International Journal of Nursing Studies 52 (2015) 1097–1106

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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns

Review

Older adults’ definitions of health: A metasynthesis Misoon Song a, Eun-Hi Kong b,* a b

Seoul National University, College of Nursing. The Research Institute of Nursing Science, Republic of Korea Gachon University, College of Nursing, Republic of Korea

A R T I C L E I N F O

A B S T R A C T

Article history: Received 20 August 2014 Received in revised form 30 January 2015 Accepted 5 February 2015

Background: Despite many gerontological studies focusing on the health of older adults, little attention has been paid to their perceptions of health. Understanding older adults’ health perceptions is important because their self-perceptions are important predictors of and strongly related to survival and mortality. Older adults have different perceptions of health compared with younger adults because of their age-related changes, diseases, and limitations. There are also differences between older adults’ and health professionals’ perceptions of health. Objectives: The purpose of this systematic review was to analyze and synthesize qualitative studies that have explored older adults’ perceptions of health. Methods: Four electronic databases were searched for qualitative studies published from the earliest year to 2013, revealing 12 studies for inclusion. The systematic review employed three components of the meta-study including meta-data-analysis, metamethod, and meta-theory. Results: Five health themes are identified from the included studies: ability to do something independently, absence or management of symptoms, acceptance and adjustment with optimism, connectedness with others, and feeling enough energy. Conclusion: Future gerontological research should use appropriate existing health theories and develop new health theories specific to older adults. Healthcare providers should evaluate and revise their health definitions according to older adults’ health perceptions and provide appropriate health interventions. Policymakers should have an in-depth understanding of older adults’ health perceptions to establish effective olderadult-centered health policies. ß 2015 Elsevier Ltd. All rights reserved.

Keywords: Aged Health Qualitative research Review

What is already known about the topic?  Health greatly affects older adults’ quality of life, life satisfaction, happiness, well-being, and successful aging.  Understanding older adults’ health perceptions is important because their self-perceptions are important predictors of survival and mortality.

* Corresponding author at: Gachon University, College of Nursing, Seungnamdaero 1342, Sujeong-gu, Seongnam-si, Gyeonggi-do 461-701, Republic of Korea. Tel.: +82 10 9866 0638. E-mail addresses: [email protected] (M. Song), [email protected] (E.-H. Kong). http://dx.doi.org/10.1016/j.ijnurstu.2015.02.001 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.

 During the last two decades, there has been an increase in qualitative studies focused on older adults’ health perceptions. There is, however, a scarcity of research integrating the results of these studies. What this paper adds  Older adults perceive health as everything, high priority, life process, way of life, or philosophy.  Older adults define their health as the ability to do something independently, absence or management of symptoms, acceptance and adjustment with optimism, connectedness with others, and feeling enough energy.

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 The ability to do something independently was identified as the most important health theme among older adults. 1. Introduction The population of older adults is growing globally by 2% each year and is expected to continue to grow and reach 21% of the general population in 2050 (United Nations, 2002). Health greatly affects older adults’ quality of life, life satisfaction, happiness, well-being, and successful aging (Bishop et al., 2006; Smith et al., 2002). Regarding health definition, the World Health Organization (WHO) (1948) offered, ‘‘A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.’’ O’Donnell (2009) defined optimal health as ‘‘a dynamic balance of physical, emotional, social, spiritual, and intellectual health’’ (p. iv). Through concept analysis, Wang (2005) defined health as ‘‘a process and outcome that involves subjectivity, individuality, objectivity, culture, dynamics, self-control, external control, changeability, and development’’ (p. 40). Although the term ‘‘health’’ has been commonly used, its definition is still very broad, ambiguous, complex, various, and multidimensional (Maben and Clark, 1995; Wang, 2005; Williamson and Carr, 2009). Despite many gerontological studies focusing on the health of older adults, little attention has been paid to their perceptions of health. According to research, older adults have different perceptions and experiences of health compared with younger adults because of their normal age-related changes, chronic diseases, disabilities, and limitations (Tan et al., 2014). In addition, Giummarra et al. (2007) reported differences and similarities between older adults’ and health professionals’ health perceptions. Understanding older adults’ health perceptions is important because their self-perceptions are important predictors of and strongly related to survival and mortality (Alfonso et al., 2012; Blazer, 2008; Inchingolo, 1997). During the last two decades, there has been an increase in qualitative studies focused on older adults’ health perceptions. In addition, Noghabi et al. (2013) conducted a concept analysis of health in older adults and reported health as physical, mental, social, familial, spiritual, and economic welfare. There is, however, a scarcity of research integrating the results of qualitative studies regarding health perceptions of older adults. Therefore, the purpose of this systematic review is to describe and synthesize qualitative studies regarding older adults’ health definitions. 2. Methods 2.1. Synthesis methodology This review was conducted using the Paterson et al. (2001) research process of meta-study: ‘‘formulating a research question, selection and appraisal of primary research, meta-data-analysis, meta-method, meta-theory, and meta-synthesis’’ (pp. 11–12).

