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Community health promotion programs for seniors : program focus and contributing factors to composition Calsaferri, Kim 1990

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COMMUNITY HEALTH PROMOTION PROGRAMS FOR SENIORS: PROGRAM FOCUS AND CONTRIBUTING FACTORS TO COMPOSITION by KIM CALSAFERRI B.S.R. (O.T.), The U n i v e r s i t y of B r i t i s h Columbia, 1983 A t h e s i s submitted i n p a r t i a l f u l f i l l m e n t of the requirements f o r the degree of Masters of Science i n The F a c u l t y of Graduate Studies ( I n t e r d i s c i p l i n a r y ) We accept t h i s t h e s i s as conforming t o the required standard THE UNIVERSITY OF BRITISH COLUMBIA OCTOBER 1990 <g> KIM CALSAFERRI, 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada Department ( I n t e r d i s c i p l i n a r y ) DE-6 (2/88) - i -TABLE OF CONTENTS ACKNOWLEDGEMENTS i v ABSTRACT v LIST OF TABLES v i INTRODUCTION 1 CHAPTER 1 REVIEW OF THE LITERATURE 5 I. DEFINING HEALTH PROMOTION 5 I I . THE EMERGENCE OF HEALTH PROMOTION 9 I I I . THE EMERGENCE OF HEALTH PROMOTION FOR SENIORS 11 IV. THE FOCUS OF HEALTH PROMOTION PROGRAMMING FOR SENIORS 12 V. RECENT RESEARCH ON HEALTH PROMOTION PROGRAMS FOR SENIORS 15 CHAPTER 2 METHODOLOGY 18 I. THE ETHNOGRAPHIC RESEARCH TRADITION 18 A. THE ETHNOGRAPHIC RESEARCH TRADITION 18 B. THE HISTORICAL DEVELOPMENT OF ETHNOGRAPHY 20 C. THEORETICAL FOUNDATIONS OF ETHNOGRAPHY 25 Phenomenology 25 Symbolic Interactionism 28 D. RESEARCH TECHNIQUES EMPLOYED IN ETHNOGRAPHY 32 E. SUMMARY 37 I I . THE RESEARCH DESIGN 37 A. ETHNOGRAPHIC RESEARCH AND HEALTH PROMOTION FOR SENIORS 37 B. THE RESEARCH PURPOSE 39 C. THE RESEARCH GOALS 39 D. FORESHADOWED QUESTIONS 39 E. DEFINITION OF TERMS 40 I I I . THE RESEARCH METHODOLOGY 41 A. THE SAMPLE 42 B. THE PROGRAM SELECTION PROCESS 43 C. THE SUBJECT SELECTION PROCESS 43 D. CONFIDENTIALITY AND RESEARCH CONSENT 44 E. THE ROLE OF THE RESEARCHER 45 F. DATA COLLECTION AND RESEARCH TECHNIQUES 47 The F i e l d Diary 47 The F i e l d Notes 48 The Interviews 52 The Documents 54 The Protocols 54 G. DATA ANALYSIS 55 - i i -CHAPTER 3 THE PLACES, THE PEOPLE AND THE EMERGING ISSUES 59 I. PROGRAM A 59 A. DESCRIPTION 59 B. EMERGING ISSUES 61 Program O r g a n i z a t i o n and Process 61 Attendance 63 Community Issues 64 Housing 61 Out Reach 65 Community Involvement 66 Social Interaction and Support 67 C. SUMMARY 68 II. PROGRAM B 69 A. DESCRIPTION 69 B. EMERGING ISSUES 70 Program Organization and Process 70 Attendance 71 Social Interaction and Support 73 Community Issues 73 Community Involvement 73 Out Reach 74 C. SUMMARY 75 III. PROGRAM C 75 A. DESCRIPTION 75 B. EMERGING ISSUES 76 Program Organization and Process 76 Attendance 78 Social Interaction and Support 79 Community Issues 80 C. SUMMARY 80 IV. PROGRAM D 80 A. DESCRIPTION 80 B. EMERGING ISSUES 82 Program Organization and Process 82 Social Interaction and Support 83 Community Issues 84 Housing 84 Community Involvement 85 Attendance 85 C. SUMMARY 86 V. PROGRAM E 86 A. DESCRIPTION 86 - " M i -ff. EMERGING ISSUES 88 Program Organization and Process 88 Attendance 89 Community Issues 90 Community Involvement 90 Housing 91 Out Reach 92 Social Interaction and Support 92 C. SUMMARY 93 CHAPTER 4 PROGRAM FOCUS AND FACTORS CONTRIBUTING TO PROGRAM COMPOSITION 94 I. PROGRAM FOCUS 95 A. INDIVIDUAL BEHAVIOURAL CHANGE COMPONENTS 97 B. UNDERLYING ENVIRONMENTAL AND COMMUNITY CHANGE COMPONENTS 99 C. SUMMARY 102 II. FACTORS CONTRIBUTING TO PROGRAM COMPOSITION 102 A. PROGRAM ORGANIZATION AND PROCESS 103 Application of a Wellness/Health Promotion Approach 104 Varying Degrees of Structure 106 The Roles of Seniors and Professionals109 Program Funding 112 Historical Development of Wellness/ Health Promotion 114 SUMMARY OF A 115 B. PROGRAM ATTENDANCE RATIONALE AND PATTERNS 116 SUMMARY OF B 120 CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS 121 I. THEORETICAL IMPLICATIONS OF THE STUDY 121 A. RESEARCH QUESTIONS 122 II. LIMITATIONS OF THE STUDY 137 III. IMPLICATIONS FOR FUTURE RESEARCH 139 IV. PRACTICAL IMPLICATIONS FOR PROGRAM PROCESS AND ORGANIZATION 140 A. INTERNAL INFLUENCES 140 B. EXTERNAL INFLUENCES 141 BIBLIOGRAPHY 143 APPENDICES A. RESEARCH CONSENT FORMS 157 B. OBSERVATION SCHEDULE 160 C. EXAMPLES OF OBSERVATION PROTOCOLS 162 D. INTERVIEW SCHEDULE 177 E. INTERVIEW QUESTIONS 179 F. EXAMPLE OF SENIOR AND PROFESSIONAL INTERVIEW PROTOCOLS 183 - i v-ACKNOWLEDGEMENTS The completion of th i s thes is was made possible through the encouragement, support and generosity of fami ly, f r iends , UBC facu l t y , and professionals and seniors of the health promotion programs studied. I would l i ke to thank my family whose influence has given me strength to bel ieve in my a b i l i t i e s , to adapt to change, and to meet the many challenges presented throughout my l i f e . I am pa r t i cu la r l y indebted to my "Gran" whose wisdom and grace have provided me with ins ight into aging we l l . My f r iends have supplied me unending support and encouragement. They have sens i t i ve l y provided me with humour, hugs, company to exerc ise, ins igh ts , meals, and most importantly, a be l i e f in my a b i l i t i e s to complete t h i s thes i s . I would l i k e to thank the members of my committee, Dr. John Milsum, Dr. Nancy Waxier-Morrison, Dr. Lyn Jongbloed and Dr. P a t r i c i a Vert insky. Their commitment to the development of t he i r students and to excellence in scholar ly a c t i v i t i e s , i s deeply appreciated and respected. F i n a l l y , t h i s thes is i s dedicated to the seniors and professionals whose be l ie f in wellness and health promotion i s a confirmation that l i v i n g and dying well i s poss ib le . -v-A B S T R A C T The purpose of t h i s study i s to invest igate the program focus and contr ibut ing factors to program composition of f i ve health promotion programs for seniors. The programs are selected using opportunist ic sampling from f i ve d i f fe rent local areas in metropolitan Vancouver. The f i ve areas together const i tute metropolitan Vancouver. A theoret ica l framework based on health promotion as a process which enables people to take control of t he i r health promotion programming and recognizes that s o c i a l , p o l i t i c a l , and organizat ional interventions are as important as indiv idual act ions, i s used to support the purpose of t h i s study. An ethnographic approach i s used to co l l ec t observat ional , interview and documentary data on program focus, process and organizat ion. The data are analyzed qua l i t a t i ve l y to further the understanding of health promotion as a process central to indiv idual and group empowerment in program focus and organizat ion. The f indings confirm that these programs focus predominantly on indiv idual behaviour change e f fo r ts and only minimally on underlying environmental and community change fac tors . In the process of examining these health promotion programs for seniors, themes emerged which shed l i gh t on which factors most inf luence program composition. Program organizat ion and process which involves mul t ip le h i s t o r i c a l , theoret ica l and organizat ional factors are seen to most heavi ly inf luence program composition. - v i -L I S T O F T A B L E S Table 1: Number and Type of Subjects Selected f o r Interview 44 Table 2: Indiv idual Behavioural Change Components 96 Table 3: Environmental and Community Change Components 97 Table 4: Varying Degrees of Program Structure 107 Table 5: The Program Funding Sources: Space, Equipment Miscel laneous S u p p l i e s , Manpower 113 1 INTRODUCTION My interest in this study developed from my perspective as an occupational therapist, which requires that I view health from a holistic perspective. When I work with individuals whose performance 1s impaired, i t is important to view them within the context of their environment. Also, as occupational therapists highly value a client-centered approach this necessitates the involvement of each individual as an active participant in the planning and intervention process. I understood that health promotion is intended to foster the involvement of individuals in decision making processes about their health needs, and was aware that a health promotion philosophy recognizes that both individual behaviour and environmental factors contribute to and influence health and well-being. Health promotion is a recent addition to the health care delivery system. Although s t i l l secondary to disease treatment, health promotion has gained a great deal of support since the mid-1970's and through the publication of a number of charters, frameworks and reports i t has been established as a legitimate component of our present health care system (Epp, 1986; Lalonde, 1975; International Conference on Health Promotion, 1986; U.S. Department of Health, Education and Welfare, 1979). There is no definition of health promotion upon which everyone agrees, but the following two are frequently quoted, and are used in this study: "Health promotion involves any combination of health education and related organizational, po l i t i c a l and economic interventions designed to 2 f a c i l i t a t e behavioural and environmental changes conducive to health" (Green, 1979). "Health promotion is the process of enabling people to increase control over, and to improve, their health" (World Health Organization, 1986). As health promotion recognizes that social, p o l i t i c a l and organizational conditions are as important as personal actions in determining health, the following two definitions are used in this study: Individual Behavioural Change Components include programming that focuses upon personal health attitudes, self-management of chronic health conditions, nutrition, exercise, stress management, personal sense of purpose, personal support systems and personal environmental awareness and participation. Environmental and Community Change Components include programming that includes a focus on those p o l i t i c a l , economic and organizational factors that affect promotion of immediate individual behavioural change components, e.g. available community supports, self-help groups, outreach services, Information networks, environmental hazards, and social and economic factors such as social isolation, poverty and ageism. Health promotion 1s viewed as having great potential for improving the health needs of Canada's rapidly growing senior population. However, there are those who suggest that many health promotion programs continue to focus on the Isolated individual as the target for behaviour change, 3 and place l i t t l e or no emphasis on those underlying social, p o l i t i c a l and organizational factors that keep seniors impoverished, socially isolated and disadvantaged. (Health Services and Promotion Branch, 1986; Minkler & Pasick, 1986). Although the success of health promotion programs is viewed as dependent on the effective incorporation of both individual behavioural and environmental components, l i t t l e research has been conducted to describe health promotion program focus or to analyze the factors that contribute to program composition. This present ethnographic research represents an early attempt to describe the focus of the program components and the contributing factors to program composition, for five health promotion programs for seniors, in the city of Vancouver, British Columbia. Ethnographic research is viewed as particularly well suited to this study as i t focuses on social organizations within specific contexts and provides a holistic perspective without superimposing the researcher's value system on the situation. An ethnographic approach enables the researcher to examine the perspectives of the senior participants and the professionals about the health promotion philosophy, the program focus, the program process and the factors which contribute to program composition of each health promotion program. Opportunistic sampling is used to select one program from five different local areas of metropolitan Vancouver. In the role of participant as observer, the researcher conducts participant observation of a l l five programs, for a period of two months. This is followed by 4 i n t e r v i e w s w i t h two c a t e g o r i e s o f s e n i o r p a r t i c i p a n t s and t h e p r o f e s s i o n a l w e l l n e s s c o o r d i n a t o r s . As w e l l , a n a l y s i s o f documents g a t h e r e d from s e n i o r p a r t i c i p a n t s and w e l l n e s s c o o r d i n a t o r s p r o v i d e s I n s i g h t about program components, t h e p r o c e s s o f program development and what b e s t e x p l a i n s program c o m p o s i t i o n . T h i s s t u d y l e n d s s u p p o r t f o r t h e c l a i m t h a t h e a l t h p r o m o t i o n programs f o r s e n i o r s remain narrow i n f o c u s and c o n t i n u e t o c o n c e n t r a t e on i n d i v i d u a l l e v e l change. F u r t h e r , 1t i l l u s t r a t e s how h i s t o r i c a l , t h e o r e t i c a l ( t h e a p p l i c a t i o n o f a w e l l n e s s / h e a l t h p r o m o t i o n approach) and o r g a n i z a t i o n a l f a c t o r s ( v a r y i n g d e g r e e s o f s t r u c t u r e , t h e r o l e s o f s e n i o r s and p r o f e s s i o n a l s , and f u n d i n g ) m a r k e d l y i n f l u e n c e program f o c u s and p r o c e s s and hence enhance o r i n h i b i t t h e a b i l i t y o f t h e program t o f u l f i l l t h e i n t e n t i o n s o f h e a l t h p r o m o t i o n . F i n a l l y , t h i s s t u d y f o c u s e s on e x p l o r i n g program f o c u s , program p r o c e s s and t h e f a c t o r s w h i c h b e s t i n f l u e n c e program c o m p o s i t i o n , 1t a l s o r a i s e s q u e s t i o n s about t h e r o l e t h a t macro, meso, and m i c r o - l e v e l I n f l u e n c e s p l a y i n p e r p e t u a t i n g n a r r o w l y - f o c u s e d , I n d i v i d u a l i s t i c h e a l t h p r o m o t i o n . 5 CHAPTER 1 REVIEW OF THE LITERATURE A study of the focus and c o n t r i b u t i n g f a c t o r s t o h e a l t h promotion programs f o r s e n i o r s i n Vancouver, B r i t i s h Columbia, n e c e s s i t a t e s an examination of the r e l a t i o n s h i p among the f o l l o w i n g f a c t o r s : the s h i f t 1n emphasis and acceptance of h e a l t h promotion as an i n t e g r a l part of h e a l t h care; the emergence of h e a l t h promotion programs f o r s e n i o r s ; the present focus of s e n i o r s ' h e a l t h promotion programs; and the f a c t o r s t h a t u n d e r l i e program composition and v a r i a t i o n . In t h i s chapter, h e a l t h promotion 1s defined and aspects of h e a l t h promotion programs d e l i n e a t e d . The f a c t o r s t h a t c o n t r i b u t e t o the emergence of h e a l t h promotion programs are discussed t o provide a context w i t h i n which recent research of e x i s t i n g h e a l t h promotion programs f o r s e n i o r s can be explored. I. DEFINING HEALTH PROMOTION J u s t twenty years ago h e a l t h promotion was l i t t l e understood. Today health promotion a t t r a c t s the study and a t t e n t i o n of academics, heal t h care p r o v i d e r s , p o l i c y makers, voluntary and community o r g a n i z a t i o n s and la y people a l i k e . This i n t e r e s t has generated numerous attempts at d e f i n i n g h e a l t h promotion and e x p l a i n i n g i t s approach. As yet there i s no agreed-upon d e f i n i t i o n of h e a l t h promotion and i n p a r t i c u l a r of h e a l t h promotion f o r the e l d e r l y (Duncan & Gold, 1986; Brown, 1982; Mullen, 1986; Health S e r v i c e s and Promotion Branch, 1986). However, consensus e x i s t s t h a t h e a l t h promotion i s more than the treatment of d i s e a s e , the t r a d i t i o n a l focus of biomediclne. Proponents of t h i s concept consider p h y s i c a l , mental and s o c i a l aspects of h e a l t h . Health promotion, a broad 6 concept, is concerned with the quality of l i f e . Emphasis is placed on both individual and environmental determinants of health and well-being (Epp, 1986; Estes, Minkler, & Paslck, 1986; Mollenill, 1987; International Conference on Health Promotion, 1986; Kickbusch, 1989). Although the definitions offered have much in common, they differ in their emphasis on which factors are the appropriate targets for change efforts. More specifically, environmental factors are viewed as particularly Important by some health promoters, while the individual determinants of health are often the focus with others. For example, Thatcher (1988) who defines HEALTH as: "a dynamic state of biopsychosocial well-being in which individuals are able to perform those functions deemed necessary and desirable to maintain existence in their environment," affirms Pender's (1982) definition of HEALTH PROMOTION as: "activities directed toward sustaining or increasing the level of well-being, self-actualization and personal fulfillment of a given individual or group." This definition implies, that only i f the Individual or group takes responsibility for health promotion behaviours, will enhancement of well-being follow (Thatcher, 1989). In contrast, Green et a l . (1986) defines HEALTH PROMOTION as: "any combination of health education and related organizational, po l i t i c a l and economic Interventions designed to f a c i l i t a t e behavioral and environmental changes conducive to health." The emphasis here, 1s on a variety of interventions to f a c i l i t a t e both behavioural and environmental changes conducive to health. This is viewed by many as offering a more sophisticated definition than more conventional health promotion concepts because of the focus on the social, cultural and 7 economic influences on health and health behaviour (Estes, Fox & Mahoney, 1986; Minkler & Pasick, 1986; Mlnkler, 1985). The World Health Organization (WHO) defined HEALTH as: "a state of complete physical, mental and social well-being, not merely the absence of disease" (WHO, 1948). This definition has gained worldwide recognition and acceptance. During the 1980's various WHO publications proposed an expanded vision of health and health promotion. HEALTH was expanded to include: "the extent to which an individual or group is able on the one hand to realize aspirations or needs and on the other hand, to change or cope with the environment." (WHO, 1984) HEALTH is viewed as: "a resource for everyday l i f e , not the object of living." (WHO, 1984) HEALTH PROMOTION was defined as: "the process of enabling people to Increase control over, and to improve, their health." (WHO, 1986) and 1s seen as: "a mediating strategy between people and their environments, synthesizing personal choice and social responsibility in health." (WHO, 1986) This perspective emphasizes social and personal resources as well as physical capacity. Consistent with Green et a l . (1986) this implies a more positive and integrated look at health which recognizes environmental Influences. This vision attempts to Integrate the Individual and social components within an ecological framework. Health promotion is seen to complement the existing health care system but 1s not viewed as synonymous with health care. Of major significance is the fact that less emphasis 1s placed,on the individual and more on the influence of environmental 8 factors. Thus a trend that began 1n the early 1950's, which placed most emphasis on Individual responsibility for health, is reversed (O'Neill, 1989/90). A federal publication entitled "A New Perspective on the Health Of Canadians" by Lalonde (1974), translated such findings Into the form of a working document which legitimized the idea of developing health practices and policies within a broader context. Lalonde suggested that people's health was influenced by a broad range of factors; human biology, li f e s t y l e , the organization of health care and the social and physical environments in which people live. Today this concept has been expanded to include an emphasis on broader quality of l i f e Issues. The event that played the largest role 1n publicizing this new health promotion vision was the f i r s t International Conference on Health Promotion held in Ottawa in 1986. An important product of this conference was the Ottawa Charter for Health Promotion (1986) which further expanded the World Health Organization's concepts by developing health promotion strategies to realize i t s definitions namely: building healthy public policy; creating supportive environments; strengthening community actions; developing personal s k i l l s and reorienting health services. These strategies captured a vision of health that move beyond the individual to the larger society and the environment within which they are part. 9 II. THE EMERGENCE OF HEALTH PROMOTION The shift in emphasis from a biomedical definition of health and well-being toward a broader conceptual framework that encompasses physical, social, p o l i t i c a l and economic environmental factors, as well as individual l i f e s t y l e and behavioural choices, signifies the emergence of health promotion now exemplified by the WHO's ecological paradigm of public health (Kickbusch, 1989). Multiple factors have contributed to health promotion as i t exists today. The work of Dubos (1979), 1n enlarging the understanding of the individual's adaptation to the social and physical environment, of McKeown (1976), who pointed out the role of Improved nutrition, changing personal habits and sanitation, in achieving marked improvements in health status, and of Belloc and Breslow (1972), who demonstrated an association between li f e s t y l e habits and physical health status, has contributed to an overall understanding of determinants of health and the importance of environment, social factors and l i f e s t y l e as major determinants of health status. Fries and Crapo (1981), noted that an increase 1n the incidence of chronic disease was likely as more people survive Illness that previously caused death earlier in l i f e . They postulated that l i f e s t y l e modification and promotion of healthful behaviour can: a) alter the aging process; b) improve the social, physical and mental functioning of seniors; b) reduce the d i s a b i l i t i e s of aging; and c) extend a vigorous l i f e up to the end of the "natural biological l i f e span" through the "compression of morbidity". (Fries, 1980; 1983; 1984) 10 Now that chronic disease is a major precursor of death, many people believe the major emphasis of health care must shift from acute Illness treatment towards removal of and assistance with those risk factors associated with chronic disease (Labonte, 1988; Fries, Green, & Levine, 1989; International Conference on Health Promotion, 1986; Epp, 1986; Mollenill, 1987; Larson, 1988; Evans, 1989; Kickbusch, 1989). The 1986 federal document "Achieving Health for A l l : A Framework for Health Promotion" reinforces this emphasis and the necessity for developing health practices and policy within a broadened context. The fact that "health equity between high and low Income groups" was identified as "a leading challenge" indicates that this framework has gone far beyond Lalonde's (1974) perspective (Epp, 1986). This document calls for the Integration of Ideas from public health, health education and public policy and also for an expansion of the traditional use of the term health promotion. Here, health 1s portrayed as part of everyday living and as an essential dimension of the quality of our lives. This view recognizes the role of Individuals and communities in defining what health means and in striving to achieve, maintain or regain i t . The creation of healthy environments through altering or adapting the social, economic and physical surroundings 1s recognized as necessary to preserve and enhance health. Improvements in health are viewed as being dependent, not only on individual change, but also on concurrent health promotion changes within the broader physical, social, p o l i t i c a l and economic environment (Epp, 1986). Applying these concepts to health promotion for the senior population would necessarily include attention to the multiple 11 determinants of their health and well-being. Reduced Incomes, diminished power and social standing, the threat of economic and social dependency, chronic illness and disability, the loss of social supports, as well as individual l i f e s t y l e , are a l l potent determinants of health and well-being of seniors in our society (Health Services and Promotion Branch, 1986). III. THE EMERGENCE OF HEALTH PROMOTION FOR SENIORS Until recently seniors were excluded from popular wellness and health promotion activity. Probable reasons for this are that the majority of health promotion programs focus on: a) l i f e extension with seniors being viewed as having no future; b) reducing risk factors associated with premature death and disability, but the majority of seniors have lived beyond this risk; c) youth, and are concerned with the individual's responsibility for reducing risks, so that seniors are viewed as inappropriate participants; and d) absence or avoidance of disease, which is an inappropriate goal for most seniors who already suffer from at least one chronic health problem (Estes, Fox & Mahoney, 1986; Roadburg, 1985; Health Services and Promotion Branch, 1986; Somers, Kleinman & Clark, 1982). The shift in the causes of morbidity and mortality, the Increased proportion of people living longer lives and the increased costs of health care are some of the factors which have given rise to the Increased emphasis on health promotion as a legitimate component of health care (Labonte, 1988). 