Today, a greater proportion of the population of many countries is entering older age as a result of medical and technological advances as well as improved standards of living (Goklany, 2007, World Health Organization, 2011). This establishes a significant challenge to the population as individuals, communities and governing bodies regarding health promotion, disease prevention and quality of life.
Wilhelmson, Andersson, Waern and Allebeck (2005) describe quality of life as a dynamic concept and conclude that psychosocial influences are equally important with functional ability in measuring quality of life. Healthy ageing, however, is a broader concept than an absence of disease, encompassing value of lifestyle with maintenance of autonomy, security and independence while having an ability to positively adapt to life situations (Hussain, Marino, Coulson, 2005).
The inherent significance of ageing with success is a subjective one, dependent on cultural and personal expectations, psychosocial factors and life experience (Hussain et al, 2005). This essay will explore the use of a Chronic Conditions Self-Management Framework in realizing healthy ageing and how this is influenced by the individual, the community and by government policy and program formulation. It has been theorised that there is an inherent connection between who one is in old age, and who one has been in life preceding that phase (Andrews, 2009).
Cognitive functioning in the older person can be determined by the educational and mental pursuits of earlier life – with those individuals engaging in an active, involved lifestyle with mental stimulation keeping robust cognitive functioning in later life (Fritsch, McClendon, Smyth, Lerner, Friedland, Larsen, 2007). These findings were linked to implications on the concept of healthy ageing as well as the programs initiated and supported by government bodies.
A program such as Australia’s ‘Become a Swapper’ or United States of America’s ‘Healthy People 2010’ focus on physical activity and healthy food choices to improve life expectancy and quality of life. While these considerations do form a part of a pursuit of healthy ageing, activities requiring high mental requirement are not considered (Fritsch et al, 2007). Mental health is addressed, but only in the context of reducing levels of mental illnesses, not sustaining or improving cognitive abilities (Fritsch et al, 2007).
This is important to consider, given that active involvement and comprehension of choices increases participation in changes of behaviour, a focus on cognitive abilities should be an inclusive promotional feature of health promotion programs. The significance of health promotion and its implications for healthy ageing are explored further by Hussain, Marino and Coulson (2005), outlining that the individualisation of a proactive program is essential for success.
Furthermore, by adopting a holistic approach, including the physical, social, psychological and emotional aspects of healthy ageing there is an increase in likelihood of an individual adopting positive or changing health behaviours (Reicherter and Greene, 2005). Rees and Williams (2009) found by a systematic review that if individuals and health professionals work collaboratively and with mutual respect, offering active patient involvement in health decisions, increased effectiveness and participation in a health care program is achieved.
The relation between sense of control and well-being is linked to resilience and adaption to change and adversity, as outlined in a study undertaken with older persons receiving community based care (Janssen, Van Regenmortel, Abma, 2011). Emphasized domains found to be of importance by participants include personal relationships, relations with professionals, opinion about personal capability, aptitude to understand one’s circumstances and access of health and social services.
Using one-to-one educative consultation coupled with a mutually reached, goal orientated care plan will result in a positive and sustainable influence on health behaviours, in comparison to individuals being supplied commercial brochures and literature only (Morabia, Costanza, 2010). These examples show that a collaboratively created and tailored care plan for an informed and engaged individual, with timely assessments from clinicians will bring success within a self-management framework.
An individual’s functioning within the context of their environment is identified as a crucial component for health behaviour change (Nieuwenhuijsen, Zemper, miner, Epstein, 2006). In addition, primary prevention measures were recognized to allow optimal benefit for individuals’ health and overall well-being, as well as reducing use of health services. Primary measures identified within the study include cessation of smoking, adopting a healthy diet, regular exercise and prevention of secondary conditions by seeking medical advice for an existing condition.
Secondary prevention measures are also acknowledged for early detection or addressing current health concerns; as well as tertiary prevention measures aiming at minimizing suffering or disability related to an existing condition. (Nieuwenhuijsen et al, 2006). Queensland Health identifies these levels of approach within Chronic Disease Guidelines 3rd Edition (2010) as contributing to promoting health and disease prevention by engaging organisations to work jointly at national, state and local levels.
The guidelines focus on risk and protective factors, addressing lifestyle, behavioural and equity issues while taking a lifetime perspective to provide comprehensive care delivery. Respect for personal values and culture underpins the guidelines, as part of the ‘system enablers’, recognising that socio-environmental and health determinants play a role in individual capacity for lifestyle selections. This document demonstrates a consideration of individualisation of interventions by policy makers as being an important aspect of health promotion.
Because the significance of inferior lifestyle choices may not be immediately recognisable, and there is an immense range of determinants affecting our health, individuals may adopt poor lifestyle behaviours or preferences (Lawn, Schoo, 2010). Having knowledge of what to do, and taking action with empowerment are very dissimilar experiences and it was shown that actively sharing in decision making and planning with health professionals can improve self-efficacy (Lawn et al, 2010).
