older adults, ageing process, Interviewee, coping strategies, older adult patient, SOC, population, salutogenesis, British School of Osteopathy, Participation, the interview, information sheet, perceptions, successful ageing, participant, osteopathic treatment, Pilot study participants, interview data, research study, Robert McCoy, Sarah Emslie, UK population, The British School of Osteopathy, Salutogenesis Antonovsky, health promotion, Healthy ageing, interview schedule, qualitative interviews
Individual Enquiry research paper
2010 Title: A Qualitative Interview Study into Older Adults
' Perceptions of Ageing and Health Author: Sarah Emslie Supervisor: Robert McCoy MSc, BSc (Hons) & DO The British School of Osteopathy 275, Borough High Street, London SE1 1JE
ABSTRACT Background: In 2001, 20% of patients receiving osteopathic treatment in the UK were aged 60 and over (www.osteopathy.org.uk). The ageing of the population may be a great success of the 20th century but the challenge of how best to maintain health in an older population remains (Khaw, 1997). This is a challenge faced by osteopaths on a daily basis. Objectives: This study aimed to investigate the physical, behavioural and social factors
which influence the coping strategies utilised by active older adults in the context of ageing and health. Methods: Nine semi-structured interviews with a purposive sample of active older adults aged 65 and over were conducted. All interviews were analysed inductively using elements of Grounded Theory. Results: Perceptions of ageing and changes in health, health-promoting behaviours, relationship to peer group, influence of life events and looking ahead to the future emerged as themes. There was a degree of underlying anxiety evident, countered by a sense of humour throughout. Participants discussed death and dying openly. Conclusions: These findings add to our knowledge of active older adults. A collaborative approach to osteopathic management of the older adult patient is reinforced. Keywords: "Aging", "Ageing", "Coping", "Health Promotion", "Qualitative Research", "Salutogenesis", "Sense of Coherence". Page 2 of 48
INTRODUCTION Ageing may be variously defined as growing old, degeneration or regression (Bromley, 1998). Martin et al. (2008) suggest that towards later life, older adults are more likely to be required to adapt to physical, mental and social change
s. Nevertheless, despite the fact those aged over 70 display the widest variation in functional capacity of any age group, there is still a tendency to make reference to the elderly as a collective rather than in individualised terms (Thompson, 1992). In 2008, the percentage of the UK population aged 65 and over was 16%. This is projected to increase to 23% by 2033 (www.statistics.gov.uk). In the United States, there have been calls for shifting demographics (the so-called `silver tsunami') to merit an osteopathic curricula review (Guglicci and Giovanis, 2009). In 2001, 20% of patients receiving osteopathic treatment in the UK were aged 60 and over (www.osteopathy.org.uk). A `Caring for the Elderly' elective is incorporated into the 4th year curriculum at The British School of Osteopathy but will not necessarily be made available to students every year (BSO, 2009). The ageing of the population may be a great success of the 20th century but the challenge of how best to maintain health in an older population remains (Khaw, 1997). This is a challenge faced by osteopaths on a daily basis. Page 3 of 48
Salutogenesis Antonovsky's model of positive health, or salutogenesis, focused on how and why people move toward the health pole of the health ease/dis-ease continuum (Antonovsky, 1979). He proposed a move away from "the all-consuming concern with risk factors
, with pathogens" (Antonovsky, 1996, p.13). The sense of coherence (SOC) later emerged as a key concept of the salutogenic model. The SOC is the "capability to perceive that one can manage in any situation" (Lindstrom and Eriksson, 2006). The tenets of osteopathy (www.osteopathic.org) are reflected well in the salutogenic model. Health and disease are not a dichotomy but on a continuum. It is the role of the osteopath to consider a variety of factors impacting on patients and to work at moving them towards the health end of that continuum. Previous studies have investigated personal health resources from a salutogenic perspective (Forssen, 2007, Malterud et al., 2001, Wiesmann et al., 2009). In their gender-related study, Malterud et al. (2001) found that personal strength was part of a proud identity in men but that it was borne out of necessity in women. However, qualitative questions differed between male and female participants, potentially skewing the results. With the belief that women now in old age are "victims of a gendered society", Forssen aimed to explore how elderly women use humour, beauty and culture to maintain well-being (2007, p.232). It is interesting to note that comments on health were not followed up with the same interest as those concerning ill health. This seems counter-productive given the study's salutogenic context. There was agreement among the studies that individuals possess their own ideas regarding health resources and that this knowledge should be tapped (Forssen, 2007, Malterud et al., 2001, Wiesmann et al., 2009). Page 4 of 48
Cole (2007) aimed to establish whether the SOC concept (as part of the salutogenic model) could be used as a strategy to identify those older adults at risk of functional status
decline. She proposed that "a person with a strong SOC will move toward health" wherever they are located on the health ease/dis-ease continuum (Cole, 2007, p.97). The questionnaire method of predominately white women produced results which, whilst statistically insignificant, were suggestive of a causal relationship between a weak SOC and functional status decline. Similarly, an investigation into the determinants of subjective well-being found that it was significantly influenced by the individual's evaluation of their situation as well as their SOC (Schneider et al., 2006). Following the first 25 years of salutogenic research, studies have agreed that salutogenesis could create a solid theoretical frame
work for health promotion (Lindstrom and Eriksson, 2005, Cole, 2007). Other Models and Concepts Healthy ageing may not necessarily need to be defined as an absence of decline but rather as the optimum health possible for the older individual (Bryant et al., 2000). Peel et al.'s (2005) systematic review summarised existing evidence regarding the behavioural determinants of healthy ageing and concluded that there is a need to standardise concepts and terminology. This was apt given the authors' statement that health extends beyond the absence of disease or infirmity, yet studies of ageing with disease or functional decline as the outcome were not included in their search criteria. Page 5 of 48