2.2. Search methods The authors planned the search strategy before starting the search. The two authors discussed appropriate databases and search terms before the search and then independently conducted database searches. Inclusion and exclusion criteria (Table 1) were applied in the selection of primary research. Four electronic databases related to health of older adults were searched from the earliest year to 2013: Ovid MEDLINE (1946–2013), CINAHL (1981– 2013), EMBASE (1966–2013), and AGELINE (1978–2013). The database searches were conducted with combinations of the following keywords: health*, health behavior, health promotion, health beliefs, aged, elderly, older adult, older people, seniors, qualitative research, qualitative study, qualitative methods, qualitative analysis, grounded theory, phenomenology, ethnography, narrative, qualitative descriptive, interview, focus groups, and anthropology. The searches retrieved numerous papers. Therefore, the database search was limited to published research articles and dissertations in English. Studies that targeted older adults with specific diseases were excluded because those studies focused on the impact of the disease on health and the process of transition. The authors also excluded papers that included any of following keywords in the research title: cancer, dementia, Parkinson, cognitive, HIV, stroke, vascular, oral, dental, mental, spiritual, and social. In addition, the reference lists of related review articles were hand searched by the authors. 2.3. Study selection results Fig. 1 outlines the search procedure and outcome. The initial literature search yielded 1464 papers. Using EndNote X7, the search results were exported and 136 duplicates were removed. In case of insufficient or unclear contents of some abstracts, full-text articles were obtained and screened by the two authors. They independently examined the retrieved studies and judged them against inclusion and exclusion criteria. To include more articles, the quality of articles was not included in the exclusion criteria. Disagreements regarding inclusion between the authors were resolved through discussion or consultation with another expert. A total of 12 studies were finally included. 2.4. Study characteristics Each of the 12 studies clearly described its purpose: describe health definition, perception, belief, view, image, or meaning (Table 2). Regarding the type of qualitative inquiry, four were descriptive studies (Ballard-Ferguson, 1991; Kaufman, 1996; Oudt, 1988; Viverais-Dresler and Richardson, 1991), two used phenomenology (Ebrahimi et al., 2012; Wondolowski and Davis, 1991), and one was a grounded-theory study that generated an older-adult health model (Bryant et al., 2001). Five studies did not report the type of qualitative inquiry (Collins et al., 2006; Davis et al., 1991; de la Rue and Coulson, 2003; From et al., 2007; Perry and Woods, 1995).

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Table 1 Literature inclusion and exclusion criteria. Inclusion criteria

Exclusion criteria

 Primary research studies that explored perception, perspective, experience, definition, belief, meaning, model, image, concept, or understanding of health  Studies that used qualitative research  Studies that used mixed methods that provided the results of qualitative research  Studies that provided demographic participant data  Studies that included older adults participants (65 years old)  Studies that provided sufficient qualitative data

 Studies that provided insufficient data regarding participants, methods, or results  Studies that focused on older adults with specific diseases (e.g., cancer, dementia, Parkinson disease, HIV, stroke, heart disease, diabetes, arthritis, or cognitive impairment)  Participants were older adults of a very special group (e.g., migrants, refugee, prisoners, nuns, homeless, or homosexual/bisexual people) or hospitalized older adults  Studies that included adults younger than 65 years and did not provide separated qualitative data for the older adults  Studies that focused only on oral, dental, functional, mental, spiritual, or social health  Studies that focused on the lifetime experiences of older adults  Duplicate studies of another included study (or participants)

