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Barriers to Health Promotion in

Community Dwelling Elders
a

Mary Ann Stark , Carla Chase & Alice DeYoung

Bronson School of Nursing, Western Michigan University,

Kalamazoo, Michigan
b

Occupational Therapy Program, Western Michigan University,

Kalamazoo, Michigan
Version of record first published: 06 Nov 2010.

To cite this article: Mary Ann Stark, Carla Chase & Alice DeYoung (2010): Barriers to Health Promotion
in Community Dwelling Elders, Journal of Community Health Nursing, 27:4, 175-186
To link to this article: http://dx.doi.org/10.1080/07370016.2010.515451

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Journal of Community Health Nursing, 27:175186, 2010

Copyright Taylor & Francis Group, LLC
ISSN: 0737-0016 print/1532-7655 online
DOI: 10.1080/07370016.2010.515451

Barriers to Health Promotion

in Community Dwelling Elders
Mary Ann Stark
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Bronson School of Nursing, Western Michigan University, Kalamazoo, Michigan

Carla Chase
Occupational Therapy Program, Western Michigan University, Kalamazoo, Michigan

Alice DeYoung
Bronson School of Nursing, Western Michigan University, Kalamazoo, Michigan

As the number of elders who live in the community increases, promoting their health and independence is a priority of nursing care. As suggested in the Health Promotion Model, barriers can impede
the practice of health promotionn. In this descriptive correlational study, community-dwelling elders
65 and older were recruited (N=141) to examine the relationship between attentional demands as measured by the Attentional Demands Survey and health promotion. The results indicate that attentional
demands may act as barriers, reducing elders ability to engage in health promotion. Community
health nurses can focus care toward reducing attentional demands and improving health promotion.

As the baby boom generation (those born between 1941 and 1964) ages, the impact on communities and health care will be significant, as their need for care and services grows and brings dramatic changes in health care and in society (Young & Capezuti, 2010, p. 112). That trend continues as the first of this generation reaches 65 in January 2011, with the number of those 65 and
older steadily increasing from 35 million in 2000 to an anticipated peak of 71 million by 2030,
with the fastest growing segment being those over 85 years old (Center for Disease Control and
Prevention, 2003). Care at the home and community level will become even more important as the
healthcare system prepares for this silver tsunami. The benefits of keeping older adults healthy include their continued ability to participate and contribute to the life of the community, as well as
spending less on medical costs and long-term care (Young & Capezuti, 2010). In addition, the objectives that have been proposed for Healthy People 2020 reflect the importance of addressing the
needs of this generation, particularly in the area of health promotion. Increasing elders management of chronic health conditions, encouraging engagement in leisure-time physical activities,
and decreasing the risk of falls are all areas where health promotion may be beneficial (US Dept of
Health and Human Services, 2009).

Address correspondence to Dr. Mary Ann Stark, PhD, RNC, Associate Professor, Bronson School of Nursing, Western
Michigan University, 1903 W. Michigan Ave, Kalamazoo, MI 49008. E-mail:mary.stark@wmich.edu

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When exploring best practices for home and community health promotion, it is important to
consider the barriers to acceptance and compliance. Jansens (2006) work in attentional demands
and its impact on the functional status of community-dwelling elders indicates that those tasks that
require additional processing and more focused attention or concentration (higher attentional demands) may become more difficult with age and, thus, negatively impact the ability to manage
daily activities to their satisfaction. The purpose of this study was to examine the attentional demands that might act as barriers to the practice of health promoting behaviors in community
dwelling elders (65 and older).