Rowe and Khan (1987) introduced the concept of successful ageing in an attempt to focus on heterogeneity within age groups. They proposed that the modifying effects of diet, exercise and psychosocial factors had been underestimated. In their study investigating different models of successful ageing, Bowling and Iliffe (2006) highlighted a dilemma in its use as a concept. Is it an outcome in itself, or rather a precursor to some other outcome measure (e.g. quality of life)? The authors concluded that their results "support a generalist approach to health maintenance in later life rather than a narrower focus" (Bowling and Iliffe, 2006, p.613). Despite this suggestion and Rowe and Khan's original intentions, the concept of successful ageing continues to be cited in the literature in the context of disease (Cavalieri, 2006). Hickey et al.'s (2005) systematic review attempted to identify approaches to measuring health-related quality of life (HR-QOL). No studies were found to have used HR-QOL instruments that were old-age specific. They concluded that questionnaire items tend to be phrased predominantly in relation to physical function and thus may inadvertently discriminate against older individuals. Bergland and Narum (2007) took this problem as the basis for their qualitative study which attempted to elucidate what quality of life meant to elderly women. Their results were characterised by 3 qualities; "sameness within change, power-empowerment and the quest for meaning" (p.39). Previous studies have placed coping strategies in the context of specific healthrelated issues facing the older adult (e.g. chronic pain
) and have largely reported the perceptions of older adults in response to closed questionnaire questions (Barlow et Page 6 of 48
al., 1997, Savelkoul et al., 2001, Wrosch and Schulz, 2008). Martin et al.'s (2008) original study was borne out of the fact there was little information available on how the `oldest-old' cope with adverse events in relation to health. They demonstrated that sexagenarians tended towards active coping and concluded that this age group may feel active adaptation to health problems is possible. Aim This study aimed to investigate the physical, behavioural and social factors which influence the coping strategies utilised by active older adults in the context of ageing and health. It did not necessarily follow that these purposive measures would exclude individuals suffering from a disease or disorder of some kind (Bryant et al., 2000). Rationale Qualitative research explores the individual's own ideas and concerns in order to gain an in depth understanding of subjective phenomena (Oppenheim, 1992; Robson, 1993). It has been described as a "holistic perspective which preserves the complexities of human behaviour" (Greenhalgh, 2006, p.166). Strawbridge et al. (1996) expressed concern that the concept of successful ageing may direct the focus towards a small, elite segment of the population. However, by seeking out these active individuals, or those with a strong SOC, this study aimed to learn from those who have knowledge of the reality (Forssen, 2007, Malterud et al., 2001, Wiesmann et al., 2009). To the researcher's knowledge, there have been no studies which have used this purposive approach in relation to the SOC concept. It was hoped that Page 7 of 48
emerging themes would inform future osteopathic management of the older adult patient. Page 8 of 48
A review of the literature was undertaken in December 2008 and again in January 2010. The second review was carried out in an effort to be inclusive of newly discovered concepts of ageing and/or health. It was also deemed necessary to add to the key search terms in light of unexpected findings surrounding anxiety, death and dying. The tables below provide a summary of the key search terms.
Cochrane Library PubMed
(Aging OR ageing) AND coping strategies ("Aging"[MeSH] OR ageing) AND coping strategies "Adaptation, Psychological"[MeSH] AND late adulthood
None None None
No. of hits 330
No. of relevant articles 7
Cochrane Library PubMed
ageing salutogenesis anxiety AND ageing "aging" [Mesh] AND salutogenesis
"aging" [Mesh] AND "health
"aging" [Mesh] AND death
ageing OR aging AND
*"Health promotion" is the MeSH term for salutogenesis
No. of hits 83
No. of relevant articles 3
0 Too many hits 10
Additionally, a search on the CINAHL database (www.cinahl.com) by discipline and subject identified a number of specific journal titles. A further electronic search was conducted on these and other recommended titles, including the Journal of the Royal
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Society for the Promotion of Health, Age & Ageing, Journal of Ageing and Health, Research on Ageing, Working with Older People and Medical Humanities. A search of key osteopathic journals e.g. the Journal of the American Osteopathic Association was also performed. Subjects The study recruited 9 members of the general public (2 male:7 female) aged between 65 and 79, on a convenience basis. A purposive sample (Bowling, 1997) of 2 participants was recruited via a poster advertisement displayed in an adult (over 50s) day centre. Individuals who choose to attend age-specific centres may not be representative of all older adults. For this reason, advertisements were placed in a variety of locations including leisure centres, libraries, a bowling club and among the members of a walking group. This led to the recruitment of 5 participants. Finally, the study used 'snowball' sampling (Robson, 1993) by getting recruited subjects to identify other members of the population interested in taking part. 2 participants were recruited via this method. Inclusion Criteria Individuals aged 65 or over (the current classification of retirement age
is 65). Individuals who considered themselves to be active physically and/or socially. Exclusion Criterion Individuals with dementia and those who would be unable to communicate effectively. Page 10 of 48
Ethics The project received ethical approval from the British School of Osteopathy's Research Ethics Committee. Informed Consent. Participants were provided with a Participant Information Sheet (appendix 1) and asked to complete a Consent Form (appendix 2) confirming their willingness to participate. However, each individual was asked to contact the researcher within one week of the interview taking place if he or she experienced any anxiety about taking part. This allowed sufficient time for any queries or concerns to be raised. Harm Minimisation. Participants were asked to explore their experiences of, and attitudes towards, ageing and health. The sensitivity of discussing participant age and health status was taken into consideration. During the interview briefing (appendix 3) it was made clear that the interview could be stopped at any time and recommenced only if the participant were happy to continue. It was not anticipated that any of the proposed questions would provoke psychological or emotional distress and no such scenario arose. Pilot Stage In September 2009, the entire interview process, including draft interview schedule, PIS, consent form (appendices 1, 2 and 3) and recording equipment, was piloted. Particular attention was paid to the interview schedule in order to ascertain and develop effective prompts for coping strategies. Pilot study participants
were also Page 11 of 48
asked to evaluate their experience of the process. This resulted in the following minor amendments to question content and ordering: Page 12 of 48
Please could you tell me a little bit more about yourself?
