Selected determinants of health behaviour of people aged over 65

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1 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No. 3/2016 (20-26) Selected determinants of health behaviour of people aged over 65 (Wybrane czynniki determinujące poziom zachowań zdrowotnych osób powyżej 65 roku życia) G J Nowicki 1,D, M Młynarska 2,A, B Ślusarska 1,E,F, P Rzońca 2,D,B, M Kotus 3,C, A Zagaja 4,D Abstract Introduction. Factors influencing successful ageing, i.e. ageing free from diseases common in the old age, include selected life style determinants. One of the categories of human behaviours, which constitutes the style of life and determines its quality, is health behaviours. The aim of the study. The assessment of the level of health behaviours of people aged over 65, depending on selected factors such as: the feeling of pain, the limitation of functional capacity, comorbidity and the self-evaluation of one s health state. Materials and Methods. The study was conducted from July to September 2013, on 505 people aged 65 and older in 5 randomly selected Primary Health Care (POZ) facilities located in the Lubelskie voivodeship. In order to assess the level of health behaviours and the four categories thereof, Juczyński s Health Behaviours Inventory (Inwentarz Zachowań Zdrowotnych, IZZ) was used. Results. The evaluation of the level of health behaviours for the studied group of people aged over 65 showed the average IZZ of points (SD = 15.94) % (n = 218) of the respondents had a low level of health behaviours (1-4 sten), 36.43% (n = 184) an average level (5-6 sten), and only 20.40% (n = 103), a high level (7-10 sten). has revealed that the level of the declared health behaviours of people above 65 years of age depended on the perception of pain (p <0.001), reduced mobility (p <0.001), comorbidities (p <0.001) and the self-assessment of one s health (p <0.001). Conclusions. Among people over 65 years of age, a lower level of health behaviours was affected by the declared level of pain, the reduction of mobility, comorbidities, and low and very low self-perceived health. Seniors from the studied group, in more than 43%, received low scores of health behaviours, which indicates that the analyzed factors are important in the development thereof. Key words health behaviours, the elderly, comorbidity, pain, reduced mobility. Streszczenie Wstęp. Czynnikami wpływającymi na pomyślne starzenie się, rozumiane jako starzenie wolne od chorób, które najczęściej występują w wieku podeszłym, są niektóre elementy stylu życia. Jedną z kategorii zachowań człowieka, która składa się na styl życia i decyduje o jego jakości, są zachowania zdrowotne. Cel pracy. Ocena poziomu zachowań zdrowotnych osób powyżej 65 roku życia w zależności od wybranych czynników takich jak: odczuwanego bólu, ograniczenia sprawności funkcjonalnej, wielochorobowości oraz samooceny stanu zdrowia. Materiał i metoda.badania przeprowadzono od lipca do września 2013 r. wśród 505 osób w wieku powyżej 65 roku życia w losowo wybranych 5 jednostkach Podstawowej Opieki Zdrowotnej (POZ) na terenie województwa lubelskiego. W celu oceny poziomu zachowań zdrowotnych i ich czterech kategorii posłużono się Inwentarzem Zachowań Zdrowotnych (IZZ) wg, Juczyńskiego. Wyniki.W ocenie poziomu zachowań zdrowotnych dla badanej grupy osób powyżej 65 roku życia średnia IZZ wyniosła 76,49 pkt. (SD=15,94). 43,17% (n=218) badanych miało niski poziom zachowań zdrowotnych (1-4 sten), 36,43% (n=184) respondentów miało przeciętny poziom zachowań zdrowotnych (5-6 sten), natomiast tylko 20,40% (n=103) wysoki (7-10 sten). Analiza statystyczna pozwala stwierdzić, że poziom deklarowanych zachowań zdrowotnych osób powyżej 65 roku życia zależy od odczuwania bólu (p<0,001), występowania ograniczeń sprawności (p<0,001), liczby schorzeń (p<0,001) oraz samooceny stanu zdrowia (p<0,001). Wnioski. Wśród osób powyżej 65 roku życia niższy poziom zachowań zdrowotnych determinowany jest deklarowanym stanem odczuwanego bólu, ograniczeniami sprawności funkcjonalnej, wyższym stopniem wielochorobowości oraz złą i bardzo złą samooceną stanu zdrowia. Seniorzy w badanej grupie w ponad 43% uzyskali niskie wartości zachowań zdrowotnych, co wskazuje, że analizowane czynniki mają istotne znaczenie w kształtowaniu ich poziomu. Słowa kluczowe zachowania zdrowotne, ludzie starsi, wielochorobowość, ból, ograniczenie sprawności. Author Affiliations: 20