THEORETICAL FRAMEWORK
The Health Promotion Model (HPM), which was developed with consideration of the multidimensional nature of persons and the unique environment in which each person functions, was the
framework that guided this research (Pender, Murdaugh, & Parsons, 2005). This model considers
factors that influence a persons practice of health promoting behaviors, defined as those activities
that attain positive health outcomes, improved health, or improved quality of life (Pender et al.,
2005). Physical activity, good nutrition, healthy interpersonal relationships, stress management
resources, spiritual growth, and a sense of personal health responsibility are attitudes and behaviors that promote health (Walker, Sechrist, & Pender, 1987). This model allows for examining factors associated with improved health promotion and allows focusing on personal and environmental factors that influence health promotion (Young & Capezuti, 2010).
In the HPM, individual characteristics (such as age, gender, and self-esteem) and previous behavior
are considered, as they are thought to influence whether an individual participates in health-promoting
behaviors (Pender et al., 2005). In addition, the HPM suggests that there are behavior-specific
cognitions and affect that influence motivation for specific health promoting behaviors. These factors
are ones that are often modifiable and subject to nursing intervention. Perceived barriers to action is another factor thought to influence health promoting behaviors and amenable to nursing interventions.
These barriers to action can be actual or perceived barriers, such as time, inconvenience, difficulty of
the behavior, and expenses as well as personal costs (Pender et al., 2005). When barriers are high and
readiness to act is low, health promoting behaviors are less likely (Pender et al., 2005).
One potential barrier to health-promoting behaviors may be attentional demands, which are
factors that can serve as distractions or competing stimuli to the ability to focus or direct attention.
The ability to focus, or pay attention, is important for daily activities, including health promotion,
and functioning and may be especially difficult in situations where there are distractions (Jansen,
2006; Stark & Cimprich, 2003). For the elderly, age-related changes and new life circumstances
can serve as attentional demands that may act to deter health-promoting behavior. Jansen and
Keller (1999) proposed that attentional demands be described within four domains. The first domain is physical-environmental, and includes external factors such as noise, poor lighting, and
weather (Jansen & Keller, 1999). Presence of stairs and poor building design may make navigating the environment difficult, and serve as a barrier to health-promoting activities. The second domain is informational, and includes factors that make perception and information processing difficult. Hearing and vision changes may make it difficult for a person to interact in some health
promotion activities such as attending an exercise class. The third domain is behavioral demands,
which are factors that interfere or restrict activities (Jansen & Keller, 1999). A sense of vulnerabil-

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ity or changes in physical mobility may limit health promotion behaviors. Affective demands are
emotions, worries, or preoccupations that must be inhibited for daily functioning (Jansen &
Keller, 1999). Feelings of loss, loneliness, and worries about health or safety might interfere with
health promoting activities. Thus, attentional demands may be barriers (either perceived or actual)
to the practice of healthy behaviors for elderly persons. In research with elderly, community-dwelling women (65 and older), Jansen and Keller (2003) found that women who reported
more attentional demands also reported more depressive symptoms and poorer health than women
with fewer attentional demands. In a later study of elder men and women, those with fewer
attentional demands also reported better health than those with more attentional demands (Jansen,
2006). Although the presence of attentional demands is theoretically related to the practice of
health promoting behaviors in the HPM, empirical research supports that attentional demands are
related to health (Jansen, 2006; Jansen & Keller, 2003).
The effects of aging and the rate of change with age vary from person to person, however, there
are some general changes to be considered when exploring a relationship between attentional demands and health promotion. Physically, the body slows in its ability to react to changes in the environmentboth in quick responses to a challenge involving balance or movement and in slower
responses as when attempting to reach homeostasis following environmental temperature changes
(Kail & Cavanaugh, 2010; Ojha, Kem, Lin, & Winstein, 2009; Shumway-Cook & Woollacott,
2000). Cognitive changes can be described similarly in that fluid intelligence, which is the ability
to respond quickly to multiple stimuli and to problem-solve, slows down with age. On the other
hand, crystallized intelligence, which is stored knowledge gathered over a lifetime, does not decrease substantially in the absence of disease (Kail & Cavanaugh, 2010). The combination of
these normal age-related changes can lead to the need for more focused attention on tasks, especially more complicated ones such as driving. This higher attentional demand can reduce the ability to effectively multitask, can require greater energy expenditure overall, and may lead to a decrease in participation in some higher-level tasks, including health promoting behaviors. In this
way, attentional demands may act as barriers to health promotion.
The relationship between attentional demands and health promotion has not been explored in
community dwelling elders. If these barriers are amenable to interventions, elders might be more
inclined to practice health promotion. The research questions proposed for this study are: (a) Is
there a relationship between attentional demands and health promotion? And (b) Is there a difference between younger (6574 years old), older (7584 years old), and oldest (85 and older) elders
in their attentional demands?