12 More specifically, several reasons underlie the increasing emphasis on this type of intervention among seniors: a) this group 1s the fastest growing segment of this nation's population; b) 86% have chronic conditions; c) the consequences of chronic health conditions typically are disproportionately severe for seniors, resulting 1n restrictions on personal independence and overall quality of l i f e ; d) while representing only 11% of the population, seniors account for about one-third of a l l health care costs; and e) they are the most likely to need high cost personally restrictive long term care (McDaniel, 1986; Marshall, 1987; Health Services and Promotion Branch, 1986; Statistics Canada, 1985; Smith, 1988). Also, as noted, health promotion has gained v i s i b i l i t y as a major policy issue in response to a number of federal health documents (Lalonde, 1974; Epp, 1986). Although these publications do not specifically highlight the elderly, together they have contributed to a conceptual framework for national health promotion activities for a l l Individuals. IV. THE FOCUS OF HEALTH PROMOTION PROGRAMMING FOR SENIORS To physicians, health promotion may mean providing prescriptive l i f e s t y l e advice; to hospitals, i t might assume the appearance of patient education programming in chronic Illness management; to health departments, i t may appear as programming which promotes healthy behaviour; and at the community level, i t might be expressed as concern in 13 terms of adequate financial resources, transportation, housing and access to services (Labonte, 1988). To date, the literature suggests that health promotion programs for seniors, as for other groups in society, tend to focus on the Isolated individual as the target for behaviour change efforts (Estes, 1983; Kickbusch, 1989; Draper, 1988; Mlnkler & Paslck, 1986). However, some experts in the f i e l d believe that by focusing programming on individual change efforts, attention is deflected from those environmental factors that heavily influence health practices and over which seniors may have 1ittle control. Although these experts claim programs focus predominantly on li f e s t y l e change and only minimally on the underlying environment and community change, no direct research exists to support or negate these claims. Two national surveys 1n the United States on senior centers and services (National Council on the Aging; Krout, 1985) and a review of a random selection of health promotion programs for seniors in Canada (Taylor, 1983) and the U.S. (Gilbert, 1986; Brown, 1982; Minkler & Paslck, 1986; Weiss & Sklar, 1983; Barbaro & Noyes, 1984; Dunn, 1985; Gesham-Kenton & Wisby, 1987; Wilson, Patterson & Alford, 1989; H1gg1ns,1988) reveal the major areas of concern to be drug use and abuse, chronic health monitoring, smoking cessation, health education, nutrition awareness, stress reduction, promotion of fitness, mental health and recreation. A l l these are individual l i f e s t y l e and behavioural components. This emphasis 1s not f e l t to Include an attack on the underlying causes of environmental determinants of health. Minkler & Pasick (1986) noted that seniors are: taught the importance of exercise but not how to 14 participate safely 1f they live in a high crime area; told which foods are nutritional, but not how to afford them i f living near or on the poverty line; and taught to identify and manage l i f e stresses but rarely encouraged or helped to work Individually or collectively towards eradicating the root causes of these stresses. Some health promotion programs do combine l i f e s t y l e change elements with a broader focus on increasing responsibility for oneself and control over the social, physical and economic environment (Lalonde and Fallcreek, 1985; Minkler, 1985; Wechsler & Minkler, 1986). This broader focus emphasizes the a b i l i t y of individuals to bring about change 1n their environment rather than simply helping them to cope with and adjust to li f e s t y l e and health problems. However, as these programs remain few in number, the message is clear; individual responsibility for health s t i l l remains the predominant focus today (Labonte, 1988; Smith, 1988; Health Services and Promotion Branch, 1986). L i t t l e empirical information exists that would allow for an assessment of how comprehensive are senior center and health promotion activities and services (Krout, 1986), let alone their specific focus or how and why programs vary. Almost without exception, research has focused on the elderly individuals' socio-demographic characteristics, the factors that differentiate participants from non-participants, and the degree to which they u t i l i z e senior centers and health promotion programs (Krout, 1986; Krout, 1990; Buchner & Pearson, 1989). 15 V. RECENT RESEARCH ON HEALTH PROMOTION PROGRAMS FOR SENIORS Although some research 1s being conducted in the specific area of health promotion and the elderly, 1t is extremely limited 1n scope and quantity. The predominant focus is on program evaluation in the areas of cost containment, health maintenance, functional Independence, illness risk reduction, health knowledge, and health behaviour change (Rakowski, 1986). Some researchers (Weiss & Sklar, 1983; Nelson et a l . , 1984; Ho et a l . , 1987; Gresham-Kenton & W1sby, 1987; Bender & Hart, 1987; Krout, 1988; Smith, 1988; Weiler, Chi & Lubben, 1989; Wilson, Patterson & Alford, 1989) seek alternatives to a biomedical approach. For a long time data were not available to link seniors' health with medical utilization and costs. Some writers do claim that seniors health promotion programs provide more cost effective care and have potential to decrease excessive biomedical utilization and health care costs (Minkler, 1985; Weiss & Sklar, 1983; Barbaro & Noyes, 1984; Vlckery, Kalmer, Lowry, Constant1ne & Loren, 1983; Ho et a l . , 1987). Others suggest that costs will not decrease as this necessitates broadened service delivery (Nelson et a l . , 1984; Russell, 1984; Gori, Ritcher & Yu, 1984). Those studies which address the benefits of health promotion for seniors focus predominantly on individual behaviour and li f e s t y l e changes. Some researchers suggest older people who participate 1n programs demonstrate: a) maintenance of health and functional Independence (Weiss & Sklar, 1983; Nelson et a l . , 1984; Wilson, Patterson & Alford, 1989); 16 b) a reduction 1n h e a l t h r i s k s (U.S. P u b l i c Health S e r v i c e and A d m i n i s t r a t i o n on Aging, 1984; Lalonde & F a l l c r e e k , 1985; Weiss & S k l a r , 1983; Kempner, 1986; Cox & Monk, 1989); c) increased personal knowledge, awareness and r e s p o n s i b i l i t y i n h e a l t h - r e l a t e d matters ( F i t c h & S H v i n s k e , 1988; U.S. P u b l i c Health S e r v i c e and A d m i n i s t r a t i o n on Aging, 1984; Lalonde & F a l l c r e e k , 1985; Nelson et a l . , 1984; Barbara & Noyes, 1984); and d) c o n s t r u c t i v e behavioural changes toward h e a l t h i e r l i f e s t y l e behaviours and improved hea l t h s t a t u s (Higglns, 1988; Jordon-Marsh & Neutra, 1985; Smith, 1988; F i t c h & S H v i n s k e , 1988; Lalonde & F a l l c r e e k , 1985; Nelson et a l . , 1984; Barbara & Noyes, 1984; M i n k l e r , 1985; U.S. P u b l i c Health S e r v i c e s and A d m i n i s t r a t i o n on Aging, 1984). Few documents and research e f f o r t s i d e n t i f y s e n i o r s ' h e a l t h promotion programs which focus on i n d i v i d u a l h e a l t h behaviour and e f f o r t s aimed at enabling s e n i o r s t o take c o n t r o l of hea l t h d e c i s i o n s , t o create healthy environments and coordinate healthy p u b l i c p o l i c y , as l a i d out by Epp (1986), WHO (1986) and Green, et a l . (1980). Although the idea of developing programming and research w i t h i n a broader context has been l e g i t i m i z e d , the l i t e r a t u r e i n d i c a t e s I t s presence 1s extremely rare 1n p r a c t i c e . Of two w e l l documented U.S. programs, the WalUngford Wellness P r o j e c t and the Tenderloin Seniors Outreach P r o j e c t , only the former has undergone e m p i r i c a l study. One outcome study confirmed e f f e c t i v e n e s s 1n promoting and s u s t a i n i n g i n formation, a t t i t u d e and behaviour change i n s e n i o r s over 54 years of age (Lalonde & F a l l c r e e k , 1985). Programming components were c l e a r l y I d e n t i f i e d and the d e s c r i p t i o n c l e a r l y Indicated a focus on both I n d i v i d u a l behaviour and environmental Issues. More 17 r e c e n t l y i n Canada, Meeks & Johnson (1988), documented a p r o j e c t undertaken at a suburban s e n i o r s ' center, where a comprehensive h e a l t h promotion program was developed based on h e a l t h promotion l i t e r a t u r e , on assessment of the s e n i o r s needs and I n t e r e s t s and on a review of community resources. Although e v a l u a t i o n has not yet occurred, the program was designed with t h i s i n mind. The involvement of s e n i o r s and relevant community s e r v i c e s i n the program planning stage i s a noteworthy f e a t u r e . From the l i t e r a t u r e reviewed, 1t 1s c l e a r t h a t the type and q u a n t i t y of research required f o r knowledge development i n h e a l t h promotion as envisioned by Epp (1986), WHO (1986), and Green et a l . (1980), d i f f e r s c onsiderably from the l i f e s t y l e - o r i e n t e d research t h a t has been the trademark of h e a l t h promotion u n t i l r e c e n t l y . Research t h a t i n v e s t i g a t e s the process, focus and v a r i a t i o n of h e a l t h promotion programs, which 1s the i n t e n t i o n of t h i s present research, w i l l add t o research i n h e a l t h promotion. This l i t e r a t u r e review has i n d i c a t e d t h a t much work l i e s ahead f o r h e a l t h promoters, researchers, care p r o v i d e r s , p o l i c y makers, the media and other segments of s o c i e t y 1f h e a l t h promotion 1s t o be assured an I n t e g r a l place i n the h e a l t h care system. 18 CHAPTER 2 METHODOLOGY This chapter i s d i v i d e d Into three s e c t i o n s f o r the purposes of d e s c r i b i n g , d e f i n i n g and applying the ethnographic research t r a d i t i o n as a research methodology. Sect i o n one gives a general account of the .ethnographic research t r a d i t i o n . S e c t i o n two discusses the research design, purpose, goals and foreshadowed questions of t h i s study. Section three describes the a p p l i c a t i o n of the ethnographic research t r a d i t i o n t o t h i s study by presenting the data c o l l e c t i o n techniques, the r o l e of the researcher and the process of a n a l y s i s . I . THE ETHNOGRAPHIC RESEARCH TRADITION A. THE ETHNOGRAPHIC RESEARCH TRADITION S o c i a l science research has been described "as a choice between two c o n f l i c t i n g research paradigms" (Hammersley & Atkinson, 1983). These paradigms are o f t e n l a b e l e d q u a n t i t a t i v e and q u a l i t a t i v e (Schwartz & Jacobs, 1979) and nat u r a l i s m and p o s i t i v i s m (Hammersley & Atkinson, 1983). The issue between the two paradigms, i s the nature of the s o c i a l world and how i t should be studie d . In recent years q u a l i t a t i v e research has received i n c r e a s i n g a t t e n t i o n . This i s p a r t l y due t o the ongoing d i s c u s s i o n of q u a l i t a t i v e versus q u a n t i t a t i v e research, but a l s o t o the r e a l i z a t i o n t h a t there are many problems i n the s o c i a l sciences t h a t can best be studi e d with a q u a l i t a t i v e approach. Terminology i n t h i s t r a d i t i o n " v a r i e s from user t o user" (Bogdin & B i k l e n , 1982). A l s o , t h i s t r a d i t i o n has many l a b e l s . I t i s known as 19 " f i e l d work, ethnography, case study, qualitative research, interpretive procedures, f i e l d research," (Burgess, 1984), naturalistic inquiry and participant observation. In this study the term e t h n o g r a p h y will be used to identify the tradition. Ethnography has been associated with the collection of "soft" data (Bogdin & Biklen, 1982), collected in the f i e l d or natural setting (Hammersley & Atkinson, 1983), and studied from the participants' point of view (Burgess, 1984). Ethnographers "focus upon the ways in which participants interpret their experience and construct reality" (Burgess, 1984) rather than on an objective reality. In this way there is a fundamental difference between ethnography and positive science. Ethnographers must understand the world as the participant does, unlike positive scientists who study objective facts that exists outside the person. This tradition which goes back to the latter part of the nineteenth century, has i t s roots in more than one academic discipline (anthropology, sociology, social psychology and education) and Includes particular schools and methods such as "symbolic interactionlsm, inner perspective, the Chicago School, phenomenological, case study, Interpretive, ethnomethodological, ecological and descriptive" (Bogdin & Biklen, 1982). 20 B. THE HISTORICAL DEVELOPMENT OF ETHNOGRAPHY Because ethnography has multiple names, takes many forms and is conducted in a wide variety of settings, confusion exists about what i t i s . In order to appreciate the usefulness of this tradition, this section will define and explore the different labels and describe the historical context and genesis of ethnography. This tradition emerged towards the end of the nineteenth century during the era of urbanization. The impact of mass migration from rural to urban areas created vast social problems. It was the descriptive, indepth documentation of this social suffering by journalists, social workers, social surveyors and photographers, that laid the foundation for this research tradition (Bogdin & Biklen, 1982). The term ethnography comes from anthropologists who studied foreign cultures in their natural settings. Ethnography is defined as "the branch of anthropology that deals descriptively with specific cultures" (Websters New World Dictionary, 1980). This branch of anthropology is known as social anthropology. Ethnography is the label given to the methodology that generates the basic descriptive data on which social anthropology is founded. Two anthropologists, Boas and Malinowski contributed much to this f i e l d . Boas and his co-workers were amongst the f i r s t anthropologists to spend time in the f i e l d or natural setting. This time was, however, brief and much reliance was placed on informants who spoke the native language. Boas, a cultural r e l a t i v i s t , contributed the concept of culture and stressed the belief that each culture under study should be approached inductively (Bogden & Biklen, 1982). Malinowski (1922), who f i r s t 21 documented these f i e l d work techniques also insisted that a theory of culture had to be grounded in specific human experiences, based on observations and inductively sought (Malinowski, 1960). Unlike Boas, who had acquired his data predominantly from documents and informants, Malinowski was the f i r s t social anthropologist to draw his data primarily from the experience of living among and participating in the daily lives of those primitive societies he studied (Wax, 1960). On a similar search for meaning and understanding in human experiences, a significant number of sociologists in the classical tradition have recognized and stressed the importance of participant observation in methodology (Bruyn, 1962). One of the f i r s t and classic statements on the technique and purpose of participant observation was made by Florence Kluckhohn (1940: 331). "Participant observation is the conscious and systematic sharing, insofar as circumstances permit 1n the l i f e a c tivities, and on the occasion in the interests and affects of a group of persons. Its purpose 1s to obtain data about behaviour through direct contact and in terms of specific situations in which the distortion that results from the investigator being an outsider, is reduced to minimum." In the 1920s and 1930s the Chicago School, a group of sociologists at the sociology department in Chicago, began contributing further to this f i e l d of multiple labels. While these sociological researchers differed in some ways, they also shared common theoretical and methodological assumptions. Theoretically, personalities and symbols were viewed as emerging from social interaction (Faris, 1967) and methodologically they 22 relied on the study of a single case or unit such as an individual, a group, a neighbourhood, or a community (Wiley, 1979). Although the characteristics of the Chicago School methodology are numerous, the following are frequently highlighted. Researchers relied on f i r s t hand data gathering, a technique that was heavily influenced by W.I. Thomas and Robert Park. Also, as by this time few settings existed that had been untouched by contact with the west, these ethnographers turned to the study of subcultures. The emphasis on Intensive study of city l i f e provided the beginning of a trend, which continues to be the focus of those trained in the anthropological tradition today. Some important works emerging from this focus on subcultures include: The Gold Coast and The Slum (Zorbaugh, 1929); The Boys Gang (Thrasher, 1927); The Hobo (Anderson, 1923); Boys in White: Student Culture in Medical School (Becker, Geer, Huges & Strauss, 1961); and, Timetables (Roth, 1963). As al l these studies have a number of commonalties (e.g., meaning is of essential concern, the natural setting 1s used as the direct source of data, participant observation is used as a data collection method, and descriptive data are analyzed inductively), 1t becomes apparent that these researchers have a similar understanding of what is meant by ethnography and work from a common methodological tradition. The term n a t u r a l i s t i c I n q u i r y is also used in conjunction with ethnography. However, existing formulations of naturalistic research diff e r markedly. Naturalistic theorists and practitioners have seldom been in agreement on what they meant by this method (Denzin, 1971). Catton (1966) views i t as a rigorous positivism. For Matza (1969) i t is seen as humanism in disguise. In education qualitative research is often 23 called naturalistic inquiry as the researcher is found where events occur naturally and the data is gathered by people engaging 1n natural behaviour (Guba, 1978: Wolf, 1979). For s t i l l others such as Barker (1968), and Hutt and Hutt (1970), naturalistic inquiry 1s equated with ecological psychology and/or ethology. Lofland (1971) describes naturalism as a deep commitment to the collection of rich and often atheoretical ethnographic specimens of human behaviour. Denzin (1971) perceives a l l such formulations of naturalistic inquiry as deficient due to what he perceives as an absence of a more general theoretical perspective. He proposes a view of naturalism which stems from Mead's behaviourism (1934, 1938) and Blummer's (1969) symbolic interactionism. "I ca l l this version of the research act naturalistic behaviourism and mean by the term that studied commitment to actively enter the worlds of native people to render those worlds understandable from the standpoint of a theory that is grounded in the behaviours, languages, definitions and feelings of those studied" (Denzin, 1971: 168). Once again an umbrella term, naturalistic Inquiry, exists that refers not only to ethnography but also to several other different theoretical and methodological strategies. The term qualitative research appears to have become more popular in the 1970s among educational ethnographers. At this time these methods could not claim a central position in research methodology but they were no longer labeled fringe efforts. As methodological debates continued between quantitative and qualitative factions, qualitative evaluation research gained prominence (Guba, 1978; Patton, 1980), and some well known 24 researchers in quantitative circles (Cronback, 1975; Glass, 1975; Bronfenbrenner, 1976), discovering that "hard science" was not adequate, began exploring and advocating qualitative approaches (Bogdin & Biklen, 1982). Although some qualitative researchers (Wolcott, 1973; Metz, 1978; Rist, 1978) in education were doing what they considered "fieldwork, participant observation, indepth interviewing or ethnography-by spending extended amounts of time at the research site with the research subjects or with documents" (Bogdin & Biklen, 1982), there did not then and does not now, appear to be a clear common understanding of the term ethnography as i t relates to education. It is apparent that the exact use and formulation of labels associated with ethnography vary markedly from person to person and from discipline to discipline, and continue to evolve and change over time. 25 C. THEORETICAL FOUNDATIONS OF ETHNOGRAPHY Ethnography has important theoretical and epistemological foundations. These include phenomenology, symbolic interactionism, cultural ethnography and ethnomethodology. Phenomenology and symbolic interactionlsm are discussed further as both have relevance to this study. Phenomenology Phenomenology, which represents the effort to describe human experience as i t is lived (Merleau-Ponty, 1964), is not just a research method but is also a philosophy and an approach (Psathas, 1973). It has been suggested that the failure of researchers to understand the difference between phenomenology as a philosophy, as an approach or as a research method has lead to those more comfortable with quantitative methods claiming phenomenolgy is "ambiguous and ill-defined and f u l l of cryptic yet pregnant slogans" (Koch, 1964). Contrary to this accusation, phenomenology, as a research method , can be differentiated as a viable and useful qualitative approach (Ornery, 1983). The phenomenological method is both descriptive and Inductive. Researchers who u t i l i z e this mode attempt to understand the meaning of experiences, events and interactions to ordinary individuals in particular settings and situations (Bogdin & Biklen, 1982). The task of the phenomenological method is to describe through investigation a l l those phenomena, Including human experience as these appear "in their f u l l e s t breadth and depth" (Spiegelberg, 1965). In order to ensure that the phenomenon is Investigated as i t is experienced or truly appears, "phenomenological inquiry begins with silence" (Psathas, 1973). The 26 researcher must prepare to see rather than think about the phenomenon (Spiegelberg, 1976). To do this the individual must approach the phenomenon with no anticipated expectations or categories. Also as the phenomenologist has no preconceived operational definitions and is not seeking to validate an existing theory or concept, a l l research data can be accepted as given. The researcher attempts to understand and emphasizes the perspective of the participants in the experience. Phenomenological researchers strive to enter the conceptual world of their subjects in order to appreciate the meaning individuals construct around activities and events in their daily lives (Geertz,1973). The concern, then, of the researcher is both to understand the subjective perspective of the individual who has the experience and the effect that i t has on the behaviour or lived experience of that person (Morris, 1977). The goal of the method is to describe the total picture of the lived experience, including the meanings those experiences have for individuals who take part in them. Blumensteil (1973) describes the method succinctly as "the trick of making things whose meanings seem clear, meaningless and then, discovering what they mean." So where did this phenomenological method come from? Phenomenology as a method for the human sciences grew out of a philosophical movement that is s t i l l in a process of cl a r i f i c a t i o n . Researchers in the social sciences who gave form to the phenomenological methods were inspired but not bound to phenomenological philosophy. Edmund Husserl (Davis, 1973) can largely be credited with the birth of the phenomenological philosophy as a school of thought and as a method. It appears that this method began to crystallize in reaction to the denigration of philosophical knowledge 27 and the objectification of humans (Ornery, 1983). The resultant method is a solitary, introspective process that aims at "seeing the clear apprehension of the evident giveness" (Kohak, 1978). Spiegelberg (1960,1970) identified six methodological steps that are common to a l l Interpretations or modifications of phenomenological philosophy- descriptive phenomenology; phenomenology