Representations of old age in falls prevention websites: implications for likely uptake of advice by older people.
Introduction: The representations of old age in falls prevention
websites were explored and considered for their potential impact on
older people's uptake of the advice.
Method: Websites were searched for using the strategy of a previous systematic-style review and evaluated using the principles of discourse analysis.
Findings: In the analysis of 33 websites, three main subject positions afforded to older readers were identified: (1) Passive recipients: victims of the ageing process, ignorant, ill-informed and vulnerable; (2) Rational learners: responsive to information, rational problem solvers and compliant with prescriptive advice; and (3) Empowered decision makers: actively engaged with and evaluative of information, autonomous and responsible for their course of action.
Discussion: Falls prevention websites were rarely designed according to evidence-based recommendations concerning fit with positive self-identity and empowerment of active self-management of health. Although the representation of older people as passive and inert was most evident, the image of empowered decision makers was most likely to engage older people in preventing falls.
Conclusion: Occupational therapists should ensure that they represent older people in a positive and respectful manner in falls prevention information, both that available through the internet and in written form.
Falls, internet, older people.
(Safety and security measures)
Falls (Accidents) (Prognosis)
Falls (Accidents) (Risk factors)
Falls (Accidents) (Prevention)
Health promotion (Methods)
Nyman, Samuel R.
Hogarth, Harriet A.
Victor, Christina R.
|Publication:||Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 College of Occupational Therapists Ltd. ISSN: 0308-0226|
|Issue:||Date: August, 2011 Source Volume: 74 Source Issue: 8|
|Topic:||Event Code: 260 General services Computer Subject: Internet|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Falls are a major cause of morbidity and mortality: one in three people aged 65 years and above fall each year and, of these, 20-30% become less mobile and more at risk of premature death (Skelton and Todd 2004). In addition to the physical consequences, psychological factors, such as fear of falling, are associated with a premature curtailment of activities and a reduced quality of life (Lachman et al 1998, Zijlstra et al 2007). The financial costs of falls are also high at an estimated 981 million [pounds sterling] per annum for the United Kingdom (UK) (Scuffham et al 2003). The risk of falls has been strongly associated with several factors, some of which are not amenable to change (for example, being female, older, and having a history of falls) (Lord et al 2007). Nonetheless, falls have been successfully prevented in randomised controlled trials using exercise and Tai Chi, and in some contexts multifactorial assessment and intervention, home safety modification, vitamin D supplementation, and gradual withdrawal of excessive or balance-impairing medications (Gillespie et al 2009). Although those at risk of falls need to be identified and provided with more focused interventions, efforts are also required to reduce the overall risk of falls in the wider older population (Department of Health 2002, Gillespie et al 2003, Chang et al 2004, Skelton and Todd 2005).
The internet has become ubiquitous in everyday life and has great potential for health promotion as a cost-effective means of mass communication (Skinner et al 1993, Street Jr and Rimal 1997, Eakin et al 2001). While not all older people are currently online, this segment of the population is rapidly growing in internet usage and, in the UK, is currently estimated at 26% of over-65s (Office for National Statistics 2008). In addition, as 63% of the UK's cohort aged 55-64, who are next to enter retirement age, are estimated to be online (Office for National Statistics 2008), the internet has the potential to become a powerful medium of health promotion for younger older people.
There are a number of websites that present falls prevention advice and in some cases these have been subject to formal evaluation (Yardley and Nyman 2007, Nyman and Yardley 2009a, 2009b). Evidence-based recommendations have been made by the Prevention of Falls Network Europe (ProFaNE) for engaging older people in falls prevention interventions (Yardley et al 2007a), and suggestions have been made on how to implement them in practice (Nyman and Ballinger 2008).
Websites that present falls prevention advice, however, are of concern in that, as with most web-based material, there is little control over their content, with the potential for advice to be published that is not evidence-based and even harmful (Helwig et al 1999). A recent systematic-style review was conducted to evaluate the content of international falls prevention websites (Whitehead et al 2007). The authors found that the quality of the websites was poor in terms of coverage of falls-related information against evidence-based guidelines (Gillespie et al 2003, National Collaborating Centre for Nursing and Supportive Care 2004); credibility against the Health on the Net Code of Conduct for Medical and Health Websites (2009); and usability against guidelines developed by the National Institute on Aging and the National Library of Medicine (2009).
