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Older Adults’ participation in preventive health maintenance activities and perceived satisfaction with the healthcare provider
Clinical Effectiveness in Nursing (2006) 9S1, e16–e24
Clinical
Effectiveness
in Nursing
http://intl.elsevierhealth.com/journals/cein
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction with the healthcare provider Judith E. Hupcey
a,b,*
, Barbara Biddle
a
a
School of Nursing, College of Health and Human Development, The Pennsylvania State University, 1300 ASB/A110, 600 Centerview Drive, Hershey, PA 17033, USA b Department of Humanities, College of Medicine, The Pennsylvania State University, 1300 ASB/A110, 600 Centerview Drive, Hershey, PA 17033, USA
KEYWORDS Satisfaction; Older adult; Preventive health; Health promotion; Health maintenance
Summary
Objectives: As the number of community-dwelling older adults increases, assisting them to maintain health is an optimal goal of care. Adherence to treatment plans, medical follow-up, and the participation in preventive health maintenance activities (PHMA) are primary approaches to health maintenance. But the impetus for this group to request or assent to PHMA remains unclear. Thus, the purpose of this study was to determine whether satisfaction with healthcare providers influenced community-dwelling older adults’ participation in PHMA. Design: A descriptive design was used to investigate whether healthcare satisfaction influenced participation in PHMA in a population of community-dwelling older adults. Sample, Setting, Measures: Thirty-nine community-dwelling older adults completed two questionnaires, participation in PHMA and the patient satisfaction in healthcare providers scale. Results: The majority of participants were satisfied with their healthcare providers but that finding had little influence on PHMA participation. Conclusions: Healthcare provider satisfaction may play a limited part in influencing whether older adults participate in PHMA. The onus remains on the geriatric healthcare provider to educate, encourage, schedule, refer, and follow-up on the completion of PHMA to help safeguard the health of community-dwelling older adults. c 2006 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +1 717 531 4211; fax: +1 717 531 5339. E-mail address: [email protected].
As the number of people over the age of 65 continues to grow, the importance of keeping these individuals healthy and living independently is paramount. What makes this even more essential
1361-9004/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.cein.2006.11.005
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction is the fact that the majority of non-institutionalized individuals rate their health to be good to excellent (Administration on Aging [AOA], 2002). With this in mind, one of the primary goals of older adult care is to maintain the individual’s health and quality of life. This can be done either by preventing disease, if possible, or more practically, reducing the effects of disease processes and improving and/or preserving the older adult’s ability to function (Kane et al., 1999). As of 1999, older adults had four times the number of hospital days as younger people, with an average stay of six days compared to 4.1 for individuals under the age of 65 (Administration on Aging [AOA], 2002). Keeping community-dwelling older adults healthy and functioning at their individual optimal level is imperative as the cost of healthcare, particularly inpatient care, continues to soar. Assistance in maintaining health in communitydwelling older adults is dependent on adequate medical follow-up, adherence to the treatment plan, and participation in preventive health maintenance activities (PHMA) including: routine check-ups, blood pressure check, eye examinations, dental examinations, Papanicolaou tests and mammography (women), prostate and prostate-specific antigen (men), bone density, fecal occult blood, cholesterol check, pneumonia and influenza vaccines. Health maintenance habits also may be influenced by the older adult’s characteristics (Beisecker, 1996; Beisecker and Beisecker, 1996), trust in the healthcare provider (O’Malley et al., 2004), and perceived satisfaction with the healthcare encounter (McCormick et al., 1996). Thus the purpose of this study was to determine whether satisfaction with the healthcare provider influenced community-dwelling older adults’ participation in PHMA activities.
Background Characteristics of the older adult There are numerous characteristics related to older adults that may influence both satisfaction with a healthcare encounter and the participation in preventive health maintenance activities. These include variables such as gender, ethnicity, religious affiliation, socioeconomic status, selfefficacy, and health status. Gender and ethnicity are shown to influence the physician-patient relationship (Cooper-Patrick et al., 1999; Ferguson and Candib, 2002). Cooper-Patrick et al. (1999) surveyed 1816 adults and found that African American
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patients felt that their physician visits included significantly less participatory decision-making than Caucasian patients, especially in race-discordant relationships. Moreover, participatory decisionmaking influenced satisfaction with the physicianpatient relationship in all ethnic groups. General characteristics of older adults may affect the patient-provider interaction. Irish (1997) reported that older individuals frequently remained passive in healthcare interactions to avoid being perceived as disrespectful or challenging. The physician is considered as the expert and so the older adult allows the physician to make decisions about treatment options and the amount of information needed. Older adults place a high level of trust in their healthcare providers and may view them as authority figures; thus a healthcare provider’s attitude and words of encouragement may have a great impact on the health behaviors of the older adult (Beisecker et al., 1996; Kane et al., 1999; Maly et al., 1998). On the whole, characteristics of the older adult may influence participation in PHM. For example, with increasing age, older adults may begin to refuse certain work-ups and treatments (Resnick, 1998) and providers may not readily offer preventive health services (Alliance for Aging Research, 2003; Bergman-Evans and Walker, 1996; Mandelblatt et al., 1999; Silliman et al., 1997). On the other hand, religious affiliation and religious salience has been found to increase the use of preventive healthcare (Benjamins and Brown, 2004). A positive self-perception about aging may also increase the participation in health-related behaviors (Levy and Myers, 2004). Physician-patient communication was found to influence specific patient health related outcomes and satisfaction with the provider (Hupcey et al., 2004). Kaplan et al. (1989) found patients who were more controlling during a visit, asked more questions and directed the conversation, had better follow-up care and less functional limitations and health problems. Rost et al. (1989) supported this finding and also found that patients who were more interactive with the physician during the initial visit were more likely to be compliant with physician recommendations for new medications.
Content of the healthcare encounter The content of the encounter includes factors related to the interaction itself (e.g., communication) and an older adult’s ability to: explain the reason for the visit and other concerns, to understand the medical treatment plan, and be in
e18 agreement with the plan. These areas are significant because healthcare providers’ behaviors during an office visit are positively related to patient outcomes such as satisfaction, information recall, and compliance with the treatment plan/recommendations (Bertakis et al., 1995). The provider’s communication behaviors have been found to impact patient satisfaction and evaluation of a provider more than a provider’s medical expertise (Harrigan et al., 1990; Hupcey et al., 2004). Greene et al. (1994) examined patient satisfaction and found that older patients are more satisfied when their office visits are longer and when healthcare providers listened to them about patient initiated topics, as opposed to them listening to lengthy medical information provided by the healthcare provider. Nonverbal communication also was found to influence outcome in terms of patient understanding and satisfaction in both a general population and the elderly (Larsen and Smith, 1981; Irish, 1997).