of the essences; phenomenology of the appearances; constitutive phenomenology; reductive phenomenology; and hermeneutlc phenomenology. Most phenomenological researchers in the social sciences have been Inspired by, rather than directly applying, Spiegelberg's philosophical phenomenological method, and prefer not to restrict the phenomenological approach to a sequence of steps or a structured methodology (Psathas, 1973; Morris, 1977; Swartz, 1979). The Impetus for the human sciences evolved out of what researchers perceived as the failure of the method of natural sciences to adequately explain the phenomenon the human scientists were investigating. Human science researchers believed the traditional methods of the natural sciences were too simplistic and demeaning (Ornery, 1983). The strongest impetus for this methodological development was in psychology. Van Kaam (1959, 1966) formulated the f i r s t approach. Two other much-utilized phenomenological methods are those identified by Giorgi and associates (1975) and later Calaizzl (1979). It is clear that while researchers who advocate the use of phenomenology display theoretical and methodological differences they a l l share to some degree the goal of understanding human subjects from their 28 point of view and describing human experience as i t 1s lived. This 1s one of the goals of this study. Symbolic Interactionism Symbolic interactionlsm, the dominant perspective in Social Psychology, also guides the thinking and research of many sociologists. It is a social-scientific perspective which takes a less deterministic view of human beings than quantitative perspectives and a more c r i t i c a l approach to science. Here, theorizing is generally limited to the micro level. Instead of focusing on the individual and their personality characteristics (as have classical psychologists), or on the social structure or the situation which causes individual behaviour (as have social psychologists who draw from classical sociology), symbolic interactionlsm focuses on the nature of the interaction and on the dynamic social activities taking place between persons. (Wells, 1978; Bogdin & Biklen, 1982). Symbolic interactionism emphasizes that the self evolves through the exchange of meaningful symbols with other human beings. Social l i f e and it s rewards are viewed as an emerging product of interaction (Berger & Luckman, 1967). Other Important Ideas distinguishing this perspective and related to its focus on interaction are the attention symbolic interaction pays to defining interaction, the present and the individual as an active rather than passive participant in the world. Interaction is not simply defined as what is happening between people, but also by what is happening within the person. Each individual is viewed as acting in the present. The past only enters the present as i t is recalled in the present. Finally, 29 symbolic i n t e r a c t i o n i s t s view i n d i v i d u a l s as being unpredictable and a c t i v e i n t h e i r world. I n d i v i d u a l s are seen as making conscious choices about t h e i r a c t i o n s i n r e l a t i o n s h i p t o both themselves and others, and thereby d i r e c t i n g and r e d i r e c t i n g themselves ac c o r d i n g l y (Charon, 1985). Congruous with phenomenology and b a s i c t o symbolic i n t e r a c t i o n i s m i s the assumption t h a t human experience i s mediated by i n t e r p r e t a t i o n (Blummer, 1967). I n d i v i d u a l s , o b j e c t s and experiences are not viewed as possessing t h e i r own meaning; meaning i s given t o them. People act as i n t e r p r e t i n g , d e f i n i n g , symbolic animals rather than on the ba s i s of predetermined responses t o previous i n t e r a c t i o n s or t o predefined o b j e c t s . I n t e r p r e t a t i o n i s aided through i n t e r a c t i o n with others and through t h i s i n t e r a c t i o n the i n d i v i d u a l c o n s t r u c t s meaning (Bogdin & B i k l e n , 1982). There are s p e c i f i c schools w i t h i n symbolic i n t e r a c t i o n t r a d i t i o n , the most common d i v i s i o n being between the Iowa School and the Chicago School. S o c i a l s c i e n t i s t s such as Koch i n the Iowa school conduct q u a n t i t a t i v e research, while the Chicago school which 1s derived d i r e c t l y from the work of the founders of symbolic I n t e r a c t i o n i s m , conduct q u a l i t a t i v e research ( W e l l , 1979; Bogdin & B i k l e n , 1982). Although symbolic I n t e r a c t i o n i s m can c l a i m some herita g e from German s o c i o l o g i s t s Max Weber and George Simmel and French p s y c h o l o g i s t G a b r i e l Tarde, i t i s u s u a l l y t r a c e d back t o the work of Americans George H. Mead, John Dewey, James W.I. Thomas and Charles Cooley (Me l t z e r , Petras & Reynolds, 1975). Cooley i s best remembered f o r h i s concepts of "primary group" and "l o o k i n g g l a s s s e l f " - the notion t h a t each I n d i v i d u a l ' s s e l f perception emerges from how we b e l i e v e others perceive us. Thomas i s known f o r h i s emphasis on " the d e f i n i t i o n of the s i t u a t i o n " - the idea t h a t i n terms of 30 social consequences i t is the person's perception of reality, not the reality i t s e l f that matters. Dewey, the pragmatist and philosopher, taught at the University of Chicago and was the center of the symbolic interaction c i r c l e . Much of Mead's Influence comes through the publishing of his lectures and notes by students. Equally as important is the integration and interpretation of his work by sociologists such as Herbert Blummer. He is symbolic interactions leading exponent. Blummer stresses the symbolic nature of human interaction, the existence of self and the conscious construction of the interaction within the social context (Blummer, 1969; Charon, 1985; Wells, 1979). Symbolic interactionists are c r i t i c a l of the traditional social science, with i t s use of sc i e n t i f i c methodology for studying human beings. They believe that human study must be determined by the nature of the empirical world under study. Symbolic Interactionists believe they must understand how humans; define situations, act in the present, and solve problems confronting them. This would mean a major shift in thinking for other scientists who contend the past causes present action. The symbolic interactionist c a l l s for a different direction, as summarized by Blummer (1969, p. 48): "Symbolic Interactionists believe that the determination of problems, concepts, research techniques, and theoretical schemes should be done by the direct examination of the actual empirical social world rather than by working with a simulation of that world, or with a preset model of that world, or with a picture of that world fashioned in advance to meet the dictate of some imported theoretical scheme or of some scheme of sc i e n t i f i c procedure, or with a picture of the world built up from partial 31 and untested accounts of that world. For symbolic interactionists the nature of the empirical social world is to be discovered, to be dug out by a direct, careful and probing examination of that world." A central goal then of social science, viewed by the symbolic interactionist, is the careful description of human interaction. This is achieved through careful observation of social action, description of the important elements Involved, followed by description and redefinition of these elements. Another important rule is the gathering of data through observing real l i f e situations (Charon, 1985). Denzin, who has done significant empirical work within the perspective of symbolic interactionism coined the term "Naturalistic Behaviourism" for a methodology which outlines the principles that he believes should govern sc i e n t i f i c inquiry within this tradition (Denzin, 1971). Both Denzin's description of naturalistic behaviourism and his own work in the study of deviance stand as examples of a symbolic Interactionist approach to s c i e n t i f i c investigation. Although empirical studies drawing from symbolic Interactionism are tremendously diverse, each focuses on interaction, definition, meaning and social worlds. This is the case with the present study. As such, they a l l conform to a great extent to the sc i e n t i f i c principles outlined by Denzin and are based on the data from real l i f e situations. 32 D. RESEARCH TECHNIQUES EMPLOYED IN ETHNOGRAPHY This section reviews the various techniques and methods employed 1n ethnography. Usually, ethnographers are found in natural settings and study a defined soda! unit such as "a person, a status, a type of behaviour, a relationship, a group, or a nation" (Strauss, 1970). The goal of the research "i s focused on analytic abstractions and constructions for the purpose of description, or verification, and/or generation of theory" (Strauss, 1970). In the f i r s t stage of research, the ethnographer must gain access. cultivate rapport, begin developing sensitizers and remain open to the participants and the settlngfs). The ethnographer "gains access" to the selected setting(s) by obtaining both formal and informal permission to carry out the research (Bogdin & Biklen, 1982; Burgess, 1984; Hammersley & Atkinson, 1983). At times, formal access is obtained from an authority who is not a participant in the setting(s) under study. Informal access is the primary mechanism for establishing rapport with the participants. When the goal of the research is to achieve the participants' perspective, informal access is of primary importance. Once access has been gained and rapport is developed the research can proceed. The methods an ethnographer uses to collect data in the setting include the use of a f i e l d journal, recording of f i e l d notes, formal and informal observations, Indepth interviews and documentary analysis. The ethnographer must draw up an observation schedule to outline the times when observations will be conducted. This schedule must be 33 comprehensive so as t o e n s u r e t h a t o b s e r v a t i o n s w i l l t h o r o u g h l y r e f l e c t t h e a c t i v i t i e s , e v e n t s , p l a c e s and p e o p l e 1n t h e s e t t i n g ( s ) . Once t h e o b s e r v a t i o n s c h e d u l e i s f o r m u l a t e d t h e e t h n o g r a p h e r w i l l o b s e r v e i n a c c o r d a n c e w i t h t h e p l a n . Two t y p e s o f o b s e r v a t i o n s a r e r e c o r d e d ; I n f o r m a l and f o r m a l o b s e r v a t i o n s . I n f o r m a l o b s e r v a t i o n s b u i l d a g e n e r a l d a t a base about t h e s e t t i n g and t h e p a r t i c i p a n t s , w h i l e f o r m a l o b s e r v a t i o n s p r o v i d e d e t a i l e d o b s e r v a t i o n s o f s p e c i f i c a l l y chosen a c t i v i t i e s , e v e n t s and p e o p l e . The f i e l d j o u r n a l , a r e c o r d o f t h e r e s e a r c h p r o c e s s and t h e r e f l e x i v i t y o f t h e e t h n o g r a p h e r s r o l e on t h e s e t t i n g , c o n t a i n s r e c o r d e d i m p r e s s i o n s , a n a l y t i c n o t e s , p e r s o n a l r e f l e c t i o n s and f e e l i n g s , t h o u g h t s , i d e a s and i m p o r t a n t e v e n t s as p e r c e i v e d by t h e e t h n o g r a p h e r . Two o t h e r i m p o r t a n t t e c h n i q u e s documented i n t h e f i e l d j o u r n a l a r e r e f l e x i v i t y and t h e development o f s e n s i t i z i n g c o n c e p t s . The r e f l e x i v e c h a r a c t e r o f s o c i a l r e s e a r c h r e c o g n i z e s t h a t we a r e p a r t o f t h e s o c i a l w o r l d we s t u d y . T h e r e f o r e , t h e r e i s no way we can e s c a p e t h e s o c i a l w o r l d i n o r d e r t o s t u d y 1t. T h i s i s a fundamental t e n a n t t o t h i s t r a d i t i o n and means t h e p r o c e s s o f s o c i a l i n q u i r y , t h e r e s e a r c h e r , t h e p a r t i c i p a n t s and t h e s e t t i n g a r e a l l p a r t o f t h e same r e a l i t y and t h e r e f o r e a r e a l l a component i n u n d e r s t a n d i n g t h e s o c i a l w o r l d . R e f l e x i v i t y means e t h n o g r a p h e r s must t a k e i n t o a c c o u n t t h e i r e f f e c t on t h e s e t t i n g . T h i s can be a c c o m p l i s h e d by t e s t i n g h y p o t h e s e s a g a i n s t o t h e r i n f o r m a t i o n and d a t a c o l l e c t e d 1n t h e s e t t i n g ( s ) . S e n s i t i z e r s a r e i d e a s , c o n c e p t s and t h e o r i e s t h a t emerge o u t o f t h e d a t a o r a r e t h o s e b r o u g h t t o t h e r e s e a r c h by t h e r e s e a r c h e r . S e n s i t i z e r s e n a b l e t h e r e s e a r c h e r t o d e v e l o p awareness 34 of patterns and understanding of the participants in the settlng(s) (Hammersley & Atkinson, 1983). The beginning stages of the research process have been described as being on the top of a funnel. At this time, the funnel is wide open and the ethnographer experiences a sense of confusion and bewilderment. At this time, i t is important that the ethnographer remains open to ideas, experiences and concepts. As research continues the funnel narrows and the ethnographer becomes progressively more focused and cl a r i t y develops. Stage two of the research process involves the development of an extensive data base. The informal and formal observations, followed by the interviews, serve to build this data. Ethnographic interviews are reflexive. Usually, ethnographers do not decide beforehand on the interview questions, though the researcher may develop a l i s t of issues to be covered which may reflect observations. By now the ethnographer should be an accepted and unobtrusive part of the setting(s). Sensitizing concepts, ideas, hunches and analytic notes continue to be documented 1n the f i e l d journal. If the sampling plan is not comprehensive enough, i t should be modified to capture the f u l l experience of the participants and ensure an adequate data base. At this time there can be a danger of "going native" (Burgess, 1984). This only occurs i f the ethnographer becomes so involved with the participants that there is an over identification with their perspective. The f i e l d journal 1s the place where "going native" 1s monitored to avoid premature saturation 1n the setting. The ethnographer constantly reviews the data base. Sensitizing concepts, hunches and analytic notes must be explored to determine their 35 e f f i cacy in analyzing the data. The ethnographer should take a break from the set t ing from time to time (between processes such as observations, interviews and formal ana lys i s ) , to maintain perspective and to review the emerging sens i t i z i ng concepts. This allows the theory to emerge from the data. Now, the data i s reviewed for key words, phrases, ideas, top ics , a c t i v i t i e s , patterns and themes in preparation for coding and ana lys is . Also the researcher should be aware of inconsistencies and exceptions or negative instances to emerging patterns. As the researcher focuses more s p e c i f i c a l l y on the set t ing the research process moves down the funnel. When the data base i s complete stage three, the coding process can begin. Coding (Glaser, 1978: 55): "(1) both fol lows upon and leads to generative questions; (2) f ractures the data, thus f reeing the researcher from descr ip t ion and forc ing in terpretat ion to higher leve ls of abst ract ion; (3) i s the p ivota l operation for moving towards the discovery of a core category or categor ies; and so (4) moves toward ult imate integrat ion of the ent i re ana lys is ; as wel l as (5) y ie lds the desired conceptual densi ty" . The coding categories must allow for the Inconclusiveness of a l l the par t i c ipan ts , a c t i v i t i e s , events and se t t ing (s ) . A lso , the sens i t i z i ng ideas, concepts and theory must be constantly reviewed for the inclusiveness of data. As such the ana ly t ic framework that i s developed from th i s process ar ises from the data. The ethnographer uses induction to develop a comprehensive analys is of the data. The data are coded through sens i t i z i ng concepts to develop 36 categor ies, themes and typologies which form a model for the analys is of the data. To check the analy t ic framework the frequency, d i s t r i bu t ion and t y p i c a l i t y of the categories in the emerging model are taken into account. The constant comparison method (Glaser, 1964, p. 439) i s used fo r : "(1) comparing incidents appl icable to each category; (2) integrat ing categories and the i r propert ies; (3) de l imi t ing the theory; and (4) wr i t ing the theory". This method provides a process where by the ethnographer can induct ively develop theory from the data. At t h i s point the ethnographer i s ready to t r iangulate the data and the model. Tr langulat ion en ta i l s cross va l ida t ion or comparison of data to determine whether there i s corroboration between the mul t ip le data sources (e.g. documents in and between set t ings) and mul t ip le data co l l ec t i on procedures (e.g. documents, interviews and observat ions). The f i n a l stage of ethnographic research i s l i nk ing the researchers model to theory. This i s viewed as an important part of the ethnographic research process. Glaser & Strauss (1967), who developed "grounded theory", believed the emergence of theory from data ensures a " f i t " between the theory and the soc ia l phenomena being studied. Grounded theory requires that researchers induct ive ly compare the i r data and theory, with other data and theory concerning the soc ia l world. Theoret ical integrat ion i s important i f substantive and formal theory i s to be generated. 37 E. SUMMARY In recent years interest in ethnography has grown as a reaction to pos i t iv ism and as recognit ion that t h i s t rad i t i on i s better able to provide an adequate framework for soc ia l research. Ethnographers are interested in the ways in which ind iv idua ls construct r ea l i t y and they acknowledge the fact that the researcher i s also part of the soc ia l world they study. The research process consis ts of def in ing the soc ia l un i t , gaining access to the set t ing and developing rapport to expl icate the par t i c ipan ts ' perspective and the i r experience of the soc ia l world (Hammersley & Atkinson, 1983; Strauss, 1987; Bogdin & B ik len , 1982, Strauss & Glaser , 1970). II. THE RESEARCH DESIGN This sect ion reviews ethnographic research as a methodology for t h i s research project . The research design i s presented fo l lowing which the purpose, goals and foreshadowed questions of the study w i l l be out l ined. A. ETHNOGRAPHIC RESEARCH AND HEALTH PROMOTION FOR SENIORS Despite a long standing t rad i t i on in sociology and anthropology (Becker, 1970; Blummer, 1969; Glaser & Strauss, 1967), qua l i ta t i ve methods that attempt to understand the rea l i t y of people's l i v e s , are only recently gaining c r e d i b i l i t y in human and soc ia l serv ice research. Most research in t h i s f i e l d has re l ied on quant i tat ive methodology which u t i l i z e s precise sampling s t ra tegies and s t a t i s t i c a l ana lys is , 1n an attempt to seek the facts or causes of soc ia l phenomenon and human 38 behaviour. In contrast , ethnographic research in the phenomenological and symbolic i n te rac t ion is t t r ad i t i ons , s t r i ves to understand human experience and behaviour from the actors ' perspect ive. Ethnographic methods emphasize the ind iv idual and the i r perception of experiences, events and in teract ions in the world, and therefore, produce data that i s r i c h , i n -depth and deta i led (Patton, 1980). In the f i e l d of health promotion "research questions iden t i f i ed are wide-ranging and complex" and "as such they are not eas i l y adaptable to narrowly focused short-term invest igat ions that use only quant i tat ive methods" (Health and Welfare Canada, 1989/90). Many advocates of health promotion for seniors bel ieve health promotion research needs to place increased emphasis on qua l i ta t i ve methods ( M o l l e n i l l , 1987; Mart in, Robertson & Altman, 1988; Minkler & Pasick, 1986). Ethnographic research i s pa r t i cu la r l y well sui ted to the present study which emphasizes ind iv idua ls ' perspectives about the program components and process in f i v e health promotion programs for seniors in the Vancouver area. A health promotion program involves a soc ia l organizat ion where groups of seniors in teract with health promotion coordinators in regular and structured ways. Po ten t ia l l y the behaviour of seniors and coordinators are mutually inf luenced. A lso , both groups' behaviour may be influenced by rules and re la t ions developed over t ime. In order to describe the components and factors contr ibut ing to program composition (the purpose of the research), an understanding of the perspectives and a c t i v i t i e s of the coordinators and seniors involved, i s v i t a l . As ethnographic inquiry focuses on organizations within spec i f i c contexts and provides a h o l i s t i c perspect ive, without superimposing the 39 researcher's value system on the situation, it is deemed the most appropriate method for this study. B. THE RESEARCH PURPOSE The purpose is to study the programming components and contributing factors to composition in health promotion programs for seniors in the city of Vancouver, British Columbia. C. THE RESEARCH GOALS In this ethnographic research the goals were developed to enable the researcher to gather information from a variety of perspectives on vital functions and processes. The specific goals are: 1) To examine the perceptions of both the participants and coordinators, with regard to both the program components and the factors contributing to program composition. 2) To describe and analyze program planning processes, program components and the factors which contribute to program composition. 3) To identify themes, patterns and categories from an analysis of the various perspectives. 4) To identify implications of the information gathered for future program process and development. D. FORESHADOWED QUESTIONS Health promotion programs for seniors in the city of Vancouver have a variety of components. Questions arise about these components which include: 40 1) What i s the focus of program components? (A top ic of in terest to the researcher i s the balance of focus among programs between ind iv idual behavioural change and underlying environmental and community change components. As these categories are brought to the research by the researcher they would have been abandoned, i f not app l icab le , as the research proceeded.) 2) Does the p r o f i l e of program components vary among health promotion programs? 3) What factors best contr ibute to explain t h i s var ia t ion? Some possible explanatory factors may be: - organizat ional s t ructure, e . g . , funding sources, program con t ro l , organizat ional goals and frameworks - perspectives of coordinators - perspectives of par t i c ipa t ing seniors - program s ize - c u l t u r a l , economic, and soc ia l charac te r i s t i cs of the community. E. DEFINITION OF TERMS Health Promotion Program: A program which incorporates "any combination of health education and related organ izat iona l , p o l i t i c a l and economic intervent ions designed to f a c i l i t a t e behavioral and environmental changes conducive to health" (Green, 1980). A health promotion program enables people "to increase control over and to Improve the i r health (World Health Organizat ion, 1986)." 41 Individual Behavioural Change Components: Programming that focuses upon personal health attitudes, self-management of chronic health conditions, nutrition, exercise, stress management, personal sense of purpose, personal support systems, and personal environmental awareness and participation. Underlying Environmental and Community Change Components: Programming that includes a focus on those political, economic and organizational factors that affect promotion of immediate individual behavioural change components, e.g., available community supports, self-help groups, outreach services, information networks, environmental hazards, and social and economic factors such as social isolation, poverty and ageism. Seniors: Individuals 55 years and older. Ethnographic inquiry proceeds from the position that hypotheses may emerge as the data collection occurs and the researcher is better able to appreciate the meaning individuals construct around activities. Therefore as events and experiences occur, initial tentative questions may be abandoned if subsequent data fails to support them. I I I . THE RESEARCH METHODOLOGY This section applies the ethnographic research approach to this study, in terms of the details of selecting the sample; the role of the researcher; gaining access; data collection techniques; and analyzing the data of the study. 