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London Metropolitan University
• To understand the factors that influence the health of older people
• To learn about the role of health promotion in older people’s health
• To develop health promotion strategies that you can use to support healthy ageing
Healthy ageing has been defined as the process of developing and maintaining the functional ability that enables well-being in older age. However, as people age, many will develop chronic diseases. Therefore, while life expectancy worldwide has been increasing, this does not necessarily result in a healthy full lifespan, with disability and ill-health often negatively affecting a person’s end of life. This article examines the nursing skills required to support older people to live healthy lives against a backdrop of rising levels of chronic conditions. Nurses have a vital role in supporting health improvements in older people by providing targeted solutions such as lifestyle modifications, strengthened social networks and enhanced resilience.
Nursing Standard. doi: 10.7748/ns.2021.e11693
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
CorrespondenceChristine.Cartwright@staffs.ac.uk
Conflict of interestNone declared
Hayes L, Cartwright CH (2021) Using health promotion to support healthy ageing. Nursing Standard. doi: 10.7748/ns.2021.e11693
Published online: 27 September 2021
Across the past three decades, the concept of health has been examined extensively in the academic literature (Bunton et al 1995, Adamson 2019). However, possibly the most cited definition has been that proposed by the World Health Organization (WHO), which noted that ‘health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO 2014). This definition formed part of the WHO’s original 1948 constitution and remains unchanged. In 1948, the definition was considered ground-breaking because it extended the concept of health beyond a focus on disease to incorporate both mental well-being and the social domains. However, the WHO (2014) definition has also attracted criticism, primarily focused upon the use of the phrase ‘complete physical, mental and social well-being’ in relation to optimal health. This focus on ‘complete’ health would result in many people, and certainly older people, being classified as unhealthy most of the time and, given the rise in long-term conditions, it is a concept that has come to be regarded as outdated (Huber et al 2011).
Data collected on the health of people across Europe has shown that although more than 40% of older people in England aged 65 years and over reported having no long-term conditions, of those who did, more than 40% reported having one chronic condition and more than 15% reported having two or more chronic conditions; a rate of chronic conditions slightly higher than the average for the European Union (Organisation for Economic Co-operation and Development and European Observatory on Health Systems and Policies 2019).
Older people also have higher rates of morbidity compared with younger adults. In 2016, morbidity was shown to increase significantly with age, doubling by the time people reached their 60s compared with those aged in their 20s, and almost doubling again for people aged in their 80s (Public Health England (PHE) 2018a). As part of a qualitative study exploring older people’s perception of health, Tkatch et al (2017) noted that older people tended to consider themselves as having ‘successfully aged’ irrespective of their clinical health status, demonstrating that people can perceive themselves to be healthy despite the presence of chronic disease. Therefore, in an ageing population, any definition of health needs to be inclusive and recognise these wider perceptions of health (Fallon and Karlawish 2019).
The health of older people can be understood as a dichotomy between objective and subjective aspects, the objective being a person’s clinical or medical status, including long-term conditions or chronic diseases; and the subjective being their self-reported health (Tkatch et al 2017). It is important that nurses understand older people’s perceptions of their health status, because it is not unusual for individuals to have one or more well-controlled health conditions that have little influence on their ability to function (WHO 2015). Therefore, any practical definition of health in ageing should be holistic and focus in part on an individual’s functional abilities rather than relying solely on their objective health status (WHO 2015). For nursing, with its emphasis on person-centred care, interventions should be focused on the individual’s perception of their health and what they want to achieve in terms of factors such as their functional ability.
• In an ageing population, any definition of health needs to recognise older people’s perceptions of health
• Any public health interventions aimed at supporting healthy ageing should strive to respect older people’s autonomy
• Health promotion provides a clear role for nurses because adopting a healthy lifestyle reduces the risk of developing chronic conditions in later life
• A holistic approach to health promotion in older people is essential because ensuring healthy ageing requires more than lifestyle modification alone; it also incorporates independence, personal growth and social well-being
The WHO (2015) developed a public health framework to support healthy ageing and identified various ways in which this could be promoted. These included the consideration of age-friendly environments within sectors such as health services, transport, housing, and information and communication.