Health promotion activities General personal health behaviors in older adults are on average as good as, if not better, than younger individuals (Kane et al., 1999). Numerous studies have explored health promotion activities in the older adult. These studies are broken down by: participation in health promotion programs, predictors of preventive health behaviors, comparison of health promotion behaviors between control and experimental groups, and the impact of community-based programs (Heidrich, 1998). These studies document both the positive results in terms of behaviors from any type of health promotion programs or interventions and the fact that older adults view health promotion as important and do engage in these activities (Curbow et al., 2004; Stewart et al., 1997). However, what is not known is whether satisfaction with the healthcare provider also contributes to participation in PHMA. Therefore, the purpose of this study is to investigate whether satisfaction with the healthcare provider influenced community-dwelling older adults’ participation in PHMA activities.
Methods Research design This study was part of a larger focus group project that qualitatively investigated factors that influenced older adults’ trust and satisfaction in health-
J.E. Hupcey, B. Biddle care providers. This descriptive piece focused on determining whether satisfaction, measured quantitatively using the Patient Satisfaction with Health Care Provider Scale (Cherkin et al., 1988), influenced older adults’ participation in preventive health maintenance activities. For this study, the term healthcare provider was used to describe both nurse practitioners and physicians, given that no differences were found in early research between patient satisfaction with care provided by nurse practitioners or physicians (Pinkerton, 2000; Roblin et al., 2004).
Sample Thirty-nine community dwelling older adults from various socioeconomic and ethnic groups, living in surrounding areas of a northeastern US city were targeted for the study. The final sample consisted of 39 older adults ages 59 to 93 years old. The self-selected participants were residents in a senior housing development or were attendees at three different senior centers.
Measures Two quantitative measures were used, a researcher developed tool that measured both sample demographics and participation in preventive health maintenance activities (PHMA) and the Patient Satisfaction Questionnaire by Cherkin et al. (1988). The researcher-developed participation in PMHA tool was informally pre-tested with 25 older adults and evaluated for clarity, ease of administration, and time for completion (5–6 minutes). This tool included background characteristics of the older adult such as: age, gender, marital status, ethnicity, education, geographic location, financial status, insurance status, length of the relationship with the present healthcare provider, and a list of the top chronic medical conditions found in older adults. These included arthritis, hypertension, cancer, heart disease, hearing impairment, cataracts, orthopedic impairments, sinusitis, and diabetes (AOA, 2002). The instrument also included a list of the recommended preventive health maintenance activities with some based on gender: (a) mammography and Pap smear (Papanicolaou test) on the female questionnaire and (b) digital prostate examination and prostate-specific antigen (PSA) on the male questionnaire (Kane et al., 1999). The inclusive list, except for specific tests mentioned above, included routine check-up, blood pressure evaluation, eye examination, dental examination, bone density, stool for occult blood,
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction cholesterol level, pneumonia inoculation (in the last 10 years), and influenza vaccine. The Patient Satisfaction Questionnaire (PSQ) was originally formulated by Ware and colleagues (1978) to measure attitudes toward physicians and medical services. This tool was later revised by Cherkin et al. (1988) to examine the perceptions that patients of primary care physicians had regarding their care. The result of this revision was to formulate an 18 item questionnaire. The items are scored one through five; with one being strongly disagree to five being strongly agree (Marsh, 1999). Range of scores is 18 to 90, with 90 representing the highest level of satisfaction (after nine of the items are reversed scored). Marsh (1999) revised the scale and rewrote certain items to eliminate specific medical terms, such as ‘‘doctor’’ replacing it with ‘‘healthcare provider.’’ Upon retest of the questionnaire, Marsh found an internal reliability coefficient of Cronbach’s alpha of r >.80. The question ‘‘I’m very satisfied with the care I receive from my healthcare provider’’, which was of particular interest to this study, showed a Chronbach alpha of .88 and inter-item correlation of .65 (Marsh, 1999). The researchers used both questionnaires to determine and describe participation in PHMA and healthcare provider satisfaction.
Procedure Following approval from the University’s Institutional Review Board, the directors of three senior centers and one housing project were contacted for approval to use their facility as a potential site for the study. All the directors agreed and facilitated the project, either by advertising the study in their monthly newsletter or posting a flyer. Once the study was advertised, the directors had sign-up sheets available that specified specific dates and times that the study would be conducted. After the participants arrived, the study was explained, informed written consent obtained and then the participants completed the questionnaires. If questions arose, then assistance was given to some participants (groups). Specifically, the researchers answered questions about form completion, which was presented to the whole group, (such as where to check boxes) and ensured that all the pages of the questionnaire were completed. Participants were not pre-tested for mental status, since all were able to sign-up for the study and independently get themselves to the study site. In addition, every participant actively participated and appropriately answered verbal questions before and during the focus group.
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Results Participants (n = 39) ranged in age from 59 to 93 years (M = 73, SD = 10). There were 35 females and 4 males (since the number of males was too small for appropriate analysis of performance of malespecific PHMA, these were not reported). The ethnic breakdown of the sample was: white (n = 32), African-American (n = 3), and American Indian (n = 4). Twenty-four participants were widowed, three participants were currently married and 12 were separated or divorced. Educational attainment ranged from 9th grade (n = 1) to college degrees (n = 5), with the majority having a high school diploma (n = 20). The majority of participants lived in suburban areas (n = 32), while four lived in a city and three in rural areas. Of the 36 who answered the question regarding financial status, 21 rated their finances as adequate or more than adequate and 15 considered themselves as ‘‘just getting by’’ or poor. All of the participants had basic national medical insurance (Medicare) and the majority (n = 32) had a supplemental insurance. The number of medical conditions the participants had ranged from 0 to 5. The majority had arthritis (n = 24), followed by hypertension (n = 22), heart disease (n = 11), diabetes and sinusitis (n = 9), hearing impairments (n = 7), cancer (n = 6), and cataracts (n = 5). The number of years participants saw their present healthcare provider ranged from within months to 43 years (M = 9 years, SD = 7). Thirty-one of the participants said that their insurance allowed them to pick their healthcare provider.