42 A. THE SAMPLE In order to explore the purpose of t h i s study the researcher iden t i f i ed sen iors ' health promotion programs from a sample of Vancouver Health Department sen iors ' health promotion programs. The par t i cu la r programs were selected for the fo l lowing reasons: 1) These programs were s p e c i f i c a l l y labeled sen iors ' health promotion programs. In fac t , in November 1984 the Vancouver Health Department establ ished sen iors ' wellness (health promotion) posi t ions in each health unit in response to a request by the Council Committee for Seniors for sen iors ' programming. The s ta f f has been at work for s ix years implementing sen iors ' health promotion projects in conjunction with seniors and sen iors ' in terest groups in f i ve d i f fe rent areas of urban Vancouver. Together these f i ve areas make up the parameters of Vancouver C i t y . Twenty three programs were in operation when th i s research began. The f i ve coordinators e i ther i den t i f i ed ex is t ing sen iors ' in terest groups or agencies in the community, or were approached by them. The development of health promotion act iv i t ies/programs was f a c i l i t a t e d through these community groups or agencies. 2) Sat is fac tory access to the necessary groups and data appeared l i k e l y because two coordinators were approached and were supportive of the research as i t would explore program process. Program process was viewed as the key aspect of each program, and qua l i ta t i ve methods which could describe the structures and dynamics of t h i s ongoing program process were deemed essent ia l to program evaluat ion. A lso , access to indiv idual programs and seniors appeared l i k e l y because a working re la t ionship 43 already existed between the coordinators and the seniors in the selected programs. B. THE PROGRAM SELECTION PROCESS One health promotion program was selected from each of the coordinator's areas: Area One: 1 coordinator, 4 programs Area Two: 1 coordinator, 8 programs Area Three: 1 coordinator, 1 program Area Four: 1 coordinator, 6 programs Area Five: I coordinator, 4 programs Opportunistic sampling was used for program selection I.e., the researcher conducted the study in one setting per area where cooperation was most easily obtained. C. THE SUBJECT SELECTION PROCESS All five coordinators were interviewed. In each of the five settings, two categories of seniors were asked to volunteer to be interviewed. There were at least one senior from category one, and at least two seniors from category two. Table 1 outlines the subjects selected from each setting. The number of senior interviewees increased with the program size. Twenty one seniors were interviewed 1n a l l . Senior interviewees from category one, were based on the following criteria: they were active participants in program development and/or implementation; they had been program participants for at least one year; they were viewed by other seniors as a senior leader; and they were able 44 TABLE 1 NUMBER AND TYPE OF SUBJECTS SELECTED FOR INTERVIEW SENIOR PROGRAM SIZE PROFESSIONAL CATEGORY 1 Female Male CATEGORY Female 2 Male A 20 1 1 0 2 2 B 35 1 0 2 2 2 C 20 1 2 0 2 0 D 10 1 2 0 2 0 E 55 1 3 0 2 1 h is tor ians of the program. Seniors in category two met only one c r i t e r i o n ; they were program par t i c ipants . Where possible a male was selected as one of the two in category two, because very few men attended these programs and i t was deemed important to obtain a male perspect ive. D. CONFIDENTIALITY AND RESEARCH CONSENT In order to protect the in tegr i ty and r ights of the par t i c ipants , the names of the seniors , the coordinators, the programs and the i r locat ions have not been i den t i f i ed . Conf iden t ia l i t y was guaranteed to everyone as part of the consent process for par t i c ipa t ion in the research study. The coordinators were unanimous in the i r approval of the research proposal. Each health promotion program was then approached by the researcher, and approval and permission was unanimous from the seniors. Let ters of research consent and agreement to par t ic ipa te in the study are in Appendix A. 45 E. THE ROLE OF THE RESEARCHER The role of the researcher can be regarded as a range of p o s s i b i l i t i e s that f a l l on a continuum between the 'complete par t i c ipan t ' and the 'complete observer. ' Two other roles which f a l l between these are the 'par t i c ipant as observer' and the 'observer as par t i c ipan t ' (Gold, 1958; Junker, 1960; Hammersley & Atkinson, 1983; Wil l iamson, Karp, Dalpin & Gray, 1986). The 'complete observer' and the 'complete par t i c ipan t ' remain t o t a l l y d isguised, with the 'complete observer' observing from a concealed posi t ion and the 'complete par t i c ipan t ' observing by becoming almost f u l l y involved in the se t t i ng , both emotionally and behavioural ly. The two remaining roles d i f f e r according to the emphasis placed on the amount of detached observation versus act ive pa r t i c i pa t i on . The 'par t i c ipant as observer' tends to par t ic ipate yet openly states her /h is research intent ions to those being studied. The 'observer as pa r t i c i pan t ' , on the other hand, i s a more formal role and the contact with the par t ic ipants tends to be b r ie f and essen t ia l l y observation only. The 'par t i c ipan t as observer' ro le was the goal of the researcher for t h i s study. The researcher met with the coordinators and seniors to explain the purpose of the study. The researcher 's role con f l i c t was minimal as she retained su f f i c i en t elements of ' the stranger' (Gold, 1958) yet was able to develop her re la t ionships with informants to the point of intimate sharing. There was l i t t l e danger of over - ident i fy ing or 'going nat ive ' (Mal inosk i , 1922) with the seniors, because the di f ference in age and needs were su f f i c i en t to preclude the 'going nat ive ' dynamic. The 46 re la t ionship between the researcher and coordinators was somewhat d i f fe rent for the professionals had s i m i l a r i t i e s with the researcher in age and soc ia l ro le . However, the coordinators did not attend a l l port ions of the programs which decreased the opportunity for 'over rapport ' (Hammersley & Atkinson, 1983) to develop. The researcher was aware of the dynamic and t r i ed to guard against the tendency to accept the ideas and opinions of the coordinators. The seniors and coordinators were br iefed on the nature of the study and the role of the researcher. A l l observations were openly recorded in front of the par t ic ipants The researcher had conducted a small p i l o t project f i ve months e a r l i e r in one selected se t t ing . Due to the low turn over in coordinators and seniors most ind iv idua ls were fami l i a r with the researcher in t h i s se t t ing . The p i l o t project served to acquaint and sens i t i ze the researcher to seniors and the role of the coordinator. 47 F. DATA COLLECTION AND RESEARCH TECHNIQUES The researcher maintained a f i e l d d ia ry , recorded f i e l d notes of observations, conducted audio-taped interviews, co l lec ted pert inent documents, and typed the observations and interviews into a computer in a protocol format for ana lys is . This process was s imp l i f i ed with the use of a computer program ca l led The Ethnograph (Se ide l , K jo iseth , Seymour, 1988) which assisted the researcher with the mechanical tasks of protocol formatting and the categor izat ion of data. I t in no way inter fered with the ana ly t ica l process of the study. The F ie ld Diary The f i e l d diary or journal was maintained throughout the study to monitor r e f l e x i v i t y , inferences, and impressions held by the researcher. I t was used to record the researchers impressions, hunches, re f l ec t i ons , ideas and ana ly t ic notes while in the se t t ing . An example of an impression, a re f lec t ion and a hunch in the f i e l d dairy i s the entry on May 1st, 1989 which reads; When one of the wellness coordinators spoke with me today and mentioned she l i kes to close things down in the summer as fee ls the seniors need a break, I wondered who c los ing down the program was fo r , her or the seniors and who makes th i s dec is ion ; profess ionals , seniors or both. I made a mental note to observe the decis ion making process in th i s group as my hunch was professionals decide. The diary was also used to record and to monitor thoughts and fee l ings about the researcher 's ro le and her re la t ionships with seniors and coordinators. As the study proceeded, the f i e l d diary was used to 48 speculate on emerging themes, patterns and possible categories for the analys is of the data. The Field Notes As a par t ic ipant observer the researcher kept f i e l d notes each time she was in each se t t i ng . As the researcher was involved in a l l aspects of the programs, the f ie ldnotes recorded a l l a c t i v i t i e s and events that t ranspired in the programs during the informal, formal and focused observation periods. (The observation schedule i s l i s t ed in Appendix B. Examples of informal, formal and focused observations are in Appendix C.) The overt role of the researcher allowed her to openly record observations. These observations were noted in f i ve note pads (one for each se t t i ng ) . At the s ta r t of each observation the format was recorded i . e . the date, time, place and people. The f i e l d notes began with informal observations. Two informal observations were conducted in each se t t i ng . The researcher recorded the format, a general descr ip t ion of the se t t ings , the tone, dress, and a check l i s t of descr ip t ive observations out l ined by Spradley (1980, p. 78). The informal observations were general and descr ip t i ve . One example of a protocol which recorded an observation of the scene on f i r s t entering a program on May 3rd, 1989 fo l lows: OB: I a r r ive at approx. 12:45 pm and walk into the C C . I t i s a very large bui ld ing with many recreat ion a c t i v i t i e s . I am instructed to move upstai rs to the Room where 49 Program E is held. The doors are locked but a number of women are inside. I meet one volunteer (V.1) who I introduce myself to. I was able to get in saying I am the researcher. There are 9 woman busy at booths and wandering back and forth chatting. I notice 8 seniors are locked out. Inside the door there is a long table where 3 people are stationed. I understand from V.2 who approached me and introduced me to a number of the Seniors that this area is the Registration area. Two woman, V.1. and V.3. are behind the table now chatting. The table has a sign "registration" on i t . V.5. approaches me and tells me about the "Seniors in Action" day. He has some pieces of paper with him and explains that they are Info about this event on May 6th at a CC. He also has Program E's philosophy and goals. He offers them to me and tells me I can Xerox them in the library down stairs. V.1. has'pointed out 50 a l l the seniors volunteers and the i r s tat ions and takes me around and introduces me to everyone. BR: I am aware I am made very welcome. The informal stage provided the researcher with the opportunity to develop acceptance in the set t ing and sens i t ized her to the seniors, the professionals and the program schedule. The formal observation notes were more s p e c i f i c . Two formal observations were conducted in each se t t ing . The researcher documented format, rout ine, verbatim 'nat ive language' and any emotional responses that were expressed. For example, a protocol from one program describes an in teract ion between a volunteer and two seniors at the massage area: OB: I move to the foot massage area. A volunteer, 1 female and 1 male are present. The female was at the shoulder massage area before. The male i s having a foot massage. MALE: Is i t s t i l l ra ining hard? FEMALE: No. I go to get my na i l s done. I'm s p o i l t . I wasn't cut t ing them r igh t . The RN does a good job. Then I go to Eatons for a coffee. VOL: And make a day of i t . So your muscles are good. There you go. MALE: Thank-you. OB: Woman changes place with man. 51 FEMALE: I sn ' t she good. OB: She makes th i s comment to me FEMALE I fee l so good af ter t h i s treatment. I had my shoulders done too. I t was during these observations that a rapport between the researcher and par t ic ipants seemed to heighten. The focused observation notes were the most s p e c i f i c . These focused on program process and planning in each se t t ing . For example, the fo l lowing from a protocol i s a segment of a planning meeting which was attended on July 17th, 1989, were a professional i s d iscussing senior par t ic ipant involvement in decis ion making about program content with the senior volunteers. PROF: One thing I got to le t you guys know about on the 1st day back in September in stead of having a guest speaker w e ' l l use the time as an open discussion with the attenders as to what i t i s that they w i l l l i ke to have at Program E. Now we are th inking of things in terms of guest speakers but we might come up with some ideas i f you l i ke t h i s kind of impute for the a c t i v i t i e s and that kind of thing and they might even suggest . . . I t sorta w i l l be a chance to f ind out what kind 52 of things they would l i k e to see. What do you think? OB: A # speak at once nodding in agreement and verba l iz ing they think t h i s i s a good idea. No further comments are made from the seniors. PROF: So that would be between 3:00 & 4:00 instead of a guest speaker. Two focused observations were conducted in each se t t i ng . In those set t ings where spec i f i c committee meetings were held, these were attended. Where planning meetings did not e x i s t , the port ion of the program which involved program planning was observed. The Interviews Three approaches to interviewing approaches were combined in t h i s study: the informal conversational interview, the general interview guide approach, and the standardized open-ended interview (Patton, 1980). The researcher used the two l a t t e r interview approaches to obtain data that was systematic and thorough, while informal conversational interviewing was used to maintain the f l e x i b i l i t y and spontaneity of responses. The common charac te r i s t i c of a l l three ethnographic interviewing approaches 1s that they provide "a framework wi thin which respondents can express the i r own understandings in the i r own terms" (Patton, 1980, p. 205). The purpose of these interviews was to understand how seniors and coordinators viewed the program. A lso , i t was important to learn the 53 par t ic ipants terminology and to capture the i r indiv idual perspectives and experiences. P r io r to the formalized interview per iod, informal conversational interviewing took place in the observation period. This type of interview i s a phenomenological approach to interviewing in which the researcher has no preconceived ideas about what can be learned by ta lk ing to the seniors and coordinators in the program. The responses from these informal interviews and data gathered from the f i e l d observations were reviewed to move the researcher from a level of general i ty to that of a more spec i f i c nature where a set of issues could be explored in the formal interview phase (Becker, 1954). Following the observation per iod, the researcher conducted audio-taped, semi-structured interviews with a l l f i ve coordinators and 21 seniors. The coordinators and seniors in category one were each interviewed for one hour, and the seniors in category two for hal f an hour. These interviews combined the general interview guide approach with a standard open-ended interview. A set of top ics served as a check l i s t to construct open-ended questions. Interviews conducted with coordinators and seniors from category one allowed examination of the fo l lowing topic areas: h is tory of wel lness/heal th promotion for seniors in Vancouver; funding; program h is to ry ; program frameworks and goals; program focus and content; program process; senior and coordinator par t i c ipa t ion in program planning and implementation; attendance patterns; and, spec i f i c program themes. Topics d i f fe red s l i g h t l y for the seniors in category two, where the focus was spec i f i c to each program The topic areas comprised: program h is to ry ; program content and process; attendance patterns; 54 community cha rac te r i s t i cs ; and, emerging program themes. (The interview schedule i s out l ined in Appendix D. Interview Questions are l i s t e d 1n Appendix E.) The Documents Documents which provided ins ight about program a c t i v i t i e s and the process of program development were gathered from seniors and coordinators throughout the data co l l ec t i on phase . These included Health Department and spec i f i c program conceptual frameworks, goals, schedules, funding sources and minutes of pert inent committee meetings. The P r o t o c o l s The wri t ten observations from the f i e l d notebooks and the interview data were typed into protocol format. This allowed for ease of reading and coding of the de ta i l s and descr ipt ions of the a c t i v i t i e s and in teract ions in each se t t ing . See Appendix C for examples of informal, formal, focused observation protocols. See Appendix F for examples of interview protocols of a coordinator, a category one and a category two senior . The observation and interview data were typed into a computer at the end of each data co l l ec t i on per iod. The process of t ranscr ib ing data was useful in i t s e l f as i t provided the researcher with another opportunity to reread the information thus increasing her f a m i l i a r i t y with the data. Ideas, hunches and ins ights were often added to the f i e l d journal during t h i s process. 55 Once the protocols and the documentary data were reviewed for patterns, categories and themes th i s became the data base for coding and analyzing. G. DATA ANALYSIS The underlying assumptions of ethnographic research suppose a lack of separation between the data co l l ec t i on and the analys is phases. As such, data analys is was continual throughout t h i s research study. Like most ethnographic s tud ies, t h i s project did not begin with a theory or hypothesis to tes t . I t should be noted however, that the researcher was interested in the balance of focus among selected health promotion programs between indiv idual behaviour change and environmental and community change components, which i s an idea brought to the research from the l i t e ra tu re (Minkler & Pasick, 1986; Minkler, 1983). However, t h i s tentat ive question would have been abandoned i f subsequent data f a i l e d to support i t . In t h i s way the researcher was most interested in the perceptions, experiences and processes that emerged from the set t ing and these data were analyzed to ident i fy pat terns, themes and categories of understanding (Glaser & Strauss, 1976). Ideas, hunches, emerging s e n s i t i z e r s , patterns, themes, categories and ana ly t ic notes were documented in the f i e l d diary as data was co l lec ted from observations, interviews and documents. The researcher used sens i t i z i ng ideas and concepts to more f u l l y explain the p r o f i l e of program components and contr ibut ing factors to program composition. The constant comparison of data and sens i t i z i ng concepts resulted in the development of coding themes and categories (Glaser, 1964). This 56 process of inductive analys is produced themes and categories in two ways. Some emerged d i r ec t l y from seniors and coordinators e .g . soc ia l in teract ion and support, housing, outreach, and from the program plan ( i n i t i a l l y i den t i f i ed in the p i l o t p ro jec t ) , while others that they did not label or name were noted by the researcher e .g . program organizat ion and process, attendance and community issues. I t should be noted that soc ia l support and attendance were unanticipated categor ies. Socia l support, a s ign i f i can t theme to the seniors , emerged from the program plan category. Although program plan was a frequent category in the p i l o t project , i t was unnecessary to further explore th i s as a theme in the research study. Instead the comparison of program p ro f i l es became important using the sens i t i z i ng concepts ' Ind iv idual Behaviour Change' and 'Environmental and Community Change Components,' brought from the l i t e ra tu re . Program process and organizat ion was the most frequently occurr ing category wi thin and across the set t ings . I t was also evenly d is t r ibu ted across the data sources. This category became the core concept of the developing model. Tr iangulat ion was used to cross va l idate or compare information in order to determine whether there was corroboration of the data across time, across people, across methodological techniques and to pinpoint theory pert inent to the research. In soc ia l research the researcher i s warned to avoid re l iance on a s ing le piece of data as there i s danger that undetected error in the data production process could render the analys is incorrect . In t h i s study i t was just as important and i l luminat ing to look for d i f ferences between the 57 types of data as to look for diverse kinds of data that lead to the same conclusion. For example, a Health department document proposed a framework for health promotion for older adults that would address both indiv idual behaviour change and underlying environmental and community change components in health promotion programming for seniors (Mart in, Robertson and Altman, 1988), yet spec i f i c program out l ines included no community and environmental change elements. S im i l a r l y , interviews conducted with coordinators and seniors shed l igh t on s i m i l a r i t i e s and di f ferences in perspect ives. Par t ic ipant observation allowed the researcher to view which program components actua l ly ex is ted . In t h i s example t r iangu la t ion promoted comparison of information between mult ip le data sources and among mul t ip le data co l l ec t i on procedures, as i t involved that which was documented, which was commented on through interview and which was observed by the researcher. I t i s an important technique in f i e l d research that theory must ar ise from and " f i t " the data (Bogdin & B ik len , 1982; Burgess, 1984; Hammersley & Atkinson, 1983). The researcher reviewed the data and categories to l ink the theoret ica l concepts emerging from the data to ex i s t i ng theory. For example as concepts related to personal autonomy and control were out l ined in documentary data and made reference to by coordinators and seniors , i t became evident that v ic t im blaming, empowerment and helplessness were concepts emerging from the data. Also as sen iors ' involvement in program process and organizat ion was a c lea r l y desired ob jec t ive , and as organizat ional goals are a facet of organizat ional behaviour, organizat ion theory i s relevant to t h i s study. 58 The conclusions w i l l discuss l i t e ra tu re and theory related to senior par t i c ipa t ion in program process and organizat ion of health promotion programs and how th i s af fects sen iors ' empowerment and con t ro l , and the focus of the programming. I f however, the researcher was to conduct addi t ional analys is of the substantive theory and acquire material from other studies which pertained to a data category, she could end up with a formal theory for a conceptual area such as how the decis ion making process af fects autonomy and control of groups within soc ie ty . This f i na l stage i s beyond the goal of t h i s present research. 