As subject positions are socially negotiated, conflicts in communication commonly arise when individuals disagree, not necessarily with the content, but with the undesirable subject position implicitly afforded to them (Danziger 1976, Kingston 2000, Grenier 2007). Thus, an older person may object not to the advice of a health professional to reduce risk, but to a health professional's implicit expectation that the older person is to assume an undesirable identity and associated role within the relationship (for example, an incompetent identity and passive role in the management of his or her health).
The purpose of this qualitative study, therefore, was to evaluate falls prevention websites for their representations of old age and subsequent likely acceptance and engagement amongst older people. In addition, it was aimed to compare these representations against two of ProFaNE's evidence-based recommendations concerning fit with positive self-identity and empowerment of active self-management of health (Yardley et al 2007a).
Systematic search for websites
The authors of the previous systematic-style review of falls prevention websites conducted their search for websites in October 2006 (Whitehead et al 2007). In the present analysis, every website identified from the previous review was included and the list of websites was updated with a full re-run of the search strategy in May 2009. Full details of the search strategy and inclusion criteria have been reported previously (Whitehead et al 2007). Briefly, 54 searches were performed on three search engines (18 searches each) of Google, Yahoo! and MSN, using the keywords of 'falls', 'preventing falls', 'falls prevention', 'reducing falls', 'improving balance' and 'balance training', independently and in combination with either 'older people' or 'elderly'. The first 20 hits from each search were reviewed with a total of 1080 websites reviewed.
The inclusion criteria were that websites presented information on falls risk factors or prevention in English and targeted members of the public. Websites were excluded if they required payment or membership, were chat rooms, clubs, discussion groups, solely advertising, focused on a single area of falls prevention (for example, Tai Chi only), or provided only a directory of links or downloadable documents. Links to other relevant sections on websites were followed, but not to external websites. In addition to the above criteria, websites were excluded that predominantly provided home hazard checklists for reducing falls risk because they did not provide rich textual data and so were less informative for the purpose of the qualitative analysis. As the content of websites is subject to change, the text of each website was printed in hard copy for analysis. Ethical approval was not required because the websites were in the public domain for public consumption.
Thirty-two websites from the previous review (Whitehead et al 2007) were successfully located, but not the remaining four, presumably because the websites were no longer available. The re-run of the search strategy added a further 23 websites. However, 22 websites were excluded because they predominantly provided home hazard checklists for reducing falls risk. Therefore, the analysis was performed on 33 websites, of which one targeted adult children of older people, with the remaining targeting older people (see Appendix 1 for the list of websites). No record was kept of the reason for exclusion for the websites reviewed in the updated search, although most search hits were of websites already identified by Whitehead et al (2007), who found that half of the hits from their searches were duplicates (see Fig. 1).
[FIGURE 1 OMITTED]
Qualitative analysis of representations of old age
Using the principles of discourse analysis (Ballinger and Cheek 2006), the subject positions afforded to the reader were analysed; that is, the assumptions made of older people and how to engage them to prevent falls, and the options afforded to act on the advice. This methodological approach is influenced by the work of Foucault (1975, 1977), whose perspective of discourse 'provides a set of possible statements about a given area, and organises and gives structure to the manner in which a particular topic, object, or process is to be talked about' (Kress 1985, p7). This approach was selected both for offering a systematic way of reviewing texts (in this case, websites), and because it acknowledges the productive potential of texts in constructing reality rather than simply reflecting it (Ballinger and Cheek 2006). The discourse analytic stages described by Ballinger and Cheek (2006), influenced by Foucault's interest in the construction of the subject, include the identification of objects and subjects within the texts (in this instance, the websites), how these are positioned and an exploration of the types of world or reality within the texts implied by this. The specific ways in which the website texts were analysed are detailed in the procedure below.
ProFaNE offered six recommendations for engaging older people in falls prevention interventions (Yardley et al 2007a). Four recommendations were not used in this study because they referred to the content of advice, design of interventions, or enlisting support from health professionals and relatives: (1) 'Raise awareness in the general population that undertaking specific physical activities has the potential to improve balance and prevent falls'; (2) 'Utilise a variety of forms of social encouragement to engage older people in interventions'; (3) 'Ensure that the intervention is designed to meet the needs, preferences and capabilities of the individual'; and (4) 'Draw on validated methods for promoting and assessing the processes that maintain adherence, especially in the longer term' (Yardley et al 2007a, pp232-33). Two further recommendations concerned the presentation of advice and were used in the present analysis of the subject positions afforded to older readers (Yardley et al 2007a): (1) 'When offering or publicising interventions, promote benefits which fit with a positive self-identity' (p232), and (2) 'Encourage confidence in self-management rather than dependence on professionals, by giving older people an active role' (p233).