2 1. Community Nursing Unit, Chair of Oncology and Environmental Health, Medical University of Lublin 2. Department of Expert Medical Assistance with Emergency Medicine Unit, Medical University of Lublin 3. Department of Anaesthesiological and Intensive Care Nursing, Medical University of Lublin 4. Department of Ethics and Human Philosophy, Medical University of Lublin Authors contributions to the article: A. The idea and the planning of the study B. Gathering and listing data C. The data and interpretation D. Writing the article E. Critical review of the article F. Final approval of the article Correspondence to: Grzegorz Józef Nowicki, DHSc, Department of Family Medicine and Community Nursing, Chair of Oncology and Environmental Health, Faculty of Health Sciences, Medical University of Lublin, Staszica 6 Str., PL Lublin, Poland, grzesiek_nowicki@interia.pl Accepted for publication: July 2, D I. INTRODUCTION emographic ageing of the world s population is a global process. Currently, the world s average life expectancy is over 60 years, with the Japanese and the Australians living the longest (82.2 and 80.6 years respectively) [1]. In Europe, the longest life expectancies are attributed to the French and the Swedes, being 80.6 years on average in both cases, followed by the Italians 79.9, the Greeks 79.3, the Dutch 79.1 and the Germans 78.9 [2]. It is predicted that from 2005 to 2050, Europe will experience an increase in the number of people aged over eighty by 43 million, and at the same time, there will be a significant decrease in the number of young people [3]. This problem also applies to the situation in Poland, although, according to the Eurostat data from 2010, Poland it is one of the "youngest" countries and occupies the 8 th place in the ranking by the level of demographic old age [4]. The process of ageing is influenced by various determinants including social, demographic, cultural, economic, genetic, and health factors. The most important determinant of health is lifestyle and associated health behaviours [5]. A healthy lifestyle is essential in any age group, and for the elderly who have led an unhealthy lifestyle so far, it is of particular significance. The very concept of "lifestyle" is one of the basic social categories, allowing to describe the way people live, their behaviours, standards, customs and culture. A healthy lifestyle, according to public health specialists, is a combination of all actions undertaken by individuals, aimed at maintaining and improving their health and preventing diseases. Actions characteristic of this type of lifestyle comprise four basic factors: proper nutrition, avoiding alcohol and nicotine, regular physical activity, and avoiding stress [6-12]. Old age in the context of the entire course of the human life is its last stage and it should be considered from various perspectives, including the biological, psychological and social one. In the biological context, this period can be associated with the gradual decline in mobility, the deterioration of organs and of system functioning, and increased pain. All of these lead to weakness and the impairment of bodily functions, resulting in the inability to adjust to changing external and internal environment [13]. What is more, these natural processes can directly affect the health behaviours undertaken by seniors. The aim of the study was to assess the level of health behaviours of people aged over 65, depending on selected factors such as: pain, mobility constraints, comorbidities and the evaluation of one s own health. II. MATERIAL AND METHODS A survey was conducted from July to September 2013 on 505 people over 65 years of age who were patients of 5 Primary Health Care Outpatient Clinics (POZ) located in the Lubelskie voivodeship (Poland); 3 of the clinics were located in the Lublin district (the Non-Public Health Care Institution ANI-MED, tbe Non-Public Health Care Institution UNI-MED and the Specialist Outpatient Department for Rural Occupational Diseases located in the Institute of Rural Health) and two institutions were outside of Lublin (the Non-Public Outpatient Centre in Turobin and the Non- Public Outpatient Centre Goraj in Goraj). The patients were recruited on a random basis from persons over 65 years of age who reported to the clinics. Only those respondents were chosen for the study who having been provided with full information about the purpose of the study and the study methods consented to participate. The research was carried out using the method of diagnostic survey, with the application of Z. Juczyński s Health Behaviour Inventory (IZZ) [14]. 21

3 The tool consists of 24 items defining various types of health-related behaviours and the item 25 defined as "other", where a respondent can provide their own assertions that have been not mentioned in the items before. For each statement, respondents assign a specific number depending on how the information applies to them: 1 almost never; 2 rarely 3 from time to time; 4 frequently; 5 almost always. By analysing the frequency of various behaviours indicated by the respondents, it is possible to determine the intensity of behaviours conducive to health and the importance of the four health categories i.e. correct eating habits, prophylactic measures, health practices, and a positive mental attitude [14]. Among healthy eating habits, the research tool recognizes the type of food eaten by respondents e.g. the frequency of consuming whole-grain