The focus is on supporting the development and maintenance of older people’s functional ability, with the overall aim of enabling them to engage in activities that they enjoy. This includes identifying and minimising barriers that might hinder health-promotion activities, providing services that reduce or reverse physical decline, and ensuring the availability of equipment to promote independence and autonomy.
The ultimate aim is to optimise each individual’s potential in older age (WHO 2015), as well as developing accessible and supportive environments (WHO 2017), with nurses adjusting their care according to the clinical area in which they are working.
The WHO (2015) also stated that addressing diversity, reducing inequity and enabling choice should form part of any public health approach to healthy ageing, and these concepts are consistent across UK policy and guidance documentation (National Institute for Health and Care Excellence (NICE) 2015, Government Office for Science 2019, International Longevity Centre UK 2020, Seaman et al 2020).
Any public health interventions aimed at supporting healthy ageing should strive to respect older people’s autonomy, promote prevention, early identification and management of long-term conditions, and encourage behaviour such as exercise and healthy dietary choices (WHO 2015, NHS 2019, International Longevity Centre UK 2020).
Recently, a public health approach to healthy ageing has been developing within the UK (PHE 2020, International Longevity Centre UK 2020). While PHE’s consensus on healthy ageing focuses primarily on disease prevention, it also explores strategies for reducing health inequalities between younger and older people, and challenging the use of ageist language, culture and practices (PHE 2020). These negative attitudes and behaviours can be actively challenged by nurses when promoting the rights of older people through person-centred care. For example, nurses can actively role model positive behaviours towards older people, as well as familiarising themselves with the stigma and negative attitudes towards ageing, which are identified in publications such as Doddery but Dear (Centre for Ageing Better 2020). One aspect of this publication is how communication and language can act as a barrier when people place an older person in a stereotypical ‘deficit’ position, rather than regarding them as an individual with unique personal abilities and strengths.
The WHO (2014) has recommended a holistic approach to the promotion of physical and psychological well-being as people age, suggesting that a one-dimensional approach is insufficient, and that effective healthcare requires a range of interventions. Historically, however, health promotion has generally not targeted older age groups (Age Concern and Mental Health Foundation 2006, Golinowska et al 2016, Daly et al 2019). This is an issue, because older people’s health needs differ from those of the younger population significantly. For example, health promotion in older people is not based on one aspect of health or single condition, but is multifaceted and includes such areas as disability, nutrition, obesity and/or sleep quality (Chiu et al 2020).
The UK advisory think-tank on healthy ageing, the International Longevity Centre UK, has focused on preventative strategies to improve older people’s quality of life, for example by enacting policies such as improving public transport and basing older people’s outreach services in easy-to-access locations such as supermarkets (International Longevity Centre UK 2020).
Supporting healthy ageing is particularly important given that life expectancy in many parts of the world has increased substantially, but people’s lifespans do not always reflect this, with people’s end of life often marked by a period of disability and ill health (Royal Society and the Academy of Medical Sciences 2020). For example, at the age of 65 years, around half of the remaining life of older people will be affected by disability, a trend that is increasing in women (Centre for Ageing Better 2019, Royal Society and the Academy of Medical Sciences 2020). Therefore, although people in the UK are living longer, the implication that this will lead to a healthy old age has not been clearly demonstrated.
The need to address this discrepancy between longer life and expectations of optimal health has led to various initiatives that seek to increase the number of healthy years a person can expect to live. For example, the UK government ‘grand challenge’ missions focus on an industrial strategy to meet the needs of an ageing society, enabling people to remain at work longer and developing markets for goods and services that meet older people’s needs (HM Government 2017, University College London Institute for Innovation and Public Purpose 2019).
Health promotion sits within a public health remit and is defined by WHO (2021) as ‘the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.’ Some of these interventions can be addressed by nurses in practice.
Health promotion provides a clear role for nurses because it is known that adopting a healthy lifestyle reduces the risk of developing ill-health and disability in later life (Department of Health 2001). Recognising diversity in older age is also an important issue for nurses because it enables an understanding of the individual’s personal health journey, rather than considering older people as a homogenous group (WHO 2018, International Longevity Centre UK 2020). The ethos of health promotion for nurses can therefore be viewed as one of empowerment, by enabling individuals to increase control over their own health, and advocacy, by attempting to reduce health inequalities (Daly et al 2019).