What kind of things does your life involved at the moment?
Q1. What, if any, changes in health have you experienced in recent years? Physically/mentally/emotionally? Q2. Do you associate these changes with getting older? Why? In what way?
Q1. What, if any, changes in health have you experienced in recent years? Physically/mentally/emotionally? If not, why do you think that is? Q2. Do you associate change "X" with getting older? Why? In what way? Did "X" affect you earlier in life?
Q.3 What impact have these changes had on your life? Positive/negative? What has been worse/what has been better? Physically/mentally/socially?
Q3. What impact has "X" had on your life? Positive/negative? What has been worse/what has been better? Physically/mentally/socially?
Q4. What steps have you taken in order to cope with (address each change separately)? Have you sought help from your GP/friends/family? Have you actively made changes to your lifestyle?
Q4. What steps have you taken in order to manage "X"? Have you sought help from your GP/friends/family? Have you actively made changes to your lifestyle? Have you sought any form of manual therapy?
Q5. Why do these steps work, or not work, for you? Positive/negative? Physically/mentally/socially? Q6. Do you think you are developing different ways of looking after yourself as you get older? What's different? How? Why?
Q5. Unchanged Return to question 2 Q6. Do you think you are developing different ways of looking after yourself as you get older? What's different? How? Why? Is there anything that worries/concerns you?*
*Incorporated in as a prompt following the first interview proper. The ordering of questions 2 to 5 was amended so that each arising issue was discussed separately and in its entirety before moving on.
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Interviews A series of 9 semi-structured, face-to-face interviews (lasting between 20 and 40 minutes), plus 2 pilot interviews, were conducted. Interviews were recorded by a digital device and transcribed verbatim by the researcher. Data were then coded for underlying meaning using categorical content analysis
(Gillham, 2005) with elements of Grounded Theory (Glaser and Strauss, 1967) in order to generate themes. A code was assigned to each substantive word or phrase, generating a total of 134 codes. These were later grouped into sub-themes and themes. An inter-rater reliability study was performed on 22% of the data (2 interviews), randomly selected by an independent colleague. The aim of the study was to increase accuracy and consistency of coding and to reduce researcher bias. Initial agreement of 44.7% was reached. Discussion over errors of omission and comission followed and agreement of 90.8% was ultimately arrived at. 2 codes were removed and 7 new codes generated. An intra-rater reliability study was carried out on 22% of the data (the first 2 complete transcripts). A small number of codes were amended or removed entirely and a total of 12 new codes were generated at this stage. Page 14 of 48
RESULTS The following 6 themes emerged from the study: Perceptions of ageing Perceptions of changes in health Health-promoting behaviours Relationship to peer group Influence of past life events Looking ahead to the future Perceptions of Ageing In general, participants were pragmatic in their approach to ageing. The majority expressed feelings of gratitude, good fortune or luck. Many felt able, even determined, to adapt to age-related changes. Others were more relaxed and accepting of change, often maintaining a sense of humour in the process. However, milestone birthdays (e.g. 70) were a source of anxiety. Feelings of increasing vulnerability and resentment were mentioned by a minority. The categorisation of self as old or elderly emerged as a strong sub-theme. "When you're younger you put this label onto older people and you realise you're slipping into that category" Interviewee 4 A growing awareness of ageing as a journey or process was referred to, with some giving consideration to their own place in the world. The majority of participants made explicit their increasing awareness of age with specific agreement regarding mortality. Page 15 of 48
"I've got to the point one does think about this idea of how long one's here and all that sort of stuff." Interviewee 1 Some participants had begun to consider how others perceived them now that they were older, including whether they themselves might be a source of amusement. There was strong agreement among participants of an increasing awareness of becoming the cause of concern to others. "If there was anything majorly wrong with me I would tell them but if there's nothing majorly wrong...kids get anxious..." Interviewee 5 Perceptions of Changes in Health There was notable difference among the participants regarding changes in health and their relationship to age. A minority agreed that `aches and pains' are normal with age whilst one asked indignantly why that should necessarily be so. Quality of sleep remained unchanged in all but one of the group. The majority of participants agreed that some changes were age-related. "I'm aware I'm gradually losing physical strength I suppose...gradually." Interviewee 5 "I think as you get older the [blood] pressure does change." Interviewee 9 This coincided with a strong perception that other health issues were not related to ageing. "Mentally...all my life I've always got people's names muddled up. It's not new...and so the fact that I'm still like that doesn't really make a lot of difference." Interviewee 2 "...[high] cholesterol...which I think comes to most of us really who live in this kind of society..." Interviewee 6 Page 16 of 48
A degree of anxiety was expressed by a minority over urinary incontinence and the implications when planning what to do and where to go. However, there was consensus among participants that various health-related issues had little or no impact on their lives. There was a sense of living with the problem and making do. "Every couple of years I need a bit of treatment, the rest of the time I live with it." Interviewee 1 "I make lace...which is a little bit of a concern because I've got a little bit of arthritis in my thumb joints...but I don't think it will cause a problem." Interviewee 8 Health-Promoting Behaviours A positive mental outlook was conveyed by the majority of the group, both implicitly and explicitly. Furthermore, positivity was cited as a strategy for dealing with adverse situations or events. There was consensus among participants in terms of physical activity
. "...I try to walk if I can for at least an hour, maybe an hour and a half every day...hail, rain and sunshine." Interviewee 3 "I'm fairly active. I garden...I enjoy gardening and do all of the physically active stuff with that." Interviewee 8 For some, increased planning was mentioned as a strategy for maintaining levels of physical and social activity. A general slowing down was almost encouraged in order to minimise the risk of falls and of overdoing it generally. Nevertheless, all participants liked to be busy but for varying reasons. For most, it was simple enjoyment. A minority seemed almost fearful of what would happen if they weren't busy, whilst one spoke of it as a distraction from the reality of being apart from family. Page 17 of 48