METHODS
To address the research questions, a descriptive correlational survey design was used. Following
institutional review board approval from the university where we teach, a sample of community
dwelling elders was recruited from senior centers, churches, and community agencies. Signs were
posted in some sites, and a research assistant personally attended some senior groups to invite participation. Anyone who was interested was given a packet that included a consent document, three
research questionnaires, and a postage-paid addressed envelope. If the participant consented to
participate, the participant could complete the questionnaires and return them via the postal service. Data were collected between May and July 2008 in a county in southwest Michigan.

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A sample of elders (65 and older) that lived independently in the community was recruited. Although many elders live in the community, their ability to navigate and participate in the community may be deterred by barriers they encounter. Health promotion is vital to maintaining their independence. Thus, community-dwelling elders were the population of interest. The researchers
invited anyone who was age 65 or older and could read, write, and understand English to participate if they were at one of the recruitment sites and lived independently. The final sample included
141 elders, with 46.1% of the sample (n=65) age 65 to 74, 38.3% (n=54) age 74 to 85, and 15.6%
(n=22) age 85 and older. The sample was mostly female, White, educated; most were not employed but did volunteer (see Table 1).

TABLE 1
Description of Sample

Gender
Male
Female
Race
Caucasian
African American
Latino
Marital status
Married
Widowed
Never married
Divorced
Residence
Apartment
House
Number of others in residence
Lives alone
One other person
Two or more
Highest education
Grammar school
Some high school
Graduated high school
Some college
Graduated college
Employed
Employed
Not employed
Volunteer
Yes
No
Age
Hr worked per week
Hr volunteer per week
Hr per week in other activities

49
92

34.8
65.2

139
1
1

98.6
.7
.7

84
42
4
11

59.6
29.8
2.8
7.8

20
121

14.2
85.8

52
82
6

31.6
58.2
4.3

1
7
38
37
58

.7
5.0
27.0
26.2
41.1

12
129

8.5
91.5

96
44

68.1
31.2

Mean

SD

Range

76.1
20.8
5.4
2.9

7.2
15.9
4.2
2.2

6594
3.550
.2520
015

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Instruments
The two major concepts of interest to this study were health promotion and attentional demands that
may serve as barriers to the practice of health promotion. Three research measures were used for this
study. The first instrument was the Health Promoting Lifestyles Profile II (HPLP II; Walker, et al.,
1987) that was developed to measure the components of a healthy lifestyle (Pender, Murdaugh, &
Parsons, 2001). This instrument has demonstrated content, construct, and criterion-related validity
(Walker & Hill-Polerecky, 1996). The 52-item tool contains statements regarding behaviors used to
promote health to which the respondent is instructed to indicate one of four descriptors (never, sometimes, often, and routinely). The mean of all items was calculated for an overall HPLP II score, as directed by the HPLP II authors. In addition, six subscales were calculated by finding the mean of the
items of that subscale (Walker et al., 1987). The subscales were health responsibility (HR), physical
activity (PA), nutrition (NUTR), spiritual growth (SG), interpersonal relations (IPR), and stress
management (SM). For all scales, a higher score indicates greater health promotion; possible scores
ranged from 1 to 4. When reliability was tested, the HPLPII had testretest stability after 3 weeks
and internal consistency (Walker & Hill-Polerecky, 1996). For this sample, internal consistency, as
measured by Cronbachs alpha for the HPLPII, was .95. The Cronbachs alpha for the subscales
were .83 (HR), .87 (PA), .85 (NUTR), .86 (SG), .82 (IPR), and .76 (SM).
The second instrument used for this study was the Attentional Demands Survey (ADS) that
was developed to measure elders attentional demands, factors in daily living that require mental
effort to negotiate (Jansen & Keller, 1999). If many attentional demands are encountered, the elder
is more prone to mental fatigue and ineffective functioning in daily life. The ADS has four domains with corresponding scales, physical-environmental (PE), informational (INF), behavioral
(BEH), and affective (AF). The 42 item ADS listed demands that elders might encounter and asks
that they indicate effort required for this demand on a five point scale (not at all=0; somewhat =2;
a lot=4). Items in the individual scales were summed according to instructions; higher scores indicated more demands (Jansen & Keller, 1999). In this sample, the total ADS (sum of all items) had
a Cronbachs alpha of .96. Internal consistency computed by Cronbachs alpha for the individual
scales was .90 (PE), .91 (INF), .84 (BEH), and .88 (AF).
The third research instrument was a demographics questionnaire that we developed for the
study. Age, gender, employment status, and volunteer work are examples of items included in this
tool.
Data Analysis
Data were entered into SPSS 16.0 and cleaned. Descriptive statistics were determined for all variables of interest; scales were computed. Appropriate nonparametric and parametric tests of association were run as determined by the research questions. An alpha of .05 was determined a prior.
RESULTS
The first research question asked whether there was a relationship between attentional demands
(ADS) and health promotion (HPLPII). There was a moderate negative correlation between
HPLPII and the total ADS scale (r= .48, p=.000). A negative correlation was found between