As a theoretical framework, a theory or model was used in six of the 12 included studies (see Table 2): Orem’s self-care model (Ballard-Ferguson, 1991), Smith’s typology of health model (Ballard-Ferguson, 1991), phenomenology (Ballard-Ferguson, 1991), Pender’s health promotion model (Viverais-Dresler and Richardson, 1991), Parse’s human science nursing perspective (Wondolowski and Davis, 1991), the cultural competency community-care model (Collins et al., 2006), Cox’s interaction model of client health behavior (Davis et al., 1991), social constructionism (de la Rue and Coulson, 2003), and socio-environmental theory of gerontology (de la Rue and Coulson, 2003). The theories or models employed in six of the included studies significantly influenced the findings. Most of the employed

theories (or models) were very diverse and had not been developed targeting older adults. The other six studies, however, did not use a theory or model (Bryant et al., 2001; Ebrahimi et al., 2012; From et al., 2007; Kaufman, 1996; Oudt, 1988; Perry and Woods, 1995). The included studies’ year of publication ranged from 1988 to 2012. Eight of the studies were reported by nursing scholars, one by a social-work scholar, two by scholars of medicine, and one by health scholars. Eight studies were conducted in the United States, two in Sweden, one in Canada, and one in Australia. Informants were recruited from the community (six studies), a senior or retirement center (three studies), rural areas (two studies), a health-care facility (one study), and a veteran’s

Fig. 1. PRISMA flow diagram of screening process.

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Table 2 Summary of included studies. Author (year)

Purpose Type of qualitative study Theoretical framework Discipline Ethical issues

Setting Country (ethnicity or race) Number of participants (age range) Method of sampling Method of data collection

Saturation of data Method of data analysis Description of data analysis Method of trustworthiness Statement of findings

Ballard-Ferguson (1991)

To describe definition of health Descriptive study Phenomenology, Orem’s self-care model, and Smith’s typology of health model Nursing Verbal consent, confidentiality, anonymity, and freedom to discontinue To describe perceptions of health and a model of healthy aging Grounded theory Not reported Medicine Informed consent, confidentiality

Urban community United States (African American) 55 (75–98) Random sampling One-on-one interview

Not reported Content analysis In-depth description of data analysis Peer debriefing Clear statement of finding

Healthcare facility United States (not reported) Not reported 22 (65–90) Maximum variation and random sampling One-on-one interview

Saturation of data Grounded theory-type analysis In-depth description of data analysis Peer debriefing, extended engagement with the participants, triangulation, purposive sampling, thick description, and audit trail Clear statement of finding Not reported Content analysis Brief description of data analysis Not reported Clear statement of finding

Bryant et al. (2001)

Collins et al. (2006)

Davis et al. (1991)

de la Rue and Coulson (2003)

Ebrahimi et al. (2012)

From et al. (2007)

Kaufman (1996)

To describe definition of health Not reported Cultural competency communitycare model Nursing Informed consent and confidentiality To investigate the health beliefs Not reported Cox interaction model of client health behavior Nursing Informed consent, anonymity, and confidentiality To explore meaning of health Not reported Social constructionism and socioenvironmental theory of gerontology Health Institutional review board approval, informed consent, anonymity, and confidentiality To explore experiences with and perceptions of the phenomenon of health Phenomenology Not reported Medicine Informed consent, right to withdraw, confidentiality, and Institutional review board approval To attain deeper understanding of views of health Not reported Not reported Nursing Informed consent, right to withdraw and refuse, anonymity, confidentiality and institutional review board approval To present definition of health Descriptive study Not reported Social work Not reported

Senior citizen center United States (Hispanic and African American) 45 (65–92) Convenience sampling One-on-one interview Rural county United States (white and black) 31 (65–94) Convenience sampling One-on-one interview

Not reported Content analysis In-depth description of data analysis Peer debriefing Clear statement of finding

Rural area Australia (not reported) 5 (78–88) Homogenous sampling One-on-one interview, photographs, and autobiographical material