Uninformed individuals have a tendency to view self-management as compliance, while individuals with knowledge, skill and confidence to self-manage see it as being in control (Dixon, Hibbard, Tusler, 2009). Wiesmann and Hannich (2010) state that an individual with a strong sense of coherence and self-efficacy tends to be more resourceful and engaged in practicing self-management, making positive choices and achieving progressive behaviour changes.
Weismann et al’s study, involving a large group of older persons, found that the characteristics for such an individual include a comprehension of ones’ world, being able to adapt and manage changes in life and having a sense of meaningfulness in ones’ life. This group also identified mobility and ability to independently perform activities of daily living as major inferences of quality of life.
An emphasis on enabling the individual with a goal to enhancing quality of life, while using action planning and goal setting is identified as an effective tool in behaviour change toward health promotion (Harrison, Fullwood, Bower, Kennedy, Rogers, Reeves, 2010). This exemplifies that self-management programs using self-efficacy and enabling guidance are identified as most successful in enhancing outcomes for individuals with chronic conditions.
Health promotion practice is not limited to providing appropriate programs and services to enable persons to improve lifestyle, but also incorporating physical, social, economic and political environments to enable individuals to recognize that they can influence determining factors (Queensland Health, 2010). Community beliefs must be incorporated in an encompassing structural approach, also extending to other systems such as education, agriculture, taxation, transport and import/exports (Queensland Health and the Royal Flying Doctor Service, 2007).
A study to identify disparities between urban and rural health promotion expenditure indicated a gap in provision of health care services in rural areas in the United States of America (Meng, Wamsley, Liebel, Dixon, Eggert and Van Nostrand, 2009). A multicomponent nurse home visit intervention followed, based on the philosophy of health coaching, empowerment and self-management of the recipients. A consumer-directed care model was adopted while teaching self-management skills enabling the individuals to more effectively interact with their primary care physician.
The results were cited by the authors as having important implications for public policy with potential in achieving effective and cost-neutral community-based health-promotion and disease self-management within the rural aged population. Thus educating an individual can influence and alter health determinants and result in positive changes to health behaviours and comprehension. Prevention and maintenance are identified as essential components of a chronic disease self-management framework, incorporated within an organised health care system linked to policies and resources within the community (Larsen, 2006).
Queensland Health (2010) identified a barrier to self-management can be an ineffectual clinical information system if the system will not allow information distribution between providers and care settings. With the introduction of this organisation’s electronic Primary Health Care Information System, excellence and safety of treatments with a flow of appropriate documentation is expected, and will ensure continuity within the plan of care for the individual.
An effective care plan must be established in full consultation with the patient, with interventions directed at increasing patient participation resulting in positive changes in self-care and self-behaviour (Rees and Williams, 2009). Moreover, patient-centred action plans that are formulated in one session and evaluated at the next, lead to an increase in self-efficacy and compliance (Jonker, Comijs, Knipscheer and Deeg, 2009). So this could mean a flawless continuation of the individual’s care plan at each encounter if an effective information system is employed.
This illustrates the importance of an easily accessed, coordinated community based primary healthcare service focussing on preventative education and a patient-centred approach. Health promotion and long-term management of chronic conditions is currently dominating healthcare in most developed countries, with increasing financial pressures on healthcare systems to cope with a swollen requirement for health services (Dixon et al, 2009).
An organized approach with a more effective use of resources occurred with the introduction of the Australian Commonwealth Government’s Enhanced Primary Care (EPC) initiative in 1999 (renamed Chronic Disease Management (CDM) in 2005) (Department of Health and Ageing, 2011). Funded annual health assessment and promotion of health screening is offered within the scheme, with the assessment including medical, physical, psychological and social functioning indicators. A care plan with an individualised plan of action is created by the General Practitioner (GP) in consultation with the individual, with mutually agreed management goals generated.
By increasing preventative advice, support and intervention, continuity and coordination of resources and services, healthy behaviours and positive health outcomes for the recipients are the anticipated result (Newman, 2006). When complex care needs are identified, the GP then collaborates with allied health professionals for a team-based approach to challenges (Department of Health and Ageing, 2011). Newmann (2006) found that successful health promotion interventions and programs include major roles for non-physicians, such as Nurse Practitioners and Allied Health professionals.
This data could be related to implementation of further Nurse Practitioner-led and Registered Nurse-led services within the primary health care setting in Australia. An evaluation research project involving the development of a Mental Health Nurse Practitioner outpatient service based at the Royal Prince Alfred Hospital in Sydney produced positive results as a primary care service (Wand, White, Patching, 2011). The project ran as a trial for a period of twelve months. Firstly, the program was identified as an appropriate scope for the provision of a primary care service and interrelated well within the inclusive local health care structure.