A researcher (HAH) analysed each website with particular reference to the subject position of the older reader, the position of the writer and the two ProFaNE recommendations of interest (Yardley et al 2007a), using prompts for analysis (see Table 1). After circulation of the electronic notes, a discussion was held with three researchers (SRN, HAH and CB) to reach consensus on the emergent findings and how to structure the analysis. The authors identified three dominant discourses and agreed the terminology to describe them best. A researcher (HAH) then reframed the analysis under these three dominant discourses. Another researcher (SRN) then put these notes from the analysis into prose and contextualised them in relation to the falls prevention literature.
The analysis identified three subject positions: the older person as passive recipient, as rational learner and as empowered decision maker.
Older person as passive recipient
This was the dominant subject position afforded to the older reader and was adopted by every website to some degree. The image of older people projected was that they were both at risk of falls and ignorant about how to prevent them. Passive recipients were perceived as victims of the ageing process, with age-related declines in faculties and functioning, and implicitly informed that they would inevitably fall. As a result, older people were represented as incapable of being responsible for their health care. For example, older people were assumed to need help and support with the most basic of activities: 'Have a neighbour watch you walk down the path.' (47) * In addition, the assumed older reader was not credited with any knowledge or problem-solving capability: 'And be careful when walking on wet or icy surfaces. They can be very slippery!' (2) The use of an imperative tone and exclamation marks may also be patronising to the older reader, especially when they are likely to be computer literate and, therefore, relatively young and educated (Adler 2002, Fox and Fallows 2003, Fox 2004). In many instances, older people's homes were assumed to be unsafe places to live, cluttered with furniture and dangerously placed wires: 'Remove oversized furniture and objects' (4) and 'Remember "a place for everything and everything in its place"'. (9)
Although a lot of information was provided, in many places it was not explained with the expectation that older people will simply follow the advice. In terms of the options available for action, passive recipients were advised to seek professional help: see their general practitioner for advice on taking medicines, looking after their feet, exercise classes, healthy eating, and where to get help around the home, for example if changing light bulbs was a problem. A local pharmacist and optician were also suggested as sources of advice. There were also contradictions in this representation of old age: the older reader was assumed not to have the capacity to prevent falls, but to be able to find a suitable health professional to assess his or her falls risk. In addition, the older reader may well have proactively searched the internet for falls prevention advice, but was assumed to be incapable of independent action.
Older person as rational learner
The second most frequent subject position used by the majority of websites assumed that older people were service users and responsive to facts, with conscious reasoning and problem solving. The advice was presented in a way to appeal to older readers' rational understanding of risk: 'Foot problems can increase the risk of falling' (1) and 'Some medicines can make you dizzy and increase your risk of a fall'. (1) While rational learners were assumed to be capable of independent thought, the information was still driven by the health professional's agenda, including reference to the economic burden of older people's falls. In addition, the information was at times presented in a way that could cause potential alarm or anxiety. For example, older readers were to seek medical advice or face the potential of being moved into a care home because of a fall.
Similarly to passive recipients, rational learners were provided with
a lot of information that was not explained. Older readers were never given the sense that they were the experts with respect to their own health choices in the context of their own lives and situations, and there was no flexibility to apply the advice because there was only one option available for action: to seek advice from their general practitioner, local pharmacist and optician.
Older person as empowered decision maker
This was the least frequent subject position, with no website consistent in its use. Health promoters positioned themselves as partners, rather than as experts delivering prescriptive advice, thus sharing information and permitting older readers to contextualise the information to their own practices and preferences, and to prioritise accordingly. Indeed, it was assumed that older readers would evaluate the information using a variety of criteria, such as the costs or benefits to their social and personal identity, as well as a perceived risk of injury: 'Some falls might not cause a physical injury, but may affect your confidence' (19) and 'That's why it is worthwhile to be practical about the risk of falling. You can take some basic precautions, without always having to worry about falling.' (37)
The text was empowering because it included explanations about the mechanisms of falling, thereby enabling older readers to follow through lines of argument rather than unquestioningly accepting lifestyle recommendations; for example, 'If your muscles and joints don't get a regular workout, they get weaker over time. And that puts you at greater risk for balance problems.' (17) In acknowledging older readers as empowered decision makers, the text was more tentative in tone, showed appreciation that not all older people are the same, and conceded that despite precautions some falls may still occur.