59 CHAPTER 3 THE PLACES, THE PEOPLE AND THE EMERGING ISSUES This chapter provides a descr ip t ion of f i ve wel lness/heal th promotion programs from observat ion, interview and documentary data. Each descr ipt ion includes program h is to ry , content, funding, organizat ional s t ructure, wel lness/heal th promotion approach and the demographics of each local area in which the program i s located. A descr ip t ion of the par t ic ipants and professionals involved i s given. Emerging issues from each program are discussed using the ana ly t ic headings; program organizat ion and process, attendance, soc ia l in teract ion and support, and community issues (housing, community involvement, outreach). These emerging issues are presented in the order of the frequency they occurred in each program. F i n a l l y , each program i s summarized ou t l in ing pert inent data from the descr ip t ion and discussion of emerging issues. I . PROGRAM A A. DESCRIPTION Program A began in 1987 at a local community center in urban Vancouver. The community in which i t i s located contains about 32,000 residents (Canada Census, 1986), 21% of whom are seniors 55 years and o lder . Although 85% of the residents have Engl ish as the i r mother tongue, the ethnic d i ve rs i t y i s large. Ethnic representation at Program A includes; Eng l ish , Sco t t i sh , French, East Indian, Chinese and Ukrainian. The community contains a mix of low to high Income fami l ies and s ing le residents. Housing var ies from s ing le to mult ip le dwel l ings, of which 70% are rented and 77% are apartment and duplex in type. This i s a community 60 in t rans i t i on where affordable mul t ip le resident dwell ings are s tead i ly being demolished and replaced by expensive duplex and quadruplex condominiums. Program A i s a j o i n t l y sponsored endeavour between the Vancouver Health Department and a community center. A needs assessment conducted by a community developer, hired by the Health Department led to i t s incept ion. Seniors were asked to ident i fy health promotion needs at a health forum. Following th i s a Seniors Advisory Committee was formed and seniors, in partnership with Health Department s ta f f , began to plan and implement neighbourhood health programs. Program A i s one of these. Although th i s program has no d i r ec t l y funded pos i t ions , a wellness coordinator who i s paid by the Health Department, implements and, where necessary, f a c i l i t a t e s t h i s and other senior wellness programs in Community A. As w e l l , one community center s ta f f member who conducts seniors programming, has input into the development and ongoing running of the program. Space i s provided by the community center. Program planning occurs on an ad hoc basis between seniors and profess ionals . The community center provides an exercise inst ructor and the wellness coordinator f a c i l i t a t e s d iscussions. The program i s a " f ree heal th-re lated program for ind iv iduals 55 years p lus . " I t operates on Wednesdays 10:00 a.m. - 12:00 p.m., throughout the year. The average attendance i s 20 people, four of whom are men. Program components include; "fun and f i t ness exerc ise" , "once a month blood pressure monitoring"."refreshments", and "d iscussion on health related top i cs , chosen by the par t i c ipan ts . " 61 Although there i s no o f f i c i a l wel lness/heal th promotion approach, the wellness coordinator adopts "A Framework for Health Promotion: Older Adu l ts " , a draf t document produced in 1988 by the Vancouver Health Department. Here the goal i s to "promote the phys ica l , mental, s o c i a l , and personal wel l -being of older adu l ts , using st rategies a f fect ing both the indiv idual and the environment." Seniors support t h i s broad perspect ive, though the i r primary focus i s on ind iv idual l i f e s t y l e change. B. EMERGING ISSUES Program Organization and Process Program organizat ion and process, which concerns how seniors are involved in the decis ion making process and the running of the wellness program, i s the most typ ica l of a l l issues that emerged about Program A. The professionals and seniors d i f f e r in the i r b e l i e f s . Though seniors are verbal ly encouraged to be involved through mechanisms such as the Seniors Advisory Committee, act ive par t i c ipa t ion i s often blocked by profess ionals . Conversely, seniors give a double message to profess ionals ; while they say they want to be involved, the i r act ion often indicates they would rather not take on planning and leadership respons ib i1 i t i es . One professional gave the message that "seniors should be helped to fee l l i k e they are gett ing control over programming," which can be "achieved by (us) s ta r t ing where they are and working in partnership with them, "where they are seen as a resource and we are working with what they have rather than with what we think they need"; however other professionals have taken act ions that do not support t h i s philosophy. For 62 example, when a proposal for an Outreach Program was submitted to a federal funding agency by the seniors, i t was vetoed by a community center professional group which had designated i t s e l f to address seniors needs. The seniors wanted a part-t ime coordinator of outreach a c t i v i t i e s . However, the professional group contacted the funding agency and suggested the seniors were capable of running the program themselves. Over time the seniors f e l t so stymied by these professionals that they "got discouraged" and "gave up" on the idea. The message from professionals i s that they know what seniors need. This message i s also given by the Seniors Advisory Committee. This committee though formed to act as a consult ing body on seniors needs, has not allowed senior leaders to share the i r perspect ives. In turn , the seniors present a mixed message about the i r involvement in program organizat ion and process. On the one hand some speak about how they have t r i ed to be involved in program planning but are constantly disregarded by profess ionals . "We t r i ed to acquire outreach funding" but "got discouraged." "We make suggestions to professionals l i ke what topics we want to ta lk about, but as far as running the group we don't have any say." One sen io r ' s perspective represented others on the funct ioning of the Seniors Advisory Committee by saying, "I get the impression that there are cer ta in professionals within that group who are making the decisions for people." The other common response from seniors was one of reluctance and lack of motivation to par t ic ipa te in program decis ion making. Comments varied from "seniors lack the commitment" and "seem reluctant to be 63 involved" to "we are supposed to make decis ions" but "we only have so much energy" and "we don't want to give that much t ime." Attendance Seniors and professionals agree that although there are mult ip le reasons for senior attendance at Program A, soc ia l in teract ion and support i s of primary importance. Attendance patterns are influenced most by gender di f ferences and the i nd i v i dua l ' s proximity to the program. Although the program i s predominantly u t i l i z e d by women, there i s a be l ie f that "there are men out there" , who could come but "are re luc tant . " One of the attending men bel ieves "reluctance i s a psychological th ing. I think men are on the whole quite int imidated by large quant i t ies of women." Other seniors bel ieve "men are not interested in exercises and s o c i a l i z i n g " , that "maybe they don't see i t (the program) as the i r t h ing " , or that "they are too shy" and "not as motivated as women to jo in th ings . " Many seniors and professionals however are surprised at the number of men who do come. I t i s in terest ing to note that th i s program began with one man and three women, and there has always been a man in the group. Another factor a f fect ing attendance patterns i s the proximity of ind iv idua ls to the program. A number of people f e l t that the community center i s "too fa r away for many to come" and that others are put of f by "a big h i l l to climb when coming from a cer ta in d i r e c t i o n . " Some seniors had been keen to s ta r t an out reach program in another part of t h i s community because of those access problems. 64 Community Issues Housing. Housing emerged as an issue for th i s group as seniors had concerns about tax and rental increases, and f e l t the i r neighbourhoods were changing adversely. Although professionals indicated seniors could take control by "speaking out," seniors were l e f t fee l ing "discouraged" and "without a l te rna t i ves . " The housing c r i s i s was viewed as a "very serious business". "What seniors are worried about i s how much the i r taxes have increased th i s year" , "rents doubled but incomes d idn ' t " and "with taxes up what i s the s ing le person going to do about an apartment. I t ' s very expensive, more than any amount of money that most of us have with the old age pension". These concerns lead to discussions on the " lack of a l te rnat ives" and expression of " fears and resentments" such as "to l i ve within our means a lo t of people are having to leave th i s area" and "rental stocks are decreasing." Many were "angry" and concerned that "the neighbourhood i s changing" and fears were expressed that "seniors are being kicked out of t he i r places and having to go to another area altogether that i s af fordable" . Those who owned homes were concerned " i f we s e l l where do we go?" Professionals suggested taking control in some way. Such as "wr i t ing l e t te rs to government", attending "housing forums" and making "phone c a l l s to a local number establ ished to deal with tax and rental concerns." Though some seniors followed through with these ideas many f e l t the changes "were inev i tab le" and f e l t "discouraged" and helpless as there was l i t t l e they could do to e f fect change. 65 Out Reach. Out reach i s the process and programming involved in reaching out to seniors who are not attending a wel lness/heal th promotion program. A group of seniors , with the support of one pro fess iona l , submitted a proposal to a federal agency to fund a part-t ime posi t ion to coordinate out reach a c t i v i t i e s . Professionals inter fered with th i s process and eventual ly the seniors gave up and withdrew the proposal. There were however, seniors in the group who were unenthusiastic about involvement in out reach a c t i v i t i e s . One professional stated that "at one point seniors wanted to do out reach and organized a proposal requesting funding for a part-t ime out reach person, where that person could work with the group to f ind out what programs seniors want. In the middle of t h i s process along came a group of profess ionals , and they a l l said they (the seniors) d idn ' t need a programmer, that they could to i t themselves." However the seniors "d idn ' t want to take the respons ib i l i t y on, they wanted to work with someone to do the out reach". They "never agreed" with the professionals but then the funding agency "agreed the seniors should do i t themselves". Seniors supporting these comments said "we t r i ed to get the grant and a l l we got was the run-around so we dropped i t for a wh i le " , as the funding agency kept "changing the ru les" . One senior said we "don't want to go from door to door as we f ind i t hard to knock on doors of perfect st rangers". This comment was made in support of an out reach coordinator who would invest igate how best to acquire information and u t i l i z e the seniors in the program in a way they fee l comfortable. 66 Although professionals were viewed as in ter fer ing in t h i s process, i t should be noted that there are those seniors that don't appear enthusiast ic about out reach. The fo l lowing comments h ighl ight t h i s : "a considerable number of people are happy to come on Wednesday but they are not pa r t i cu la r l y concerned with having more people", or "they think i t would be desirable but not essen t ia l " and "so some are for out reach, but i f you look at the 14 other people here and ask them about out reach, I think you would get a t a c i t agreement, yes that would be a good thing but don't involve me in i t " . Community Involvement. Community involvement includes sen iors ' par t i c ipa t ion in a c t i v i t i e s outside the wel lness/heal th promotion program. Although community center s ta f f encouraged senior involvement in organized t r i p s into the community, those community oriented a c t i v i t i e s most pursued by seniors, such as volunteering and out reach, did not receive support by most profess ionals . Although Seniors were encouraged to attend organized t r i p s , volunteering was the community a c t i v i t y most frequently discussed by seniors. Many of those who attend Program A are involved in volunteering and indicated that t h i s has been and w i l l continue to be an important aspect of t he i r l i v e s . Seniors suggested "we a l l were used to doing community work and volunteer work" or that they do i t because "seniors have to keep busy i f they don't they stay at home a l l the time and tha t ' s no l i f e . " A number spoke of the importance of the soc ia l component of volunteer ing. "Although we are working, so we don't have a chance to chat that much, I 've made a lot of f r iends there (Red Cross) . " 67 I t i s noteworthy here that volunteering was pursued without much professional encouragement. Out reach was one example of senior involvement in a community a c t i v i t y which was not supported by profess ionals . The exception was the wellness coordinator who saw "the program as an entry point for a number of women who then volunteer or get involved on some committee." Also t h i s indiv idual kept the par t ic ipants abreast of issues in the community that af fect seniors , so they had information of meetings and forums in which they could par t i c ipa te . Soc ia l Interact ion and Support Socia l in teract ion and soc ia l support are the primary reasons why seniors par t ic ipa te in Program A. Seniors come ear ly and leave la te , taking time to chat on a one-to-one basis or in small groups. Both seniors and professionals acknowledge the importance of t h i s aspect of the program. "Friendship i s the primary component of the program" and " f r iends are (viewed as) a health i ssue . " The program is seen as a place for " fe l lowsh ip" , "soc ia l support", "companionship" and "to make f r i ends . " The program i s considered to be important as i t provides "a place to ta lk " and "a chance to be with adul ts" fo l lowing retirement. Program A i s seen to provide "a car ing environment" where there i s "support when spouses d ie" and "a lo t who are iso lated can come and met new f r i ends . " I t i s seen as "more soc ia l than phys ica l " and that seems to explain "why we s ta r t a hal f hour ear ly to have a l i t t l e chat before we get into the exerc ise . " I a lso noticed that people stay la te and chat af ter the 68 program and some commented they "walk home" together and sometimes "go out for lunch". C. SUMMARY Program A has operated for over three years at an urban community center. On average twenty women and four men regular ly attend a predominantly l i f e - s t y l e oriented program. Components include; exerc ise, once monthly blood pressure checks, refreshments and heal th-re lated discussion groups. Seniors acknowledge the importance of a soc ia l component through the i r ear ly a r r i va l and staying af ter the program to chat. The only community issue discussed was housing. Although Program A is based on a wel lness/heal th promotion approach which claims to promote senior involvement and par t i c ipa t ion in program planning and implementation, professional dominance has negatively influenced seniors attempts to take control of , and to expand programming. 69 II. PROGRAM B A. DESCRIPTION Program B began at a Unit of the Vancouver Health Department in the f a l l of 1984. This unit i s in a loca l area of Vancouver which contains a population of 25,000 people of which 26% are seniors. Here, there i s a mix of low to middle income fami l ies and s ing le residents. This community has a var iety of ethnic populations of which Engl ish, Chinese, Punjabi, and German make up 88% of the population (Canada Census, 1986). The mix of program attenders was as fo l lows; Engl ish, German, Chinese, I t a l i a n , and one East Indian. The housing mix i s predominantly single-detached homes (76%) and mul t ip le family dwell ings (13% duplex, 7% apartment). 68% of these dwell ings are owned (Canada Census, 1986). Program B i s j o i n t l y sponsored by the local Seniors Network Society and the Vancouver Health Department. This program began af ter the Seniors Network was approached by a wellness coordinator to j o i n t l y implement a seniors wellness program. The wellness drop-in has no d i r ec t l y funded pos i t ions , but the services of the wellness coordinator, a nurse, and a volunteer coordinator are funded by the Health Department and a paid Seniors Network member plays a leadership ro le . Senior volunteers provide the manpower to maintain the weekly programming and the space i s furnished by a Health Uni t . The program i s free and operates every Monday, year round between 10:00 a.m.- 1:30 p.m. The average attendance i s 35 people, a th i rd of whom are men. I t i s " for persons 55 years and better" and " i s based on the be l i e f that people who have access to health information and opportunit ies for physical f i tness and gett ing to know each other, w i l l 70 feel better and have more energy." Program components include: blood pressure and weight checks, neck, shoulder and foot massage, exerc ises, re laxat ion, a luncheon and a wellness topic of in teres t . Although there i s no o f f i c i a l de f i n i t i on of wel lness/heal th promotion, both seniors and professionals embrace a "who l i s t i c " focus to health in which "phys ica l , mental and soc ia l aspects" are a l l important to "qua l i ty of l i f e " . The professionals add a focus on the "environment", " se l f care" , and the use of "community development s t ra teg ies" to " t ry to give seniors the s k i l l s to look af ter and maintain the i r hea l th . " B. EMERGING ISSUES Program Organization And Process Program organizat ion and process, the most typ ica l theme of Program B, concerns issues of senior leadership, "cooperative decis ion making" and whether or not seniors are "encouraged to use and share the i r own resources." In fac t , decis ions are made by seniors v ia volunteer committees, and then presentation to the larger group where discussion and consensus occur. A partnership ex i s t s between leaders (both professional and senior) and seniors (both volunteers and non-volunteers), that fosters seniors drawing on the i r own resources to run the wel lness/heal th promotion program themselves. Although one senior and one professional were iden t i f i ed as the pr inc ipa l leaders or "the spark p lugs" , the primary decis ion making occurs through planning meetings of small groups of senior volunteers. One senior put t h i s w e l l - "there are d i f fe rent ones, (who) form a group of people who w i l l run the speakers or what ever we do." Suggestions are 71 then "put before the group and we see what they th ink . " Leaders are not viewed as in te r fe r ing in t h i s process. "Well there i s a leader you know, but the leader we can not c a l l a leader in the sense of saying, you do th i s and that . The leader keeps every thing in order and keeps a l ink between one thing and another." The majority of seniors who attend the program are involved in some way. The volunteers "meet in September each year and organize for the reg is te r ing , massage, ta l ks and other jobs . " Cooperative decis ions are made about most aspects of the program inc luding; "volunteer involvement", "program changes", "problem so l v ing " , issues of space", "summer programs", planning the " t a l ks " and se lec t ing and scheduling "summer t r i p s . " As one senior said "we kind of keep i t as democratic as poss ib le . " Senior leaders and professionals play a d i f fe rent role from the senior volunteers and general program par t i c ipants . The professionals see themselves as " f a c i l i t a t o r s and advocates and hopeful ly stay out of the way so they (the seniors) can run the i r own show." One year ago the wellness coordinator encouraged the senior leader to ask the group for volunteers. This resulted in the formation of the ex is t ing committees. At t h i s time a s h i f t in process took place from a leader taking charge, to the creat ion of a partnership with seniors, where cooperative decis ion making resu l t s . Attendance Although there are mult ip le reasons for attendance at Program B, the "number one" given i s " fe l lowsh ip . " This program i s predominantly 72 attended by women. Gender di f ferences and seniors proximity to the program have the most impact on attendance patterns. The most c i ted reason for attendance was, " fe l lowsh ip . " This incorporates; the "company", because " i t i s a f r iend ly p lace" , where "there are nice people to ta lk to" and that people are "accepting" and "receptive to new people." Another reason frequently mentioned was "gett ing out". In exploring th i s i t appears that some feel "there i s nothing for older people to do" and "they feel alone by themselves" so " i t gets them out" and provides "a place to pass the t ime". The professionals share th i s perspective and bel ieve some seniors attend because they have " l o y a l t i e s " to cer ta in volunteers. Gender d i f ferences were viewed as having the most inf luence on who does and doesn't come to the program. Although i t i s acknowledged that there are more women that men in the senior age group, other reasons are given for the marked di f ference in numbers between the sexes. These include: "we haven't got the pattern of a c t i v i t i e s they want" or "men tend to be rec lus ive" and are "more reserved" or "too shy". Some believed "the men in the i r 60's and 70's (who) come for B.P.s only" attend for "the break in routine" and "to chat ." I t was f e l t that "women are more involved in things l i ke t h i s as are more s o c i a l . " 73 Socia l Interact ion and Support Seniors and professionals agree that soc ia l in teract ion and soc ia l support are the primary reasons why people attend. Comments from seniors support t h i s ; "number one i s fe l lowsh ip" , and " there 's an at t i tude generated where everybody i s welcome." The program provides an a l ternat ive from " s i t t i n g home" and a place "to get out with other people where "you can shoot the breeze and people know who you are" . Many said "when you t a l k , you f ind you have the same problems" and "you forget your t roub les . " A couple of seniors mentioned that "soc ia l in teract ion i s important i f you are going to have physical hea l th" . Observation c lea r l y indicted the importance of the soc ia l aspect to people. Seniors sat and chatted throughout the program in groups, over cards, while wait ing for blood pressure checks, over lunch and during the other a c t i v i t i e s . Some spoke in the i r own languages and mentioned that t h i s was important to them. There was a constant buzz of chatter . Community Issues Community Involvement. Par t i c ipa t ion in and contr ibut ion to a number of community a c t i v i t i e s and events i s supported by seniors and profess ionals . Volunteer work i s the primary means through which people par t i c ipa te . This i s not surpr is ing as i t i s the major mechanism used to encourage involvement in Program B. Most of the seniors interviewed f e l t " i t ' s important to help. One senior leader mentioned that " i f you analyzed the group, most of them (Seniors) are involved in something else in the community." The types of 74 a c t i v i t i e s mentioned were "meals on wheels", "dr iv ing people to doctors" and running "exercises and re laxat ion" at other wellness programs. Information about community a c t i v i t i e s was d is t r ibu ted by leaders and non-leaders, usual ly at lunch time. Small volunteer tasks were undertaken by the group during Wellness Drop-In time. Summer t r i p s were organized to take senior wellness par t ic ipants out into the community. I t was general ly f e l t that people were encouraged "to contr ibute" and "share the i r resources", however there are those who do not par t ic ipate and th i s also appears acceptable. Out Reach. Out reach, although l im i ted , does e x i s t . I t was the professional and senior leader who iden t i f i ed present out reach a c t i v i t i e s and could see the potent ia l fo r expansion in t h i s area. The phone t ree , a form of soc ia l support where seniors who don't attend for 2 or 3 weeks are contacted by phone, was the only outreach a c t i v i t y i den t i f i ed by seniors. A l l other a c t i v i t i e s related to out reach were iden t i f i ed by profess ionals . For example senior volunteers share the i r resources through running exercise and relaxat ion classes in two seniors bui ld ings in t h i s community. A health f a i r i s being planned which the professional hopes w i l l encourage seniors to share ideas and resources. Apparently a funding agency has approached the program about providing funding for a short term project and the professional has suggested to the senior leader that the funds could be used "to t ra in seniors to do bereavement counse l l ing . " 75 C. SUMMARY Program B which i s located in a Unit of the Vancouver Health Department has been in operation for over f i ve years. On average 35 seniors attend regu lar ly , of whom a th i rd are men. Though the program components (exerc ise, re laxat ion, blood pressure checks, massage, luncheon, refreshments, health related presentations) are predominantly l i f e - s t y l e in focus, professionals have stepped back from taking control and seniors d i rec t program planning, implementation and s ta f f program a c t i v i t i e s . Out reach, though l im i ted , i s conducted and the soc ia l component i s well integrated into program a c t i v i t i e s . I I I . PROGRAM C A. DESCRIPTION Program C, one of many seniors programs in a seniors center, began in 1986. This center i s located in a part of Vancouver which contains a population of 5,900. Seniors aged 55 years and over make up 26% of the residents. The area contains a mix of low to middle income fami l ies and s ing le residents. Housing var ies very l i t t l e with 98% of the dwell ings being rental apartments. 