Health and wellbeing promotion strategies for ‘hard to reach’ older people in England: a mapping exercise.

The version of the article that has been accepted for publication. This version may include revisions resulting from peer review but may be subject to further editorial input by Cambridge University Press.Background: Older people from deprived areas, the oldest old and those from ethnic minorities engage less in health promotion interventions and related research, potentially generating inequities. Aim: To explore and map the extent to which such ‘hard to reach’ groups of older people, are the focus of local health and wellbeing strategies in England. Methods: Document analysis of current health and wellbeing promotion strategies in a purposive sample of 10 localities in England with high proportions of some or all of the three hard-to-reach groups. Documents were analysed using an interpretive approach. Findings: A total of 254 documents were retrieved and reviewed. Much of the content of the documents was descriptive and reported the implications for resources/services of population ageing rather than actual initiatives. All localities had an Older People’s Strategy. Strategies to counter deprivation included redistribution of winter fuel payments, income maximisation, debt reduction and social inclusion initiatives, a focus on older owner occupiers and recruitment of village ‘agents’ to counter rural deprivation. The needs of the oldest old were served by integrated services for older people, a community alarm service with total coverage of the 85+ population, and dietary advice. The needs of Black and Ethnic Minority (BME) older people were discussed in all localities and responses included community work with BME groups, attention to housing needs and monitoring of service use by BME older people. Three other themes that emerged were: use of telecare technologies; a challenge to the idea of ‘hard to reach’ groups; and outreach services to those at most risk. Conclusions: Document analysis revealed a range of policy statements that may indicate tailoring of policy and practice to local conditions, the salience of national priorities, some innovative local responses to policy challenges and even dissenting views that seek to redefine the policy problem.Peer reviewe

Engaging ‘hard to reach’ groups in health promotion: the views of older people and professionals from a qualitative study in England

Background Older people living in deprived areas, from black and minority ethnic groups (BME) or aged over 85 years (oldest old) are recognised as ‘hard to reach’. Engaging these groups in health promotion is of particular importance when seeking to target those who may benefit the most and to reduce health inequalities. This study aimed to explore what influences them practicing health promotion and elicit the views of cross-sector professionals with experiences of working with ‘hard to reach’ older people, to help inform best practice on engagement. Methods ‘Hard to reach’ older people were recruited through primary care by approaching those not attending for preventative healthcare, and via day centres. Nineteen participated in an interview (n = 15) or focus group (n = 4); including some overlaps: 17 were from a deprived area, 12 from BME groups, and five were oldest old. Cross-sector health promotion professionals across England with experience of health promotion with older people were identified through online searches and snowball sampling. A total of 31 of these 44 professionals completed an online survey including open questions on barriers and facilitators to uptake in these groups. Thematic analysis was used to develop a framework of higher and lower level themes. Interpretations were discussed and agreed within the team. Results Older people’s motivation to stay healthy and independent reflected their everyday behaviour including practicing activities to feel or stay well, level of social engagement, and enthusiasm for and belief in health promotion. All of the oldest old reported trying to live healthily, often facilitated by others, yet sometimes being restricted due to poor health. Most older people from BME groups reported a strong wish to remain independent which was often positively influenced by their social network. Older people living in deprived areas reported reluctance to undertake health promotion activities, conveyed apathy and reported little social interaction. Cross-sector health professionals consistently reported similar themes as the older people, reinforcing the views of the older people through examples. Conclusions The study shows some shared themes across the three ‘hard-to-reach’ groups but also some distinct differences, suggesting that a carefully outlined strategy should be considered to reach successfully the group targeted.Peer reviewedFinal Published versio

Self-reported visual function in healthy older people in Britain: an exploratory study of associations with age, sex, depression, education and income

Background. Tractable but undetected visual impairment in older people may be relatively common, particularly amongst the very old and in more deprived populations. Measurement of visual acuity is unlikely to be helpful in identifying this impairment, but targeted assessment of visual function may be beneficial. There is uncertainty about the defining characteristics of the target group. Objective. To explore factors associated with self-reported visual impairment in community dwelling older people. Methods. Design: secondary cross sectional analysis of baseline data from a randomised controlled trial. Setting: three large group practices in outer London. Participants: older people aged 65 and over enrolled in a study of health risk appraisal. Method: postal questionnaire using questions from the National Eye Institute Visual Function questionnaire. Results. Moderate or extreme visual function loss occurred in 4 to 12% of community-dwelling older people in this population reporting less than excellent vision, depending on which aspect of visual function is considered. Visual function loss in this subgroup increases in prevalence with advancing age, but is not associated with female sex, low educational attainment or low income. It is associated with depressed mood. Conclusion. Questions about visual function identify a group of older people whose vision and mental state needs further investigatio

