Journal of Primary Prevention, 3(2),Winter, 1982
Spotlight The Elder Program: A Strategy for Prevention Ann H. Crowe and Ruth R. Middleman Kent School of Social Work Louisville, Kentucky The older population has grown and will continue to increase at a rapid rate. With this growth, the need for services has expanded, and a tremendous multiplication of the formal services for older persons has emerged. However, because of the current grim economic picture, with funds redistributed away from social and human services, many programs which were valuable resources to older persons are no longer available. Throughout history, informal support systems--kin, friends, and neighb o r s - h a v e provided the bulk of social and health related services for older persons. By furnishing social support, assistance with daily living tasks, and help during times of illness and crises (Gurian & Cantor, 1978), these "informal supporters" fill needs for both service provision and prevention outside the confines of formal services (Collins & Pancoast, 1976). The value and impact of informal support systems is more readily apparent as formal human services are curtailed. The Elder Program described in this article seeks to strengthen the potential of the informal support system through an educational approach to initiating or enhancing viable neighborhood support groups for community-based older persons. It is predicated on the following assumptions which suggest that support-enhancement activities among the elderly are highly appropriate: (1) the daily problems or crises in the lives of older persons are not seen as resulting from failures of the individuals themselves, but are a part of the normal life experience and a concomitant need for support; (2) in considering the needs of older persons and the development of responsive formal and informal support systems, a holistic approach is taken which requires thinking about individuals as unique and whole beings functioning within a total environmental system; (3) there are older people living in neighborhood situations who do not have a responsive informal support system, and are, therefore, at risk;
T h e E l d e r P r o g r a m is a M o d e l D e m o n s t r a t i o n P r o j e c t f u n d e d b y t h e A d m i n i s t r a t i o n on A g i n g , G r a n t #04-AM-000005. 0278-095X(82)1600~0133502.75
133
©1982Human SciencesPress
Journal of primary Prevention
134
(4~ there are older people in neighborhood areas who have skills and resources developed throughout their lives for meeting the idiosyncratic needs of their peers, and for diminishing their risk of isolation and institutionalization.
Elder Project Purpose Professional intervention in the informal support system is an appropriate and productive method of enhancing the quality of life of older adults in an economical and efficient manner. The Elder Program developed an educational model to strengthen networks among older persons. It is the product of combining principles and techniques of primary prevention, informal support system intervention, community organization, outreach, and older adult education. Three key principles of primary prevention are: (1) measures are proactive; i.e., they seek to instill lifestyles that are less hazardous to the psychological or physical health of older persons; 12) efforts are oriented to working with groups (or even total populations} rather than individuals; and (3) main methods are education and social work, not medical or psychiatric treatment models (Forgays, 1978, p. 218}. We are, therefore, in agreement with Forgays in our emphasis on the two preventive techniques, which influenced the development of a model for strengthening neighborhood support systems: {1) competency training; and {2) the use of techniques centered around the impact of social systems on individuals (Forgays, 1978, p. 236}.
Competency Training Competency involves living one's life with the least amount of emotional or physical damage. Competency training seeks to modify behaviors and promote lifestyles that are healthy. In a population of older persons the route to maintaining or acquiring this sort of "life-competency" appears to be associated with self-confidence, self-reliance, self-labeling as able, and keeping a stock of problem solving skills intact (Birren & Renner, 1980, p. 25}.
Intervention in Social Systems r
Competency training to promote changes in lifestyles is not sufficient. A prerequisite to successful lifestyle modification appears to be the availability of a social group or institution in the target group's environment through which the change is reinforced and maintained. Currently our social environments tend not to provide support for healthy lifestyle change and in fact they are often more supportive of unhealthy ways of living (Mettlin, 1979). Thus, the
Spotlight
135
utilization of social systems or networks designed to exert a positive impact on the target population complements competency training approaches. Using natural community supports among older persons in a geographic locality can capitalize on the strengths of existing relationships to provide a collective experience which gives members a wider range of alternative lifestyle options, ideas for making and maintaining preventive changes individually and in the community, support in undertaking lifestyle change, and assistance in carrying out the change effort.