79% of the senior population l i ve alone. This local area contains a mix of ethnic populations inc lud ing: French, Chinese, German, Ukrainian, Hungarian, Po l ish and Dutch. Engl ish (72%) make up the majority group (Canada Census, 1986). Program C draws a mixed c l i e n t e l e of "mostly Caucasian" (Engl ish, Sco t t i sh , I t a l i a n ) , "a couple of F i l i p i n o s " , "several Chinese" and "One East Indian." This mix i s affected by the fact that many attenders t rave l here on foot or by bus from other local areas. 76 The wellness program is j o i n t l y sponsored by the Seniors Center and a Unit of the Vancouver Health Department. I t began when the wellness coordinator was approached by an ex is t ing seniors group at the center. They wanted a wellness program s im i la r to that in another area of Vancouver. Although th i s program i s staf fed and funded by the seniors center, serv ices are also provided by a wellness coordinator and a nurse who are paid by the Health Department. Decisions about programming are made by these professionals and two senior volunteers at a monthly Wellness Committee meeting. The senior volunteers a lso provide the manpower to run the weekly program. The program i s free and operates on Mondays from 1:00- 3:00 p.m. Par t ic ipants are "55 years and bet ter . " The average number of attenders i s 20 people, of whom 6 are men. Program components include; weekly blood pressure and weight checks, fun and f i tness exerc ise, and a health related presentat ion. There i s no o f f i c i a l wel lness/heal th promotion approach at th i s center. However seniors iden t i f i ed "keeping healthy in mind and body" as a common theme, while professionals focused more on the process, seeing the p r i o r i t i e s as "bu i ld ing leadership, providing information and working with professionals to teach them how to get seniors to pa r t i c i pa te . " B. EMERGING ISSUES Program Organization and Process Program organizat ion and process was the most t yp ica l theme of Program C. Professionals believed seniors should "par t ic ipa te in creat ing a wellness program" through being given control of decis ion making and 77 ongoing program development; however act ive par t i c ipa t ion by general par t ic ipants i s not encouraged. Only one mechanism ex is ts for senior involvement. Seniors must become "volunteers" and then they can attend monthly Wellness Committee meetings where program planning and decis ion making occurs. Indeed senior par t ic ipants did not see themselves as involved in program decis ion making except for those who are designated as senior volunteers. The fo l lowing comments indicate t h i s ; "I don't know who gets them (the speakers that i s ) , I never get asked". In response to being questioned i f the group i s asked what they want, a senior volunteer mentioned, "no, t ha t ' s a good idea and we should ask them i f they want to par t ic ipate in the volunteering, some of them cou ld . " A un i la te ra l decis ion was made by the professionals about c los ing the program during summer as they fee l "the seniors need a break". A number of seniors said that although " i t s good to have (a break), some seniors would come." The only means for par t ic ipant involvement i s through the volunteers. One volunteer commented that "occasional ly they (the par t ic ipants) w i l l come up to you and say I wish we had a program on such and such. I ' l l say O.K." These suggestions are taken to the monthly meeting. Two volunteers and two professionals (a program coordinator employed by the seniors center and a wellness coordinator employed by the Health Department), are members of the Wellness Committee. The volunteers perceive the meetings as par t ic ipatory and that "everyone gives the i r ideas." However, cooperative brain storming and decis ion making was not apparent during observation. Seniors did make suggestions about par t ic ipant involvement, content and t iming of a c t i v i t i e s , but these were 7 8 often ignored by professionals leaving communication of ideas on these matters to the professionals alone. Attendance The wellness program draws "a mix" of people who attend pr imar i ly for the " f r i ends . " Non-attenders are said to be those who are not able "to walk" or "catch a bus." Although there are a number of reasons why people attend the program, a need for soc ia l contact i s the most frequently mentioned. Seniors said they were " looking for f r i ends " , or they " l i ked the f r iends they'd made" and " l i ked to see them every week". A number mentioned how the exercise segment was important to them, and i t soon became apparent that they enjoyed in teract ing with the volunteer who runs t h i s segment of the program. "Blood pressures" were thought to be the biggest drawing card for the men. Other reasons given for attending were, for "something to do", to l i s t e n to "the speakers" and because "I l i ke to he lp . " Program C draws a mixed c l i e n t e l e . " I t ' s a changing d rop- in . " Even though "most of the people who drop-in l i ve nearby", "there are people from Ker r i sda le " , the "North Shore" "and quite a few come from Burnaby." A number mentioned they also attend other wellness programs. Mobi l i ty inf luences who does and doesn't attend. Seniors must be able to "walk over" or be "well enough to get the bus." Apparently the attendance of men "has dropped o f f " . One senior wondered i f i t was because "there are too many women." Another said "men don't come for the exercise as they fee l too shy." Apparently "a few men used to come and jo in in the program but then they dropped of f and now a lo t play ping pong" instead. Other 79 reasons given for non-attendance were; "some go to other places and prefer i t bet ter" , "some people prefer to go to programs in the i r own area" and one volunteer wondered i f the numbers " f e l l of f when the nurse wasn't here and then a couple of times the speakers d idn ' t show." Although "the numbers have increased since winter" (1988), i t i s f e l t by both professionals and senior volunteers that "the program could fo ld at any t ime." This be l ie f leaves one with a sense of a tentat iveness about the future of the program. Socia l Interact ion And Support Program C provides a place for soc ia l contact and interact ion for seniors. Many said "I l i ke to meet f r iends and come to ta lk to them." Others mentioned "they need to mix around with people and ta lk otherwise they get lonely" or " the i r f r iends have died and i t ' s a place to meet some new people." One senior volunteer noted that although i t i s "a place they kind of get together, they don't rea l l y t a l k . " Seniors and professionals both agree that the soc ia l aspect of t h i s program is of primary importance. One professional f e l t attendance was influenced by the exercise inst ructor as "they rea l l y enjoy her and so at t h i s point i f she l e f t , a lo t of people would stop coming." I t i s also in terest ing to note that many of the men who attend for blood pressure checks s o c i a l i z e over the ping-pong table which i s just around the corner from the open space used for the program. 80 Community Issues There were no data on community involvement, housing or outreach. This program does not advocate community involvement although the exercise volunteer did mention a "Seniors S t ru t " , and one professional le t seniors know what other a c t i v i t i e s were scheduled in the center. The program components focus on indiv idual l i f e s t y l e and behavioural change issues. C. SUMMARY This program has operated for over four years and i s one of many programs run at a seniors center. Average attendance i s twenty people, approximately s i x of whom are men. Program components include; blood pressure, weight checks, exercise and a health related presentat ions, which are l i f e s t y l e in focus. Although professionals claim to f a c i l i t a t e senior leadership and par t i c ipa t ion they dominate program decis ion making and planning. No community issues are addressed by t h i s program. IV. PROGRAM D A. DESCRIPTION Program D began at a community center in 1988. The local area in which the community center i s located, comprises about 19,000 (Canada Census, 1986) residents of whom 26% are seniors over the age of 55 years. This community contains a mix of middle to high income fami l ies and s ing le residents. 79% of seniors here l i ve alone. Most dwell ings are owned (85%), of which 88% are s ing le detached houses and 11% are duplexes and apartments. A number of houses and apartments have recently been demolished and replaced by larger homes and condominiums. Many residents 81 fee l t h i s i s changing the face of the neighbourhood. The ethnic combination of t h i s area i s pr imar i ly Engl ish (86%). A lso , small numbers of Chinese, German, French, and Greek residents ( to ta l 9%) l i ve in t h i s area. The wellness program exempli f ies th i s mix with a l l attenders being Caucasian except for one Chinese woman. Program D i s co-sponsored by the local community center and a Unit of the Vancouver Health Department. I t was implemented by a senior volunteer. Short ly a f ter i t ' s inception a wellness coordinator approached the members of the program and the community center s ta f f , and became involved. This wellness program has no d i r ec t l y funded pos i t ions , although i t u t i l i z e s the services of the wellness coordinator from the Vancouver Health Department and space plus some s ta f f input from the community center. Senior volunteers and a re t i red nurse of fer the i r services to run sections of the program. Program D i s free and operates on Tuesdays from 9:00 a.m. - 12:00 p.m., a l l year. I t serves seniors "55 years and bet ter . " An average of 10 women attend each week. Program components include: once monthly blood pressure checks, shoulder massage, fun and f i tness exerc ise, refreshments, and a discussion sect ion on a broad range of top ics . This program has developed no o f f i c i a l de f i n i t i on of wel lness/heal th promotion. However, both senior and professional interviewees agreed, that a wel lness/heal th promotion approach considers; "body, mind, s p i r i t and companionship" as well as "using knowledge" as essent ia l ingredients The professional also adopts "A Framework for Health Promotion: Older Adults" as a health promotion approach. She adds that "wellness i s a process" and therefore the role of the professional i s to f a c i l i t a t e what 82 a group or ind iv idual "establ ishes wellness or qual i ty of l i f e to be to them." 1 B. EMERGING ISSUES Program Organization and Process Program organizat ion and process i s the most typ ica l theme in th i s se t t ing . Leadership roles and respons ib i l i t i e s are not c lea r l y del ineated, resu l t ing in overt confusion and con f l i c t between one senior and a professional leader. These ind iv idua ls hold d i f f e r i ng perspect ives; the professional supports cooperative decis ion making and senior involvement, while the senior leader wants no professional interference and wants to maintain the status quo. This tension between the designated leaders i s not i den t i f i ed as an issue by the par t i c ipants . Seniors value both leaders' contr ibut ion to the program and feel they are involved. The designated leader started the program and views hersel f as the leader. She fee ls "we rea l l y don't need the Department of Publ ic Health" and that the professional involved "has taken over" and " i s not rea l l y needed." Her view of the Health Department's role i s "to provide f l u shots and equipment." She stated that "the seniors ran the discussion up un t i l when the professional 'took i t over' and c lea r l y indicates a preference for con t ro l l i ng the program independently without professional inter ference. Tension was obvious and was expressed in t h i s statement "I'm not sure where I f i t in and what I'm supposed to do." The professional views the s i tua t ion quite d i f f e ren t l y , perceiving her role as a " f a c i l i t a t o r " who therefore "looks to the senior par t ic ipants for the dec is ions" . She would l i ke to see them more involved 83 in the program e .g . taking blood pressures, par t i c ipa t ing more as volunteers wi thin the program and involv ing themselves in out reach projects. The senior par t ic ipants did not voice an opinion about the ex is t ing power struggle and strongly valued both leaders contr ibut ion to the program. To them the senior leader "runs exercises and massage" and the professional acts as a resource and i s involved in the discussion sect ion. They had taken on the role of se lec t ing and organizing topics with encouragement from the profess ional . There was no expression of concern by seniors about the i r lack of involvement in other components of the program. Socia l Interact ion and Support Although seniors gave many reasons why they attend Program D i t i s c lear that soc ia l support and soc ia l in teract ion are of primary importance to the group. Professionals agree and observations support t h i s perspect ive. Seniors tend to ar r ive ear ly and stay for the refreshments af ter exerc ises. Both periods were busy with chatter . The d iscuss ion, though not personal per se, does allow for seniors to ta lk about issues for which they need support e .g . housing. The s ign i f i cance of the soc ia l element of the program to seniors was apparent by the i r comments; "a lo t come in to chat" , or " for the companionship", "the s o c i a b i l i t y " , and "the in teract ion with people." Another senior pointed out how th i s support network i s s i gn i f i can t ; "Seniors shouldn't be alone. At least t h i s i s a thing where everybody shows up and i f some one doesn't show up for a couple of times someone 84 phones." A professional stated t h i s i s a place "they can get together and have a nice chat. Somewhere they are rea l l y welcome". Community Issues Housing. The housing c r i s i s was a very s ign i f i can t issue in the Vancouver area while t h i s research was conducted. This local community was affected as housing pr ices sky-rocketed leaving seniors concerned about large tax increases and the lack of housing a l te rna t i ves , should they choose to s e l l the i r homes. The view held by the senior leader and professional d i f fered from the par t i c ipants . They perceived housing as a non-issue to t h i s group. Seniors described the c r i s i s as "a traumatic th ing" and stated they were " f r ightened." They said they were "angry" about the " increase in taxes" . They spoke about wanting to keep the i r "own homes and that (they) almost f e l t pressured to s e l l . " Also they expressed concerns about " lack of housing a l te rna t i ves . " Some of them were "very worried about moving. Where would we go?" Some said they "don't want to leave the area and i f they had rental apartments they would be a l l r i gh t . " Others stated they "wouldn't subject themselves to renting as tha t ' s too uncer ta in . " The senior leader f e l t housing wasn't an issue at a l l saying "I'm s ick of l i s ten ing to i t . I t ' s not an issue for th is group." In terest ing ly she stated she f e l t housing was only brought up as an a issue because the professional was interested. The professional appeared to agree with th i s senior , s ta t ing that as "most owned the i r own homes, housing has never been an i ssue . " However, i t was apparent that ind iv idual senior par t ic ipants did hold fears about the housing c r i s i s and appreciated discussing i t . 85 Community Involvement. Although announcements were made about some community a c t i v i t i e s such as t r i p s with other seniors wellness programs and involvement with the "Seniors In Action Day"; volunteer ing, out reach and community involvement were not encouraged through the program. Seniors agreed, saying "we are not rea l l y encouraged" though one senior said "one time we were asked to help out with f l u shots and a fun run but otherwise we are not encouraged." The professional believed " th i s group was ready for some out reach a c t i v i t i e s " saying "they rea l l y wanted a project to do". However, t h i s was not stated by any of the interviewees. Attendance Program D i s attended pr imar i ly for " s o c i a l " reasons, by "act ive" people a l l of whom are women. Although various reasons for attendance were stated- "they enjoy the a c t i v i t y and exerc ise" , "the discussion makes i t very in te res t ing" , " i t ' s an opportunity to get out" , and " i t ' s close and convenient"- the need for "soc ia l support" and " s o c i a b i l i t y " were the ones most valued. The seniors and professional bel ieve that men don't come because "they do not want to be involved in a program f u l l of women, because they fee l overpowered, threatened and in t imidated." Also "another aspect i s that s o c i a l l y , men have depended on women and for them, when they are re t i red or widowed, to come out in a group, i s rea l l y a monumental task. " 86 Seniors and the professional viewed attendance s i m i l a r l y . The professional added that she f e l t "the iso la ted person w i l l never attend these groups unless the group i s healthy enough to reach out" to them. C. SUMMARY Program D i s located in an urban community center and has been operating for one year. Though the program i s predominantly l i f e s t y l e in focus (blood pressure checks, massage, exerc ise, refreshments and health related d iscuss ions) , community issues (housing, environmental hazards) are discussed. Socia l components are well integrated into programming. Though con f l i c t was apparent over leadership roles between one senior (who started the program) and a professional (who bel ieves seniors in the program should be given greater opportunity to par t ic ipa te in program planning and implementation), par t ic ipants were s a t i s f i e d with the leadership and program content. V. PROGRAM E A. DESCRIPTION Program E, the f i r s t health promotion program for seniors in Vancouver started at a downtown community center in 1984. The local area i s a diverse sel f -contained community which has a population of about 37,000 (Canada Census, 1986) people of which 23% are seniors. This area contains a mix of low to high income fami l ies and s ing le residents. Although th i s community comprises a var ie ty of ethnic groups, 77% are Engl ish. French, German, Po l i sh , Chinese, Spanish and Hungarian make up 12% of the populat ion. This ethnic mix i s repl icated at Program E. 91% 87 of residents rent, and 99% l i ve in apartments. One of the important changes over the las t few years has been the demolit ion of more and more low cost accommodation. The wellness project developed out of the area 's Seniors Network. Seniors and Vancouver Health Department s ta f f organized a Health Fa i r in June 1982 to promote se l f - ca re for seniors. After the f a i r many seniors expressed an in terest to continue with a program. Three wellness workshops funded by the Health Promotion Directorate, Health and Welfare Canada, were conducted by a wellness consultant between Apr i l 1983 and Apr i l 1984. A number of indiv idual seniors who attended these workshops became wellness volunteers and with the assistance of Vancouver Health Department s ta f f , the program began. Program E remains a co-sponsored endeavor between the Seniors Network and the Vancouver Health Department. A community center provides space. Program E had no funded pos i t ions . A wellness coordinator, a nurse and a coordinator of volunteers, paid by the Vancouver Health Department, ass i s t with the ongoing development and running of the program. A number of wellness volunteers maintain the weekly funct ioning of the drop-in and are involved in program planning through a monthly combined Volunteer/Advisory Committee Meeting. Appointed Network Volunteers, one community center s ta f f member and three Health Department professionals also attend these meetings. The program i s a "a community program of se l f -he lp and support by seniors for seniors 55 years and up who are Seniors Network members. The average number of attenders i s 55 people, of whom approximately 15 are men. I t operates Wednesdays 1:00 p.m. - 4:00 p.m, a l l year except for August. 88 Program components include: blood pressure checks, one-to-one hands on relaxat ion (shoulder and foo t ) , community resource information, refreshments, a c t i v i t y tab le , exerc ise, weekly speaker sec t ion , peer counsel l ing and consul tat ion from occupational therapy, physiotherapy, nu t r i t i on , pharmacy and nursing on a rotat ing basis . Special events take place throughout the year. The fo l lowing o f f i c i a l de f i n i t i on of Program E was developed by the professionals and volunteers; "wellness i s the maximization of a person's phys ica l , emotional, soc ia l and s p i r i t u a l wel l -being both through indiv idual e f fo r t and community ac t i on . " B. EMERGING ISSUES Program Organization and Process Program organizat ion and process i s the most typ ica l theme of t h i s program and addresses issues of senior /professional leadership, namely whether seniors u t i l i z e the i r own s k i l l s and resources and who i s involved in the running and decis ion making process of the program. Although seniors are encouraged to be involved, the only mechanism ex is t ing for t h i s i s to be a wellness volunteer. This en t i t l es seniors to par t ic ipate in running the program and attendance at the monthly Volunteer Meetings. Here, the majority of the decisions af fect ing programming are made. The meetings are attended by senior volunteers (both of Program E and the loca l Seniors Network) and a small number of professionals from the Vancouver Health Department and the community center. Discussion occurs and decisions are made about program "philosophy, goals, changes, speakers" and issues to do with the ongoing running of Program E. Only 89 the senior volunteers and the professionals attend these meetings. The other par t ic ipants have minimal input into program design and implementation, except through the occasional "brainstorming sess ion" . Senior par t ic ipants and volunteers view one senior and one professional as the primary leaders, but the other volunteers are also acknowledged for the i r leadership ro le . Planning meetings are general ly run by profess ionals . One senior volunteer (regarded as the senior leader) was asked cont inual ly for her opinion and the other wellness volunteers were encouraged by professionals to share the i r views and par t ic ipate in the decis ion making process. Although volunteers and professionals a l i ke bel ieve attenders have input into the program, senior par t ic ipants interviewed did not perceive t h i s , saying, "although we do make a comment occas iona l ly , we don't give input because we are not volunteers." Professionals stated they "would l i ke to see more input from seniors" and "need more volunteers" to expand the program. Professionals noticed that at volunteer meetings "people t ry to refer decis ions" to them, but the professionals t ry to take respons ib i l i t y only for "those things that are rather urgent or something of a medical nature", and otherwise attempt to turn issues and decisions back to the group. Attendance Program E i s attended by " a l l kinds" of seniors, predominantly "women." They come for mul t ip le reasons, pr imar i ly for "soc ia l contact" and "support." "Men" and "people who don't get out in the community" are seen as the non-attenders. However, i t i s also c lear that some of the 90 attenders do not have any other community involvement except for th i s program. Seniors and professionals share the same perspectives on attendance issues. The " a l l kinds" of people include: seniors who are "mainly women because they l i ve longer"; ind iv idua ls "se t t led in t h i s area" ; those who have "chronic i l l n e s s " ; or suffered " losses of partners" and "are smart enough to attend (because) they have always been looking out for themselves." This program also "reaches a lot of people not involved in other th ings . " Although "blood pressure" i s viewed by many as a major drawing card espec ia l ly for the men, many come for the "speaker" sect ion , or "because they see th i s as a l ink to the community they don't otherwise have." The primary reason for attendance however, i s "companionship" and the "support that happens when people get together." Seniors and professionals agreed that i t i s "old people who don't want to help themselves and can ' t get out and get involved with any body or any th ing" that don't attend. Men were viewed as non-attenders because they are "a f ra id to be amongst so many women", where "women are in charge" and that they e i ther "tend to withdraw and i so la te " or are " involved in other th ings . " Community Issues Community Involvement. Program E's philosophy encourages seniors to par t ic ipa te in the community and partake in "community ac t ion" . However, the focus on these concerns i s " l im i ted" to