Not reported Life history research approach (thematic analysis) In-depth description of data analysis Participant feedback Clear statement of finding

Community Sweden 22 (65) Purposive sampling One-on-one interview

Not reported Giorgi’s phenomenological analysis In-depth description of data analysis Bracketing, thick description, investigator triangulation, and peer debriefing Clear statement of finding

Community Sweden 19 (70–94) Convenience sampling One-on-one interview

Not reported Content analysis In-depth description of data analysis Participant feedback, peer debriefing, and thick description, Clear statement of finding

Senior center, Veterans Hospital clinic United States (African American and white) 67 (67–91) Convenience sampling Focus group

Not reported Content analysis Brief description of data analysis Not reported Clear statement of finding

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Table 2 (Continued ) Author (year)

Purpose Type of qualitative study Theoretical framework Discipline Ethical issues

Setting Country (ethnicity or race) Number of participants (age range) Method of sampling Method of data collection

Saturation of data Method of data analysis Description of data analysis Method of trustworthiness Statement of findings

Oudt (1988)

To generate in-depth narrative of health behavior Descriptive study Not reported Nursing Institutional review board approval, informed verbal consent, anonymity, confidentiality, and right to withdraw and refuse To capture images of health Not reported Not reported Nursing Not reported

Community of a midwest state United States (white) 30 (85) Purposive and convenience One-on-one interview

Not reported Miles and Huberman’s approach In-depth description of data analysis Triangulation and peer debriefing Clear statement of finding

Retirement center United States (not reported) 10 (70–91) Convenience sampling One-on-one interview

Viverais-Dresler and Richardson (1991)

To investigate perceptions of health Descriptive study Pender’s health promotion model Nursing Not reported

Wondolowski and Davis (1991)

To discover meaning of health Phenomenology Parse’s human science nursing perspective Nursing Oral consent informed of rights

Northeastern Ontario Canada (Canadian born of varying ethnic origins) 28 (65–94) Snowball sampling One-on-one interview Metropolitan community United States (not reported) 108 (80–100) Convenience sampling One-on-one interview

Not reported Feminist interpretive principles and content analysis In-depth description of data analysis Triangulation and participant feedback Clear statement of finding Not reported Thematic analysis Brief description of data analysis Not reported Brief statement of finding

Perry and Woods (1995)

hospital clinic (one study). The types of sampling were convenience sampling (seven studies), random sampling (two studies), maximum variation (one study), snowball sampling (one study), homogeneous sampling (one study), and purposive sampling (one study). The number of informants ranged from five to 108. The data were collected through one-on-one interviews (11 studies) and focus groups (one study). Ethical issues were described in nine studies and three studies did not report any information related to ethical issues. IRB approval was reported in only three studies. Data saturation was described in one study. Methods of data analysis included content analysis (six studies), thematic analysis (two studies), phenomenological analysis (two studies), grounded theory analysis (one study), Miles and Huberman’s approach (one study), and feminist interpretive principles (one study). In-depth description of the data analysis was presented in nine studies. The research methodologies of the included studies influenced their findings. Four of the 12 included studies were descriptive studies and eight studies used content or thematic analysis so that the findings were more descriptive and less interpretive. The method of trustworthiness was described in nine studies: peer debriefing, triangulation, participants’ feedback, thick description, bracketing, and audit trail. The findings were clearly stated in 11 studies. 2.5. Quality appraisal To appraise the studies’ quality, two appraisal tools were combined and used: The Primary Research Appraisal

Not reported Phenomenological analysis In-depth description of data analysis Verified by a known researcher Clear statement of finding