Program Methodology The Elder Program is a 3-year Model Demonstration Project funded by the Administration on Aging through the Gerontology Center and Kent School of Social Work at the University of Louisville.The goal of the project is to develop or strengthen neighborhood support systems through an educational program emphasizing information, resources, and skill development. Project staff developed a workbook for program participants containing information about personal competency of older persons, including: health, finances, housing, law, and use of time. The workbook also has materials in the skill building areas of: outreach to others, individual helping methods, problem solving, individual case advocacy, legislative advocacy, and group maintenance. The content is presented at a fifth to seventh grade reading level, is reproduced in large print, and is made more attractive with written and drawn illustrations in the workbook. Each participant in the program is provided a copy of the workbook, but encouragement to read it is handled with sensitivity according to the educational experiences and]or visual impairments of participants. The program was implemented with 206 participants in 11 groups. The groups were recruited within six specific neighborhood areas. The neighborhoods were selected to allow for testing of the model in areas with differing characteristics. Four urban and two rural neighborhoods were chosen, ranging in total population from under 2,000 to over 25,000 persons. The neighborhoods were characterized as: urban, black; urban, ethnic; urban, socioeconomically heterogeneous; suburban, black; rural/small town, white; and rural/small town, black. The percentage of residents aged 60 and over ranged from only 4% in the suburban neighborhood to 25% in the urban ethnic neighborhood. The size of the neighborhoods varied from as small as approximately 75 square blocks to over 450 square blocks, and all neighborhoods had a large proportion of households below the poverty level. Six groups were developed in the urban black neighborhood, three in high rises and three at community sites. Only one group was organized in each of the other five neighborhoods. Eighty-nine percent of the 206 participants were females and 73% were black. The average age of participants was 68.5 years, with the range being from 30 to 94 years of age (in two groups some younger participants were recruited). Previous educational experience varied from first
136
Journal of Primary Prevention
grade through 17 years of formal education. Seventy-two percent of the participants lived in varied housing arrangements in the community, while 28% lived in senior citizens housing. One half lived alone. Project methodology was refined, modified, and adapted to meet the needs of each neighborhood group. Neighborhoods were selected to allow for testing of the model with as many varied populations as possible. Final selection of each neighborhood was influenced, in part, by staff members' personal knowledge and/or contact within each area, a practice which would be realistic for an agency service provider. Project staff then collected data about the neighborhood and familiarized themselves with the people and places in it. Newspaper articles, written histories, and other information about each neighborhood were obtained. Staff walked or drove through each neighborhood noting local landmarks, service agencies, and first getting a "feel" for the community. Service providers and community leaders {e.g., ministers, presidents of neighborhood organizations} were contacted and the program was explained to them. Finally, an advisory group was formed in most of the neighborhoods to assist with information gathering and to provide sanction for the development of the program and linkages with older residents of the area. Once a decision was made to implement the project in a neighborhood, a recruiter was selected. This person was hired by the project directly or through a subcontract with a community agency. Her responsibilities were to contact 15-20 potential participants, explain the program, and assist with evaluation data collection and general program implementation. Criteria for selection of the recruiter included the following: age 60 or older; resident of the neighborhood; ability to communicate effectively about the program; ability to relate positively with peers; knowledge of the community and community resources. Criteria for selection of participants included: age 60 or older; ability to attend weekly meeting regularly; interest in learning about the program. Eight weekly educational meetings were held with each group. The content of these meetings followed the workbook material. Each meeting lasted four hours and included lunch. Educational methods used were consistent with andragogical ladult learning) theory {Ingalls, 1973; Knowles, 1970; Middleman, 1982). Information was presented by films, guest speakers, and staff. Skill building and values clarification were addressed by small and large group discussions, practice exercises, and task assignments between meetings. Each group selected "areas of concern" using a modified nominal group technique {Delbecq, Van de Ven & Gustafson, 1975}. Typical concerns were: loneliness, problems with the community sewage disposal system, housing,
Spotlight
137