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HPLPII and each of the four ADS scales (physical-environmental r= .42, p=.000; informational
r= .47. p=.000; behavioral r= .39, p=.00; affective r= .40, p=000). Elders who perceived more
attentional demands also had fewer health promoting behaviors.
The second research question asked whether there were differences between three age groups
in their perception of attentional demands. Means were calculated for ADS for each age group
(see Table 2). To test whether the differences were significant, one-way ANOVA was computed
for each of the ADS scales and the total ADS score. There was a significant difference on the total
ADS between the 6574 age group and the 7584 age group, but no difference between the oldest
group (85 and older) and either of the two younger groups (F=3.72, df=2,136, p=.027) when
Bonferroni post hoc tests were performed. The 75- to 84-year-olds had the highest attentional demands as measured by ADS and the 65- to 74-year-olds had the least. In addition, there were significant differences in informational (F=4.62, df=2,137, p=.011) and behavioral (F=3.36, df=2,
137, p=.038) scales between these two age groups, similar to that observed on the total ADS (see
Table 2). On all ADS scales, the 75- to 84-year-olds had higher means than the younger age group
(6574); the 75- to 84-age-year-old group reported more attentional demands than the younger
group (see Table 2). To determine the effect that the increased perception of attentional demands
might have on health promotion, the correlation between ADS and HPLPII was determined for
each age group (6574 year olds, r= .40, p=.001; 7584 year olds, r= .56, p=.000; 85 and older,
r= .55, p=.009) showing that attentional demands had a greater effect on the two older groups
than the youngest group.
To further explore the attentional demands of the three age groups, the means reported by each
group for each of the 42 items of the ADS were calculated and ranked. Items with higher means indicated the item created more effort in daily life. The top five items for each group are listed in
Table 3. The demands which the sample found least affected their daily functioning are listed in
Table 4. Not having enough light and having to move were demands that each age group identified
as problematic. Of particular interest is that for all age groups, managing medications required
very little effort for this sample of elders.
As attentional demands are thought to be amenable to nursing interventions (Jansen, 2006), relationships between demographic attributes of the group and the primary variables of interest in
this study were explored. There were no differences in ADS (t=.42, df=137, p=ns) or HPLP II
(t=.42, df=139, p=ns) when marital status was considered (married or currently single, which included never married, divorced, or widowed). In addition, there was no difference between men
and women on ADS (t=.76, df=137, p=ns) or HPLPII (t=1.42, df=121.72, p=ns). There was a
TABLE 2
Attentional Demands by Age Groups

Attentional Demands
Survey (ADS) Scale
Physical-environmental
Informational
Behavioral
Affective
Total ADS

6574 Age Group

(n=65)

7584 Age Group

(n=54)

85 and Older Age

Group (n=22)

SD

SD

SD

20.5
10.8
5.9
14.3
51.8

10.4
9.1
4.9
8.4
26.9

25.1
15.7
8.5
17.4
66.7

12.2
10.1
6.5
9.9
36.1

26.3
15.5
6.6
16.0
64.4

10.7
8.0
5.4
9.1
28.3

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TABLE 3
Greatest Attentional Demands Reported by Age Groups
65 to 74 years of age
1. Not enough light
2. Uncomfortable or harsh weather conditions
3. Having to move
4. Missing family or friends who have died or live far away
5. Noise distractions
75 to 84 years of age
1. Uncomfortable or harsh weather conditions
2. Buildings that are hard to find your way around in
3. Not enough light
4. Having to move
5. Missing family or friends who have died or live far away
85 and older
1. Trouble hearing
2. Having to move
3. Bright sunlight and glare
4. Not enough light
5. Noise distractions

