed to increase older men's participation in health promoting and screening activities, which ultimately would impact positively on the health and well-being of this population.

Limitations

There are several methodological limitations associated with the present research. Firstly, due to the small sample size of this study and the specific locality of the research (Wanganui) generalisations cannot be made to the larger New Zealand population of older men. Future studies should draw on a larger representative cross-sectional sample, including men from different ethnicities, geographical locations, socio-economic backgrounds and living arrangements. The results of the present study do however provide a basis and starting point for larger future studies.

Secondly, the use of the OMHPSI would need to be revised, alterations made to the measures used and then the revised tool piloted on another group of older men to ensure its transferability to a New Zealand context. For example, modifications to the health screening section would include questions related to having participated in BMI, HbA1c, cholesterol/ lipid, cognitive, alcohol history and kidney function screenings. The previously mentioned suggested additions are all integral to health screening and meet one of the Ministry of Health's current health targets for improving the health and independence of older people (Ministry of Health, 2011).

Thirdly, the sample was possibly over-represented by men who were more motivated and healthier. This limitation is supported by Loeb, Steffensmeier and Kassab (2011), as well as Gallant and Dorn (2001) who identify that older men who engage in a healthy lifestyle may have been more likely to participate and also may be more likely to survive to older age than those who made poor lifestyle choices.

Conclusion

Despite the limitations of this small study, the results give nurses some insight into a selected number of the health education and health screening activities older men participated in. This research identified that before the OMHPSI could be used on a larger sample of older men in New Zealand significant modifications would need to be made. To enable nursing to appropriately develop and improve care for older men, it is vital that nurses understand this population group's health and health needs. Such understanding of older men's health beliefs and behaviours will enable health professionals to facilitate and provide health education and health promoting activities that support healthy lifestyle choices.

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Janette Dallas RN, MN, Nurse Manager Professional Practice Development, Christchurch Hospital Stephen Neville RN, PhD, FCNA(NZ), Postgraduate Programme Coordinator--Nursing, School of Health and Social Services, Massey University, Albany
Table 1.
Health Education Programmes Participated in During
Previous 12 months (N=59)

Education Programmes                       Percentage

Driving safety                                     3%
Taking medications                                19%
Selecting and preparing foods                     14%
Exercising                                        19%
Being safe in your home or neighbourhood          14%
Getting immunised                                 56%
Falls prevention                                  10%
Health education                                   8%
Adult learning                                    14%
Other programs attended                            2%
No programs attended                              44%
Didn't know where/when                            24%
Didn't make the time to go                        14%
Other reasons not to attend                        8%

Table 2.
Health Screening Programmes (N=58)

Screening Programme                    Percentage

Blood pressure screening                      76%
Blood test for prostate cancer (PSA)          50%
Blood in bowel movement                       21%
Colonoscopy                                    9%
Physical exam                                 48%
Hearing exam                                  38%
Eye exam                                      55%
Skin cancer exam                              12%
Other                                          7%
No participation in health screening          17%
Didn't know where they were                   12%
Didn't make the time                           3%
No need                                        5%

Table 3.
Health Problems (N = 58)

Problems                         Percentage

High Blood pressure                     34%
Heart Problems                          56%
High cholesterol                        28%
Trouble hearing                         43%
Vision problems                         38%
Cancer                                  12%
Arthritis                               31%
Osteoporosis                             2%
Lung problems                            5%
Urine problems                          22%
Stomach / bowel problems                 5%
Diabetes                                16%
Depression                               7%
Dental problems                         14%
Other                                   12%
I have no problem at this time           9%

Table 4.
Barriers to Healthy Lifestyle Choices (N=50)

Barriers                                       Percentage

No time                                                4%

Not interested                                         6%

Trouble with transportation                            2%

Don't know what to do                                   0

I feel there is not much I can do                      4%

Not very motivated                                    12%

Afraid of making problems worse                        4%

Costs too much money                                   6%

Don't know of any programs or screenings               8%
available

Other barriers, included acting as a                   6%
caregiver,

Cannot think of anything that prevents                66%
me from participating in a healthy lifestyle
choice

Table 5.
Benefits of Healthy Lifestyle Choices (N=52)

Benefits                            Percentage

Feel healthier                             54%

Feel better about self                     52%

Have more energy                           44%

Better able to cope                        48%

More mentally alert                        46%

Have fun                                   56%

Get to be with other people                62%

Sleep better                               50%

Other                                       4%

I cannot think of any benefits of          13%
healthy lifestyle choices

Table 6.
Self-Rated Health, Lifestyle and Satisfaction
With Healthy Lifestyle Choices

Personal evaluations of     Number of    Percentage of
health                     respondents    respondents

Health status (N=58)
Excellent                            8             14%
Good                                39             67%
Fair                                10             17%
Poor                                 1              2%
Missing data                         1             --

Healthy lifestyle (N=56)
Always healthy                      24             43%
Frequently healthy                  24             43%
Occasionally healthy                 6             11%
Never healthy                        2              4%
Missing data                         3             --

Satisfaction with level of healthy lifestyle choices (N=56)
Always satisfied                    19             34%
Frequently satisfied                30             54%
Occasionally satisfied               7             13%
Never satisfied                      0
Missing data                         3
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