crime, transportation, health, and neighborhood cleanup. Through the use of committee work at each session, the groups identified ways to solve the problems they selected. At the beginning of each series of meetings, project staff discussed termination with participants and pointed out possible alternative directions the group might choose to follow after the planned program ended. These options included continuing to meet as a group and defining their own focus, or discontinuing meetings and utilizing their skills and information in other groups and activities. Project staff observed and documented project outcomes which exemplify its impact. These included, but were not limited to, the following: 1. A n increase in various helping activities between group members was noted in numerous instances. For example, a 65-year-old woman lived alone and knew only two other members of the group prior to its beginning. During the meetings she shared with the group an experience of a few years earlier when she was hospitalized for a leg amputation and returned to her home without anyone to assist her. She was virtually bedridden for several days without food or other care until some neighborhood children discovered her and obtained help. Following the group meetings she was hospitalized again for cataract surgery. When project staff checked with her following this surgery, she reported that several members of the group were visiting her regularly and assisting with meal preparation, housekeeping, shopping, and the like. 2. Participants also became interested in outreach strategies to other older persons in their neighborhood. For example, one group organized a volunteer transportation service available to any older persons living in the area. Those in the group with cars organized a schedule and publicized phone numbers where they could be contacted. Anyone may call requesting transportation for medical appointments, shopping, and so forth. If the person receiving the call cannot make the needed trip, he or she contacts another group member and arranges the transportation. No fee is charged for this service, but donations are accepted. 3. Project participants spent time during the eight weekly meetings working on solutions to neighborhood concerns. In several instances, these endeavors were continued beyond the eight meetings. For example, one group, whose concern was neighborhood crime, organized and implemented a "Crime Awareness D a y " for older persons in the area. They invited speakers from the Police Department, Rape Awareness Center, Economic Crime Unit, and other community agencies to inform area residents of crime prevention techniques. Approximately 75 older persons from the area attended the day-long meeting which included a brown bag lunch and social hour. 4. M a n y of the participants also reported significant personal benefit from the educational program. For example, a 76-year-old woman who had completed the eighth grade decided to enroll in adult education courses in order to obtain her GED following her participation in the Elder Program. Because she has a pronounced hearing loss, she tape-records her classes and
138
Journal of Primary Prevention
replays them at home for review. Other participants have reported an increase in confidence which they attribute to participation in the program. They report activities such as writing legislative representatives and speaking out at public meetings which they had not done before. Each of the 11 groups chose to continue involvement on their own in some way after the project's sessions. One group organized formally with elected officers, by-laws, and regular monthly meetings. Other groups continue to function in varying ways, ranging from using their learnings in other groups to continuing the Elder Project group with monthly meetings for socialization and/or education. The Participant Workbook and Leader's Guide are other project outcomes. These will be available (on a limited basis) for distribution and replication of the program to others who may wish to initiate an Elder Program. For further information regarding this program contact the authors at the Gerontology Center, Kent School of Social Work, University of Louisville, Louisville, Kentucky.
References
Birren, J.E. & Renner, V.J. Concepts and Issues of Mental Health and Aging. In J.E. Birren and R.B. Sloane (Eds.), The handbook of mental health and aging. Englewood Cliffs, NJ: Prentice-Hall, 1980. Collins, A.H. & Pancoast, D.L. Natural helping networks, a strategy for prevention. Washington, D.C.: NASW, 1976. Delbecq, A.L., Van de Ven, A.H., Gustafson, D.H. Group techniques for program planning, a guide to nominal group and delphi processes. Glenview, IL: Scott, Foresman and Company, 1975. Forgays, D.G. (Ed.}, Primary prevention of psychopathology: Volume II--Environmental influence. Hanover, NH: University Press of New England, 1978. Gurian, B.S. & Cantor, M.H. Mental health and community support systems for the elderly. In Usdin & Hofling (Eds.), Aging: The process and the people. New York: Brunner/Mazel Publishers, 1978. Ingalls, J.D. A trainers guide to andragogy (Stock No. 017-061-00033-0). Washington, D.C.: U.S. Government Printing Office, 1973. Knowles, M.S. The modern practice of adult education. New York: Association Press, 1970. Mettlin, C. Prerequisites of successful lifestyle intervention. Social Science & Medicine, 1979, 13A, 559-562. Middleman, R.R. Teaching and training, a study guide. Louisville, KY: Raymond A. Kent School of Social Work, University of Louisville, 1982.