TABLE 4
Demands That Were Least Difficult by Age Groups
65 to 74 years of age
1. Managing medications
2. Going to the doctor or clinic or special appointment
3. Reading or responding to mail
75 to 84 years of age
1. Managing medications
2. Feeling sad about your present life situation
3. Not enough living space
85 and older
1. Being along or isolated
2. Managing medications
3. Other people do not listen or understand you

positive and weak but significant relationship between age and attentional demands (r=.24,
p=.005); age was not related to health promotion (r=.13, p=ns). As the sample was very homogenous on race, a relationship between race and attentional demands or health promotion could not
be explored. When those who had a high school education or less was compared to those who had
attended at least some college (or more), there was a significant difference on both the ADS
(t=2.29, df=137, p=.024) and HPLPII (t=4.21, df=139, p=.000). Those with more education perceived fewer attentional demands (M=55.25, SD=28.8) and had more health promoting behaviors
(M=2.94, SD=.45) than those with less education (ADS M=68.04, SD=35.2; HPLPII M=2.6,
SD=.46). Those who were employed (M=61.6, SD=31.5) had significantly lower ADS scores than

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those who were not employed (M=36.6, SD=21.4) (t=2.69, df=137, p=.008) although the number
working was small (see Table 1). There was no difference between those who were employed and
those who were not on HPLPII. On the other hand, those who volunteered had significantly higher
means on HPLPII (M=2.88, SD=.46) than those who did not (M=2.71, SD=.51; t=2.05, df=138,
p=.042). They also had lower ADS (M=56.06, SD=30.86) than those who did not volunteer
(M=66.19, SD=32.11; t=1.76, df=136, p=.080).
In summary, attentional demands were negatively and significantly associated with health promotion in this sample of community dwelling elders. There were significant differences among
age groups with elders 75 to 84 years old reporting significantly more attentional demands than
those in the younger group. Older groups reported more attentional demands than the younger
group of elders and this was associated with decreased health promotion.

DISCUSSION
The significant negative relationship between attentional demands and health-promoting lifestyle in elders is consistent with the HPM (Pender et al., 2005). With aging, elders have declining physical, social, and cognitive abilities that can serve as barriers to health promotion activities. On the ADS scale, this sample had higher scores on the total ADS scale than what was
reported in studies of other community dwelling elders indicating the presence of more
attentional demands (Jansen, 2006; Jansen & Keller, 2003). On only one of the scales (affective), did the current sample have a slightly lower score (15.8) than what Jansen and Keller
(2003) reported (15.9).
The HPM suggests that some personal demographic characteristics may influence health promotion behaviors. Consistent with what was reported by Jansen (2006), there was no relationship
between ADS and marital status. In this study, there was a weak but significant positive correlation between the ADS and age, which was not present in Jansens research. Elders in our study
who worked or volunteered had lower ADS scores than those who did not work or volunteer. Perceiving fewer attentional demands may make working and volunteering easier, in addition to encouraging health promoting behaviors.
A relationship between ADS and health has been reported. In previous studies, more attentional
demands were associated with poorer self-reported health and difficulty in daily functioning
(Jansen, 2006; Jansen & Keller, 2003). This can be explained by the HPM. As elders encounter
attentional demands that serve as barriers to health promoting behaviors, health may be impacted.
Although the sample in this study reported more attentional demands when compared to other
samples (Jansen, 2006; Jansen & Keller, 2003), they also reported more health-promoting behaviors when compared to other samples that included elders (Acton & Malathum, 2000; Callaghan,
2006; Lee, 2009). Age, marital status, and gender were not associated with health promoting behaviors in this sample of elders, as has been reported in other research (Acton & Malathum, 2000).
In another sample that included adults of a large age range (2179), employed adults had fewer
health promoting behaviors than those who were retired (Acton & Malathum, 2000). This was not
the case in this study of elders, although those who volunteered reported more health-promoting
behaviors than those who did not volunteer. The finding that the elders with more education engaged in more health promoting behaviors has been reported elsewhere (Acton & Malathum,
2000).