Participation in preventive health maintenance activities The participation in preventive health maintenance activities in the sample ranged from a low of 51% for bone density testing to a high of 95% for a routine check-up, blood pressure screen, and flu shot (see Table 1, showing % of participation in PHMA). The lowest preventive health maintenance activities participated in were dental examination, 56%; pap smear, 69%; stool for occult blood, 69%; and pneumonia shots, 70%. In addition to the ones previously mentioned, the preventive maintenance activities that at least 3/4 of the older adults participated in were cholesterol check, 86%; eye examination, 86%; and mammography (women), 94%.
Satisfaction with healthcare provider The all-inclusive scores for satisfaction with the healthcare provider (see Table 2) ranged from
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J.E. Hupcey, B. Biddle
Table 1 Participation in preventive health maintenance activities: participation and levels of satisfaction with healthcare provider Number of total responses n = 39
Participation total: percent and number of participants
Unsatisfied n=4
Satisfied n = 15
Highly satisfied n = 20
Percent and number of participants
Percent and number of participants (male = 1)
Percent and number of participants (males = 3)
Check-up
39
Blood pressure
39
Eye exam
39
Dental exam
39
Pap smear
35
Mammogram
35
Bone density
35
Stool -blood
39
Cholesterol
37
Flu shot
39
Pneumonia shot
39
95% 37 95% 37 87% 34 56% 22 69% 24 94% 33 51% 18 69% 27 92% 34 95% 37 69% 27
75% 3 75% 3 75% 3 50% 2 75% 3 75% 3 25% 1 25% 1 100% 4 100% 4 50% 2
100% 15 93% 14 80% 12 80% 12 79% 11 (n = 14) 100% 14 (n = 14) 73% 11 100% 15 80% 12 100% 15 80% 12
95% 19 100% 20 95% 19 40% 8 59% 10 (n = 17) 94% 16 (n = 17) 30% 6 55% 11 90% 18 90% 18 65% 13
Preventive health measure
46–90 (M = 72, SD = 12). The majority of the sample scored in the high satisfaction range with a score of P72 (n = 20). Fifteen participants were satisfied, with a score between 54 and 71 and only 4 were unsatisfied with a score of less than 54. The specific question ‘‘I’m satisfied with the care I receive’’ had a mean score of 4 (range 2–5). The lowest rated questions were, ‘‘It’s hard to get an appointment’’ and ‘‘There are things about the care I receive that could be improved’’ with reversed scores of 2.2 and 2.1, respectively.
Satisfaction and participation in preventive health maintenance activities The participation and non-participation in PHMA did not seem to be related to satisfaction with the provider since participants highly satisfied with their healthcare practitioner did not always have PHMA performed (see Table 1). Overall, there were a limited number of PHMA that were not performed and the numbers for each of these maintenance activities were scattered among the three levels satisfaction. In addition, there were only four par-
ticipants who were dissatisfied, and only one of them did not perform four of the activities (routine check-up. blood pressure, eye exam, dental exam, and bone density).
Discussion The majority of elders in this study were satisfied or highly satisfied with their healthcare providers, although many felt that is was hard to get an appointment and that there were things about their care that could be improved (see Table 2). Although the sample was small, it appears that older adults’ satisfaction with their healthcare provider had little direct influence on the participation in PHMA. The least performed PHMA (bone density testing, 51%; dental examination, 56%; pap smear, 69%; stool for occult blood, 69%; and pneumonia vaccines, 69%) were the ones that participants routinely did not have performed despite the fact that they were highly satisfied with their healthcare provider. This finding is important since each of these non-performed preventive health
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction Table 2
Patient satisfaction questionnaire PSQ results
PSQ Questions Note: questions 2,5,6,8,9,13,14,17,18 are reverseda
Range (R), mean (m) [reverse mean (rm)]
1. If I have a healthcare question, I can reach my healthcare provider without any problems. 2. It’s hard to get an appointment with my healthcare provider right away.a 3. My healthcare provider always does his or her best to keep me from worrying. 4. My healthcare provider always treats me with respect. 5. Sometimes my healthcare provider makes me feel foolisha 6. My healthcare provider causes me to worry a lot because he or she doesn’t explain medical problems to me.a 7. My healthcare provider respects my feelings. 8. My healthcare provider hardly ever explains my medical problems to me.a 9. My healthcare provider is not as thorough as he or she should be.a 10. My healthcare provider encourages me to get a yearly exam. 11. My healthcare provider is very careful to check everything when examining me. 12. My healthcare provider asks what foods I eat and explains why certain foods are best. 13. My healthcare provider ignores medical problems I’ve had in the past when I seek care for new problems.a 14. My healthcare provider doesn’t explain about ways to avoid illness or injury.a 15. I’m very satisfied with the care I receive from my healthcare provider. 16. The care I receive from my healthcare provider is just about perfect. 17. My healthcare provider could provide better care.a 18. There are things about the care I receive from my healthcare provider that could be better.a
R- 1–5 m = 3.9
a
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R- 1–5 m = 2.8 [rm = 2.2] R- 2–5 m = 4.1 R- 3–5 m = 4.2 R- 1–5 m = 1.8 [rm = 3.2] R- 1–5 m = 1.75 R- 2–5 m = 4.2 R- 1–5 m = 2 [rm = 3.0] R- 1–5 m = 2.4 [rm = 2.6] R- 1–5 m = 4.1 R- 2–5 m = 3.9 R- 1–5 m = 2.6 R- 1–5 m = 2.1 [rm = 2.9] R- 1–5 m = 2.25 [rm = 2.75] R- 2–5 m = 4 R- 1–5 m = 4 R- 1–5 m = 2 [rm = 3] R- 1–5 m = 2.9 [rm = 2.1]
1 = strongly disagree to 5 = strongly agree.
maintenance activities has both financial and health-related implications for the older adult. The least participated in PHMA are of concern not only because of their influence on the future health of the older adult, but also because these PHMA need to be ordered by or actually performed by the healthcare provider. The exceptions are dental and eye examinations where older adults may be required to make their own appointments. The significance of bone density testing, Papanicolaou tests, fecal occult blood tests, and pneumonia vaccines will be discussed below.
The financial cost of osteoporotic fractures is enormous, with direct medical cost for the year following the fracture at over $11,000 for hip or distal femur fractures (Melton et al., 2003). In addition, overall morbidity attributed to the fracture significantly increases following osteoporotic fractures (Kanis et al., 2001). Since osteoporosis is one of the most prevalent age-related conditions in both women and men, it is a disease that will continue to rise with the aging population (Theodorou et al., 2003). Thus screening for and treatment of individuals with osteoporosis should be of utmost concern among healthcare providers.