Sections on lifestyle management were most frequently written with the assumption that the older reader was an empowered decision maker, although this was often in contradiction to the use of a passive recipient subject position throughout the preceding advice. This is potentially confusing for the older reader because, for example, one website asked older readers to consider themselves fearfully at risk of being placed in a nursing home due to a fall, and then later asked them to consider kickboxing as a form of physical activity. The information in the lifestyle management sections was thoroughly explained, informing the older reader of its importance and how it reduces falls. This section was empowering because a range of options for action were presented, enabling choices varying from simple daily tasks to classes and solo activities outside the home. One website used goal setting, which can be engaging and inspire a sense that one is able to effect personal change. As positive encouragement from peers and health professionals supports the uptake of exercise and physical activity (Horne et al 2010), one website used personal testimonials, conferring autonomy and dignity on those older people who have chosen to share their experiences: 'I have recently been able to come off some medication, and I have now virtually put away my walking stick.' (19)
The representations of old age afforded to older readers in online falls prevention advice were investigated. Websites were searched for systematically and 33 identified for inclusion in a discourse analysis. Within these, three subject positions were identified: the older person as passive recipient, rational learner and empowered decision maker. These subject positions are discussed in relation to two key ProFaNE recommendations for communicating falls prevention advice.
Comparison with ProFaNE recommendations
In contrast to recommendations made by ProFaNE (Yardley et al 2007a), the passive recipient and rational learner subject positions neither projected an image of old age that would fit with a positive identity nor engaged older people to use information in order actively to self-manage their health. These two subject positions are therefore not likely to be readily taken up by older people (Bunn et al 2008).
For passive recipients, the patronising tone in the text gave the impression that the older person is being talked at rather than spoken with, and older people were assumed to be uninformed, lacking common sense and generally ignorant. Advice presented in such a fashion has already been negatively perceived (Yardley et al 2006b). Older people have also reported the notion of a personal risk of falling as a threat to their identity and autonomy (Health Education Board for Scotland [HEBS] 2001, Ballinger and Clemson 2006, Yardley et al 2006a, 2006b) and appear eager to convey that they are instead healthy (Hughes et al 2008, Buttery and Martin 2009), independent (Hughes et al 2008) and not at risk of falling (Ballinger and Payne 2000, 2002, Simpson et al 2003). In addition to the likelihood of being ineffective, because older people do not identify themselves as at risk of falling (HEBS 2001, Hughes et al 2008), websites that characterise older people in this negative light are potentially alienating readers.
For rational learners, the older person was simply regarded as a rational service user, with omission of the more complex social and cultural factors that influence lifestyles and behaviour. This approach is similar to health psychology models, such as the health belief model, that incorrectly assume that individuals are always rational and that information is sufficient for engagement (Ogden 2000).
The passive recipient and rational learner subject positions presented falls prevention advice from the health professional's agenda, which is of note. This is because while health care staff may be primarily concerned with objective risk and safety issues, older people themselves may be more concerned with social and emotional issues, such as social participation in meaningful activities and avoidance of embarrassment (Ballinger and Payne 2000, 2002, Arcury et al 2001, Yardley and Smith 2002, Grenier 2007). References to the economic cost of falls and the use of scare tactics, such as the threat of moving people into nursing homes, assumes that older people are a drain on the economy (Victor 2006). This approach may be alienating, and even distressing, as older people appear deeply concerned with not being perceived as a burden on others (Furstenberg 1986, HEBS 2001, Belza et al 2004, Takahashi and Asakawa 2005). In addition, negative factors, such as fear of falls, perceived risk of falls and increased falls risk have not been predictive of intention to undertake strength and balance training (Yardley et al 2007b).