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Increasing health-promoting behaviors in elders may have many benefits. In a study of elders
(60 and older), Armer and Conn (2001) found that physical activity was significantly associated
with self-rated health. In a study of men who were 55 and older, Loeb (2004) reported that men
who practiced more health-promoting behaviors also reported better health. In addition, health
promotion has been linked to spirituality with elders reporting more spirituality also engaging in
more health promoting behaviors (Armer & Conn, 2001; Callaghan, 2006).
The findings of our study suggest that interventions to reduce attentional demands may allow community dwelling elders to increase their health promoting behaviors and potentially improve their health. Many nursing interventions to reduce attentional demands in the physical-environmental, informational, behavioral, and affective domains have been proposed
(Jansen, 2006). Although the effects of aging may increase attentional demands, this research
suggests that the greatest increase in attentional demands occurred in the 75- to 84-year-old
group. The subjects who were 85 and older did not see a significant increase in attentional demands. That the 85-year-old and older subjects are still living in the community may suggest
that they are reasonably healthy and least affected by attentional demands related to aging. Elders who have many attentional demands may no longer be able to live in the community at this
age. Thus, the 65- to 74-year-old age group might be a target group for interventions to reduce
elders attentional demands.
Many of the items that the elders in this study found most demanding (see Tables 3 & 4) were
physical or environmental demands (Jansen & Keller, 1999). The physical environment can be
modified proactively to support independence and safety by providing handholds for stability, visual cues for sequencing or better lighting for reading medication information. Lawton (1982), a
pioneer in the field of environmental gerontology, explored interactions between older adults and
the environment. He created the theoretical framework used to study how the physical environment could act as barriers or as a support to function, recognizing that needs change with age, illness, or injury. Over the years, his work has led to studies that support the effectiveness of environmental modifications as an important part of an intervention package that reduces nursing home
admissions, reduces falls and fear of falling that leads to inactivity, and supports continued independence (Beswicket et al., 2008; Gillespie, Gillespie, Robertson, Lamb, Cumming, & Rower,
2003). Even minor changes to the physical environment can increase ease of use and support
healthy behaviors in a variety of ways.
Medication adherence is an important health-promotion behavior employed by the elderly,
with approximately 74% of community-dwelling elders taking at least one prescription medication (Swanland, Scherk, Metcalf, & Jesek-Hale, 2008). The item managing medications required the least effort for the first two age groups according to the findings in this study. However, McDonald-Miszczak, Neupert, and Gutman (2008) reported that elderly subjects
overestimated their adherence with medication, with younger-old adults self-reports less accurate than those of the older-old adults. Cognitive status, executive function, and working memory have been correlated positively in studies addressing medication adherence in community-dwelling elderly (Insel, Morrow, Brewer, & Figueredo, 2006; McDonald-Miszczak et al.,
2008). In both studies, the elderly subjects were less accurate in managing medications when
distractions or busyness occurred between the time they remembered that a medication needed
to be taken and when they actually took the medication. Although the elderly adults in this
study did not perceive medication management as an attentional demand, their actual adherence
is unknown.