Spotlight The Elder Program: A Strategy for Prevention Ann H. Crowe and Ruth R. Middleman Kent School of Social Work Louisville, Kentucky The older population has grown and will continue to increase at a rapid rate. With this growth, the need for services has expanded, and a tremendous multiplication of the formal services for older persons has emerged. However, because of the current grim economic picture, with funds redistributed away from social and human services, many programs which were valuable resources to older persons are no longer available. Throughout history, informal support systems--kin, friends, and neighb o r s - h a v e provided the bulk of social and health related services for older persons. By furnishing social support, assistance with daily living tasks, and help during times of illness and crises (Gurian & Cantor, 1978), these "informal supporters" fill needs for both service provision and prevention outside the confines of formal services (Collins & Pancoast, 1976). The value and impact of informal support systems is more readily apparent as formal human services are curtailed. The Elder Program described in this article seeks to strengthen the potential of the informal support system through an educational approach to initiating or enhancing viable neighborhood support groups for community-based older persons. It is predicated on the following assumptions which suggest that support-enhancement activities among the elderly are highly appropriate: (1) the daily problems or crises in the lives of older persons are not seen as resulting from failures of the individuals themselves, but are a part of the normal life experience and a concomitant need for support; (2) in considering the needs of older persons and the development of responsive formal and informal support systems, a holistic approach is taken which requires thinking about individuals as unique and whole beings functioning within a total environmental system; (3) there are older people living in neighborhood situations who do not have a responsive informal support system, and are, therefore, at risk;
T h e E l d e r P r o g r a m is a M o d e l D e m o n s t r a t i o n P r o j e c t f u n d e d b y t h e A d m i n i s t r a t i o n on A g i n g , G r a n t #04-AM-000005. 0278-095X(82)1600~0133502.75
133
©1982Human SciencesPress
Journal of primary Prevention
134
(4~ there are older people in neighborhood areas who have skills and resources developed throughout their lives for meeting the idiosyncratic needs of their peers, and for diminishing their risk of isolation and institutionalization.
Elder Project Purpose Professional intervention in the informal support system is an appropriate and productive method of enhancing the quality of life of older adults in an economical and efficient manner. The Elder Program developed an educational model to strengthen networks among older persons. It is the product of combining principles and techniques of primary prevention, informal support system intervention, community organization, outreach, and older adult education. Three key principles of primary prevention are: (1) measures are proactive; i.e., they seek to instill lifestyles that are less hazardous to the psychological or physical health of older persons; 12) efforts are oriented to working with groups (or even total populations} rather than individuals; and (3) main methods are education and social work, not medical or psychiatric treatment models (Forgays, 1978, p. 218}. We are, therefore, in agreement with Forgays in our emphasis on the two preventive techniques, which influenced the development of a model for strengthening neighborhood support systems: {1) competency training; and {2) the use of techniques centered around the impact of social systems on individuals (Forgays, 1978, p. 236}.
Competency Training Competency involves living one's life with the least amount of emotional or physical damage. Competency training seeks to modify behaviors and promote lifestyles that are healthy. In a population of older persons the route to maintaining or acquiring this sort of "life-competency" appears to be associated with self-confidence, self-reliance, self-labeling as able, and keeping a stock of problem solving skills intact (Birren & Renner, 1980, p. 25}.
Intervention in Social Systems r
Competency training to promote changes in lifestyles is not sufficient. A prerequisite to successful lifestyle modification appears to be the availability of a social group or institution in the target group's environment through which the change is reinforced and maintained. Currently our social environments tend not to provide support for healthy lifestyle change and in fact they are often more supportive of unhealthy ways of living (Mettlin, 1979). Thus, the
Spotlight
135
utilization of social systems or networks designed to exert a positive impact on the target population complements competency training approaches. Using natural community supports among older persons in a geographic locality can capitalize on the strengths of existing relationships to provide a collective experience which gives members a wider range of alternative lifestyle options, ideas for making and maintaining preventive changes individually and in the community, support in undertaking lifestyle change, and assistance in carrying out the change effort.