In terms of diet and nutrition, a minority were relaxed, content that the good habits
of a lifetime did not necessitate change. There was consensus in relation to getting older and the need to make adjustments. "In the last few years I've become more conscious about what I was eating." Interviewee 3 "...I thought because of getting older, you really must lose weight..." Interviewee 4 A strong theme of independence emerged generally and in terms of activities of daily living. There was a sense of its fundamental importance to these individuals. New challenges and experiences were sought out by many of the group. "...I quite love being on my own actually...I don't have to answer to anybody" Interviewee 3 "I'm learning to play the cello which I've been doing for about 3 years which I'm not very good at but it's a challenge." Interviewee 4 Relationship to Peer Group There was strong agreement that participants tended to turn to friends and peers for support, advice or reassurance. A minority would seek out age-specific material in the media. Of the 3 participants who were married, there was no consensus as regards spousal influence. "I suppose other people make comments and you agree and so you just...pick up generally that this is something everybody experiences and it's a common occurrence...not be too concerned about..." Interviewee 8 Page 18 of 48
The comparison between self and others emerged as a similarly strong theme with the majority more inclined to view their peers in a less favourable light. "I have quite a few friends who are not as active as I am and they can't walk as fast as I can and they find things all a bit of a chore. I won't get to that situation..." Interviewee 9 Influence of Past Life Events It was a strong theme that participants would relate (physical, social or emotional) aspects of their lives now to previous life events. Past unsatisfactory relationships influenced the present lives of a minority of participants, leading to increased selfassuredness in those women concerned. The impact of retirement emerged as a major sub-theme, with the majority of participants perceiving it in a positive way. "I'm actually healthier now than I was 10 years ago because I've got the time..." Interviewee 5 "I think it's [retirement] pleasant because I've got to know groups of people about my age..." Interviewee 7 Family history of illness (e.g. heart disease) and bereavements had impacted on a minority of individuals throughout their lives. "I think when you lose a parent very early on, in a funny way you expect the same thing to happen to you, so when I reached 40 I was quite surprised..." Interviewee 5 Of the 6 participants who lived alone, the majority were keen to view their circumstances in a positive way. Page 19 of 48
"Well I suppose since my husband died I'm doing things that I enjoy doing that perhaps he didn't" Interviewee 9 Looking Ahead to the Future All participants had given consideration to the future in a variety of ways. A minority were practical in their approach and had either moved to a smaller property in preparation or had plans to return to their cultural roots. "...it would be very convenient to sort a place that we know that we like...it might be our last move...so that's what we did..." Interviewee 2 "[I want] to be as near to the community that I was born and raised in for a while...I want to be amongst people that I still vaguely relate to..." Interviewee 6 The majority of participants expressed feelings of anxiety towards the future. Specifically, there was strong agreement that the prospect of dementia was concerning, as was the potential of becoming a burden on one's family. "I also worry about getting dementia or Alzheimer's...I do worry about that...because you wouldn't know you've got it..." Interviewee 1 "I'd also have a horror if my children had to look after me..." Interviewee 7 Whilst the majority raised concerns over potential future illness and suffering, a more accepting attitude towards death itself emerged as a strong sub-theme. "Most of me thinks when you die, that's it...so death isn't frightening..." Interviewee 4 Hypothetical action over potential health problems was, in itself, a strong sub-theme, however there was difference among the group. Some individuals acknowledged that they were uncertain of such matters, even conceding that they may respond Page 20 of 48
differently if the interview was to be repeated next year, next month, or even the next day. "...am I going to be brave and say I don't want treatment...just let me die...or am I going to go through the horror...of chemo and all that stuff..." Interviewee 1 "...at what point do...do you decide that you're going to take a bucketful of tablets so that you don't become a burden on your children?" Interviewee 8 Figure 1 illustrates the influence of anxiety within all 6 themes. Page 21 of 48
"...you start panicking...oh goodness, am I going to go senile..?" Interviewee 9
Cancer Dementia Suffering Becoming a burden
Cause of concern to others Vulnerability Risk of falls
"...my body is not going to look after me..." Interviewee 4
"I've lost friends...and it does make you think...how long have we got?" Interviewee 7 Bereavements Friends in ill health Loss of a parent at a young age
"...there I am, hoping I don't meet anyone in the lift because I'm in dire straits..." Interviewee 2 Incontinence Frightened by a diagnosis
"That's what I worry about...like everybody at my age..." Interviewee 1 Concerns of a generation Loneliness Media influence Figure 1
"...I'd much rather not be on drugs..." Interviewee 5 Medication Not doing the `right' things Must keep busy
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DISCUSSION A series of 9 semi-structured, qualitative interviews were undertaken in order to explore the factors which influence active older adults in dealing with the ageing process and changes in health. Following pilot interviews, it was deemed appropriate to alter the wording of a key question so that "coping" was not employed. This enabled participants to talk freely without the potentially negative connotations of the word "cope." This decision was supported by previous research. According to existing literature, women do not cope as well as men, despite the fact there is "little conclusive evidence to show this is the case" (Malterud et al., 2001, p.187). Although the salutogenic perspective is related to the "coping tradition" (Malterud et al., 2001, p.183), its strengths lie in its "adaptability and universal use" (Lindstrom and Eriksson, 2005, p.440). Bergland and Narum agreed, arguing that "coping seems to mean contending with or attempting to overcome difficulty" (2007, p.49). "Not everybody of 75 or 76...not everybody has aches and pains...not everybody is worse obviously." Interviewee 3 Unexpected Findings Whilst the emergence of perceptions of changes in health as a theme was expected, the variety in perceptions of ageing was less so. All participants demonstrated a highly analytical nature as regards themselves and the ageing process but were more inclined to approach tangible changes in health with pragmatism. Anxiety, death and dying were not expected to have featured so heavily in the data. However, these sub-themes were offset by humour and openness throughout. Page 23 of 48