Bone density Papanicolaou test Bone density testing is an important preventive measure for both men and women (Kanis et al., 2001; Campion and Maricic, 2003; Melton et al., 2003; Theodorou et al., 2003), however only 51% of this sample were screened for osteoporosis.
Only 69% of the females in this sample had a recent pap smear done while 31% (n = 11 of 35 women) did not. Although the American Cancer Society does not recommend pap testing after the age of 70, if
e22 the woman has had three or more technically satisfactory normal tests within the past 10 years or following a total hysterectomy that was performed for benign reasons (Saslow et al., 2002), many of these women told us their past history of testing had never been discussed with their healthcare providers. Under screened or unscreened women and women with other risk factors for cervical neoplasm and cancer should be encouraged to have pap tests performed.
Fecal occult blood tests The incidence of colorectal cancer continues to rise and is the third most frequently diagnosed cancer and second leading cause of cancer deaths in the United States (Singh et al., 1995; Roncoroni et al., 1999; Levin et al., 2003). One of the contributing factors to this phenomenon is the delay in diagnosis of the disease, with only 37% being detected at an early stage (Levin et al., 2003). This diagnostic delay may occur before or after the patient experiences symptoms. Although routine sigmoidoscopy is recommended for individuals after the age of 50 (Smith et al., 2003), fecal occult blood tests (FOBT) are an additional cost effective preventive screening measure that has been shown, when done annually, to decrease mortality from colorectal cancer by 33% (Mandel et al., 1993). Although the American Cancer Society (Smith et al., 2003) suggests that both annual FOBT along with sigmoidoscopy every five years are needed for optimal screening, an annual FOBT is acceptable. This simple and inexpensive test is one that is easily done with the patient taking the samples at home and returning the cards to the provider for testing; but this needs to be encouraged by the healthcare provider.
Pneumococcal vaccine Pneumococcal pneumonia (caused by streptococcus pneumoniae) accounts for 500,000 cases of pneumonia each year in the United States (HealthLink, 2000; Zimmerman et al., 2003). The elderly are hardest hit by this with invasive bacterial disease developing in those over age 65 at a rate of 50–83 in 100,000 and in those individual over age 70, the mortality is almost 60% (Zimmerman et al., 2003). A one-time dose of the pneumococcal vaccine is recommended for all individuals over the age of 65 (American Lung Association, 2002), however nationally only 54% of the older adults are vaccinated. In this study, the percent not vaccinated was lower (31%) than the national average not vaccinated (Table 1).
J.E. Hupcey, B. Biddle
Implications for geriatric practice The majority of participants participated in PHMA, however, satisfaction with their healthcare provider appeared to have little effect on the decision to participate in PHMA. This study supported the findings of Curbow et al. (2004) where community-dwelling older adults also were concerned about maintaining a healthy lifestyle and adhered to a PHMA schedule. Perhaps the following five questions from the PSQ were most telling regarding patient satisfaction and healthcare providers, but did not clarify whether satisfaction influences participation in PHMA, (#3: My healthcare provider always does his or her best to keep me from worrying; #4: My healthcare provider always treats me with respect; #7: My healthcare provider respects my feelings; #15: I’m very satisfied with the care I receive from my healthcare provider; #16: The care I receive from my healthcare provider is just about perfect). What emerges as most important in this study is that geriatric practitioners’ advisement seemed to be the key for participation in health maintenance activities and this is supported by PSQ question #10 (My healthcare provider encourages me to get a yearly exam) with a mean of 4.1. In addition, this finding supports studies by Irish (1997) and Kane et al. (1999) who assert that patients view their physician as the expert and advisor. The prevalence of healthcare providers’ use of and recommendation for clinical preventive services also was seen as an issue in prior research. Bergman-Evans and Walker (1996) found that a limited number of providers actually provided these services for older patients and with increasing age, fewer recommendations were offered. Thus it is imperative that professionals who interact with older adults encourage the participation in PHMA including dental, eye, and other examinations, which are not performed by the primary provider. The older adult should be encouraged to request certain testing be done or an appropriate referral made by their primary provider.
Limitations The major limitation of this study is related to the small sample size including gender under representation. Specifically, since there were only four males in the study, male-specific PHMA were not reported. Although the sample size was appropriate for a focus group study, the numbers were too small for statistical comparisons and for results to be generalized. Lack of recall by the older co-
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction hort also may have been a problem. Using other sources of data (such as chart reviews) would have compensated for any lack of memory. In summary, from this small study, healthcare provider satisfaction may play a limited role in influencing whether older adults participate in preventive health maintenance activities. The onus remains on the geriatric healthcare provider to educate, encourage, schedule, refer, and followup on the completion of PHMA to help safeguard the health of the community-dwelling older adults.
Acknowledgement The study was funded by a seed grant from the College of Health and Human Development, The Pennsylvania State University.
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e24 O’Malley, A.S., Sheppard, V.B., Schwartz, M., Mandelblatt, J., 2004. The role of trust in use of preventive services among low-income African-American women. Preventive Medicine 38, 777–785. Pinkerton, J.A., 2000. Nurse practitioners and physicians: Patients0 perceived health and satisfaction with care. Journal of the American Academy of Nurse Practitioners 12, 211–217. Resnick, B., 1998. Health promotion practices of the old-old. Journal of the American Academy of Nurse Practitioners 10, 147–153. Roblin, D.W., Becker, E.R., Adams, E.K., Howard, D.H., Roberts, M.H., 2004. Patient satisfaction with primary care: Does type of practitioner matter? Medical Care 42, 579–589. Roncoroni, L., Pietra, N., Violi, V., Sarli, L., Choua, O., Peracchia, A., 1999. Delay in the diagnosis and outcome of colorectal cancer: A prospective study. European Journal of Surgical Oncology 25, 173–178. Rost, K., Carter, W., Inui, T., 1989. Introduction of information during the initial medical visit: Consequences for patient follow-through with physician recommendations for medication. Social Science&Medicine 28, 315–321. Saslow, D., Runowicz, C.D., Solomon, D., Moscicki, A.B., Smith, R.A., Eyre, H.J., et al., 2002. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA A Cancer Journal for Clinicians 53, 342–362.