minimal volunteer involvement, the wr i t ing of an occasional l e t t e r to government about seniors ' issues 91 and announcements during the program to par t i c ipants . On occasion senior volunteers have spoken to local p o l i t i c i a n s about seniors issues. I f community act ion i s deemed necessary, t h i s program's perspective i s represented by the local Seniors Network. The general par t ic ipants hear about community concerns, meetings and events through the occasional announcement ("Seniors in Action Day", "Environmental Act ion Conferences" and "Housing Forums"). Seniors are "not pressured" to partake in community act ion and th i s they are "pleased about." Beyond "the one-on-one peer support" that the volunteers and professionals o f fer par t i c ipants , " t h i s program tends to l ink i t s e l f as part of the Network" when community act ion i s necessary, as professionals and senior volunteers " fee l the larger number speaks volumes in comparison." "On occasion we (professionals and volunteers) have wri t ten le t te rs or a statement", about seniors issues. Housing. A "housing c r i s i s " ex is ted, which affected t h i s program's res idents, while th i s research was conducted. Housing was viewed as a major issue by both seniors and profess ionals , who f e l t "he lp less" and without "a l t e rna t i ves . " Housing was discussed by speakers and through announcements; also seniors could ta lk on a one-to-one basis with peer counsel lor volunteers. "Anxiety" was apparent about the fear of "bui ld ings being demolished" and the "s t ress of seniors being evicted not only from the i r homes but from the i r community." "Enormous rental ra ises" and the sh i f t from rental accommodation to "unaffordable" condominiums l e f t seniors with the be l ie f 92 that there were "no a l te rna t i ves . " They f e l t "discouraged", "harassed" and "he lp less . " Professionals and senior volunteers also expressed the i r impotence with t h i s matter with statements such as, "I fee l harassed, everyone wants housing and I can ' t t e l l them anything" and " i t seems as though a l l of these groups have to get together but t h i s has been going on for years and they have lost t he i r enthusiasm." A pervasive fee l ing of helplessness was apparent during t h i s period. Out Reach. Out reach emerged as a theme during the interview (data co l lec t ion) phase and was viewed as an issue only by professionals and senior volunteers. They envision expansion of the ex is t ing program into other areas of the local community, although f inanc ia l support and manpower are viewed as res t r i c t i ng t h i s v i s i o n . Out reach was not discussed by par t i c ipants . Soc ia l Interact ion and Support Socia l in teract ion and support are of primary concern to the seniors of Program E. Seniors, volunteers and professionals a l i ke acknowledge t h i s . Even though some seniors " s i t and stare while wait ing for blood pressures" or may not "make s ign i f i can t re la t ionships" with others in the program, a l l have an opportunity to in teract with other seniors and receive support in a soc ia l se t t ing . Seniors commented that they attend Program E "as much for the soc ia l i za t i on and support as anything e l s e . " Some stated "we've made new f r i ends" . Others said "you've got someone to ta lk to every week about 93 what ever i s concerning you, l i k e housing and f inances" and that i t i s an "out let when you can ta lk about your troubles and, once you're through you know that the senior volunteers keep an eye on you." Professionals agree that seniors "can ta lk with people they feel are supportive" and even i f "they don't make f r iends they do es tab l ish s ign i f i can t re la t ionsh ips . " A l l comments c lea r l y indicate the importance of soc ia l in teract ion and support in t h i s program. C. SUMMARY Program E, located in the downtown core, has been in operation for s i x years. Program components are pr imar i ly l i f e s t y l e in focus, however senior peer counsel lors also address community issues such as housing, f inances and soc ia l i so la t i on on a one to one basis with seniors. The majority of soc ia l in teract ion occurs while seniors and senior volunteers are engaged in a program a c t i v i t y . Informal soc ia l i za t i on between members i s l im i ted . The seating arrangements are not conducive to soc ia l in teract ion between members. On occasion, program leaders (professionals and senior volunteers) advocate p o l i t i c a l , economic and s t ructura l changes they bel ieve would enhance seniors posi t ion in soc ie ty . Though volunteer seniors are deeply involved in program planning and implementation th i s i s l imi ted for par t i c ipants . 94 CHAPTER 4 PROGRAM FOCUS AND FACTORS CONTRIBUTING TO PROGRAM COMPOSITION This chapter presents a cross analys is and in terpretat ion of data pertaining to program component focus and factors contr ibut ing to program composition. I t i s claimed that wel lness/heal th promotion programs have tended to focus pr imar i ly on indiv idual behavioural factors such as; personal health a t t i tudes, management of chronic i l l n e s s , d ie t , exerc ise , s t ress management, personal support systems and personal community awareness and pa r t i c ipa t ion . Minimal focus has been placed on those p o l i t i c a l , economic and organizat ional factors which keep seniors impoverished, s o c i a l l y iso lated and disadvantaged (Health Services & Promotion Branch, 1986; Minkler & Pasick, 1986). The sect ion below, PROGRAM COMPONENT FOCUS, presents data that supports t h i s c la im. Also the s i m i l a r i t i e s and var ia t ions of program focus among the programs studied are presented.. Then the sec t ion , FACTORS CONTRIBUTING TO PROGRAM COMPOSITION, discusses those elements (Program Organization and Process, Program Attendance Patterns and Rationale) that best explain program make up. The s i m i l a r i t i e s and var ia t ions of these factors among the programs studied are presented. 9 5 I. PROGRAM FOCUS In order to promote health and implement a wel lness/heal th promotion approach, Health Promotion Programs for Seniors incorporate a number of a c t i v i t i e s or components. For the convenience of t h i s research these a l l f a l l into two core areas; Individual behavioural change components and Underlying community change components. Tables 2 and 3 are schematic representation of the components in each program studied. This sect ion analyzes the extent to which Individual behavioural change and Underlying community change components are included in the programs studied. In pa r t i cu la r , i t establ ishes that the components across a l l programs are predominantly focused on indiv idual behavioural change. I t a lso presents the s i m i l a r i t i e s and var ia t ions of program components among the programs. 96 TABLE 2 INDIVIDUAL BEHAVIOURAL CHANGE COMPONENTS PROGRAMS A B C D E PERSONAL SUPPORT SYSTEMS X X X X X e .g . soc ia l a c t i v i t y , luncheon, refreshment break, summer t r i p s EXERCISE X X X X X e .g . yoga, modified aerobics, dance PERSONAL HEALTH ATTITUDES X X X X X e .g . health related discussion NUTRITION X X X X X e .g . health related d iscuss ion, weight checks STRESS MANAGEMENT X X X X e .g . massage, re laxat ion , coping s k i l l development SELF MANAGEMENT OF CHRONIC X X X X X HEALTH CONDITIONS e .g . through health related sharing and d iscuss ion, blood pressure monitoring, weight checks PERSONAL SENSE OF PURPOSE X X X X X e .g . volunteer ing, par t i c ipa t ion in decis ion making, community projects PERSONAL ENVIRONMENTAL X X X X AWARENESS AND PARTICIPATION e.g . summer t r i p s , d iscussion of environmental awareness, community pro jects , volunteering 97 TABLE 3 ENVIRONMENTAL AND COMMUNITY CHANGE COMPONENTS COMMUNITY PROBLEMS e .g . housing, out reach transportat ion COMMUNITY SUPPORT e .g . information sharing and re fer ra l SOCIAL ISSUES e .g . ageism ORGANIZATIONAL CONTROL POLITICAL ACTION e .g . seniors issues ECONOMIC e .g . poverty, program funding ENVIRONMENTAL HAZARDS e .g . crime, arch i tec tura l ba r r i e rs , environmental concerns PROGRAMS A B C D X E X X X A. INDIVIDUAL BEHAVIOURAL CHANGE COMPONENTS ' Ind iv idua l behavioural change components' are defined to include programming that focuses upon personal health a t t i tudes , self-management of chronic condi t ions, nu t r i t i on , exerc ise, s t ress management, personal sense of purpose, personal support systems and personal environmental awareness and pa r t i c i pa t i on . The welcoming, f r i end ly environment of each program provide attending seniors with a personal support system. A l l but Program C provide refreshments or a luncheon component which allows time for soc ia l in teract ion and support amongst members, volunteers and professionals. 98 Exercise, run by senior volunteers (with the exception of Program A) i s an integral part of a l l the programs. A pos i t ive image of senior involvement in exercise i s presented which helps to d ispel ageist be l i e fs commonly held by professionals and seniors about exercise and aging. Blood pressure monitoring, and health related discussion which speak to personal health a t t i tudes, nu t r i t i on , s t ress management and se l f management of chronic condit ions are addressed by a l l the programs. Spec i f i c s t ress management techniques are offered by a l l but one program (Program C) in the form of massage and re laxat ion exercises (Programs B, D, E) or coping s k i l l development (Program A). Senior volunteer pos i t ions , which are avai lab le in a l l programs, provide an avenue for seniors to draw upon the i r own resources and engage in meaningful a c t i v i t y for others, thereby addressing personal sense of meaning. Some par t i cu la r var ia t ions in programming are noteworthy. The more establ ished programs, such as Program E and Program B, use a broader array of a c t i v i t i e s to address indiv idual support systems and personal environmental awareness and pa r t i c ipa t ion . In par t i cu la r Program E i s the only one to o f fer information, support and re fer ra l through the provision of peer counsel l ing and ava i lab le brochures. Peer counsel l ing i s a spec ia l i zed form of soc ia l support which denotes intervent ion from a volunteer who i s a non-professional. Rather than being formally t rained in counse l l ing , peers o f fer support through the depth of the i r experience and an a b i l i t y to empathize and problem-solve which t h i s tends to produce. Program E i s the only one to o f fer a luncheon program. Here, a soc ia l context for eating i s provided for those seniors who may have 99 apathy towards food, thereby addressing not only soc ia l support but an underlying environmental cause of poor nu t r i t ion in the senior population. Both Program E and B conduct projects and organize summer t r i p s which provide opportunity for the development of personal support systems and encourage personal environmental awareness and pa r t i c ipa t ion . Two smaller programs (Program A and D) use in terac t ive discussion groups to address issues of personal support, personal sense of purpose, personal health issues, and personal environmental awareness and pa r t i c ipa t ion . Here, the professionals act as f a c i l i t a t o r s encouraging and supporting the par t i c ipa t ion of a l l members in co l l ec t i ve decis ion making and discussion of health related topics of in te res ts . Program A further employs par t ic ipatory discussion to share ideas on stress management and se l f management of chronic i l l n e s s . Senior involvement in community-based volunteer work which addresses personal sense of purpose and personal environmental awareness and par t i c ipa t ion i s encouraged by Programs A, B and E. B. UNDERLYING ENVIRONMENTAL AND COMMUNITY CHANGE COMPONENTS 'Underlying environmental and community change components' can be addressed when programs include a focus on those p o l i t i c a l , economic and i organizat ional factors that af fect promotion of immediate indiv idual behavioural change components for example through the a v a i l a b i l i t y of community supports, se l f -he lp groups, out reach serv ices , information networks, and by addressing soc ia l and economic factors such as soc ia l i s o l a t i o n , poverty, environmental hazards and ageism. 100 A l l except Program C combine a focus on indiv idual health behaviour with broader e f fo r ts aimed at helping seniors bring about changes in the i r environment. I t i s in terest ing to note that t h i s i s the only program that does not service a par t i cu la r community. I t i s located in the downtown business core and the majority of i t ' s members t ravel from other local areas of Vancouver. Three p o s s i b i l i t i e s to explain why community issues are not addressed include; these are viewed as unimportant, they are addressed by other serv ices within the seniors center, and professional dominance hinders senior involvement to such a degree that these issues do not emerge. Those programs which do address community issues d i f f e r markedly in how much e f fo r t and on which elements, they focus. Some concentrate more on immediate community problems, while others focus on broader economic and soc ia l issues such as soc ia l i s o l a t i o n , poverty and ageism. Most focus on these issues through discussion rather than group or community act ion. The housing c r i s i s was an immediate community issue in cer ta in l o c a l i t i e s at the time of the research, and became a focus for Program A, D and E. Affordable mult ip le resident dwell ings and apartments were being demolished and replaced by expensive duplex and quadruplex condominiums leaving many seniors concerned about tax and rental increases, ev i c t i on , and lack of affordable a l te rna t i ves . Two programs (A and D) shared ideas on methods and avenues for community act ion through group d iscuss ion. None of these programs took group ac t ion , though seniors were encouraged to do so by the professionals who led the d iscussions. Program E on the other hand, has, on occasion, responded to soc ia l and economic issues a f fec t ing seniors, but usual ly i t l i nks i t s e l f to a Seniors Network when 101 community act ion i s necessary. Program E, peer counselors provide information and re fer ra l on a one-to-one basis for seniors concerned about spec i f i c housing issues, however the focus i s on ind iv idual adaptation rather than community change. The soc ia l support ava i lab le to those who attend these programs i s not necessar i ly accessib le to many iso lated seniors who need support to venture out, or who l i v e too far away and have no means of t ransportat ion. Out reach, which i s seen as one means of addressing t h i s problem, i s only conducted by one program. Two senior volunteers from Program B conduct exercises and relaxat ion in a seniors bui ld ing in the i r local area. Seniors at Program A t r i ed unsuccessful ly to acquire funding for th i s purpose. Though i n i t i a l l y enthusiast ic to invest igate the needs of iso lated seniors in the i r area, t h i s group gave up af ter they were blocked by professionals who did not agree they needed the assistance of a paid coordinator. Program E spoke about wanting to provide out reach to another part of the i r community but stated they needed funding and addi t ional manpower to implement t h i s successfu l ly . The only program to address economic factors that e f fect the promotion of ind iv idual behaviour change i s Program E. Peer counselors discussed these issues on both a one to one and at the group l e v e l . A lso, senior volunteers have been known to par t ic ipate in community act ion through le t te rs and d i rec t dialogue with local p o l i t i c i a n s . Po ten t i a l l y , senior par t i c ipa t ion in formal and informal organizat ional structures provides a mechanism to address ageism. Ageism is a presumption held by many professionals that older people have less to o f fer as they age. In fac t , a l l the advisory boards and committees were 102 implemented to encourage and support seniors to work in partnership with professionals to encourage seniors to draw on their own resources and eventually take control of programming. Programs differ markedly as to how much control professionals relinquish to seniors. Some professionals appear to give only 'lip service' to senior input, while others (professionals involved with Program B) foster and encourage senior input at all levels, to the point that seniors run the program with only minimal professional consultation. Professional versus senior control of health promotion programs will be discussed further in the next section. C. SUMMARY Although most of these programs have moved far beyond a disease-oriented focus and consider seniors as physical, psychological and social beings who interact with their environments, they s t i l l focus heavily on the isolated individual as the target of change efforts. The underlying environmental and community change factors such as poverty, poor housing, poor transportation, negative societal attitudes and status and role change, although acknowledged are only superficially addressed. II. FACTORS CONTRIBUTING TO PROGRAM COMPOSITION In the process of examining health promotion programs for seniors, themes emerged which shed light on how these programs are organized and managed, and on the patterns and rationale for attendance. This section discusses four emerging issues presented in Chapter 3 (wellness/health promotion approach, organization and process, attendance, and social interaction and support), which are viewed by the researcher as factors 103 that contr ibute to program composition. The emerging issues are addressed under the fo l lowing headings: Program organizat ion and process (wel lness/health promotion approach, organizat ion and process) Program attendance patterns and rat ionale (attendance, soc ia l in teract ion and support) These issues are presented in order of the frequency with which they emerged from cross-program comparison. A. PROGRAM ORGANIZATION AND PROCESS The way Wellness/Health Promotion Programs are developed, organized and managed most s i g n i f i c a n t l y inf luences program composition. The organizat ional structures of programs are expected to be based on a wel lness/heal th promotion approach which highly values process in the form of sen iors ' pa r t i c i pa t i on , seniors ' empowerment and partnership between seniors and profess ionals . Three s t ructura l leve ls among programs provide t h i s opportunity: as a general par t ic ipant in general planning meetings; as a volunteer s ta f f member in formal and informal committees; and as a member of a seniors advisory board. This sect ion shows how the program composition and var ia t ion among the programs studied are influenced by: 1) the appl icat ion of a wel lness/heal th promotion approach; 2) varying degrees of structure within the programs; 3) the roles of seniors and profess ionals ; 4) funding; 5) and the h i s t o r i c a l development of wel lness/ health promotion programs for seniors in Vancouver. 104 Appl icat ion of a Wellness/Health Promotion Approach Seniors ' pa r t i c i pa t i on , sen iors ' empowerment and partnership between seniors and professionals are iden t i f i ed as elements of the organizat ion and process of wel lness/heal th promotion programs in 'A Framework for Health Promotion: Older Adul ts ' a draf t document' which "sets out the framework and mandate of The Health Departments wellness a c t i v i t i e s " (Vancouver Health Department, 1988). These notions are incorporated into the object ives of th i s document which fo l low: "OBJECTIVES: I t i s necessary to mobil ize and coordinate community resources, ( inc luding Health Department resources), to accomplish the object ives of : 1) d i spe l l i ng the myths commonly associated with aging; 2) enabling older adults to develop and/ or maintain phys ica l , mental and soc ia l wel l -being and autonomy;and 3) encouraging and supporting older adults to draw upon the i r own resources and take control of t he i r own health promotion programming. In t h i s approach older people are par t ic ipants in a dialogue with the health professional who presents ideas for considerat ion. The community group and the professional exchange the i r views on heal th, al lowing them to learn from each other while valuing the i r separate experiences and knowledge. By including older people as partners in the planning, development and implementation of programs, the process also provides opportunit ies for meaningful a c t i v i t y which increases the older 105 person's sense of con t ro l , the i r fee l ings of ef fect iveness and the i r contacts with other people." However, in order for t h i s approach to be implemented seniors must be ac t i ve ly involved at a l l planning and s ta f f ing l eve l s . The value and implementation of senior par t i c ipa t ion in volunteer s ta f f , committee and advisory board posi t ions w i l l be discussed la ter in th i s sect ion (Varying Degrees of St ructure) . Here, the par t i c ipa t ion of general senior members i s discussed. Program B, i s the only program which has a system whereby general par t i c ipants , uninvolved in volunteer or committee a c t i v i t i e s , have the opportunity to give regular input about program focus and organizat ion. This occurs at general planning sessions held, when necessary, during weekly announcement periods. One senior put th i s we l l , "d i f ferent seniors form a group of people who run the speaker sect ion or what ever other a c t i v i t i e s we have. So they put the plans before the group and see what they th ink. " Three programs have general member par t i c ipa t ion which i s l imi ted to one program component, the speaker or d iscussion sect ion. Program E involves par t ic ipants in brainstorming discussion topics however, t h i s i s l imi ted to a yearly occurrence. Programs A and D use group decis ion making to formulate agendas for upcoming discussion groups. In a very informal atmosphere, both seniors and professionals present ideas for considerat ion, and consolidate planning. A number of seniors interviewed indicated they were not given adequate opportunity to par t ic ipate in program planning and decis ion 106 making unless involved at the volunteer l e v e l . The fo l lowing comments support t h i s perspect ive: - "We make suggestions to professionals l i ke what topics we want to ta lk about, but as far as running the group we don't have any say "(Program A) . S imi la r comments are made about Program E. -"I don't know who gets them(the speakers), I never get asked." (Program C). In t h i s program, no mechanism ex is ts for input about programming by senior members at a l l . -"Although we do pass a comment occas iona l ly , we don't get asked (for input) because we are not volunteers." (Program E). F i n a l l y , one other response should be noted. Some seniors were reluctant and lacked motivation to par t ic ipa te in the decis ion making process. Comments such as; "some seniors lack the commitment" (Program A, B, E) , to "we are supposed to make decisions but we only have so much energy and we don't want to give that much time" (Program A) , a r t i cu la te t h i s point of view. Although professionals claim to support senior d i rec t ion and control of wel lness/heal th promotion programs, the present lack of organizat ional structures (with the exception of Program B) , l im i t s th i s process pa r t i cu la r l y at the general par t ic ipant l e v e l . Varying Degrees of Structure The extent to which seniors are valued and par t ic ipa te at the volunteer s t a f f , committee and advisory board member l eve l s , d i f f e r s among programs. Table 4 i s a schematic representation of the leve ls of structure among programs. 