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IMPLICATIONS FOR NURSING

The findings of this study help to inform nursing care of community-dwelling elders in several
ways. First, nurses working with community-dwelling elders often address health promotion activities regardless of the current health status of the client. Knowing the domains of attentional demands can assist nurses and others involved in caring for community dwelling elders in identifying health maintenance and illness/injury prevention needs so as to teach adaptive skills for
normal aging and assist in primary prevention. Commitment to a new health behavior requires focused attention and continuous problem-solving. For example, senior centers reach a wide audience and provide health promotion education, screening, and interventions through a variety of
programs. By focusing on attentional demands that may deter health promoting behaviors, elders
may find health promoting behaviors to be achievable. In addition, teaching elders how to reduce
attentional demands may improve daily functioning in other areas (Jansen, 2006).
This research also informs care for secondary prevention, or early diagnosis and treatment of
illness, as elders who encounter high attentional demands may experience more barriers to health
promotion. For example, elderly persons with a new diagnosis of congestive heart failure must address a number of changes simultaneously to manage their illness. New medications need to be
learned and a strategy to take them accurately must be planned. Diet restrictions require altering
grocery shopping habits, as well as eating habits, with new recipes needing to be learned. Being
aware of, and interpreting the meaning of, physical changes requires attention as well.
In tertiary prevention, or recovery and rehabilitation, nurses can focus on interventions to reduce attentional demands for clients after an injury or illness so as to facilitate recovery and independence. Nurses may find that an assessment tool such as the ADS may help in identifying elderly clients at greater risk for problems in managing a complex chronic illness. Adaptations to
the environment, assistive technology, or new techniques may provide support for these necessary
and important changes. Other home care team members, such as occupational therapists, can assess, recommend, and train in the use of these techniques to support nursing goals. An example of
this would be when someone who is diabetic has a stroke with residual weakness on one side of the
body. New methods for monitoring blood sugar levels, for storing and opening medications or preparing healthy foods may be necessary to manage medical issues appropriately with this new
physical challenge in order to support health promotion.
Second, the findings of this study suggest that although the ADS has been used as a research
tool (Jansen & Keller, 1999), adapting it for clinical assessments may be beneficial. Health care
providers who are aware of high attentional demands can more easily identify supportive services
to help clients maintain independence and health-promotion behaviors. Routinely monitoring
attentional demands, such as during annual exams or screenings, changes in magnitude or domains of demands can indicate need for further evaluation and for interventions to reduce
attentional demands (Jansen, 2006). For example, home care and hospice staff can assess the
attentional demands of elderly caregivers that may interfere with learning about new medications,
physical or occupational therapy exercises, or symptom management. Supportive interventions
can be introduced to increase the likelihood of success. Primary health care providers could use an
assessment of attentional demands during annual physicals to monitor the clients ability to manage attentional demands. High scores in a particular domain or scores increasing over time may indicate that the client needs supportive services or transition to assisted living. Adaptation and testing of the ADS as a clinical assessment is needed.

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In this study, the 75- to 84-year-old age group had the most significant increase in attentional
demands. They also reported the strongest relationship between ADS and health promotion, suggesting that this group encounters more barriers that interfere with their ability to continue activities that promote health. The findings of this study suggest that community health nurses or other
care providers should consider targetingyounger elders with interventions to reduce attentional
demands so that they might have tools and strategies in place before the demands become overwhelming. Reducing barriers such as attentional demands may empower elders to engage in
health promotion that will better support them living in and contributing to the community.
There are some limitations of the study that must be considered. First, the sample was very homogeneous and highly educated. This suggests that they have resources not available to many elders. Second, this was a survey and has all the limitations of survey research; who actually completed the survey is not known. Third, the health status and diseases of the individuals in this
sample is unknown. Their attentional demands and health promotion may be related to their current health status, rather than attentional demands. Last, that attentional demands serve as barriers
was an application of the HPM; the research design does not allow for attribution of causation.
In summary, elders experience some changes during aging that affect attention. The results of
this study suggest that these attentional demands can affect their health promotion. Nurses and
other health care providers who care for community-dwelling elders can help the elders, their families, and the communities in which they live to take measures to reduce demands (Jansen, 2006).
In doing so, nurses have an opportunity to impact elders ability to engage in health promoting
activities.