J.E. Hupcey, B. Biddle Silliman, R.A., Troyan, S.L., Guadagnoli, E., Kaplan, S.H., Greenfield, S., 1997. The impact of age, marital status, and physician-patient interactions on the care of older women with breast carcinoma. Cancer 80, 1326–1334. Singh, S., Morgan, M.B.F., Broughton, M., Caffarey, S., Topham, C., Marks, C.G., 1995. A 10-year prospective audit of outcome of surgical treatment for colorectal carcinoma. British Journal Surgical 82, 1486–1490. Smith, R.A., Cokkinides, V., Eyre, H.J., 2003. American Cancer Society guidelines for the early detection of cancer. CA A Cancer Journal for Clinicians 53, 27–43. Stewart, A.L., Mills, K.M., Sepsis, P.G., King, A.C., McLellan, B.Y., Roitz, K., Ritter, P.L., 1997. Evaluation of CHAMPS, a physical activity program for older adults. Annals of Behavioral Medicine 19, 353–361. Theodorou, S.J., Theodorou, D.J., Sartoris, D.J., 2003. Osteoporosis and fractures: The size of the problem. Hospital Medicine 64, 87–91. Ware, J.E., Davies-Avery, A., Stewary, A.L., 1978. The measurement and meaning of patient satisfaction. Health & Medical Care Services Review 1, 1–15. Zimmerman, R.K., Middleton, D.B., Burns, I.T., Clover, R.D., 2003. Routine vaccines across the life span. The Journal of Family Practice 51 (Supplement), S1–S21.
Clinical
Effectiveness
in Nursing
http://intl.elsevierhealth.com/journals/cein
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction with the healthcare provider Judith E. Hupcey
a,b,*
, Barbara Biddle
a
a
School of Nursing, College of Health and Human Development, The Pennsylvania State University, 1300 ASB/A110, 600 Centerview Drive, Hershey, PA 17033, USA b Department of Humanities, College of Medicine, The Pennsylvania State University, 1300 ASB/A110, 600 Centerview Drive, Hershey, PA 17033, USA
KEYWORDS Satisfaction; Older adult; Preventive health; Health promotion; Health maintenance
Summary
Objectives: As the number of community-dwelling older adults increases, assisting them to maintain health is an optimal goal of care. Adherence to treatment plans, medical follow-up, and the participation in preventive health maintenance activities (PHMA) are primary approaches to health maintenance. But the impetus for this group to request or assent to PHMA remains unclear. Thus, the purpose of this study was to determine whether satisfaction with healthcare providers influenced community-dwelling older adults’ participation in PHMA. Design: A descriptive design was used to investigate whether healthcare satisfaction influenced participation in PHMA in a population of community-dwelling older adults. Sample, Setting, Measures: Thirty-nine community-dwelling older adults completed two questionnaires, participation in PHMA and the patient satisfaction in healthcare providers scale. Results: The majority of participants were satisfied with their healthcare providers but that finding had little influence on PHMA participation. Conclusions: Healthcare provider satisfaction may play a limited part in influencing whether older adults participate in PHMA. The onus remains on the geriatric healthcare provider to educate, encourage, schedule, refer, and follow-up on the completion of PHMA to help safeguard the health of community-dwelling older adults. c 2006 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +1 717 531 4211; fax: +1 717 531 5339. E-mail address: [email protected].
As the number of people over the age of 65 continues to grow, the importance of keeping these individuals healthy and living independently is paramount. What makes this even more essential
1361-9004/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.cein.2006.11.005
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction is the fact that the majority of non-institutionalized individuals rate their health to be good to excellent (Administration on Aging [AOA], 2002). With this in mind, one of the primary goals of older adult care is to maintain the individual’s health and quality of life. This can be done either by preventing disease, if possible, or more practically, reducing the effects of disease processes and improving and/or preserving the older adult’s ability to function (Kane et al., 1999). As of 1999, older adults had four times the number of hospital days as younger people, with an average stay of six days compared to 4.1 for individuals under the age of 65 (Administration on Aging [AOA], 2002). Keeping community-dwelling older adults healthy and functioning at their individual optimal level is imperative as the cost of healthcare, particularly inpatient care, continues to soar. Assistance in maintaining health in communitydwelling older adults is dependent on adequate medical follow-up, adherence to the treatment plan, and participation in preventive health maintenance activities (PHMA) including: routine check-ups, blood pressure check, eye examinations, dental examinations, Papanicolaou tests and mammography (women), prostate and prostate-specific antigen (men), bone density, fecal occult blood, cholesterol check, pneumonia and influenza vaccines. Health maintenance habits also may be influenced by the older adult’s characteristics (Beisecker, 1996; Beisecker and Beisecker, 1996), trust in the healthcare provider (O’Malley et al., 2004), and perceived satisfaction with the healthcare encounter (McCormick et al., 1996). Thus the purpose of this study was to determine whether satisfaction with the healthcare provider influenced community-dwelling older adults’ participation in PHMA activities.
Background Characteristics of the older adult There are numerous characteristics related to older adults that may influence both satisfaction with a healthcare encounter and the participation in preventive health maintenance activities. These include variables such as gender, ethnicity, religious affiliation, socioeconomic status, selfefficacy, and health status. Gender and ethnicity are shown to influence the physician-patient relationship (Cooper-Patrick et al., 1999; Ferguson and Candib, 2002). Cooper-Patrick et al. (1999) surveyed 1816 adults and found that African American
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patients felt that their physician visits included significantly less participatory decision-making than Caucasian patients, especially in race-discordant relationships. Moreover, participatory decisionmaking influenced satisfaction with the physicianpatient relationship in all ethnic groups. General characteristics of older adults may affect the patient-provider interaction. Irish (1997) reported that older individuals frequently remained passive in healthcare interactions to avoid being perceived as disrespectful or challenging. The physician is considered as the expert and so the older adult allows the physician to make decisions about treatment options and the amount of information needed. Older adults place a high level of trust in their healthcare providers and may view them as authority figures; thus a healthcare provider’s attitude and words of encouragement may have a great impact on the health behaviors of the older adult (Beisecker et al., 1996; Kane et al., 1999; Maly et al., 1998). On the whole, characteristics of the older adult may influence participation in PHM. For example, with increasing age, older adults may begin to refuse certain work-ups and treatments (Resnick, 1998) and providers may not readily offer preventive health services (Alliance for Aging Research, 2003; Bergman-Evans and Walker, 1996; Mandelblatt et al., 1999; Silliman et al., 1997). On the other hand, religious affiliation and religious salience has been found to increase the use of preventive healthcare (Benjamins and Brown, 2004). A positive self-perception about aging may also increase the participation in health-related behaviors (Levy and Myers, 2004). Physician-patient communication was found to influence specific patient health related outcomes and satisfaction with the provider (Hupcey et al., 2004). Kaplan et al. (1989) found patients who were more controlling during a visit, asked more questions and directed the conversation, had better follow-up care and less functional limitations and health problems. Rost et al. (1989) supported this finding and also found that patients who were more interactive with the physician during the initial visit were more likely to be compliant with physician recommendations for new medications.