Experiences and meaning of loneliness beyond age and group identity

Research into loneliness has focussed on subpopulations, and in particular those defined by age, identifying specific contextual factors contributing to their experiences. We suggest that the ‘essence’ of loneliness cannot be fully captured by examining a unitary group and argue for broader and diverse sampling to better understand how loneliness is experienced. Informed by a symbolic interactionist approach, this study aims to elucidate experiences and meaning of loneliness among a heterogeneous group of adults. In depth interviews were conducted with a diverse sample of 37 individuals, aged 18–71 years who had experienced loneliness in the UK. Using thematic analysis, four themes were identified: Loneliness as lacking, loneliness as abandonment, lingering loneliness and the unspoken and trivialised experience of loneliness. Our analysis signals the complexity of loneliness did not necessarily conform to one-dimensional conceptualisations of the phenomenon. Loneliness is linked to interpersonal relationships, but also associated with participants’ roles and identity within society. Thus, society exacerbates and creates loneliness. Implications for the support and provision of loneliness are also discussed

Strategies to improve engagement of 'hard to reach' older people in research on health promotion: : a systematic review

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background: This review aimed to identify facilitators, barriers and strategies for engaging 'hard to reach' older people in research on health promotion; the oldest old (≥80 years), older people from black and minority ethnic groups (BME) and older people living in deprived areas. Methods: Eight databases were searched to identify eligible studies using quantitative, qualitative, and mixed research methods. Using elements of narrative synthesis, engagement strategies, and reported facilitators and barriers were identified, tabulated and analysed thematically for each of the three groups of older people. Results: Twenty-three studies (3 with oldest-old, 16 with BME older people, 2 within deprived areas, 1 with both oldest-old and BME, 1 with both BME and deprived areas) were included. Methods included 10 quantitative studies (of which 1 was an RCT), 12 qualitative studies and one mixed-methods study. Facilitators for engaging the oldest old included gaining family support and having flexible sessions. Facilitators for BME groups included building trust through known professionals/community leaders, targeting personal interests, and addressing ethnic and cultural characteristics. Among older people in deprived areas, facilitators for engagement included encouragement by peers and providing refreshments. Across all groups, barriers for engagement were deteriorating health, having other priorities and lack of transport/inaccessibility. Feeling too tired and lacking support from family members were additional barriers for the oldest old. Similarly, feeling too tired and too old to participate in research on health promotion were reported by BME groups. Barriers for BME groups included lack of motivation and self-confidence, and cultural and language differences. Barriers identified in deprived areas included use of written recruitment materials. Strategies to successfully engage with the oldest old included home visits and professionals securing consent if needed. Strategies to engage older people from BME groups included developing community connections and organising social group sessions. Strategies to engage with older people in deprived areas included flexibility in timing and location of interventions. Conclusions: This review identified facilitators, barriers and strategies for engaging 'hard to reach' older people in health promotion but research has been mainly descriptive and there was no high quality evidence on the effectiveness of different approaches.Peer reviewedFinal Published versio

The relationship between pain intensity and severity and depression in older people: exploratory study

BACKGROUND: Pain and depression are known to be associated in later life, and both have a negative effect on physical performance both separately and in combination. The nature of the relationships between pain intensity and depression in elderly persons experiencing pain is less clear. The objectives of this study were to explore which factors are associated with depressed mood in older people experiencing pain, and to test the hypothesis that older people experiencing pain are at risk of depressed mood according to the severity or frequency of their pain. In addition we explored whether other potentially modifiable factors might increase the risk of depressed mood in these persons. METHODS: The study is a secondary analysis of baseline data for four hundred and six community-dwelling non-disabled people aged 65 and over registered with three group practices in suburban London who had experienced pain in the past 4 weeks. Intensity and frequency of pain was measured using 24 item Geriatric Pain Measure (GPM) and the presence of depressive symptoms using the 5 item Mental Health Inventory. Risk for social isolation was measured using the 6 item Lubben Social Network scale and instrumental activities of daily living (IADL) were also measured. RESULTS: Overall 76 (19%) had depressed mood. Pain frequency and severity were not statistically significantly associated with depressed mood in this population. In multivariate analyses, significant predictors of the presence of depressive symptoms were difficulties with basic ADLs (OR 2.8, 95% CI 1.1.7.8), risk for social isolation (OR 4.1, 95% CI 1.8-9.3), and basic education only (OR 2.2, 95% CI 1.1-4.4). CONCLUSION: Older people experiencing pain are also likely to experience depression. Among those experiencing pain, social network and functional status seem to be more important predictors of depressive symptoms than the severity of pain. Further studies should evaluate whether improvement of social network and functional status might reduce depressive symptoms in older patients