Although all people age and will do so with individual healthcare needs (Centre for Ageing Better 2019), the aspiration for society is for people to age well and to extend their healthy years of life. For nurses, health promotion is central to this aspiration.
While elements of general health promotion guidance may be relevant for older people, there are also specific physiological changes involved in ageing such as reduced physical mobility. Therefore, Daly et al (2019) argued that a holistic approach to health promotion in older people is essential because ensuring healthy ageing requires more than lifestyle modification alone; it should also include aspects such as independence, personal growth, spirituality and social well-being. Daly et al (2019) stated that person-centred health promotion in older people should focus on several important areas:
• Physical health and enhancing functional ability, including lifestyle and/or behaviour modifications – these include focusing on increasing older people’s physical activity, improving their diet, reducing alcohol consumption, smoking, and/or obesity, preventing falls, and promoting self-management of long-term conditions.
• Social health – such as strengthening social networks and enhancing social participation.
• Holistic and wellness activities – such as meditation, yoga or spiritual growth, and holistic healthcare procedures such as advanced care planning.
• Mental health – such as enhancing resilience and addressing conditions such as anxiety or depression.
The UK government document, Future of an Ageing Population (Government Office for Science 2019), identified that a wide range of areas affecting the older population needed to be addressed including workplace adaptations, appropriate housing, and the provision of life-long learning, all of which would make social, physical and technological connectivity a reality for older people. For example, a nurse working within occupational health might be directly involved in advising on adaptations to an older person’s working environment; similarly, adult and mental health community nurses might refer an older person to social service colleagues for housing advice.
Many nursing-related health-promotion activities focus on behaviour changes including alcohol screening, smoking cessation, increasing physical activity, or providing guidance on mental health and well-being. These health promotion activities continue to be important when nurses are promoting healthy ageing in older people. However, nurses may need to adapt the methods they use to deliver these interventions so that they more effectively align with older people’s requirements. One example of this would be a nurse recommending that an older person follow an adapted exercise regimen to accommodate their arthritis (WHO 2015).
It is important for nurses to consider how health promotion initiatives can reach older people. Traditionally, this could be addressed by older people visiting primary care services as inpatients, or via face-to-face contact with nurses in the patient’s home or community clinic. However, more recently with the advent of digital technology, and particularly against the background of coronavirus disease 2019 (COVID-19), online initiatives are increasingly being adopted by nurses to maintain contact with patients.
When considering a digital approach in older people’s health promotion, it is important that nurses attempt to reach everyone across the ‘older’ age group, remembering that older people may be experiencing digital poverty as well as financial deprivation. Making appropriate adjustments to digital resources can also assist nurses in ensuring that health messages are tailored to older people. Appropriate adjustments may include changes in font sizes in digital literature, or the provision of audio files to assist with people’s understanding of health promotion materials (WHO 2015). For frontline staff such as nurses, this approach to health promotion includes being proactive, working with people in a person-centred way to enable informed choice, and using practical approaches such as Making Every Contact Count (PHE 2019).
Making Every Contact Count is a specific education programme for UK healthcare staff. It aims to promote a non-didactic approach to day-to-day interactions between staff and patients to promote positive lifestyle change (PHE 2018b).
The essential principles of Making Every Contact Count are detailed in documents from NHS Yorkshire and the Humber (2010) and NICE (2014), which contain useful person-centred guidance demonstrating how nurses might be able to motivate older people to consider lifestyle change by providing ‘brief’ opportunistic advice, such as raising awareness of areas such as reducing alcohol consumption and/or taking a healthy diet or exercise. These brief interventions use a range of behaviour change tools such as the Transtheoretical Model of Change (Prochaska and Di Clemente 1983), which can guide nurses’ discussions with older people who may be at risk due to their lifestyle behaviour or health inequalities, and may in turn lead to referral to specific behaviour-change services such as falls prevention clinics.
Extended brief interventions, which usually last more than 30 minutes and can take place over several sessions, involve more focused discussions with older people who are identified as being at high risk due to lifestyle choices, have a number of concurrent health issues, or who find it challenging to make or sustain any lifestyle changes (NICE 2014, PHE 2016).