Content of the healthcare encounter The content of the encounter includes factors related to the interaction itself (e.g., communication) and an older adult’s ability to: explain the reason for the visit and other concerns, to understand the medical treatment plan, and be in
e18 agreement with the plan. These areas are significant because healthcare providers’ behaviors during an office visit are positively related to patient outcomes such as satisfaction, information recall, and compliance with the treatment plan/recommendations (Bertakis et al., 1995). The provider’s communication behaviors have been found to impact patient satisfaction and evaluation of a provider more than a provider’s medical expertise (Harrigan et al., 1990; Hupcey et al., 2004). Greene et al. (1994) examined patient satisfaction and found that older patients are more satisfied when their office visits are longer and when healthcare providers listened to them about patient initiated topics, as opposed to them listening to lengthy medical information provided by the healthcare provider. Nonverbal communication also was found to influence outcome in terms of patient understanding and satisfaction in both a general population and the elderly (Larsen and Smith, 1981; Irish, 1997).
Health promotion activities General personal health behaviors in older adults are on average as good as, if not better, than younger individuals (Kane et al., 1999). Numerous studies have explored health promotion activities in the older adult. These studies are broken down by: participation in health promotion programs, predictors of preventive health behaviors, comparison of health promotion behaviors between control and experimental groups, and the impact of community-based programs (Heidrich, 1998). These studies document both the positive results in terms of behaviors from any type of health promotion programs or interventions and the fact that older adults view health promotion as important and do engage in these activities (Curbow et al., 2004; Stewart et al., 1997). However, what is not known is whether satisfaction with the healthcare provider also contributes to participation in PHMA. Therefore, the purpose of this study is to investigate whether satisfaction with the healthcare provider influenced community-dwelling older adults’ participation in PHMA activities.
Methods Research design This study was part of a larger focus group project that qualitatively investigated factors that influenced older adults’ trust and satisfaction in health-
J.E. Hupcey, B. Biddle care providers. This descriptive piece focused on determining whether satisfaction, measured quantitatively using the Patient Satisfaction with Health Care Provider Scale (Cherkin et al., 1988), influenced older adults’ participation in preventive health maintenance activities. For this study, the term healthcare provider was used to describe both nurse practitioners and physicians, given that no differences were found in early research between patient satisfaction with care provided by nurse practitioners or physicians (Pinkerton, 2000; Roblin et al., 2004).
Sample Thirty-nine community dwelling older adults from various socioeconomic and ethnic groups, living in surrounding areas of a northeastern US city were targeted for the study. The final sample consisted of 39 older adults ages 59 to 93 years old. The self-selected participants were residents in a senior housing development or were attendees at three different senior centers.
Measures Two quantitative measures were used, a researcher developed tool that measured both sample demographics and participation in preventive health maintenance activities (PHMA) and the Patient Satisfaction Questionnaire by Cherkin et al. (1988). The researcher-developed participation in PMHA tool was informally pre-tested with 25 older adults and evaluated for clarity, ease of administration, and time for completion (5–6 minutes). This tool included background characteristics of the older adult such as: age, gender, marital status, ethnicity, education, geographic location, financial status, insurance status, length of the relationship with the present healthcare provider, and a list of the top chronic medical conditions found in older adults. These included arthritis, hypertension, cancer, heart disease, hearing impairment, cataracts, orthopedic impairments, sinusitis, and diabetes (AOA, 2002). The instrument also included a list of the recommended preventive health maintenance activities with some based on gender: (a) mammography and Pap smear (Papanicolaou test) on the female questionnaire and (b) digital prostate examination and prostate-specific antigen (PSA) on the male questionnaire (Kane et al., 1999). The inclusive list, except for specific tests mentioned above, included routine check-up, blood pressure evaluation, eye examination, dental examination, bone density, stool for occult blood,
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction cholesterol level, pneumonia inoculation (in the last 10 years), and influenza vaccine. The Patient Satisfaction Questionnaire (PSQ) was originally formulated by Ware and colleagues (1978) to measure attitudes toward physicians and medical services. This tool was later revised by Cherkin et al. (1988) to examine the perceptions that patients of primary care physicians had regarding their care. The result of this revision was to formulate an 18 item questionnaire. The items are scored one through five; with one being strongly disagree to five being strongly agree (Marsh, 1999). Range of scores is 18 to 90, with 90 representing the highest level of satisfaction (after nine of the items are reversed scored). Marsh (1999) revised the scale and rewrote certain items to eliminate specific medical terms, such as ‘‘doctor’’ replacing it with ‘‘healthcare provider.’’ Upon retest of the questionnaire, Marsh found an internal reliability coefficient of Cronbach’s alpha of r >.80. The question ‘‘I’m very satisfied with the care I receive from my healthcare provider’’, which was of particular interest to this study, showed a Chronbach alpha of .88 and inter-item correlation of .65 (Marsh, 1999). The researchers used both questionnaires to determine and describe participation in PHMA and healthcare provider satisfaction.