Program Methodology The Elder Program is a 3-year Model Demonstration Project funded by the Administration on Aging through the Gerontology Center and Kent School of Social Work at the University of Louisville.The goal of the project is to develop or strengthen neighborhood support systems through an educational program emphasizing information, resources, and skill development. Project staff developed a workbook for program participants containing information about personal competency of older persons, including: health, finances, housing, law, and use of time. The workbook also has materials in the skill building areas of: outreach to others, individual helping methods, problem solving, individual case advocacy, legislative advocacy, and group maintenance. The content is presented at a fifth to seventh grade reading level, is reproduced in large print, and is made more attractive with written and drawn illustrations in the workbook. Each participant in the program is provided a copy of the workbook, but encouragement to read it is handled with sensitivity according to the educational experiences and]or visual impairments of participants. The program was implemented with 206 participants in 11 groups. The groups were recruited within six specific neighborhood areas. The neighborhoods were selected to allow for testing of the model in areas with differing characteristics. Four urban and two rural neighborhoods were chosen, ranging in total population from under 2,000 to over 25,000 persons. The neighborhoods were characterized as: urban, black; urban, ethnic; urban, socioeconomically heterogeneous; suburban, black; rural/small town, white; and rural/small town, black. The percentage of residents aged 60 and over ranged from only 4% in the suburban neighborhood to 25% in the urban ethnic neighborhood. The size of the neighborhoods varied from as small as approximately 75 square blocks to over 450 square blocks, and all neighborhoods had a large proportion of households below the poverty level. Six groups were developed in the urban black neighborhood, three in high rises and three at community sites. Only one group was organized in each of the other five neighborhoods. Eighty-nine percent of the 206 participants were females and 73% were black. The average age of participants was 68.5 years, with the range being from 30 to 94 years of age (in two groups some younger participants were recruited). Previous educational experience varied from first
136
Journal of Primary Prevention
grade through 17 years of formal education. Seventy-two percent of the participants lived in varied housing arrangements in the community, while 28% lived in senior citizens housing. One half lived alone. Project methodology was refined, modified, and adapted to meet the needs of each neighborhood group. Neighborhoods were selected to allow for testing of the model with as many varied populations as possible. Final selection of each neighborhood was influenced, in part, by staff members' personal knowledge and/or contact within each area, a practice which would be realistic for an agency service provider. Project staff then collected data about the neighborhood and familiarized themselves with the people and places in it. Newspaper articles, written histories, and other information about each neighborhood were obtained. Staff walked or drove through each neighborhood noting local landmarks, service agencies, and first getting a "feel" for the community. Service providers and community leaders {e.g., ministers, presidents of neighborhood organizations} were contacted and the program was explained to them. Finally, an advisory group was formed in most of the neighborhoods to assist with information gathering and to provide sanction for the development of the program and linkages with older residents of the area. Once a decision was made to implement the project in a neighborhood, a recruiter was selected. This person was hired by the project directly or through a subcontract with a community agency. Her responsibilities were to contact 15-20 potential participants, explain the program, and assist with evaluation data collection and general program implementation. Criteria for selection of the recruiter included the following: age 60 or older; resident of the neighborhood; ability to communicate effectively about the program; ability to relate positively with peers; knowledge of the community and community resources. Criteria for selection of participants included: age 60 or older; ability to attend weekly meeting regularly; interest in learning about the program. Eight weekly educational meetings were held with each group. The content of these meetings followed the workbook material. Each meeting lasted four hours and included lunch. Educational methods used were consistent with andragogical ladult learning) theory {Ingalls, 1973; Knowles, 1970; Middleman, 1982). Information was presented by films, guest speakers, and staff. Skill building and values clarification were addressed by small and large group discussions, practice exercises, and task assignments between meetings. Each group selected "areas of concern" using a modified nominal group technique {Delbecq, Van de Ven & Gustafson, 1975}. Typical concerns were: loneliness, problems with the community sewage disposal system, housing,
Spotlight
137