Tool (Paterson et al., 2001) and the Critical Appraisal Skills Program (Critial Appraisal Skills Programme, 2006). The two authors independently assessed appropriateness in terms of research purpose, qualitative methodology, theoretical framework, researcher’s discipline, ethical issues, setting, country and ethnicity of participants, sampling, data collection, data saturation, data analysis, description of data analysis, trustworthiness, and statement of findings (Table 2). Some of the included articles, however, did not report theoretical framework and ethical issues. The overall quality of all the included articles was appropriate. 2.6. Data extraction, analysis, and synthesis A research team including three nursing scholars was established for data analysis and synthesis. Two nursing scholars (the authors) were experts in gerontological nursing and had experience conducting qualitative research and meta-studies. In addition, another nursing scholar experienced in qualitative research provided consultation in the data analysis. The two authors reviewed, extracted, and analyzed independently the individual primary studies several times using the metastudy research processes (Paterson et al., 2001). ATLAS.ti 6.2 was used to facilitate data management and metadata-analysis. The meta-data-analysis included development of codes, identification of themes, and aggregation and interpretation of the included studies’ findings (Paterson et al., 2001). Inductive thematic analysis was employed for meta-data-analysis. Thematic analysis is free from any specific theory, philosophy, or discipline

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(Boyatzis, 1998), and so was the best fit to analyze the included studies from various theories and disciplines. Six processes of thematic analysis were used: ‘‘familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining/naming themes, and producing the report’’ (Braun and Clarke, 2006, p. 87). In addition, the authors conducted case summaries of all the included studies for within-case analysis. The authors compared and combined across-case analysis with within-case analysis for the identification of themes (Ayres et al., 2003). For meta-method, the two authors compared the findings of included studies that employed different methodology and examined how research methodology influenced the findings of each included study. In terms of meta-theory, the authors identified how theoretical framework influenced the findings of the included studies. For meta-synthesis, the two authors combined and extended ‘‘those ideas that were deconstructed through the three processes (meta-data-analysis, meta-method, and meta-theory) of meta-study’’ (Paterson et al., 2001, p. 13). The authors collaboratively discussed and conducted the meta-synthesis using the Paterson et al. (2001) guidelines: ‘‘work with both aggregations and contradictions of data, ask questions of the data, uncover significant assumptions underlying a body of research findings, and create better understanding and interpretation of the phenomenon’’ (pp. 113–117). 2.7. Trustworthiness To achieve trustworthiness (Guba, 1981), the two authors conducted the reviews and analyses independently. The authors held many meetings to discuss their reviews and findings, identify their similarities and differences, clarify confusing points, arrive at agreement, and analyze and synthesize the data (Paterson et al., 2001). When there was a disagreement, the authors consulted a nursing scholar experienced in meta-studies. In addition, the authors consulted and received feedback about findings of data analysis from a group of qualitative researchers. 3. Results Older adults reported that health was everything and a high priority (Ballard-Ferguson, 1991; Collins et al., 2006; Davis et al., 1991). Some older adults described health as a life process, way of life (living), or philosophy (BallardFerguson, 1991; Perry and Woods, 1995). Through metasynthesis, five assumptions related to the definition of health among older adults were identified: (1) there are not only similarities but also differences in the definition of health between older adults and other populations. (2) There are similarities in the definition of health among older adults despite their various conditions. (3) Older adults rely more on subjectivity than objectivity in their perception of health. (4) In terms of health experience, older adults are focused on their intrapersonal world rather than the interpersonal world. (5) Older adults put great emphasis on health, so that health is more than just physical health.