Procedure Following approval from the University’s Institutional Review Board, the directors of three senior centers and one housing project were contacted for approval to use their facility as a potential site for the study. All the directors agreed and facilitated the project, either by advertising the study in their monthly newsletter or posting a flyer. Once the study was advertised, the directors had sign-up sheets available that specified specific dates and times that the study would be conducted. After the participants arrived, the study was explained, informed written consent obtained and then the participants completed the questionnaires. If questions arose, then assistance was given to some participants (groups). Specifically, the researchers answered questions about form completion, which was presented to the whole group, (such as where to check boxes) and ensured that all the pages of the questionnaire were completed. Participants were not pre-tested for mental status, since all were able to sign-up for the study and independently get themselves to the study site. In addition, every participant actively participated and appropriately answered verbal questions before and during the focus group.
e19
Results Participants (n = 39) ranged in age from 59 to 93 years (M = 73, SD = 10). There were 35 females and 4 males (since the number of males was too small for appropriate analysis of performance of malespecific PHMA, these were not reported). The ethnic breakdown of the sample was: white (n = 32), African-American (n = 3), and American Indian (n = 4). Twenty-four participants were widowed, three participants were currently married and 12 were separated or divorced. Educational attainment ranged from 9th grade (n = 1) to college degrees (n = 5), with the majority having a high school diploma (n = 20). The majority of participants lived in suburban areas (n = 32), while four lived in a city and three in rural areas. Of the 36 who answered the question regarding financial status, 21 rated their finances as adequate or more than adequate and 15 considered themselves as ‘‘just getting by’’ or poor. All of the participants had basic national medical insurance (Medicare) and the majority (n = 32) had a supplemental insurance. The number of medical conditions the participants had ranged from 0 to 5. The majority had arthritis (n = 24), followed by hypertension (n = 22), heart disease (n = 11), diabetes and sinusitis (n = 9), hearing impairments (n = 7), cancer (n = 6), and cataracts (n = 5). The number of years participants saw their present healthcare provider ranged from within months to 43 years (M = 9 years, SD = 7). Thirty-one of the participants said that their insurance allowed them to pick their healthcare provider.
Participation in preventive health maintenance activities The participation in preventive health maintenance activities in the sample ranged from a low of 51% for bone density testing to a high of 95% for a routine check-up, blood pressure screen, and flu shot (see Table 1, showing % of participation in PHMA). The lowest preventive health maintenance activities participated in were dental examination, 56%; pap smear, 69%; stool for occult blood, 69%; and pneumonia shots, 70%. In addition to the ones previously mentioned, the preventive maintenance activities that at least 3/4 of the older adults participated in were cholesterol check, 86%; eye examination, 86%; and mammography (women), 94%.
Satisfaction with healthcare provider The all-inclusive scores for satisfaction with the healthcare provider (see Table 2) ranged from
e20
J.E. Hupcey, B. Biddle
Table 1 Participation in preventive health maintenance activities: participation and levels of satisfaction with healthcare provider Number of total responses n = 39
Participation total: percent and number of participants
Unsatisfied n=4
Satisfied n = 15
Highly satisfied n = 20
Percent and number of participants
Percent and number of participants (male = 1)
Percent and number of participants (males = 3)
Check-up
39
Blood pressure
39
Eye exam
39
Dental exam
39
Pap smear
35
Mammogram
35
Bone density
35
Stool -blood
39
Cholesterol
37
Flu shot
39
Pneumonia shot
39
95% 37 95% 37 87% 34 56% 22 69% 24 94% 33 51% 18 69% 27 92% 34 95% 37 69% 27
75% 3 75% 3 75% 3 50% 2 75% 3 75% 3 25% 1 25% 1 100% 4 100% 4 50% 2
100% 15 93% 14 80% 12 80% 12 79% 11 (n = 14) 100% 14 (n = 14) 73% 11 100% 15 80% 12 100% 15 80% 12
95% 19 100% 20 95% 19 40% 8 59% 10 (n = 17) 94% 16 (n = 17) 30% 6 55% 11 90% 18 90% 18 65% 13
Preventive health measure
46–90 (M = 72, SD = 12). The majority of the sample scored in the high satisfaction range with a score of P72 (n = 20). Fifteen participants were satisfied, with a score between 54 and 71 and only 4 were unsatisfied with a score of less than 54. The specific question ‘‘I’m satisfied with the care I receive’’ had a mean score of 4 (range 2–5). The lowest rated questions were, ‘‘It’s hard to get an appointment’’ and ‘‘There are things about the care I receive that could be improved’’ with reversed scores of 2.2 and 2.1, respectively.
Satisfaction and participation in preventive health maintenance activities The participation and non-participation in PHMA did not seem to be related to satisfaction with the provider since participants highly satisfied with their healthcare practitioner did not always have PHMA performed (see Table 1). Overall, there were a limited number of PHMA that were not performed and the numbers for each of these maintenance activities were scattered among the three levels satisfaction. In addition, there were only four par-
ticipants who were dissatisfied, and only one of them did not perform four of the activities (routine check-up. blood pressure, eye exam, dental exam, and bone density).
Discussion The majority of elders in this study were satisfied or highly satisfied with their healthcare providers, although many felt that is was hard to get an appointment and that there were things about their care that could be improved (see Table 2). Although the sample was small, it appears that older adults’ satisfaction with their healthcare provider had little direct influence on the participation in PHMA. The least performed PHMA (bone density testing, 51%; dental examination, 56%; pap smear, 69%; stool for occult blood, 69%; and pneumonia vaccines, 69%) were the ones that participants routinely did not have performed despite the fact that they were highly satisfied with their healthcare provider. This finding is important since each of these non-performed preventive health
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction Table 2
Patient satisfaction questionnaire PSQ results
PSQ Questions Note: questions 2,5,6,8,9,13,14,17,18 are reverseda
Range (R), mean (m) [reverse mean (rm)]
1. If I have a healthcare question, I can reach my healthcare provider without any problems. 2. It’s hard to get an appointment with my healthcare provider right away.a 3. My healthcare provider always does his or her best to keep me from worrying. 4. My healthcare provider always treats me with respect. 5. Sometimes my healthcare provider makes me feel foolisha 6. My healthcare provider causes me to worry a lot because he or she doesn’t explain medical problems to me.a 7. My healthcare provider respects my feelings. 8. My healthcare provider hardly ever explains my medical problems to me.a 9. My healthcare provider is not as thorough as he or she should be.a 10. My healthcare provider encourages me to get a yearly exam. 11. My healthcare provider is very careful to check everything when examining me. 12. My healthcare provider asks what foods I eat and explains why certain foods are best. 13. My healthcare provider ignores medical problems I’ve had in the past when I seek care for new problems.a 14. My healthcare provider doesn’t explain about ways to avoid illness or injury.a 15. I’m very satisfied with the care I receive from my healthcare provider. 16. The care I receive from my healthcare provider is just about perfect. 17. My healthcare provider could provide better care.a 18. There are things about the care I receive from my healthcare provider that could be better.a
R- 1–5 m = 3.9
a
e21
R- 1–5 m = 2.8 [rm = 2.2] R- 2–5 m = 4.1 R- 3–5 m = 4.2 R- 1–5 m = 1.8 [rm = 3.2] R- 1–5 m = 1.75 R- 2–5 m = 4.2 R- 1–5 m = 2 [rm = 3.0] R- 1–5 m = 2.4 [rm = 2.6] R- 1–5 m = 4.1 R- 2–5 m = 3.9 R- 1–5 m = 2.6 R- 1–5 m = 2.1 [rm = 2.9] R- 1–5 m = 2.25 [rm = 2.75] R- 2–5 m = 4 R- 1–5 m = 4 R- 1–5 m = 2 [rm = 3] R- 1–5 m = 2.9 [rm = 2.1]
1 = strongly disagree to 5 = strongly agree.