crime, transportation, health, and neighborhood cleanup. Through the use of committee work at each session, the groups identified ways to solve the problems they selected. At the beginning of each series of meetings, project staff discussed termination with participants and pointed out possible alternative directions the group might choose to follow after the planned program ended. These options included continuing to meet as a group and defining their own focus, or discontinuing meetings and utilizing their skills and information in other groups and activities. Project staff observed and documented project outcomes which exemplify its impact. These included, but were not limited to, the following: 1. A n increase in various helping activities between group members was noted in numerous instances. For example, a 65-year-old woman lived alone and knew only two other members of the group prior to its beginning. During the meetings she shared with the group an experience of a few years earlier when she was hospitalized for a leg amputation and returned to her home without anyone to assist her. She was virtually bedridden for several days without food or other care until some neighborhood children discovered her and obtained help. Following the group meetings she was hospitalized again for cataract surgery. When project staff checked with her following this surgery, she reported that several members of the group were visiting her regularly and assisting with meal preparation, housekeeping, shopping, and the like. 2. Participants also became interested in outreach strategies to other older persons in their neighborhood. For example, one group organized a volunteer transportation service available to any older persons living in the area. Those in the group with cars organized a schedule and publicized phone numbers where they could be contacted. Anyone may call requesting transportation for medical appointments, shopping, and so forth. If the person receiving the call cannot make the needed trip, he or she contacts another group member and arranges the transportation. No fee is charged for this service, but donations are accepted. 3. Project participants spent time during the eight weekly meetings working on solutions to neighborhood concerns. In several instances, these endeavors were continued beyond the eight meetings. For example, one group, whose concern was neighborhood crime, organized and implemented a "Crime Awareness D a y " for older persons in the area. They invited speakers from the Police Department, Rape Awareness Center, Economic Crime Unit, and other community agencies to inform area residents of crime prevention techniques. Approximately 75 older persons from the area attended the day-long meeting which included a brown bag lunch and social hour. 4. M a n y of the participants also reported significant personal benefit from the educational program. For example, a 76-year-old woman who had completed the eighth grade decided to enroll in adult education courses in order to obtain her GED following her participation in the Elder Program. Because she has a pronounced hearing loss, she tape-records her classes and
138
Journal of Primary Prevention
replays them at home for review. Other participants have reported an increase in confidence which they attribute to participation in the program. They report activities such as writing legislative representatives and speaking out at public meetings which they had not done before. Each of the 11 groups chose to continue involvement on their own in some way after the project's sessions. One group organized formally with elected officers, by-laws, and regular monthly meetings. Other groups continue to function in varying ways, ranging from using their learnings in other groups to continuing the Elder Project group with monthly meetings for socialization and/or education. The Participant Workbook and Leader's Guide are other project outcomes. These will be available (on a limited basis) for distribution and replication of the program to others who may wish to initiate an Elder Program. For further information regarding this program contact the authors at the Gerontology Center, Kent School of Social Work, University of Louisville, Louisville, Kentucky.
References
Birren, J.E. & Renner, V.J. Concepts and Issues of Mental Health and Aging. In J.E. Birren and R.B. Sloane (Eds.), The handbook of mental health and aging. Englewood Cliffs, NJ: Prentice-Hall, 1980. Collins, A.H. & Pancoast, D.L. Natural helping networks, a strategy for prevention. Washington, D.C.: NASW, 1976. Delbecq, A.L., Van de Ven, A.H., Gustafson, D.H. Group techniques for program planning, a guide to nominal group and delphi processes. Glenview, IL: Scott, Foresman and Company, 1975. Forgays, D.G. (Ed.}, Primary prevention of psychopathology: Volume II--Environmental influence. Hanover, NH: University Press of New England, 1978. Gurian, B.S. & Cantor, M.H. Mental health and community support systems for the elderly. In Usdin & Hofling (Eds.), Aging: The process and the people. New York: Brunner/Mazel Publishers, 1978. Ingalls, J.D. A trainers guide to andragogy (Stock No. 017-061-00033-0). Washington, D.C.: U.S. Government Printing Office, 1973. Knowles, M.S. The modern practice of adult education. New York: Association Press, 1970. Mettlin, C. Prerequisites of successful lifestyle intervention. Social Science & Medicine, 1979, 13A, 559-562. Middleman, R.R. Teaching and training, a study guide. Louisville, KY: Raymond A. Kent School of Social Work, University of Louisville, 1982.