Five health themes were identified: ability to do something independently, absence or management of symptoms, acceptance and adjustment with optimism, connectedness with others, and feeling enough energy. Most included studies did not report the relationships of these health themes. Only two studies argued that the themes overlap, affect, support, interact with, interdepend on, intertwine, supplement, or contribute to one another (Bryant et al., 2001; Ebrahimi et al., 2012). Employing a phenomenological approach, one study described health as ‘‘harmony and balance of the components (themes) of health in everyday life’’ (Ebrahimi et al., 2012, p. 1516). 3.1. Ability to do something independently The ability to do something independently was identified as the most important theme of health. Most of the older adults in the included studies described health as the ability to complete the activities of daily living, what they want to do, what is important to them, what you have to do, or something meaningful/valuable. Many older adults mentioned not only physical ability, but also mental or cognitive ability (Bryant et al., 2001; Ebrahimi et al., 2012; From et al., 2007; Oudt, 1988; Perry and Woods, 1995; Viverais-Dresler and Richardson, 1991). Older adults emphasized the importance of independence intertwining with ability (Bryant et al., 2001; Collins et al., 2006; Davis et al., 1991; From et al., 2007; Perry and Woods, 1995). An older adult said, ‘‘It is so nice when you can care of yourself, and do not have to be dependent on others. It is the most important thing in this world. If you cannot do it, you might as well die.’’ (Ebrahimi et al., 2012, p. 1517). For some older adults, the term of independence does not always exclude some type of assistance and ‘‘asking for help was important in maintaining independence’’ (Perry and Woods, 1995, p. 56). Older adults mentioned that ‘‘the need for help from caregivers did not automatically lead to feelings of dependency’’ (From et al., 2007, p. 282). Older adults equated health with independence and linked loss of health to dependency and burdening others (Ballard-Ferguson, 1991; Davis et al., 1991; From et al., 2007). Older adults showed pride and appreciation about their independence while they expressed worry and fear about dependency (Bryant et al., 2001; Ebrahimi et al., 2012). 3.2. Absence or management of symptoms Many older adults defined health as absence, control, management, or treatment of aging- and illness-related symptoms (Ballard-Ferguson, 1991; Collins et al., 2006; Davis et al., 1991; de la Rue and Coulson, 2003; Ebrahimi et al., 2012; From et al., 2007; Oudt, 1988; Perry and Woods, 1995). Among the symptoms, not having pain was the most frequently mentioned as the definition of health (Collins et al., 2006; Davis et al., 1991; de la Rue and Coulson, 2003; From et al., 2007; Oudt, 1988; Perry and Woods, 1995). Some older adults described health as being free from disease, the absence of illness, or the absence of medical attention (Ballard-Ferguson, 1991; de la Rue and Coulson, 2003; From et al., 2007; Kaufman, 1996). Other

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older adults, however, perceived health as ‘‘tolerance or treatment of specific symptoms and illnesses’’ (Perry and Woods, 1995, p. 56) or use of medicine (Kaufman, 1996). Some older adults mentioned that although they had illness, ‘‘they were healthy because they kept it under control with medicine’’ (Kaufman, 1996, p. 66). Some older adults thought that as long as they could manage their symptoms and illnesses, they felt healthy despite their illness, impairment, disability, and limitation (Kaufman, 1996; Perry and Woods, 1995). 3.3. Acceptance and adjustment with optimism Acceptance and adjustment with optimism was a sign and component of good health among older adults. Older adults referred to the importance of acceptance, adaptation, and adjustment to the change, illness, impairment, loss, disability, limitation, or life (Bryant et al., 2001; Ebrahimi et al., 2012; From et al., 2007; Oudt, 1988; Perry and Woods, 1995). Acceptance was linked to successful adaptation, adjustment, and compensation, which lead to good health for older adults (Ebrahimi et al., 2012; From et al., 2007). Older adults’ acceptance required a positive attitude and realistic optimism (From et al., 2007). Older adults’ positive attitudes were affected by childhood upbringing, difficult childhoods, identity, personality type, life experience, insight, self-reliance, faith, control or willpower, awareness of one’s condition, understanding of health given one’s age, acceptance of changing life conditions, adaptation, benefits of getting older, relationships with others, and comparison to others (Bryant et al., 2001; Ebrahimi et al., 2012; Kaufman, 1996; Perry and Woods, 1995). In Perry and Woods (1995), older adults proposed ‘‘realistic optimism’’—meaning ‘‘knowing one’s abilities/limitations and coping with losses related to age’’ (p. 59)—as more appropriate than positive attitude. 3.4. Connectedness with others Older adults mentioned reciprocal support, helping others (family, friends, or neighbors), close relationships, togetherness, frequent contact with others, social involvement, socialization, social context, and the environment (Bryant et al., 2001; Collins et al., 2006; de la Rue and Coulson, 2003; Ebrahimi et al., 2012; From et al., 2007; Perry and Woods, 1995; Viverais-Dresler and Richardson, 1991). Connectedness with the (social or geographical) environment was reported in two studies that employed social constructionism, socioenvironmental theory of gerontology, or Parse’s human science nursing as a theoretical framework (de la Rue and Coulson, 2003; Wondolowski and Davis, 1991). In addition, some older adults described ‘‘belief in God’’ as the definition of health (Collins et al., 2006; Kaufman, 1996). Some older adults said, ‘‘Prayer and belief in the God make you a healthy person’’ (Collins et al., 2006, p. 18). As a component of and contributor to health, older adults expressed the importance of connectedness with other people, society, the environment, and God (Collins et al., 2006; Ebrahimi et al., 2012; Kaufman, 1996).