Health risk appraisal for older people 4: case finding for hypertension, hyperlipidaemia and diabetes mellitus in older people in English general practice before the introduction of the Quality and Outcomes Framework

Background Early intervention can help to reduce the burden of disability in the older population, but many do not access preventive care. There is uncertainty over what factors influence case finding in older patients in general practice. Aim To explore factors associated with case finding for hypertension, hyperlipidaemia and diabetes mellitus in older patients. Method Two thousand four hundred and ninety-one patients aged 65 years and above were recruited from three large practices in suburban London before the introduction of the Quality and Outcomes Framework (QOF) completed a questionnaire on health, functional status, health behaviours and preventive care. Findings Those not reporting heart disease, diabetes or hypertension were included in a secondary data analysis to explore factors influencing uptake of preventive care measures. Approximately one-third denied having had a blood pressure check in the previous year. They were more likely to have had little contact with doctors and to have an unhealthy lifestyle (smoking and a high-fat diet). One-third reported a cholesterol test in the previous five years. Cholesterol measurement was reported more often by men and those with a high body mass index. Those with unhealthy lifestyles (smoking and high-fat diet), those who had only received the state pension and those who limited their activities because of a fear of falling were less likely to report cholesterol measurement. About 10% reported a fasting blood glucose measurement and were more likely to consult more often and have more medications, but they were less likely to have a high-fat diet. Preventive care uptake was associated with frequent contacts with doctors, but overall the uptake of preventive care was low. Older people with healthier lifestyles were more likely to have primary preventative care interventions. These findings provide a baseline against which the effect of the QOF on the care of older people can be measured in future studie

Health risk appraisal for older people 5: self-efficacy in patient-doctor interactions

Objective Enhancing self-efficacy is central to programmes promoting self-care and self-management. However, little is known about older people's self-efficacy in doctor-patient interactions. This paper investigates lifestyle, medical and demographic factors associated with self-efficacy in doctor-patient interactions in older people in general practice. Methods A cross-sectional analysis of data from a randomised controlled trial of older people was conducted in a health risk appraisal study in London. Self-efficacy was measured using the Perceived Efficacy in Patient-Physician Interactions Questionnaire. Results Older people with higher self-efficacy were significantly more likely to report having had recent preventive care measures such as recent blood pressure measurement and influenza immunisation. Women were less likely to have higher self-efficacy than men. Older people were significantly less likely to have high self-efficacy if they reported having poor memory, low mood, limited activities due to fear of falling, basic education, difficulties with at least one activity of daily living, reduced physical activity, living alone, or risk of social isolation. Conclusion A third of people had low self-efficacy in doctor-patient interactions. They appear to be a vulnerable group. Low self-efficacy in interactions with doctors may be a symptom or a characteristic of older people who experience social isolation and depression. Policies that depend on enhancing self-care and self-management need to consider the large number of older people with low self-efficacy in using medical services, and understanding characteristics in older people associated with lower confidence in doctor-patient interactions may be useful in clinical practice and researc

Health risk appraisal in older people 6: factors associated with self-reported poor vision and uptake of eye tests in older people

BACKGROUND Although free eye testing is available in the UK from a nation-wide network of optometrists, there is evidence of unrecognised, tractable vision loss amongst older people. A recent review identified this unmet need as a priority for further investigation, highlighting the need to understand public perceptions of eye services and barriers to service access and utilisation. This paper aims to identify risk factors for (1) having poor vision and (2) not having had an eyesight check among community-dwelling older people without an established ophthalmological diagnosis. METHODS Secondary analysis of self-reported data from the ProAge trial. 1792 people without a known ophthalmological diagnosis were recruited from three group practices in London. RESULTS Almost two in ten people in this population of older individuals without known ophthalmological diagnoses had self-reported vision loss, and more than a third of them had not had an eye test in the previous twelve months. In this sample, those with limited education, depressed mood, need for help with instrumental and basic activities of daily living (IADLs and BADLs), and subjective memory complaints were at increased risk of fair or poor self-reported vision. Individuals with basic education only were at increased risk for not having had an eye test in the previous 12 months (OR 1.52, 95% CI 1.17-1.98 p=0.002), as were those with no, or only one chronic condition (OR 1.850, 95% CI 1.382-2.477, p<0.001). CONCLUSIONS Self-reported poor vision in older people without ophthalmological diagnoses is associated with other functional losses, with no or only one chronic condition, and with depression. This pattern of disorders may be the basis for case finding in general practice. Low educational attainment is an independent determinant of not having had eye tests, as well as a factor associated with undiagnosed vision loss. There are other factors, not identified in this study, which determine uptake of eye testing in those with self-reported vision loss. Further exploration is needed to identify these factors and lead towards effective case finding