REFERENCES
Acton, G. J., & Malathum, P. (2000). Basic need status and health-promoting self-care behavior in adults. Western Journal
of Nursing Research, 22, 796811.
Armer, J. M., & Conn, V. S. (2001). Exploration of spirituality and health among diverse rural elderly individuals. Journal
of Gerontological Nursing,27(6), 2937.
Beswick, A. D., Rees, K., Dieppe, P., Ayis, S., Gooberman-Hill, R., Horwood, J., & Ebrahim, S. (2008). Complex interventions to improve physical function and maintain independentliving in elderly people: A systematic review and
meta-analysis. Lancet, 371, 725735.
Callaghan, D. M. (2006). The influence of growth on spiritual self-care agency in an older adult population. Journal of Gerontological Nursing,32(9), 4351.
Centers for Disease Control and Prevention (2003). Public health and aging: Trends in aging - United States and worldwide. Retrieved May 12, 2010 fromhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5206a2.htm.
Gillespie, L. D., Gillespie, W. J., Robertson, M. C., Lamb, S. E., Cumming R. G.,& Rower, B. H., (2003). Cochrane Database of Systematic Reviews, 1,CD000340. DOI:10.1002/14651858.CD000340.
Insel, K., Morrow, D., Brewer, B., & Figueredo, A (2006). Executive function, working memory, and medication adherence among older adults. Journal of Gerontology: Psychological Sciences, 61B, 102107.
Jansen, D. A. (2006). Attentional demands and daily functioning among community dwelling elders. Journal of Community Health Nursing, 23, 113.
Jansen, D. A., & Keller, M. L. (1999). An instrument to measure the attentional demands of community-dwelling elders.
Journal of Nursing Measurement, 7, 197214.
Jansen, D. A., & Keller, M. L. (2003). Cognitive function in community-swelling elderly women: Attentional demands
and capacity to direct attention. Journal of Gerontological Nursing, 29 (7), 3443.
Kail, R. V., & Cavanaugh, K. C. (2010). Human development: A life-span view(5thed.). Florence, KY:Thomson/Wadsworth.
Lawton, M. P. (1982). Competence, environmental press and the adaptation of older people. In M. P. Lawton, P. G.
Windley, & T. O. Byerts (Eds.), Aging and the environment: Theoretical approaches (pp. 3359). New York: Springer.

Downloaded by [Monash University Library] at 19:55 20 September 2012

186

STARK, CHASE, DEYOUNG

Leenerts, M. H., Teel, C. S., & Pendleton, M. K. (2002). Building a model of self-care for health promotion in aging. Journal of Nursing Scholarship, 34, 355361.
Loeb, S. J. (2004). Older mens health: Motivation, self-ratings, and behaviors. Nursing Research, 53, 198206.
McDonald-Miszczak, L., Neupert, S. D., & Gutman, G. (2009). Does cognitive ability explain inaccuracy in older adults
self-reported medication adherence? Journal of Applied Gerontology, 28, 560581.
Ojha, H. A., Kem, R. W., Lin, C., & Winstein, C. J. (2009). Age affects the attentional demands of stair ambulation: Evidence from a dual-task approach. Physical Therapy, 89, 10801088.
Pender, N., Murdaugh, C., & Parsons, M. A., (2001). Health promotion in nursing practice (4th ed.). Upper Saddle River,
NJ: Pearson Education.
Pender, N., Murdaugh, C., & Parsons, M. A., (2005). Health promotion in nursing practice (5th ed.). Upper Saddle River,
NJ: Pearson Education.
Shumway-Cook, A., & Woollacott, M. (2000). Attentional demands and postural control: The effect of sensory context.
Journal of Gerontology: Medical Sciences. 55A, M10M16
Swanland, S. L., Scherck, K. A., Metcalfe, S. A., & Jesek-Hale, S. R. (2008). Keys to successful self-management of medications. Nursing Science Quarterly, 21, 238246.
Stark, M. A.,& Cimprich, B. (2003). Promoting attentional health: Importance to womens lives. Health Care for Women
International, 24, 93102.
US Department of Health and Human Services. (2009). Developing healthy people 2020. Retrieved May 12, 2010 from
http://www.healthypeople.gov/hp2020/Objectives/TopicArea.aspx?id=37&TopicArea=Older%20Adults.
Walker, S. N., & Hill-Polerecky, D. M. (1996). Psychometric evaluation of the Health-Promoting Lifestyle Profile II. Unpublished manuscript, University of Nebraska Medical Center. Retrieved December 17, 2009 from http://app1.unmc.edu/
nursing/conweb/view_content.cfm?lev1=hplpii&lev2=(none)&lev3=(none)&pubstat=(none)&web=pub
Walker, S., Sechrist, K., & Pender, N. (1987). The Health-Promoting Lifestyle Profile: Development and psychometric
characteristics. Nursing Research, 36, 7681.
Young, H. M., & Capezuti, E. (2010). Celebrate age. Journal of Nursing Scholarship, 42, 111112.