breads, fruit and vegetables, salt or the avoidance of e.g. food with preservatives, etc. Prophylactic measures include adhering to doctors orders and obtaining information on health and diseases. Health practices, in turn, include everyday behaviours such as sleep, physical activity and recreation. In terms of a positive mental attitude, the following criteria were considered: avoiding too strong emotions, stress, strains, and depressing situations. Because of the fact that a variety of health behaviours must have occurred in their lifetime, the respondents were asked to take only the past year into account. The obtained results were counted in order to receive an overall rate of health behaviours intensity. The values ranged between 24 and 120 points and the higher the score, the higher the level of the declared health behaviours. Afterwards, the results were translated into sten scores as suggested by the authors of the tool. The respondents were also asked about: the feeling of pain (yes/no), reduced mobility (yes/no), the number of chronic conditions, and additionally, they were asked to assess the state of their heath on a 5-point scale: excellent, good, decent, bad, and very bad. The obtained results were statistically analysed. The values of the analysed measurable parameters were expressed with mean values and standard deviations and the non-measurable ones with frequencies and percentages. Prior to the study, the project had received a positive opinion of the Bioethical Commission of the Medical University of Lublin, number: KE-0254/242/2012. To test for differences in the measurable parameters between two groups, the Mann-Whitney U test was applied and for more than two groups the Kruskal-Wallis test along with the post hoc NIR test was used. The level of significance was established at p <0.05 indicating the existence of statistically significant differences or dependencies. The database and statistics were based on the Statistica 9.1 computer software (StatSoft, Poland). III. RESULTS Characteristics of the studied group The study group consisted of 62.38% (n = 315) women and 37.62% (n = 190) men, the majority of them were city residents 65,94% (n = 333). The age structure of the respondents was as follows: years with 243 respondents (48.12%), with 166 respondents (32.87%), and in the oldest age group, i.e. those above 85 years of age, there were 96 respondents (19.01%). The persons with higher and secondary education accounted for 50.49% (n = 255) of the respondents, while those with vocational, primary and no education for 49.51% (250 respondents) % (n = 259) of the respondents admitted experiencing pain, while 61.19% (n = 309) admitted feeling reduced physical mobility. Out of all the respondents, the majority claimed to have from 1 to 3 diseases 246 persons (48.71%), and the rest had 4 and more diseases 229 persons (45.34%). 30 respondents declared that they were healthy (5.94%). In the self-assessment of the health quality, the majority of seniors stated that it was either very bad or bad 214 (42.38%). Those who assessed their health as decent represent the second most numerous group, with 167 respondents (33.07%). It should be noted, however, that the term "decent" does not mean good. Only 124 respondents (24.56%) declared their health to be good or very good. Detailed data have been presented in Table I. Table I. The distribution of the analysed variables among the respondents Variable N % Pain Yes No Mobility limitations Yes No No diseases The number of diseases 1-3 diseases and more diseases Self-evaluation of the Very good/good respondents state of Decent health Bad/very bad The level of seniors health behaviours 22

4 The results have revealed that the assessment of health behaviours for the studied group has the average IZZ of points. (SD = 15.94). In terms of standardized units, out of 505 respondents, 43.17% (n = 218) achieved a result within 1-4 sten, which is considered a low score; 36.43% (n = 184) received a score of 5-6 sten, which is an average value; and only 20.40% (n = 103) of the respondents reported a high level of health behaviours (7-10 sten). In the of individual categories of health behaviours, it has been discovered that the highest rates were attributed to prophylactics (average: pts., SD = 5.23) and health practices (average: pts., SD = 4.09), and the lowest rates were attributed to a positive mental attitude (average: pts., SD = 4.84) and proper eating habits (average: pts., SD = 5.33). Health behaviours of the respondents and selected variables has revealed a statistically significant relationship between the stated perception of pain or lack thereof and the level of health behaviours (p <0.001). The respondents who declared no pain achieved a higher score in the overall rate of health behaviours and in two categories: proper eating habits and positive mental attitude, as compared with those who suffered from pain. Detailed data have been presented in