Secondly, a focus on solution-based health promotion and teaching was successful in assisting an extensive range of patients, being favourably responsive to a focus on wellness. Thirdly, early access and flexibility was a feature with appointments, and fragmentation between presentation and follow-up was markedly reduced as a result of enhanced coordination. Finally, mental health was recognised as under-served by the current system of healthcare, and this project raised general awareness among staff of the facility.
This example shows positive results using a Nurse Practitioner within a consultation and therapy role as a primary health care service provider. Similarly, a screening clinic for colorectal cancer is an established nurse-led service in the Repatriation General Hospital in South Australia (Morcom, Dunn, Luxford, 2005), with the Nurse Practitioner performing colonoscopic procedures. Moreover, the service is acknowledged as clearly demonstrating a well-accepted, reliable and valuable screening clinic with some patients indicating a preference for a Nurse Practitioner over a Medical Practitioner.
It is theorised by the authors that this was due to the Nurse Practitioner devoting more time to consulting and educating patients and tending to deliver more specific preventative recommendations with a dedicated focus on health promotion through coaching techniques. The role of the Nurse Practitioner in diagnostic screening is acknowledged by the authors as a well-established practice in both the United States of America (U. S. A. ) as well as the United Kingdom (U. K. ), since the early 1970s.
A Nurse-led primary health care clinic for Chronic Obstructive Pulmonary Disease was also highlighted in an evidence summary (Pamaiahgari, 2011), concluding that an organized program with individualised education is required to influence individuals for life-style changes. So this could mean with Australia’s recent health reforms considering, enhancing and promoting the role of the Nurse Practitioner and Registered Nurse within the primary health care system, provision of services can be effective in supporting and promoting self-care management in a variety of ways.
Easily accessible and affordable primary health care strategies and mechanisms within the community setting are required in order for individuals to participate (Reicherter et al, 2005). Hospitalisation can be avoided if a high standard of primary and preventative care is provided, with clinicians able to provide diagnoses, treatment and education to the individual in the outpatient or community setting (Larsen, 2006). Within the Australian Commonwealth Government’s National Health Reform, the focus is shifting from contemporaneous treatment within the hospital setting to building a strong primary health care system.
Prevention of hospital admission and individualisation of chronic disease preventative measures are objectives of the restructure (Department of Health and Ageing, 2011). Infrastructure changes being implemented allow an even skill mix of professionals and a team approach to health care for individuals (Department of Health and Ageing, 2011). In addition, interruptions in service availability and specific associated geographical health care needs are also to be addressed within the reform by creation of Medicare Locals.
Working closely with hospitals, these groups of appointed professionals and community members will take responsibility for balancing supply and demand of primary health care requirements for their local community by identifying and coordinating services to meet variances (Department of Health and Ageing, 2011). Consequently, strengthened consumer commitment and influence in structure and service provision should result in equitable and accessible community based services.
Additional changes taking effect from 1 July 2012 in Queensland, with the implementation of the Health and Hospitals Network Act 2011 will be significant for health promotion (Commonwealth of Australia, 2011). The redesign towards prevention of disease and early intervention steers the responsibility towards primary health care services, and individual accountability. Specialty services are to be expanded in the community setting and sub-acute and rehabilitation programs increased with evidence-based preventative measures being defined by the National Health Promotion and Prevention Agency (Department of Health and Ageing, 2009).
This focus on prevention by integrating and adapting the health system using evidence-based decision-making principles illustrates an alignment with the World Health Organization’s Innovative Care for Chronic Conditions Framework. This corroborates a commitment from the Government to focus on primary health care initiatives as a standard toward improving health care for the population. The Health and Hospitals Network Act 2011 also includes creation of Local Hospital Health Networks (LHHN) aiming to improve roductivity, responsibility, transparency, flexibility, receptiveness and community participation in the health care system (Health and Hospitals Network Act 2011). Talbot and Verrinder (2010) credited community participation and empowerment, with political and system support, as a major factor in effective delivery of primary health care. This is important because primary health care is integral for individuals to manage health conditions successfully as well as prevent disease (Talbot et al, 2010).
Practitioners involved in primary health care include General Practitioners, Practice Nurses, Physiotherapists, Pharmacists and other allied health professionals. This is the most commonly used area of health care in Australia, with four out of five individuals seeking care from a primary health care practitioner annually (Republic of Australia, 2011). This level of care includes medical interventions (immunisation programs, child health) as well as non-medical considerations (education, sanitation, housing, food), these having a shown equal bearing on individual and community health outcomes (Talbot et al, 2010).
With a high level of political support and the development of shared projects within the health system and its organisations, positive results and coordinated behaviour change toward health promotion should occur (Thomas, 2006). Thus coordination and involvement at an individual and community level can shape and influence health activities and behaviours. As our population ages, the proximity of the aged care sector and public health sector narrows and is more unequivocally connected, creating opportunities for policy and partnerships that will progress provision and health care measures generally (McDonald, 2010).