Perceptions of Ageing. There was vast difference between participants in the vocabulary used to describe and define ageing, of added interest given that participants were not directly questioned in this regard. Perceptions ranged from the matter-of-fact to the existential; from resentful to positive. This variation was often conveyed by one individual. "...in 100 years time, what difference is it going to make..." Interviewee 8 "There is a feeling of being on a journey actually..." Interviewee 4 "In a way I resent the fact that I can't do the things that I could do years ago...but I realise that it's part of the ageing process." Interviewee 9 Interestingly, it was the eldest participant (aged 79) who described herself not as old but as "getting old". "I don't think I'm a good representative of a lot of people who are getting old..." Interviewee 9 Anxiety. The sub-theme of anxiety grew inductively from the first interview when the participant generated his own question. "What do I worry about? You haven't asked me that question, have you?" Interviewee 1 This question was incorporated into subsequent interviews via prompting, when necessary, in a manner consistent with elements of Grounded Theory (Glaser and Strauss, 1967). Within the theme of looking ahead to the future, there was anxiety in relation to the potential for suffering or illness but not in relation to death itself. This lack of concern over death is consistent with other studies of older adults (De Raedt and Van Der Speeten, 2008, Hall et al., 2009, Hallberg, 2003). According to Moneyham and Scott (1995), concerns about the future are a major source of stress Page 24 of 48
for older adults. Participants returned to the prospect of dementia time and again which might suggest that health was valued more on the basis of mental well-being (De Beauvoir, 1977). Perhaps individuals feel they have less control over their mental well-being. If this is the case, it may be appropriate for osteopaths to broach this subject with patients in order to uncover any underlying anxiety which may well impact on treatment response and prognosis (Lederman, 2005). Anxiety was apparent in the perceptions of one participant's health issue, arising seemingly as a direct consequence of his diagnosis of osteoarthritis (OA). Furthermore, the use of language in the diagnosis gave him cause for concern. "The Dr tells me I've got mild, MILD arthritis... ...my 10 minute walk to my local station...is no longer...in the past 3-4 weeks, which is about how long I've known [diagnosis of knee osteoarthritis]...is no longer a pleasant walk..." Interviewee 6 Studies have found that patient satisfaction
relies upon the level of understanding shown and the explanation offered by the health professional (Ogden, 1996). When communicating diagnoses to patients, osteopaths should explore how the patient feels about their problem and how it might impact on everyday life. The importance of patient education
and exercise advice should not be underestimated if chronicity is to be avoided. A recent study aimed at developing an evidence-based booklet for OA found a lack of clarity among sufferers. Its cause was poorly understood and there was surprise that pain levels could improve (Williams et al., 2010). Page 25 of 48
Most participants vocalised a desire to remain busy. Superficially, this was benign enough, however in a minority of the group this desire appeared to be fuelled by a degree of anxiety. "I'd hate not to be [busy]...I can't stand it... ...I know this sounds stupid but if I open my diary for the week and there's nothing there I'm sort of...(changes subject)" Interviewee 1 Humour and Openness. A sense of humour emerged throughout the majority of interviews, conveyed solely by all 7 female participants. Previous studies have found that humour positively influences the health of older women (Forssen, 2007, Maddox, 1999). It has been suggested that humour is, in itself, a salutogenic factor (Cernerud and Olsson, 2004). "...I would say we haven't had sex...haven't tried I suppose, for about 5 years...which I find is very sad...but not sad enough to go and find anybody else thanks very much (laughs)!" Interviewee 2 "...so I wasn't OK...I couldn't get out of bed. You know what it's like in Scotland...if you're not in pain and you can get out of bed, you're alright (laughs)!" Interviewee 4 Many existing psychological and physiological theories propose that, amongst other things, humour supports feelings of self-esteem and confidence, and may lead to reduced pain and levels of stress
hormones (Forssen, 2007). If humour can be harnessed in an individual, or developed within the osteopath-patient relationship, this may have positive implications for tissue response and well-being. The numbers involved in this study do not allow for conclusions to be drawn based on gender but might indicate that women will more readily use humour to maintain physical and mental well-being. Page 26 of 48
With humour came a willingness to share and confide. In discussing her recent 70th birthday, one participant remarked: ...I'm surprised even talking to you actually because I haven't talked about it to anybody" Interviewee 4 This serves to highlight the potentially therapeutic role an osteopath can play, even as nothing more than one who will listen, to individuals who do not wish to burden friends and family with such feelings. Participants spontaneously brought up issues related to death and dying, even though the interviews had not intended to cover these areaS. Hall
berg cited a study which showed that doctors hesitate to bring up such matters, whilst patients appreciate it if they do (Ottoson, cited in Hallberg, 2003). Osteopaths may need to recognise openness in their patients and appreciate that this desire to talk about and confront death extends beyond those in the end of life phase. Key Inter-Relationships On analysis, strong inter-relationships were apparent between themes. Perceptions of Ageing and Health-Promoting Behaviours. There appeared to be a relationship between individuals' growing awareness of getting older and what they did about it in order to feel less vulnerable. Whilst not overtly health-promoting behaviours, these adaptations in everyday life were consciously exercised. "...I'm slightly slower and I almost encourage myself to be slightly slower...moving faster you're more likely to fall." Interviewee 4 "I have to allow myself to wind down because I've overdone it..." Interviewee 9 Page 27 of 48