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3.5. Feeling enough energy Older adults referred to health as energy, strength, vitality, stamina, fitness, and driving force (Davis et al., 1991; Oudt, 1988; Perry and Woods, 1995; Wondolowski and Davis, 1991). Davis et al. (1991) reported that when older adults evaluate their health, they ‘‘tended to rely on how they felt’’ (p. 13), so that being healthy meant feeling enough energy. Similarly, in Wondolowski and Davis’s (1991) study, older adults expressed that when they felt surges of energy, they felt healthy. Perry and Woods (1995) identified energy as an important health theme among older adults. In the study, one woman mentioned that ‘‘energy was what separated middle age from old age’’ (Perry and Woods, 1995, p. 55). In older adults’ minds, energy meant not only physical energy, but also emotional energy (Davis et al., 1991; Perry and Woods, 1995; Wondolowski and Davis, 1991). Older adults regarded lack of energy as lack of health (Davis et al., 1991). 4. Discussion This meta-study found that older adults experience health when they have the ability to do something independently, absence or management of symptoms, acceptance and adjustment with optimism, connectedness with others, and enough energy in their own world. The five identified themes of health in this study were similar to the health domains of Noghabi et al.’s (2013) study, which targeted older adults: The physical domain was supported by the three themes of this study (‘‘ability to do something independently,’’ ‘‘absence or management of symptoms,’’ and ‘‘feeling enough energy’’). The mental domain was supported by the themes ‘‘acceptance and adjustment with optimism,’’ ‘‘feeling enough energy,’’ and ‘‘ability to do something independently.’’ In addition, social, familial, and spiritual domains resonated with the theme of ‘‘connectedness with others.’’ However, the economic dimension of the Noghabi et al.’s (2013) study was not supported by the results of this study. The findings of this review highlighted three themes— ability to do something independently, acceptance and adjustment with optimism, and feeling enough energy. Many older adults stressed the ability to do something independently and equated health with independence in the studies included in this review. In addition, older adults expanded the definition of independence as not excluding some assistance. Independence was cited as extremely important among older adults, but was not frequently stressed in young-adult groups (Perry and Woods, 1995). The theme of ability to do something independently also supports the results of previous quantitative and qualitative studies (Giummarra et al., 2007; Trentini et al., 2012). According to previous qualitative research, independence is also a crucial theme in older adults’ healthy, active, and successful aging (Darvishpoor Kakhki et al., 2010; Hansen-Kyle, 2005; Queniart and Charpentier, 2012; Thanakwang et al., 2012; Troutman et al., 2011). Considering their age- or illness-related changes, older adults emphasized the importance of acceptance and

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adjustment with realistic optimism. This supports some attributes of healthy aging (Hansen-Kyle, 2005): the continuous process of change and adaptation, acceptance and movement toward death, and continual modification. Regarding this theme, emotional health and psychological health were addressed in the existing related studies (Chen et al., 2011; Noghabi et al., 2013). Comparing the broad and unclear descriptions from existing related studies, the theme of acceptance and adjustment with optimism in this review showed more details how older adults experience and define their health. The theme of feeling enough energy has been ignored in most health research based on the traditional Western biomedical model (Saylor, 2004). The theme of energy in this review supports Saylor’s (2004) health-definition model which added new concepts (energy, strength, fitness, and stamina) to traditional health concepts. In addition, the theme was similar to the results (listening to energy flow and vitality) of previous studies that explored the health perceptions of older women with chronic illness, adult patients, and health practitioners (Hunter et al., 2013; Shearer et al., 2009). 4.1. Research and theory This review revealed that many of the included studies did not clearly describe their qualitative inquiry methods or ethical issues. Future research needs to provide more detailed information about research methods. In addition, gerontological researchers need to carefully check underlying definitions (or assumptions) of health in existing theories and compare them with older adults’ health perceptions. Despite significance and appropriateness in other populations, the existing theories may need adjustment for use with older adults. Although many theoretical articles on health in older adults have been published, theoretical perspectives for older adults are still lacking; more studies are needed to test existing theoretical perspectives’ appropriateness and to develop new theories or models for older adults. The findings (five assumptions and themes) of this review provide important knowledge for the development of new health theories or models for older adults. The literature shows that older adults are inclined to place less emphasis on physical aspects of health, underestimate health decline, and perceive health positively, giving a widening gap between objective health status and subjective health perception among older adults (Borawski et al., 1996; Henchoz et al., 2008). Blazer (2008) argued that older adults’ health perceptions were as important as objective health status and influenced health outcomes. More research is needed regarding older adults’ health definitions compared with other population groups using qualitative methods that lead to the development of theories or models regarding health among older adults. In addition, future studies should explore the relationships among older adults’ subjective health perception, health-promotion behaviors, objective health status, morbidity, and mortality using mixed methods.