Table II. Tabela II The of health behaviours depending on mobility limitations or the lack thereof has led to the conclusion that there are statistically significant differences in the overall level of health behaviours and three categories (p <0.05). Those who did not experience mobility limitations obtained higher scores in the general level of health behaviour (p <0.001) and in the following categories: correct eating habits (p <0.001), prophylactics (p = 0.001), and a positive mental attitude (p <0.001). The results have been presented in Table II. Similar observations were made when analysing the number of declared maladies against the level of health behaviours. With the increase of the declared number of diseases, the assessment of the overall health behaviours and their four categories decreased (p <0.001). Detailed data have been presented in Table II. Another analysed variable was the self-assessment of the health quality. A statistically significant difference in the overall level of health behaviours and their four categories depending on the self-declared state of health has been revealed (p <0.05). In general, one may state that the higher the self-evaluation of the health quality, the higher the overall level of health behaviours and their four categories. Detailed data have been presented in Table II. IV. DISCUSSION Ageing is a complex and inevitable process that covers many interrelated levels. To obtain an overall picture of this process, in addition to experimental research in the field of biological sciences aimed at explaining the mechanisms of ageing, equally important considerations need to be undertaken with respect to social and psychological aspects. In recent years, there has been a growing interest in this stage of life, which, undoubtedly, is closely related to the increase in the number of people over 65 years of age. Therefore, a multilateral of the process of ageing, based on interdisciplinary research in the field of biology, medicine, pedagogy, psychology or sociology, seems fully justified [15,16]. The interest of gerontologists focused on the process of ageing and the living conditions of the elderly, together with the obtained knowledge enable to create a better future for seniors. Because ageing may occur in different ways, and the process depends on a large number of factors, its explanation still remains a major challenge for future researchers [17]. What influences successful ageing, understood as a life free from diseases, are certain lifestyle factors. One of the categories of human behaviours, which constitutes the style of life and determines its quality, is health behaviours [18]. The studied problems related to seniors and concerning their health behaviours are a part of a growing demand for studies devoted to the elderly. The paper has been focused on important issues associated with the process of ageing, including the impact of pain, the limitations of mobility, the existence of multiple diseases and the influence of the state of health on health behaviours of people over 65 years of age. Pain is a natural, subjective, negative and a very complex reaction to sensory stimuli. It is associated with actual or potential tissue damage. Experiencing chronic pain is associated not only with the emotions and suffering of the person directly concerned, but also of the closest environment. Chronic pain is more common in the elderly; however, it is not a symptom of the normal process of ageing. Pain increasing with age should be attributed to the coexistence of multiple chronic diseases, which is typical of old age [19]. In a study conducted by Kozak-Szkopek et al. on two groups of respondents: 716 persons aged 55-59, and 4979 persons over 65, the prevalence of chronic pain was greater 23

5 Table II. The influence of selected variables on the declared health behaviour of the respondents Variables The level of health behaviours Proper eating habits Prophylactic behaviours Positive mental attitude Health practices Pain The feeling of pain No pain M SD Z A / t B = 4.85 Z A / t B = 5.30 Z A / t B = 4.97 Z A / t B = ; ; ; ; M p= SD Z A / t B = ; p=0.065 mobility constrains Mobility limitations No mobility limitations M SD M Z=-5.401; Z=-6.069; Z=-3.460; p=0.001* Z=-6.415; SD Z=-1.469; p=0.142 The number of diseases No diseases (I) 1-3 diseases (II) 4 and more diseases ( M SD H=46.490; H=29.218; M H=17.944; H=63.220; ; (RM: I-II. (RM: I-II. (RM=I- SD I-III. II I-III. II III. II I-III. II M SD H=26.87; I- Self-evaluation of respondents state of health Very good/ good (I) Decent (II) Bad/ very bad( M SD H=54.971; H=54.209; M H=8.841; H= ; p=0.012* (RM: I-II. (RM: I- SD I-III. II I-III. II I-III. II M SD H=9.984; p=0.007* (RM: I- M mean. SD standard deviation. Z Mann Whitney U test results. H Kruskal Wallis test results. p- the level of statistical significance. RM intergroup differences. A Mann Whitney U test. B Student T test 24