Other behaviours included dietary modifications, seeking manual therapy and taking medications. These mirror the self-care activities highlighted in another qualitative study of older adults (Dunn and Riley-Doucet, 2007). The majority of individuals continued to participate in and enjoy the same physical and social activities as they had in previous years. This suggests that positive lifestyle habits can be maintained into later life and that the osteopath should encourage such engagement throughout the life span. Furthermore, several female participants mentioned an increase in self-confidence with age. Bergland and Narum spoke of a "continuum of selfhood" which enables individuals to retain a sense of coherence as to who they are (2007, p.49). Martin et al. (2008) concluded that sexagenarians may feel active adaptation to health problems is possible. However, a minority of participants were keen to point out that their positive attitudes were deeply entrenched. "I don't think one can take credit for what you are. You're born that way...you know, your genes and your environment...nature, nurture...develop you into the character, the personality that you are...and you can try to change yourself if you're not happy with the way you are but I think that generally you are formed by your character...or character forms the way you deal with things." Interviewee 8 This might suggest that a strong SOC is more difficult to develop as one ages. "What matters is that one has had the life experiences which lead to a strong SOC" (Antonovsky, 1996, p.15). Having said that, supposing the SOC is flexible in itself and varies between weak and strong throughout life. Perhaps then, by encouraging patients to draw on positive past life experiences i.e. periods when a strong SOC was apparent, it can be re-established. Health-Promoting Behaviours and Relationship to Peer Group. All participants were active in a variety of respects; physically, socially and mentally; possibly as a result Page 28 of 48
of this study's purposive recruitment methods. Like Dunn and Riley-Doucet (2007), this study found that participants related their own behaviours to those of their peers. Those who reported the highest levels of activity were, by and large, also those who spoke of their peer group. Some participants remarked that activities were often enjoyed alone as friends were simply not able or willing to take part. "...I think I've learnt how to do that...you know, get on and be able to enjoy things as they are on their own...and if there's not somebody who wants to do it with you, it doesn't matter." Interviewee 5 Independence emerged as a strong sub-theme generally and in relation to activities of daily living. A sense of pride was conveyed, particularly among the women. These findings concur with those of Forssen who found that (female) participants were concerned with "the ability to participate in what was important to them" (2007, p.232). Conversely, Malterud et al. (2001) found that internal strength and constitution were rarely mentioned. Independence could be classed as a `Generalised Resistance Resource' (GRR); a property of a person which feeds into the SOC, facilitating "successful coping with the inherent stressors of human existence" (Antonovsky, 1996, p.15). Other example GRRs include ego identity, cohesion and cultural stability (Lindstrom and Eriksson, 2005). However, Cole asked whether a strong SOC is cause or effect of independent functional status and highlighted this as an area requiring further investigation (2007). Regardless of this dilemma, it is an osteopath's concern to promote autonomy and agency in an individual. The above findings and previous research reinforce the notion that an exploration into what it means to be independent for that individual will facilitate effective management, tailored to that patient. Page 29 of 48
Perceptions of Ageing and Relationship to Peer Group. Although the categorisation of self as old or elderly emerged as a strong sub-theme, a minority of participants seemingly wished to disassociate themselves from their peers. "I don't really want to concentrate on that [medication]. I don't like it when elderly people talk about their health (laughs)" Interviewee 7 "You get some very boring old people sometimes..." Interviewee 2 This apparent relationship was not further explored here but might lead one to hypothesise whether all participants were quite as accepting of ageing. Taking this further, it is possible that humour was used as a decoy in some instances. It is likely that these participants would have wished to appear `active' to the researcher given that they responded to the advertisement. A curiosity about patients should be ongoing and osteopaths should be alert to the subtleties of communication. Study Critique Sample bias. The researcher deliberately recruited active individuals via purposive methods (Robson, 1993). Although this produced a biased sample, Greenhalgh suggests that individuals or groups who "fit the bill" should be sought out (2006, p.172). However, the researcher concedes that the sample was ultimately selected purely on the basis of convenience and so there was an over-reliance on accessible participants. The lack of a theoretical sampling frame therefore reduced the external validity, or generalisability, of this study (Greenhalgh, 2006, Robson, 1993). Response bias. Similarly, the locations in which advertisements were placed will have produced a sample skewed in favour of those who were highly motivated and liked to use libraries etc. (Greenhalgh, 2006). Page 30 of 48
Whilst literature on ageing is vast, the researcher found that the use of certain terminology was reductionist and that this may have hindered the initial literature search. However, a second search was undertaken in an attempt to incorporate new models and concepts. The use of "Health Promotion" as the MeSH term for salutogenesis produced diverse search results inclusive of synonymous terms in relation to disease and more importantly, health. A detailed look at the various coping types was beyond the scope of this study. The intra-rater reliability study was undertaken during the coding process and not upon its completion. This may have implications for the reliability of the study however it was felt that there was a risk of losing sight of its purpose amongst the diverse data obtained (Greenhalgh, 2006). An inter-rater reliability study was conducted in an effort to provide evidence of quality control
(Greenhalgh, 2006). The use of additional triangulation methods to further improve credibility (Robson, 1993) was not feasible. Due to the researcher's inexperience in conducting interviews, it was felt that a number of points of interest were not explored to their full potential. This was most apparent in the earlier interviews. Finally, it is important to note "there is no way of abolishing, or fully controlling for, observer bias in qualitative research" (Greenhalgh, 2006, p.172). Page 31 of 48
Implications for Future Research It would be of interest to explore the unexpected findings of anxiety and humour separately. Much of the existing literature relating specifically to death anxiety is in the context of end of life care. A larger sample size incorporating different socioeconomic, educational and racial groups may produce findings which are more generalisable to the general population. A comparative study