Making Every Contact Count can be underpinned by several theoretical behaviour change models; for example, Michie et al’s (2014) behaviour change wheel and Holden et al’s (2016) general guide to undertaking Making Every Contact Count. The Transtheoretical Model of Change (Prochaska and Di Clemente 1983) is a another commonly used behaviour change model, also known as the ‘stages of change’. This model explains behaviour change as a dynamic process where the individual progresses through several stages while adapting a behaviour such as smoking (Prochaska and Di Clemente 1983, Jiménez-Zazo et al 2020).
The stages incorporate pre-contemplation of a change, where the individual may have no intention of changing their behaviour, through to contemplation, preparation, action and maintenance.
The final relapse stage indicates that behavioural change is not always easy to achieve and may take repeated attempts. Relapse is therefore not seen as negative, but rather forms part of the change process.
The main goal of the Transtheoretical Model of Change is to develop an action plan based on the stage that the person is perceived to be in, and which seeks to prevent relapse and maintain any changes (Royal College of Nursing (RCN) 2019a). In addition, the Transtheoretical Model of Change seeks to identify an individual’s motivation to change rather than asking when they may change (Jiménez-Zazo et al 2020). Nigg et al (1999) noted that the model has been used effectively over time in older populations to promote intentional behaviour change (Barké and Nicholas 1990, Koo et al 2017). For example, a nurse may use the Transtheoretical Model of Change model to identify an older person’s readiness and motivation to change a lifestyle behaviour such as smoking. The nurse can then provide targeted support such as smoking cessation advice.
Miller and Rollnick (2012) considered that the Transtheoretical Model of Change complemented their development of motivational interviewing, a relationship that was also noted by Hall et al (2012). Motivational interviewing can contribute to behaviour change by assisting nurses to establish an older person’s readiness for change and their confidence in being able to make that change (RCN 2020).
Motivational interviewing has become an increasingly popular tool in health promotion recently, and is a significant factor in the Making Every Contact Count programme. Motivational interviewing complements person-centred care, contributing to the development of an equal power relationship between the clinician and the patient. This relationship is in direct opposition to a didactic or persuasive approach to health promotion. Motivational interviewing involves a collaborative discussion where the nurse supports change by encouraging the older person to identify reasons why they might need to change their lifestyle or behaviour (Hall et al 2012).
Procter-King and McLean (2019) argued that the fundamental principles underpinning motivational interviewing are more important for the nurse to grasp than the skills themselves. These principles include the importance of an equal power-base between the nurse and the patient, where the patient is regarded as being an expert in their own motivations and abilities, and where the most important determinant in behaviour change lies within themselves. Another fundamental belief of motivational interviewing is that the patient ‘knows what works for them’. Therefore, the nurse may have knowledge or skills to share, but a patient’s choice whether or not to engage and to change their behaviour is vital and should be respected (Procter-King and McLean 2019).
As part of any motivational interviewing session, the nurse can use a tool known as a ‘readiness-to-change ruler’, which asks the older person to rate their readiness and confidence to make any lifestyle changes on a scale of one to ten. This provides a simple indication of the older person’s attitude to change and provides insight for the nurse into how to approach any motivational discussion (RCN 2020).
When following the principles of motivational interviewing, the nurse should attempt to follow the acronym RULE (resist, understand, listen, empower) (Hall et al 2012, RCN 2019b):
• Resist the temptation to advise the older person on what they should do.
• Understand that it is the older person’s reasons for making a lifestyle change rather than the nurse’s that will bring results.
• Listen to the older person with empathy.
• Empower the older person’s own ideas for change, and assist them in identifying solutions.
It is beyond the scope of this article to outline the motivational interviewing approach in detail, but many useful resources exist for the nurse (Hall et al 2012, Miller and Rollnick 2012, Procter-King and McLean 2019). In addition, there are core nursing communication skills that should be central to any nurse’s conversations with an older person concerning lifestyle change. These communication skills include (Procter-King and McLean 2019):
Ensuring healthy ageing requires nurses to provide older people with care that is person-centred and focused on a number of important aspects such as functional ability and well-being. By using techniques such as motivational interviewing and behavioural change models, and by understanding policies such as Making Every Contact Count, nurses can influence older people’s lifestyle choices and assist them to age healthily. Nurses are ideally placed to access this group of patients, due to their work across a range of health services and their knowledge of communication skills.
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