6 in the persons over 65, as compared to the age group (41.6% and 35.1% respectively) [20]. Musculoskeletal pain syndromes are the most common type of chronic pain [21] (also in the population of people over 65); however, the signs and symptoms from the osteoarticular system do not appear suddenly or accidentally. Many predisposing factors are associated with certain unhealthy behaviours, or the type of work performed. These include the lack of physical activity, overweight, sedentary lifestyle combined together especially in sedentary, mental work, or too intense exercise and prolonged overload for some occupations, e.g. farmers. The study has revealed that the respondents who did not feel pain obtained significantly higher scores in the overall health behaviours level and in the following categories: proper eating habits, and a positive mental attitude. The mobility of the elderly depends on the process of ageing, the occurrence of various diseases, lifestyle, and socio-environmental and psychological factors taking effect in their lifetime. The capability of self-care, which decreases with age, increases the demand for different types of care. That is why elderly and disabled persons frequently need special nursing care. The care for such people is aimed at assisting in maintaining the independence from others, general support, and care in diseases [22]. The capability of self-care, or functional capacity, should be understood as the independence from others in satisfying the basic necessities of life, which include: movement, nutrition, the control of bodily functions, and maintaining personal hygiene [23]. In our study, the persons aged over 65 reporting no mobility restrictions achieved higher scores in the overall rate of health behaviours as well as the following categories: proper eating habits, preventive behaviours and a positive mental attitude than those who experienced reduced mobility. The coexistence of various diseases is a common geriatric problem. It entails the need for concurrent use of multiple medications, and the use of multiple drugs may in turn increase the risk of side effects. The phenomenon of using too many drugs is intensified by the patients themselves, who, out of the desire stay fit and healthy, expand the standard treatment with drugs sold without prescription believing that because they are sold without prescription, they are safe and have no side effects, which is not true [24]. Over 50% of elderly people suffer from three or more chronic diseases, the accumulation of which creates an individual image of the patient's health. The occurrence of many diseases at the same time is associated with higher rates of death, disabilities, adverse events; it is also associated with the necessity of increased medical care, the institutionalization of care and lower quality of life [25]. Our study has revealed that along with the increase of the number of declared illnesses, the assessment of the overall level of health behaviours and their four categories decreased. Self-assessment of health as a subjective assessment of an individual s state of health affects the level of activity, maintaining social contacts, the way of coping with stress and self-acceptance. [26] The lower the subjective evaluation of one s state of health, the lower the individual s activity and the poorer social contacts. People with higher health self-esteem are not only more active, but they also have more plans for the future and are more satisfied with life. The feeling of good health has a positive impact on the overall assessment of seniors situation. It turns out that activity of the elderly depends to a great extent on a subjective health perception, not a medical diagnosis [27]. What is more, the research conducted by Switała [28] among respondents aged over 65 has revealed that selfevaluation of health also influences consumer behaviours. The lower the respondents evaluated their health, the more often they expressed a negative opinion about its impact on their purchasing activity. In our study, with the increase in the self-assessment of the health status, the overall level of health behaviours and their four categories increased as well. V.CONCLUSIONS Among persons aged over 65, a lower level of health behaviours was determined by a declared feeling of pain, functional capacity constraints, comorbidities, and poor and very poor self-perceived health. Over 43% of the seniors in the studied group received low scores of health behaviours level, which indicates that the analysed factors are important in shaping these behaviours. VI. REFERENCES [1] Zielińska-Więczkowska H, Kędziora-Kornatowska K, Kornatowski T. Starość jako wyzwanie. Geronol Pol 2008; 16(3): [2] Badania Eurostaru, ( ) [3] Derejczyk J, Bień B, Kokoszka-Paszkot J, Szczygieł J. Gerontologia i geriatria w Polsce i na tle Europy - czy należy inwestować w ich rozwój w naszym kraju? Gerontol Pol 2008; 16(3):

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