based on those older adults who view themselves as active and those who do not might further highlight areas amenable to osteopathic intervention in terms of treatment and management. A longitudinal study would highlight changes in individuals over time. Page 32 of 48
CONCLUSION The qualitative approach allowed for the exploration of ideas and concerns which the participants themselves came up with. The emergent themes and unexpected findings may prompt us to make future observations in a different way (Greenhalgh, 2006). Anxiety should be recognised as a potentially underlying factor in relation to the past, present and future. It may be appropriate for osteopaths to discuss mental wellbeing with patients. Any underlying anxiety may well impact on treatment response and prognosis. Showing interest in older patients' whole lives and their thoughts on the future may encourage openness and the disclosure of clinically significant information. A desire to talk about and confront death extends beyond those in the end of life phase. The findings from this study support a variation of the `traditional' list of self-care activities (e.g. exercise, diet) (Maddox, 1999). Here, there was emphasis on humour and a positive mental outlook. This study reinforces the osteopathic approach to patient management. That is, by establishing what is important to the patient, (s)he and the osteopath can work collaboratively to improve physical and mental health
. Page 33 of 48
ACKNOWLEDGEMENTS Thank you to: Rob McCoy and Hilary Abbey for their help, support and enthusiasm. My inter-rater, Simone Ranson. All the participants, including pilot interviewees, for their time and insight. Page 34 of 48
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. Open University Press, Buckingham. Bowling, A. & Iliffe, S. (2006). Which model of successful ageing should be used? Baseline findings from a British longitudinal survey of ageing. Age and Ageing, 35:607-614. British School of Osteopathy (2009). Unit Information Form 0708. BSO, London. Bromley, D.B. (1998) 3rd ed. Human Ageing. Penguin Books
Ltd, London. Page 35 of 48
Bryant, L.L., Beck, A. & Fairclough, D.L. (2000). Factors that contribute to positive perceived health in an older population. J Aging Health, 12(2):169-92. Cavalieri, T.A. (2006). Clinical care for an aging population: Aging successfully in the 21st century. Journal of the American Osteopathic Association, 106(7):384-386. Cernerud, L. & Olsson, H. (2004). Humour seen from a public health perspective. Scand J of Public Health, 32:396-398. Cole, C.S. (2007). Nursing home residents' sense of coherence and functional status decline. Journal of Holistic Nursing, 25(2):96-103. De Beauvoir, S. (1977). Old Age. Penguin Books Ltd, London. De Raedt, R. & Van der Speeten, N. (2008). Discrepancies between direct and indirect measures of death anxiety disappear in old age. Depress Anxiety, 25(8):E11-7. Dunn, K.S. & Riley-Doucet, C.K. (2007). Self-care activities captured through discussion among community-dwelling older adults. Journal of Holistic Nursing, 25(3):160-169. Forssen, A.S.K. (2007). Humour, beauty, and culture as personal health resources: Experiences of elderly Swedish women. Scan J of Public Health, 35:228-234. Page 36 of 48
Gillham, B. (2005). Research Interviewing: The Range of Techniques. Open University Press, Maidenhead. Glaser, B.C. & Strauss, A.L. (1967). The Discovery of Grounded Theory: Strategies for Qualitative Research. Aldine, Chicago. Greenhalgh, T. (2006) 3rd ed. How to Read a Paper. Blackwell Publishing
Ltd, Oxford. Gugliucci, M.R. & Giovanis, A.T. (2009). Osteopathic medicine and the silver tsunami: Preparing tomorrow's first responders for the elder boom. Journal of the American Osteopathic Association, 109(9):481-484. Hall, S., Longhurst, S. & Higginson, I. (2009). Living and dying with dignity: a qualitative study of the views of older people in nursing homes. Age and Ageing, 38:411-416. Hallberg, I.R. (2003). Death and dying from old peoples' point of view. A literature review. Aging Clin Exp Res, 16(2):87-103. Hickey, A., Barker, M., McGee, H. & O'Boyle, C. (2005). Measuring health-related quality of life in older patient populations
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, 59:440-442. Lindstrom, B. & Eriksson, M. (2006). Contextualizing salutogenesis and Antonovsky in public health development. Health Promotion International, 21(3):238-244. Maddox, M. (1999). Older women and the meaning of health. Journal of Gerontological Nursing
, 25(12):26-33. Malterud, K., Hollnagel, H. & Witt, K. (2001). Gendered health resources and coping A study from general practice. Scan J of Public Health, 29:183-188. Martin, P., Kliegel, M., Rott, C., Poon, L.W. & Johnson, M.A. (2008). Age differences and changes of coping behaviour in three age groups: Findings from the Georgia Centenarian Study. The International Journal
of Aging and human development
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Ogden, J. (1996). Health Psychology: A Textbook. Open University Press, Buckingham. Oppenheim, A.N. (1992). New edition. Questionnaire Design, Interviewing and Attitude Measurement
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, 28(3):298-304. Robson, C. (1993). Real World Research. Blackwell, Oxford. Rowe, J.W. & Khan, R.L. (1987). Human aging: Usual and successful. Science, 237:143-9. Savelkoul, M., De Witte, L.P., Candel, M.J.J.M., Van Der Tempel, H. & Van Den Borne, B. (2001). Effects of a coping intervention on patients with rheumatic diseases: Results of a randomized controlled trial. Arthritis Care & Research, 45:6976. Schneider, G., Driesch, G., Kruse, A., Nehen, H. & Heuft, G. (2006). Old and ill and still feeling well? Determinants of subjective well-being in >60 year olds: The role of the sense of coherence. The American Journal of Geriatric Psychiatry, 14(10):850859. Page 39 of 48
Strawbridge, W.J., Cohen, R.D., Shema, S.J. & Kaplan, G.A. (1996). Successful aging: Predictors and associated activities. American Journal of Epidemiology, 144(2):135-141. Thompson, M.K. (1992). General practice in the post-Morgagni era. Journal of the Royal Society of Medicine, 85:438-440. Wiesmann, U., Niehorster, G. & Hannich, H. (2009). Subjective health in old age from a salutogenic perspective. British Journal of Health Psychology, 14(4):767-787. Williams, N.H., Amoakwa, E., Burton, K., Hendry, M., Lewis, R., Jones, J., Bennett, P., Neal, R.D., Andrew, G. & Wilkinson, C. (2010). The hip and knee book: developing an active management booklet for hip and knee osteoarthritis. Br J Gen Pract, 60(571):64-82. Wrosch, C. & Schulz, R. (2008). Health-engagement control strategies and 2-year changes in older adults' physical health. Psychological Science, 19(6):537-41. www.cinahl.com/library/journals.htm [accessed 28/1/10] www.osteopathic.org/index.cfm?PageID=ost_tenet [accessed 7/2/10]. www.osteopathy.org.uk/uploads/survey2snapshot_survery_results_2001.pdf [accessed 19/02/10] Page 40 of 48
www.statistics.gov.uk/cci/nugget.asp?id=949 [accessed 19/02/10] Page 41 of 48
Participant Information Sheet
What are the coping strategies used by active older adults in dealing with the ageing process and why do they work?
