Background
Nearly one in every seven Americans is 65 years or older and faces the day-to-day challenges of aging [
1]. The growing proportion of older adults in the U.S. provides a compelling reason for an increased focus on aging well and strategies to optimize the experience of aging. Demographic patterns in the U.S. have become dramatically more diverse, prompting a consideration of the ethnic and economic changes in health disparities of aging services and supports [
2]. This diversity of views regarding contexts for promoting healthy aging merits an examination at the intersection of various aspects of older adults’ lives such as race, socioeconomic status, living situation, physical and emotional health, spirituality, and other dimensions. A range of approaches for defining healthy aging from the perspectives of older adults and persons studying aging have been evaluated in the literature [
3‐
6]. These perspectives are rooted in distinct traditions of theory and empirical work that inform current practices to support aging [
7]; however, little is known about the perspectives of community-based practitioners’ who work directly with older adults and deliver programs to promote their healthy aging.
The term healthy aging is widely used in academic and research circles, yet there is limited consensus on how it might be defined [
8]. Among related theoretical constructs studied historically, “successful aging” was defined by Rowe and Kahn as freedom from disease or disease-related disability, high cognitive and physical functioning, and active engagement with life [
9]. Similarly, “effective aging” was suggested by Curb et al., 1990 as an alternative to successful aging in order to emphasize the adaptation and rehabilitation that can occur even as older adults develop health deficits (e.g., chronic conditions, disabilities) [
10]. Finally, “optimal aging” was exemplified by Ryff’s work focusing on psychological thriving and well-being [
10‐
12]. Although these perspectives complement the construct of healthy aging, they vary widely in its measurement as an outcome. In 2015, the World Health Organization defined healthy aging as the process of developing and maintaining the functional ability that enables well-being in older age [
13]. While these perspectives of aging have informed clinical, research, and policy implications, they are still underutilized in practice, potentially because of low “buy-in” from stakeholders such as those who implement health promotion programs for older adults.
The appropriate alignment of community-based practitioners’ perspectives to the needs of older adults plays a vital role in supporting healthy aging. However, most research efforts have been directed towards understanding the perceptions of older adults and scholars of aging [
14‐
17], not the community-based practitioners delivering services and supports directly to older adults. As a result, our current knowledge remains limited from the community-based practitioners point of view. Older adults’ perspective of healthy aging emphasizes factors that practitioners may or may not necessarily consider during service provision.
Considering the existing health problems of older adults and lack of evidence-based research related to the practitioners’ view on healthy aging, we conducted a qualitative perspective assessment of community-based practitioners. Practitioners’ perspectives on healthy aging and strategies they employ to promote aging can enhance our understanding of the complexities associated with care at the community level and inform interventions to maximize older adults’ healthy aging experiences. Such understanding may also contribute to building a knowledge base of possible interventions for future healthy aging policies and programs. Hence, the purpose of this study was to fill an important gap in the healthy aging literature by expanding knowledge on healthy aging by exploring the perspectives of community-based practitioners working directly with older adults.
Discussion
In this qualitative study, we provide an in-depth understanding of healthy aging from the perspectives of community-based practitioners serving older adults rather than older adults themselves, which are underrepresented in approaches that explore this construct. To date, research on healthy aging has been framed by theoretical traditions, older adult perspectives, and/or clinical perspectives. While the earlier research has value in understanding older individuals’ health and well-being, it does not fully address the intersectionality of clinical, community, and individual characteristics, which can be obtained from those providing care and programs in the community and would be important for informing interventions to enhance healthy aging.
The conceptual framework derived from the focus group data in this study depicts the intersectionality between (i) individual-level characteristics, (ii) system-level facilitators and barriers, and (iii) community-level programs and activities to promote healthy aging. Characteristics of older adults that are dependent on a cultural context they live in lies as a basic component of healthy aging. It will be important to understand the contextual factor of each individual that will help in the delivery of culturally appropriate healthcare services. Further, it shows that healthy aging attainment could be enhanced by facilitators or hindered by barriers by a broad range of constructs such as access to resources and inappropriate model of care. Practitioners who could be aware of these constructs could act on the facilitators and barriers of implementing and delivering programs and activities. Finally, the framework highlights the evidence-based programs and activities that could promote fitness and wellness of older adults. This might be useful for the community-based practitioners in delivering evidence-based services to promote healthy aging, within and beyond the Washington state.
The framework incorporates many constructs of healthy aging that is in agreement or disagreement with the perspectives of older adults in the research literature. A study conducted among Chinese older adults in Chicago’s Chinatown to understand the culturally specific views of health reported individual characteristics that influence their perceived needs of health as physical function, psychological well-being, social support, and cognitive function. These constructs are similar to the constructs reported by practitioners in our study. Similar to the findings of our study, lack of access to resources and affordability of services were reported as major negative enabling factors that inhibited their health aging attainment. In addition, Chinese older adults also reported linguistic barrier as a major obstacle [
25]; however, the linguistic barrier was not perceived as a serious hurdle by the practitioners in our study.
Further, the psycho-emotional dimension of healthy aging discussed by the practitioners, as exemplified by purpose in life, aligns well with the notion of optimal aging and eudaemonic well-being [
11]. In addition, references to happiness and living with dignity reflect the hedonic notion of well-being as emphasized in work on happiness [
26]. Older adults typically have developed improved emotion regulation as they age and have contemplated meaningful goals, reflected in hedonic and eudaemonic dimensions of well-being [
26]. Cognitive function, exemplified by ability to be proactive and planning, is consistent with elements in each of these notions of successful, effective, and optimal aging. In addition, autonomy, competence, and relatedness have been identified by older adults as essential dimensions of self-determination for which cognitive function is essential [
27]. Moreover, cognitive functioning is necessary for developing adaptation strategies and social interaction supporting engagement with one’s environment [
28,
29].