4.2. Education and practice In terms of the education of healthcare providers, the shortage of clear definitions in many important areas has been raised as a serious problem (Brydges, 2010). Among these missing definitions, older adults’ definition of health has been ignored and unknown for too long: It should be included in the education of healthcare providers and students. Many healthcare providers have received a conventional health education based on the biomedical model and have provided ‘‘reactive ill health and disease risk-specific preventive care’’ (Whitehead, 2006, p. 165). Giummarra et al. (2007) reported that healthcare providers showed some important different perspectives of health compared with older adults as well as similar perspectives. In the study, older adults emphasized empowerment, whereas healthcare providers stressed external factors in terms of health maintenance (Giummarra et al., 2007). Considering the importance of health definition and the principles of healthcare providers, they need to receive a modern health education that focuses on older adults’ health beliefs and needs. Healthcare providers need to evaluate and revise their health definitions according to older adults’ perceptions regarding health so they can provide practical older-adultcentered health education and interventions. Understanding older adults’ perceptions of health will foster active participation and increased empowerment of older adults in their healthcare. In addition, older adults’ independence, autonomy, integrity, authority, health, and quality of life will be improved. 4.3. Policy Older adults’ health is not attained through individual healthy behaviors alone; it is greatly affected by publichealth policy (Fowler, 1997; Shilton et al., 2011). According to Williamson and Carr (2009), policymakers often view health as a capital resource and employ economic definitions of health unmatched to the laity’s perceptions of health. Understanding older adults’ perceptions regarding health may help policymakers and government officials establish and implement effective older-adultcentered health policies, which would improve their health status, quality of life, morbidity, and mortality. 4.4. Limitations There were some limitations in this systematic review. Although the authors tried to include many articles, nonEnglish and unpublished studies were excluded from the review. The majority of included studies were conducted in the United States, in community settings, and by nursing scholars; there might be limitations in the generalizability of the results to other countries and geriatric settings. 5. Conclusions This review shows that older adults feel healthy when they have the ability to do something independently, an absence or management of symptoms, acceptance and

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adjustment with optimism, connectedness with others, and enough energy in their own world. The findings of this review offer new knowledge about older adults’ health perceptions and support some domains of the existing definitions of health. In addition, this review highlights three health themes—ability to do something independently, acceptance and adjustment with optimism, and feeling enough energy—that are not emphasized in existing health definitions. The results of this review explain why older adults can perceive their heath positively despite their normal age-related changes, chronic diseases, disabilities, and other limitations. The review indicates that future gerontological research should use more robust research methods and theories more appropriate to older adults. More research is needed regarding older adults’ health definitions using qualitative methods that lead to the development of new theories or models regarding health among older adults. In addition, future studies should explore the relationships among older adults’ subjective health perception, healthpromotion behaviors, objective health status, morbidity, and mortality. Healthcare providers should evaluate and revise their perceptions of health based on older adults’ health perceptions to provide older-adult-centered healthcare based on their health needs and preferences. In addition, healthcare providers should respect older adults’ need for independence and help them increase their active participation and empowerment in practice. Finally, policymakers and government officials need an in-depth understanding of older adults’ health perceptions in order to establish and implement effective older-adult-centered health policies. Conflict of interest: None declared.

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