Consistent with recommendations made by ProFaNE (Yardley et al 2007a), the empowered decision maker subject position, when used, projected an image of old age that would fit with a positive identity, and helped older people to make informed choices to self-manage their health actively. This subject position is consequently more likely to be taken up by older people (Bunn et al 2008). The empowered decision maker subject position has resonance with the 'patient empowerment' discourse described by Dixon-Woods (2001), whereby readers become active collaborators to make informed decisions. Social cognitive theory has shown that when individuals are actively involved in health behaviour change interventions, the impact of the intervention is stronger (Bandura 1997). For example, nutrition education is more effective when individuals consider their diet and set goals for improvement (Contento et al 1995); action plans help raise older people's confidence to undertake strength and balance training (Nyman and Yardley 2009b); and environmental modification interventions to prevent falls in the home are more effective if older people are actively involved in considering hazards in relation to their daily routine and preferences (Todd et al 2007).
For strength and balance training in particular, the presentation of a range of options for action is important because this permits personal choice (Yardley et al 2008), and older people are more likely to undertake activities that they enjoy doing (Wankel 1993, Yardley et al 2006a) and are in accord with their preferences (Yardley and Nyman 2007, Nyman and Yardley 2009a, 2009b). In addition, promoting immediate benefits, such as having fun and socialising, may be more engaging than long-term health benefits (Massie and Shephard 1971, Wankel 1993, Stead et al 1997, Caserta and Gillett 1998, Rose 2007). Incentives identified by older people for undertaking strength and balance training include maintaining independence, social networking, learning new things, building confidence, and looking and feeling good (Yardley et al 2006a).
Limitations of the study and future research
Visual data, such as images of older people and 'risky' home environments, would have been of interest to the analysis; however, too few images were used across the websites to be sufficient for inclusion. The additional analysis of falls prevention leaflets and pamphlets may have added greater depth to the study; however, these would have been more difficult and costly to retrieve, especially international materials. In addition, while only one website in the study targeted the younger relatives of older people, it has been assumed that the readers of falls prevention websites are older people. It is possible that relatives and carers access websites that target older people on their behalf, and so issues over the manner in which advice is communicated may be more complex in these circumstances. Future research could explore whether most older people access online falls prevention information for themselves and how best to present online information to relatives and carers of older people. Lastly, older people were not involved in the analysis, so it cannot be claimed that the interpretation is representative of the views of older people.
Three topics arose from this study for further research: (1) to explore and compare the impact of different representations of old age on uptake of falls prevention advice; (2) to investigate the influence of visual information and images of peers (for example, those used in leaflets) on older people's uptake of falls prevention advice; and (3) to investigate the determinants of preferences for different formats and styles of health promotion material, such as learning styles, health beliefs, computer literacy and level of education.
Implications for occupational therapy
It is suggested that occupational therapists follow the recommendations made by ProFaNE on communicating falls prevention advice (Yardley et al 2007a). In addition, the following suggestions are made to assist occupational therapists in writing falls prevention advice that fits with a positive self-image and is empowering for older people, both within written information leaflets and in advice available through the internet:
1. Be clear and consistent with a subject position for the older reader because this will determine the content and presentation of the advice.
2. Adopt a positive approach towards older people, and promote the immediate benefits of falls prevention activities so that the projected image of old age will fit with a positive self-identity.
3. Adopt an approach that empowers the older reader to make informed decisions (Hart 1990, Virtanen et al 2007, Bastian 2008). For example, with strength and balance training, explain how this activity will be beneficial to them in positive ways other than preventing falls (for example, increasing independence and meeting new friends), can be easy and fun to do and can improve balance, and then present a range of ways in which the activity can be carried out (Yardley et al 2008).
4. Involve older people in developing website materials and carry out usability and acceptability testing.
5. It may be that presenting advice both to frail and sedentary older people and to younger and more active older people is too difficult to achieve (Kellogg International Work Group on the Prevention of Falls by the Elderly 1987). Some activities will be too risky for frailer individuals and other suggestions patronising for more active individuals. Strategies such as targeting and tailoring may assist in making the advice more appropriate for older readers, although tailoring will require effort to make advice personally relevant (Kreuter and Skinner 2000, Kreuter et al 2000).
Unfortunately, there was no website from the present study that was exemplary. However, an example of a website that follows ProFaNE's recommendations on communicating falls prevention advice (on strength and balance training) and uses tailoring can be found at www.balancetraining.org.uk (Nyman 2007).