Moreover, our analysis shows that with aging, many individuals incur losses from their social networks and experience stressors related to the broader context of their lives and changes associated with their own physical aging, and some experience neurological dysregulation [
26]. These situations prompt a need to address the social aspects of healthy aging, such as social engagement and social support, similar to promoting social culture as pointed out by Lorek et al. [
30]. In addition, the eudaemonic dimension of well-being gives rise to a need to create and contribute to a community for many, prompting engagement in volunteerism. Social components of healthy aging, including engaging with others in social events and contributing to the community, are consistent with notions of healthy aging as in Benson et al.’s proposed centrality of human relationships revealed through social support and social engagement [
6].
Our findings also suggest that the spiritual component of healthy aging is commanding increased attention, with an appreciation of the importance of faith communities and individual spirituality, and their association with health [
31]. Indeed, the capacity to transcend some aspects of aging, including losses, may reflect spiritual dimensions of health. The spiritual dimension of healthy aging was referenced by the practitioners as they reflected on more transcendent perspectives of older adults and the positive aspects of life.
In addition to these aging services practitioners’ perspectives being reflected in the research literature to date, there is also a close alignment between their views and those of older adult participants in studies of healthy aging. For example, Phelan and colleagues found that over 90% of older Japanese-Americans and Whites participating in longitudinal studies believe the following dimensions of successful aging were most important: remaining in good health until close to death, being able to take care of oneself until close to the time of death, and remaining free of chronic disease [
32,
33]. Taken together, these perspectives from older adults bear close resemblance to those cited by the community-based practitioners who participated in this study.
There are a wide variety of programs and services available to promote healthy aging and independence among community-dwelling older adults (e.g., physical activity, fall prevention, self-management), which align with promoting fitness from our healthy aging framework. Nationally, beneficial and protective effects of physical activity are recognized across the lifespan [
34]. Physical activity programs designed specifically for older adults have been disseminated and implemented widely through community partnerships [
35]. The new multi-disciplinary approach to fall prevention is one example of how the healthcare system has modified processes to increase adoption of evidence-based programs that support healthy aging. The Centers for Disease Control and Prevention has provided physicians and nurse practitioners with a fall-risk screening and assessment toolkit to evaluate common modifiable risk factors associated with falls (e.g., gait and balance impairment, medication management, environmental hazards etc.) [
36]. Community programs have also been developed to promote wellness among older adults through self-management skills. Self-management skills are critical to maintaining quality of life and independence. The Chronic Disease Self-Management Program is an example of a program designed to improve self-efficacy and independence among community-dwelling older adults [
37,
38]. Changes in the healthcare system have sought to overcome barriers to support clinicians’ recommendations of appropriate programs, based on the needs of the individual. Practitioners can work with rehabilitation professionals (e.g., physical and/or occupational therapists) and community health workers to assist with the implementation of the recommendations [
39].
As communities continue to elaborate healthy aging programs and services, there is a need to fully encompass the multitude of views on healthy aging held by people carrying out these programs and to adopt sensitive, valid, and reliable outcome measures that capture the broad construct of healthy aging. The proposed novel conceptual framework can guide community-based practitioners in the assessment of healthy aging as well as in the development and implementation of community-based interventions to promote healthy aging, and quality improvement and program evaluation of services and supports for older adults.
This qualitative exploration of community-based practitioners’ perspectives on healthy aging has strengthened and expanded the healthy aging literature beyond theoretical frameworks and input from older adults themselves. However, the study is not without limitations that should be considered when interpreting results. First, the data used in this study are from a small sample of practitioners that did not include the full range of professionals working with older adults in the community that may limit the generalizability of study findings. It is possible that a larger, more diverse sample could have produced different themes of healthy aging. However, the current study participants brought diverse perspectives in terms of educational backgrounds, length of experience, work settings, and interactions with older adults, and data saturation was confirmed by member-checks of the themes that evolved. In fact, participants compared and contrasted their perspectives and experiences with those of other colleagues and collaborators, as well as their own personal experiences of aging and caring for older parents or grandparents. Second, the sample was purposively selected from one large metropolitan area in the Washington state of US, and hence our results may not be generalizable to other practitioners working with older adults in rural areas or facilities in other states, as their views may be subject to varying degrees of social and economic influence. As our findings are situated in a particular context, it is not our intention to generalize to other groups and contexts. However, findings of this study may provide meaningful information to the gerontological researchers in other US states or other countries on which to base subsequent future studies. Furthermore, although the participants represented diverse disciplines and backgrounds in this study, which is an important consideration for ensuring that evolving themes are informed by relevant as well as divergent views, participants’ racial/ethnic diversity was limited in the current study. It is possible there are differences in how healthy aging is viewed by practitioners from broader racial/ethnic or cultural groups, particularly for diverse populations of older adults. More research is needed to explore these potential differences. Third, our study sample included all female practitioners, the perspectives of whom may vary from the male practitioners. Some health care professions (so-called support occupations) are female-dominated profession in the US such as nursing and social work [
40], which could have led to participation of all female practitioners in the study. Fourth, there was a wide variation in the academic training level of study participants ranging from undergraduate to doctorate level. This could have led to the wide variation in the perspectives; however, it is noteworthy that diverse views of participants added depth and breadth to the study findings. Future studies are needed to explore the perspectives of practitioners stratified by demographic characteristics, particularly academic training level. Nonetheless, this qualitative study generated useful insights about the healthy aging from the perspectives of community-based practitioners that lay the foundation for future research on the well-being of older adults.
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