You are invited to take part in a research study. Before you decide to take part it is important for you to understand why the research is being done and what it will involve. Please take time to read the following information carefully and to discuss it with others if you wish. Please ask if there is anything that it is unclear or if you would like further information. The study is an exploration of the coping strategies used by active older adults in dealing with the ageing process and related health changes and why those strategies work. Thank you for reading this.
What is the purpose of this study? The study aims to investigate the physical, behavioural and social factors which influence the coping strategies used by active older adults in the context of ageing and health. Participation in the study will involve an interview with the researcher lasting approximately 30 minutes. There is little research into coping strategies and ageing from the perspective of the individual and so it is anticipated that the interview format will enable the exploration of personal experience
s and perceptions. It is hoped that the results of the study will help to inform future osteopathic management of the older adult patient.
Page 42 of 48
Why have I been chosen? Participants are invited to take part if they are aged 65 or over and consider themselves to be active physically and/or socially. You will be 1 of a total of approximately 8 participants. Do I have to take part? No. Your decision whether to take part or not will have no bearing whatsoever on your standing as a member of the community and you will have the right to withdraw from the study at any time without any detriment to future care. What does it involve? The study will take the form of a series of individual interviews, each lasting approximately 30 minutes. Questions will explore experiences of, and attitudes towards, ageing and health. The sensitivity of discussing age and health status will be taken into consideration although it is not anticipated that any of the questions will provoke emotional distress. Should such a scenario arise, the interview will be stopped and recommenced only if you are happy to continue. It is up to you to decide whether or not to take part. Participation in the research is entirely voluntary. If you do decide to take part you will be given this information sheet to keep and be asked to sign a consent form. Even if you do decide to take part, you are still free to withdraw at any time without giving any reason. Page 43 of 48
What do I have to do? Participation in a single interview of approximately 30 minutes duration. A time that is convenient to you can be agreed between yourself and the researcher. Will my taking part in the study remain confidential? All data will be stored anonymously. Quotations from the interview may be used in the final study but you will not be identified by name. Any identifiable information will be omitted from the final paper. The researcher, the researcher's supervisor, and members of the CAE Team at the British School of Osteopathy will have access to the study data. Data will be stored securely and destroyed 6 years following completion of the study. What will happen to results from the study? Collected interview data will be transcribed and analysed so that themes can be drawn out and conclusions generated. A summary of the results will be made available to you. The final paper will be put up for possible publication in relevant journals however you will not be identified. Who is organising the research? My name is Sarah Emslie and I am currently studying in my final year of the Master of Osteopathy (M.Ost) Undergraduate Degree Programme at the British School of Page 44 of 48
Osteopathy (BSO) in London. My supervisor is Robert McCoy (Structure Function Area of Study Manager and Clinic Tutor at the BSO). As a student osteopath, I have encountered several patients who attribute pain and stiffness to ageing rather than to the symptoms of a potentially treatable health problem. By investigating coping strategies and ageing from the perspective of the individual, it is hoped that the study will help to inform future osteopathic management of the older adult patient. Thank you for taking the time to read the information sheet. Contact details are given below should you have any queries or require further information.
Researcher: Sarah Emslie The British School of Osteopathy 275 Borough High Street London SE1 1JE Email: [email protected]
Tel: 07718 904032
Supervisor: Robert McCoy The British School of Osteopathy 275 Borough High Street London SE1 1JE Email: [email protected]
Tel: 020 7089 5345
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CONFIDENTIAL Participant Identification Number: CONSENT FORM
Title of Project: What are the coping strategies used by active older adults in dealing with the ageing process and why do they work?
Name of Researcher: Sarah Emslie Name of Supervisor: Robert McCoy
Please tick where appropriate
1. I confirm that I have read the information sheet for the
above study and have had the opportunity to ask questions
2. I understand that brief, anonymous extracts from the interview
may be reproduced in academic/non-academic presentations
3. I understand that my participation is voluntary and that I
am free to withdraw at any time, without giving any reason
4. I agree to take part in the above study
5. I would like to receive a summary of the results
6. Please send a summary of the result to ............................................
Name of the Participant
1 copy for the researcher: 1 copy for the participant
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Introduction Thank you very much for agreeing to take part in this interview today. The interview should last approximately 30 minutes and will explore any lifestyle changes
you have made in dealing with the ageing process. It is hoped that themes will emerge which will help to inform future osteopathic management of the older adult patient.
The interview today will be recorded and transcribed in full. All data will be stored anonymously. Quotations from the interview may be used in the final study but you will not be identified by name. Any identifiable information will be omitted from the final paper. If you feel uncomfortable about any of the questions or wish to stop the interview at any time, please do let me know. Do you have any questions for me before we begin?
Ice breaker What kind of things does your life involve at the moment? What sorts of leisure pursuits do you enjoy? "What, if any, changes in health have you experienced in recent years?" Physically/mentally/emotionally? If not, why do you think that is? "Do you associate these changes with getting older?" Why? In what way? Did any of these issues affect you earlier in life? "What impact have these changes had on your life?" Positive/negative? What has been worse/what has been better? Page 47 of 48
Physically/mentally/socially? "What steps have you taken in order to manage (address each change separately)?" Have you sought help from your GP/friends/family? Have you actively made changes to your lifestyle? Have you sought any form of manual therapy? "Why do these steps work, or not work, for you?" Positive/negative? Physically/mentally/socially? "Do you think you are developing different ways of looking after yourself as you get older?" What's different? How? Why? Is there anything that worries/concerns you? "Is there anything more you would like to add?" Many thanks for speaking with me today. I am very grateful for your time. Page 48 of 48