maintenance activities has both financial and health-related implications for the older adult. The least participated in PHMA are of concern not only because of their influence on the future health of the older adult, but also because these PHMA need to be ordered by or actually performed by the healthcare provider. The exceptions are dental and eye examinations where older adults may be required to make their own appointments. The significance of bone density testing, Papanicolaou tests, fecal occult blood tests, and pneumonia vaccines will be discussed below.
The financial cost of osteoporotic fractures is enormous, with direct medical cost for the year following the fracture at over $11,000 for hip or distal femur fractures (Melton et al., 2003). In addition, overall morbidity attributed to the fracture significantly increases following osteoporotic fractures (Kanis et al., 2001). Since osteoporosis is one of the most prevalent age-related conditions in both women and men, it is a disease that will continue to rise with the aging population (Theodorou et al., 2003). Thus screening for and treatment of individuals with osteoporosis should be of utmost concern among healthcare providers.
Bone density Papanicolaou test Bone density testing is an important preventive measure for both men and women (Kanis et al., 2001; Campion and Maricic, 2003; Melton et al., 2003; Theodorou et al., 2003), however only 51% of this sample were screened for osteoporosis.
Only 69% of the females in this sample had a recent pap smear done while 31% (n = 11 of 35 women) did not. Although the American Cancer Society does not recommend pap testing after the age of 70, if
e22 the woman has had three or more technically satisfactory normal tests within the past 10 years or following a total hysterectomy that was performed for benign reasons (Saslow et al., 2002), many of these women told us their past history of testing had never been discussed with their healthcare providers. Under screened or unscreened women and women with other risk factors for cervical neoplasm and cancer should be encouraged to have pap tests performed.
Fecal occult blood tests The incidence of colorectal cancer continues to rise and is the third most frequently diagnosed cancer and second leading cause of cancer deaths in the United States (Singh et al., 1995; Roncoroni et al., 1999; Levin et al., 2003). One of the contributing factors to this phenomenon is the delay in diagnosis of the disease, with only 37% being detected at an early stage (Levin et al., 2003). This diagnostic delay may occur before or after the patient experiences symptoms. Although routine sigmoidoscopy is recommended for individuals after the age of 50 (Smith et al., 2003), fecal occult blood tests (FOBT) are an additional cost effective preventive screening measure that has been shown, when done annually, to decrease mortality from colorectal cancer by 33% (Mandel et al., 1993). Although the American Cancer Society (Smith et al., 2003) suggests that both annual FOBT along with sigmoidoscopy every five years are needed for optimal screening, an annual FOBT is acceptable. This simple and inexpensive test is one that is easily done with the patient taking the samples at home and returning the cards to the provider for testing; but this needs to be encouraged by the healthcare provider.
Pneumococcal vaccine Pneumococcal pneumonia (caused by streptococcus pneumoniae) accounts for 500,000 cases of pneumonia each year in the United States (HealthLink, 2000; Zimmerman et al., 2003). The elderly are hardest hit by this with invasive bacterial disease developing in those over age 65 at a rate of 50–83 in 100,000 and in those individual over age 70, the mortality is almost 60% (Zimmerman et al., 2003). A one-time dose of the pneumococcal vaccine is recommended for all individuals over the age of 65 (American Lung Association, 2002), however nationally only 54% of the older adults are vaccinated. In this study, the percent not vaccinated was lower (31%) than the national average not vaccinated (Table 1).
J.E. Hupcey, B. Biddle
Implications for geriatric practice The majority of participants participated in PHMA, however, satisfaction with their healthcare provider appeared to have little effect on the decision to participate in PHMA. This study supported the findings of Curbow et al. (2004) where community-dwelling older adults also were concerned about maintaining a healthy lifestyle and adhered to a PHMA schedule. Perhaps the following five questions from the PSQ were most telling regarding patient satisfaction and healthcare providers, but did not clarify whether satisfaction influences participation in PHMA, (#3: My healthcare provider always does his or her best to keep me from worrying; #4: My healthcare provider always treats me with respect; #7: My healthcare provider respects my feelings; #15: I’m very satisfied with the care I receive from my healthcare provider; #16: The care I receive from my healthcare provider is just about perfect). What emerges as most important in this study is that geriatric practitioners’ advisement seemed to be the key for participation in health maintenance activities and this is supported by PSQ question #10 (My healthcare provider encourages me to get a yearly exam) with a mean of 4.1. In addition, this finding supports studies by Irish (1997) and Kane et al. (1999) who assert that patients view their physician as the expert and advisor. The prevalence of healthcare providers’ use of and recommendation for clinical preventive services also was seen as an issue in prior research. Bergman-Evans and Walker (1996) found that a limited number of providers actually provided these services for older patients and with increasing age, fewer recommendations were offered. Thus it is imperative that professionals who interact with older adults encourage the participation in PHMA including dental, eye, and other examinations, which are not performed by the primary provider. The older adult should be encouraged to request certain testing be done or an appropriate referral made by their primary provider.
Limitations The major limitation of this study is related to the small sample size including gender under representation. Specifically, since there were only four males in the study, male-specific PHMA were not reported. Although the sample size was appropriate for a focus group study, the numbers were too small for statistical comparisons and for results to be generalized. Lack of recall by the older co-
Older Adults’ participation in preventive health maintenance activities and perceived satisfaction hort also may have been a problem. Using other sources of data (such as chart reviews) would have compensated for any lack of memory. In summary, from this small study, healthcare provider satisfaction may play a limited role in influencing whether older adults participate in preventive health maintenance activities. The onus remains on the geriatric healthcare provider to educate, encourage, schedule, refer, and followup on the completion of PHMA to help safeguard the health of the community-dwelling older adults.
Acknowledgement The study was funded by a seed grant from the College of Health and Human Development, The Pennsylvania State University.
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