The most frequent representation of older people was as passive recipients, characterising them as inert, vulnerable and ignorant, and was unlikely, therefore, to be acceptable and engaging for older people. In contrast, the rarely used representation of older people as empowered decision makers--which characterised them as autonomous, responsible and evaluators of health advice--was in accord with ProFaNE recommendations and likely to engage older people in falls prevention. Thus, in addition to a previous review that showed that the content of falls prevention websites was found wanting (Whitehead et al 2007), this study has expanded the current state of knowledge by showing that the style of online falls prevention advice is generally poor and unlikely to engage older people, and is, therefore, unlikely to be effective. The current Code of Ethics and Professional Conduct requires that we respect and uphold clients' autonomy and choice, and involve our clients as active partners in the therapeutic process (College of Occupational Therapists 2010). This paper provides information to support how we might do this in relation to falls prevention advice accessed through the internet.
This study was funded by a grant to the first author from the University of Reading's Research Endowment Trust Fund Pump-Priming Scheme for Research in Social Sciences, and supplemented by the University of Reading's School of Health and Social Care. We thank Sarah Whitehead for providing a manuscript of her and her colleagues' systematic-style literature review of falls prevention websites, the details of the websites included in their review, and permission to use the flow chart of their website search.
Conflict of interest: None declared.
* Falls prevention websites frequently represent older people as passive recipients.
* Such representation is unlikely to be acceptable or engaging.
* More effective representation would be that of empowered decision makers.
What the study has added
The study has shown that the presentation style of online falls prevention advice is currently unlikely to be acceptable or engaging for older people, and is, therefore, unlikely to be effective.
Appendix 1. List of websites included in the analysis (n = 33, accessed on 16.05.09)
Accident Compensation Corporation
American Academy of Orthopaedic Surgeons
Buckinghamshire: National Health Service
Centers for Disease Control and Prevention
Colorado State University
Cornwall: National Health Service
http://www.direct.gov.uk/Over50s/HealthAndWellBeing/SupportAnd YourEveryDayHealth/SupportAndEveryDayHealthArticles/fs/en?CONTENT_ ID=10028039&chk=MPAIFE
Help the Aged
Informed Health Online
Loyola University Health System
Minnesota Falls Prevention
My Optum Health.com
National Institute of Arthritis and Musculoskeletal and Skin Diseases
National Institute on Aging
Royal Society for the Prevention of Accidents
Salisbury: National Health Service
Suffolk: National Health Service
University of Cincinnati
University of Maryland
Waltham Forest Older People.com
Wright State University
http://www.gshleb.org/blank.cfm?id=12&action=detail&articlepath=/ atoz/Osteo/osfalls html
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Samuel R Nyman, (1) Harriet A Hogarth, (2) Claire Ballinger (3) and Christina R Victor (4)
(1) Formerly Postdoctoral Research Fellow, School of Health and Social Care, University of Reading, Reading, and now Lecturer in Psychology, School of Design, Engineering & Computing, Bournemouth University, Poole, Dorset.
(2) Visiting Lecturer, School of Psychology, University of Southampton, Southampton.
(3) Deputy Director/Senior Qualitative Health Research Fellow, NIHR Research Design Service South Central/Faculty of Medicine, University of Southampton, Southampton.
(4) Professor of Gerontology and Public Health, School of Health Sciences and Social Care, Brunel University, West London.
* The superscript numbers after quotes relate to the websites listed in Appendix 1, but have not been cross-referenced to avoid identifying the websites giving advice in an inappropriate way.
Dr Samuel R Nyman, Lecturer in Psychology, School of Design, Engineering & Computing, Bournemouth University, Poole House, Talbot Campus, Poole, Dorset BH12 5BB. Email: firstname.lastname@example.org
Table 1. Prompts for discourse analysis of the text from falls prevention websites using two of the evidence-based recommendations made by the Prevention of Falls Network Europe (ProFaNE) (Yardley et al 2007a) * Prompts for analysis ProFaNE recommendation concerning fit with positive identity What is the older person being asked implicitly to accept about themselves? What is the older person being asked implicitly to accept about later life? Would the older person accept these representations? Would the older person be motivated or put off by these representations? ProFaNE recommendation concerning empowerment Does the older person have a voice in the discourse? Is the older person's perspective appreciated? Is all the advice explained at the appropriate level? Is the older person dictated to? Is the older person empowered to make informed choices? Is there flexibility in using the advice or only one option given? * For a quotation of the two recommendations, please refer to the subsection in the method entitled 'Qualitative analysis of representations of old age'.
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