107 TABLE 4 VARYING DEGREES OF PROGRAM STRUCTURE A B PROGRAMS C D E Par t ic ipant planning meetings health X topics only health top ics only 1x/ year Volunteer s ta f f meetings X X Program Planning meetings -Professionals and Seniors X X X Seniors Advisory Board meetings X X Of the f i ve programs, Program E has the greatest degree of s t ructure. At the time of the study, t h i s program was characterized by c lear formalized posi t ions and l ines of author i ty. These include: monthly meetings which regular ly include senior volunteers, Seniors Network representat ives, Health Department s ta f f (wellness coordinator, volunteer serv ices coordinator) , and community center program coordinator; a wr i t ten agenda and minutes; and o f f i ce space which i s s l i g h t l y more formal than other programs. The strengths of such a structure are that a l l groups associated with the program can be responsive to emerging program issues as a l l facets of program planning and implementation are addressed within t h i s group. Senior par t i c ipa t ion i s highly valued. A l im i ta t ion however, i s that general par t ic ipants are not v i s i b l y involved in program planning and decis ion making and few new faces have joined the senior volunteer ranks since t h i s program's inception s i x years ago.. 108 Program C's organizat ional structure i s s im i la r to Program A, but on a smaller sca le . The Wellness Committee (senior center program coordinator, wellness coordinator and three senior volunteers) meet on an ad hoc basis and conduct a l l program planning and decis ion making. The same strengths and l im i ta t ions apply as with Program E with the addi t ional l im i ta t ion that input from senior volunteers was observed to be undervalued by profess ionals . In terms of s t ructure, committee and volunteer s ta f f members in Program B shun the notion of h ierarchies and appear to avoid behaviours which may in fer formal i ty or bureaucracy. A l l seniors who attend are involved in some capacity in the ongoing planning, decis ion making and s ta f f i ng of program a c t i v i t i e s . Seniors refer to the structure as "democratic" viewing the senior leader and professionals as "spark plugs" in the process. One senior stated th i s we l l : "There i s a leader you know, but the leader we can not c a l l a leader in the sense of saying, you do th i s and that . The leader keeps everything in order and keeps a l ink between one thing and another." The strengths of such a structure are that Program B i s able to be responsive to the emerging needs of seniors in the i r community. The corresponding l im i ta t ions of such a loose structure might include some d isorganizat ion. Programs A and D could be described as ly ing between the Program E and Program B in terms of the i r organizat ional s t ructure. Seniors, in partnership with profess ionals , are highly involved in planning the speaker sect ion of these programs. No other organizat ional structure ex i s t s in Program D, so there i s no forum for senior or professional par t i c ipa t ion in other aspects of program development and implementation. 109 In Program A, other structures do ex is t but permit l imi ted input from seniors. For example, a Seniors ' Advisory Committee was formed to act as a consult ing body on sen iors ' needs in th i s community, but th i s body (predominantly professionals) does not permit seniors who are regarded as experts to par t i c ipa te . Also a Professional Committee of the community center in which t h i s program is housed, was instrumental in vetoing a proposal for senior out reach programming developed by seniors in the program. Overal l the lack of par t ic ipatory organizat ional structure in Programs A and D l im i t s senior par t i c ipa t ion in program planning and decis ion making and.cur ta i l s any responsiveness to emerging seniors issues. The Roles of Seniors and Professionals In a wel lness/heal th promotion approach, professionals hold up a mirror to the group so that seniors can see the i r health issues and decide which ones they want to address. Seniors become partners with professionals in the decis ion making process and, fur ther , play a role in the planning, development and implementation of programs. In order for t h i s process to work e f f ec t i ve l y , regular and open communication must be maintained between general par t i c ipan ts , front l ine volunteer s ta f f and those responsible for planning and organizat ion. Mechanisms for program recip ient feedback are essent ia l i f seniors issues are to be adequately i den t i f i ed and addressed (see Table 4, p. 105). Program B i s the only program which provides opportunity for regular open communication about a l l aspects of programming between the general par t ic ipants and those responsible for planning. Professionals function 110 as " f a c i l i t a t o r s and advocates, and stay out of the way so they (the seniors) can run the i r own show." Here, seniors use professionals pr imar i ly as resources and consultants. The seniors funct ion in two ro les , as volunteer s ta f f and as par t i c ipants . I t should be noted that one senior i s a paid member of the Seniors Network with which th i s program is a f f i l i a t e d . The majority of seniors i s involved in the running of the program in some way, whether that be "organizing exerc ise, massage, ta lks or other jobs l i k e reg is t ra t i on , or putt ing out the chai rs and preparing refreshments." Those not involved in th i s way are given the opportunity to par t ic ipate in program planning. Two of the smaller programs (A and D) have regular open communication between professionals and par t i c ipants , but only in respect to decis ion making about the speaker/discussion sect ion. Program A had no designated volunteer posi t ions though some seniors organize chair set-up, s ign- in sheets and refreshments on a regular bas is . One community center s ta f f organizes the exercise ins t ruc tor , and the wellness coordinator conducts blood pressure checks and f a c i l i t a t e s the speaker/discussion sect ion. The l a t t e r professional had encouraged the seniors to conduct exercises themselves, as some members in the group had the s k i l l s , however the community center s ta f f stepped in and organized i t for them. This h igh l ights the d i f ferent approaches that professionals involved with t h i s program hold. Program D have three senior volunteers who conduct exerc ise, massage and blood pressure checks. Neither professional nor sen ior -par t ic ipants had input into these sections of the program, though the seniors are encouraged by the professional to organize speakers. Senior and 111 professional leadership roles and respons ib i l i t i e s are not c lea r l y del ineated here and th i s resul ts in role con f l i c t and confusion between the professional and one senior volunteer. Program E and C receive l imi ted input from par t ic ipants unless seniors make ind iv idual comments. In the case of Program E, however, f ront l i ne volunteers work with professionals on program planning and organizat ion. Also two members of the seniors network, by whom th i s program is sponsored, attend these meetings. Some f i f t een senior volunteers run a l l program a c t i v i t i e s . Senior par t ic ipants on occasion make comments about programming on a one-to-one basis to the senior volunteers. Approximately once a year, senior par t ic ipants are involved in brainstorming ideas about programming. One professional i s viewed as a leader and attends a l l planning sessions. She commented that "people t ry to refer decis ions to us (the professionals) but we attempt to turn issues and decisions back to the group." Program C has four senior volunteers whose roles are to run exerc ise , blood pressure checks and man the reg is t ra t ion desk. No attempts are made to ask for more volunteers to par t i c ipa te , yet at one Wellness Committee Meeting t h i s suggestion was made by a senior volunteer and on a number of occasions the volunteers indicated they may not continue much longer. The professionals are autocrat ic . They run a l l meetings and tend to make the decis ions about programming with minimal input from the senior volunteers who attend yet these professionals advocate for increased senior leadership. 112 Program Funding This sect ion discusses how people in each program perceive funding questions and how funding i s seen to inf luence program composition. In general seniors at each center have l imi ted knowledge of funding issues. Only one or two senior volunteers were able to a r t i cu la te the funding needs and problems for the i r program. However, a number of seniors , though they knew nothing about t h i s area, stated they could "use more funds for program expansion (Program A and E ) . " I t was the professionals who demonstrated the most intimate knowledge of funding concerns related to the i r programs. Table 5 i s a schematic representation of the program funding sources for space, manpower, equipment and miscellaneous costs . 113 TABLE 5 THE PROGRAM FUNDING SOURCES -SPACE, EQUIPMENT, MISCELLANEOUS SUPPLIES, MANPOWER PROGRAMS A B C D E SPACE CC HD SC CC CC EQUIPMENT CC HD SC CC CC/ SP MISCELLANEOUS SUPPLIES e .g . refreshments SP SP SC SP SP PROFESSIONAL STAFF CC/ HD HD HD/ SC HD/ CC HD/ CC VOLUNTEERS SP SP/ SN SP SP SP/ SN CC - Community Centre SC - Seniors Centre HD - Health Department SN - Seniors Network SP - Senior Par t ic ipants Several community organizat ions supply free space, use of equipment, and s ta f f hours but the primary funding source i s the Vancouver Health Department which suppl ies space, equipment (Program B) and s ta f f (wellness coordinators) to a l l programs; a volunteer coordinator and a nurse for Program B; and a volunteer and a nurse for Program E. Three programs run out of local community centers. In the case of Program A, space i s free and a community center s ta f f member a l locates time to the program because h is posi t ion involves senior program planning. Program C, which operates from a seniors center, i s one of many sen iors ' programs for which the respons ib i l i t y l i e s with the center 's program coordinator. 114 Most program components are run by senior volunteers. Participants pay for the ongoing costs of refreshments through contributions. Program E is the only program to have carried out fund raising activities, which they do yearly, to purchase equipment unavailable from the community center. Like most voluntary groups, these programs are dependent on the good will of their host and sponsoring organizations. Funding and manpower for program expansion e.g. out reach services, is seriously constrained. Often seed money is available from federal and provincial sources but this is usually time limited. One program (A) which applied for such funds was refused, leaving the group frustrated and not understanding why they did not successfully meet the stipulated criteria. Although federal and provincial governments view health promotion as a legitimate component of the health care system, this study confirms the notion that without funding to accompany rhetoric, program development and expansion is limited. Historical Development of Wellness/Health Promotion As noted in Chapter 3, program components among the five programs studied vary l i t t l e and focus predominantly on the individual and their lifestyle. The historical development of wellness/health promotion programs for seniors in Vancouver, heavily influences program composition. All the programs studied are modelled in some way, on Program E, the first seniors wellness program in Vancouver. This program was developed and coordinated by a wellness consultant and began with a health fair sponsored by the federal government. Excited at the possibility of 115 developing an ongoing se l f - ca re program for seniors, t h i s professional worked with a seniors network soc ie ty , in proposing a wellness project to the Health Promotion Directorate of Health and Welfare, Canada. The project was funded in 1983 and was based somewhat on the Wall ingford Wellness Project in Sea t t le , Washington and the Growing Younger Program in Boise, Idaho. I t i s important to note that both these programs focus pr imar i ly on ind iv idual behavioural change (Dychtwald, 1986). A weekly program which developed into the ex is t ing program (E) began with the fo l lowing components; blood pressure checks, health nurse consul ta t ion, exercise and a health related presentat ion. Although two of the programs studied, claim to be based on data gathered by a community developer and a seniors needs assessment, these programs started with ident ica l components to those of the f i r s t health drop- in . Program composition among a l l the programs studied have changed l i t t l e in the las t s ix years since the inception of Program E, c lea r l y ident i fy ing the strong inf luence of h i s t o r i ca l factors on present program composition. SUMMARY As has been shown program composition i s influenced by mult iple h i s t o r i c a l , theoret ica l and organizat ional fac tors . Each program has combined these elements in various ways. A wel lness/heal th promotion approach i s ref lected to varying degrees depending on how thoroughly seniors and professionals embrace the underlying p r inc ip les of health promotion as out l ined by the health department (Mart in, Robertson & Altman, 1988). Only one program (B) car r ies th i s out in a s ign i f i can t 116 manner. The degree of organizat ional structure has been shown to re f lec t a continuum where l im i ta t ion or f a c i l i t a t i o n of senior pa r t i c i pa t i on , d i rec t ion and control ex i s t s . Organizational safeguards which ensure senior involvement at the par t ic ipant member level are l im i ted , fundamentally, to one program. Role var ia t ion of both seniors and professionals has influenced program makeup in varying ways from program to program dependant on how a health promotion approach i s adopted. Only one program has fostered seniors in playing a role in program planning and implementation at a l l l eve l s . The impact of the h i s t o r i c a l development on these wel lness/heal th promotion programs for seniors appears to maintain a focus on ind iv idual behavioural change. F i n a l l y , inadequate funding of health promotion a c t i v i t i e s severely l im i t s program expansion. The di f ferences and s i m i l a r i t i e s among programs highl ight how the program organizat ion and process heavi ly inf luence program composition. B. PROGRAM ATTENDANCE RATIONALE AND PATTERNS Socia l in teract ion and support are iden t i f i ed by seniors and professionals as the primary reasons for seniors ' attendance at wel lness/heal th promotion programs. However, the number of soc ia l components var ies great ly from program to program. A lso , the attendance patterns between men and women d i f f e r markedly. In t h i s sect ion i t i s shown how the rat ionale for program attendance and the d i f f e r i ng attendance patterns between men and women influence program composition in varying ways among the programs studied. 117 Program Attendance Rationale Loneliness and i so la t i on are key issues for the senior population. Approximately 10% of seniors l i v i n g in the local areas studied are not l i v i n g in f am i l i es , and 45% l i ve alone (Canada Census, 1986). Based on discussion with seniors and professionals from a l l the programs studied, the consensus was that soc ia l in teract ion and support i s a key element to health and wel l -be ing, and the prime reason for attendance. This need inf luences program composition in d i f fe rent ways. At Programs A, B and D seniors ar r ive ear ly to chat among themselves before scheduled a c t i v i t i e s begin. Yet at Program E, senior volunteers prevent entry into the wellness space un t i l 1:00 p.m. As Program E provides no seating for those l i n i ng up outside, t h i s i s viewed as nonconducive to soc ia l in te rac t ion . One senior mentioned that a number of members are " d i s s a t i s f i e d with t h i s arrangement." Also t h i s program's seating plan (chairs in rows) does not lend i t s e l f to soc ia l i za t i on once the program i s in process. In contrast , Program B conducts many a c t i v i t i e s ( reg is te r ing , wait ing for massages and blood pressure checks) in small groups and the seating arrangements ( in small groups) are very conducive to soc ia l in te rac t ion . Program A and D of fers a refreshment break fo l lowing exerc ise. This allows seniors to mingle and chat for approximately f i f t een minutes pr ior to the heal th-re lated discussion component. Program B, i s the only program to o f fer a lunch component. Here seniors s i t together for approximately hal f an hour and "shoot the breeze" while eat ing, pr ior to the discussion sect ion. One senior leader 118 mentioned "many people who stay for t h i s l i ve alone and appreciate the opportunity to eat with others. " A l l programs have senior volunteers who of fer d i f f e r i ng degrees of soc ia l support to those who attend. Seniors from a l l programs commented that these ind iv idua ls create a " f r i end l y , welcoming environment" that i s conducive to soc ia l in te rac t ion . For example, at Program C, seniors and professionals bel ieve that i f the exercise inst ructor was to leave, attendance would drop markedly. This senior takes the f i r s t f i f t een minutes to chat with par t ic ipants pr ior to commencing exerc ises. At th i s program, no other provis ion for soc ia l in teract ion i s made. Program E i s the only program to provide peer counsel lors, who of fer support, information and re fer ra l on issues of bereavement, housing, f inances, and minor physical health d i f f i c u l t i e s . A number of seniors who attend Program E commented that the presence of these ind iv iduals to ta lk with about problems has impacted on the i r l i ves in very s ign i f i can t ways. Although soc ia l factors have had an inf luence on program composition to some degree in some of the programs studied, most programs have paid l i t t l e at tent ion to the importance of a c t i v i t i e s that address the soc ia l needs of seniors . Program Attendance Patterns According to 1986 census data, women and men are s t i l l approximately equal in number, up to age 50. However, between 65 and 74, there are only 77 men to every 100 women; then between ages 75 and 84, the ra t io drops to 50 men per 100 women; and among those aged 85 and o lder , there are only 44 men per 100 women. As wel lness/heal th promotion programs for seniors 119 predominantly address the 65 to 84 age group, where the ra t io i s 63 men per 100 women, i t would be ant ic ipated that program composition among the programs studied, would re f lec t the needs of both gender groups. This i s not the case and a number of factors contribute to t h i s . F i r s t l y , i t should be noted that the numbers of males attending these programs i s extremely low. Among the programs studied there are 3 males per 10 females and one program (D) has no male par t ic ipants at a l l . Apparently, a male did attend Program D once, but did not return because there were no other men. The primary reasons given for the low male attendance are; "men are too shy," "more rec lus i ve , " and " fee l int imidated by large quant i t ies of women." Many seniors bel ieve "we haven't got the pattern of a c t i v i t i e s men want." However, a number of men mentioned that they do enjoy "the break in routine" and the "opportunity to chat" that program attendance provides. The component most attended by males i s blood pressure checks. Occasional ly , men attend the discussion sect ion and, in the case of Program E, men do meet with peer counsel lors, though i t i s f e l t that more men would use th i s service i f one of the counsel lors was male. Program A, i s the only program where the men par t ic ipate in a l l program components. Also of in te res t , was Program C, where men come for blood pressure checks and then play ping-pong on a table set up just around the corner from the open area where the program takes place. A number of men in Program B par t ic ipa te as volunteers in the organizat ion and s ta f f i ng of the program. It i s in terest ing that the senior leader i s male and a th i rd of those who attend are also male and 120 yet no program components have been added or changed to address men's needs s p e c i f i c a l l y . Program E had one male volunteer involved; however he has relocated. None of the other programs have men in posi t ions of in f luence, and even in the case of Program B where men are involved in program planning, men's a c t i v i t y needs and attendance have not been addressed. SUMMARY Although soc ia l factors are iden t i f i ed as the primary reason for program attendance, on the whole components which address soc ia l in teract ion and support are given l imi ted recognit ion and support. Although some programs have establ ished new components which foster soc i a l i za t i on and provide support mechanisms to senior par t i c ipants , others continue without recognizing the s ign i f icance of t h i s i den t i f i ed need. Program composition does not to appear re f lec t the needs of both gender groups at the present time. However, as there are greater numbers of women attending these programs, i t may be va l id to focus on the iden t i f i ed needs of women. However, as men's attendance patterns are f e l t to be influenced by a lack of appropriate a c t i v i t i e s and the int imidat ing number of women, i t may be important to explore men's health promotion needs fur ther . 121 CHAPTER FIVE CONCLUSIONS AND RECOMMENDATIONS The purpose of t h i s chapter i s to l ink the theoret ica l concepts emerging from the f indings of t h i s ethnographic research on health promotion programs for seniors with ex is t ing theory and l i t e ra tu re . The research questions are addressed, the l im i ta t ions of th i s project are discussed and the impl icat ions for future research are out l ined. F i n a l l y , p rac t ica l recommendations for future program focus and organizat ion are discussed. I. THEORETICAL IMPLICATIONS OF THE STUDY This study explores the concept of health promotion as i t re lates to the program focus and organizat ion of f i ve health promotion programs for seniors in the c i t y of Vancouver, B r i t i s h Columbia. In t h i s study a health promotion program i s defined as that which incorporates "any combination of health education and related organizat iona l , p o l i t i c a l and economic intervent ions designed to f a c i l i t a t e behavioural and environmental changes conducive to health" (Green, 1980). Furthermore, a health promotion program is one that enables people "to increase control over and to improve the i r health" (World Health Organizat ion, 1986). Because health promotion i s a mult i faceted strategy i t i s not surpr is ing that many theoret ica l concepts emerged as the data and ana ly t ic categories were developed and reviewed. Individual behaviour change and Environmental and community change components were used as ana ly t ic categories as received support from the data and l i t e ra tu re on health promotion. Personal autonomy and control which were iden t i f i ed in 122 documentary data were made reference to by seniors and coordinators. As the study progressed v ic t im blaming, empowerment and learned helplessness emerged as relevant concepts to the research data. A lso , because the promotion of senior involvement in program process and organizat ion i s a r t i cu la ted as an object ive of these health promotion programs, and because organizat ional goals are a facet of organizat ional behaviour, organizat ion theory i s relevant to t h i s study. A. RESEARCH QUESTIONS The research questions posed by th i s study are restated, followed by a br ie f descr ipt ion of the f ind ings, which are then l inked to pert inent theory and l i t e ra tu re . As there are mul t ip le leve ls of inf luence on health promotion programs these are divided into three inc lud ing; macro-level inf luences within the larger soc ie ty , meso-level inf luences at the organizat ional l e v e l , and micro- level inf luences at the indiv idual l e v e l . Questions 1 and 2 are discussed together and address how macro and micro-level inf luences impact on health promotion program focus. Question 3 discusses the impact of macro, meso and micro- level inf luences on program organizat ion and composition. QUESTION 1: What i s the focus of the program components? QUESTION 2: Does the p ro f i l e of program components vary among health promotion programs? Deta i ls of the focus and var ia t ion of program components are described in chapters three and four. A l l programs of fer a broad range of a c t i v i t i e s which have been c l a s s i f i e d under the ana ly t ic categories of Indiv idual Behavioural and underlying Environmental and Community Change 123 Components. A l l f i ve programs concentrate predominantly on Individual Behavioural Change Components which focus upon personal support systems, exerc ise, personal health a t t i tudes , nu t r i t i on , s t ress management, se l f management of chronic health condi t ions, personal sense of purpose and personal environmental awareness and pa r t i c ipa t ion . L i t t l e var ia t ion ex is ts among programs in respect to the a c t i v i t i e s offered to address these spec i f i c components although a broader array of a c t i v i t i e s i s offered by the two larger and older programs. Minimal focus i s placed on the underlying Environmental and Community Change Components which address those p o l i t i c a l , economic and organizat ional factors that af fect the promotion of immediate indiv idual behavioural change. Although a l l f i ve programs provide mechanisms for senior volunteers to par t ic ipate in program planning and decis ion making, there i s marked var ia t ion in ' r e a l ' involvement by seniors among programs. Organizational factors are discussed when question 3 i s addressed. Fundamentally, programming which addresses environmental factors i s l imi ted to one-to-one and/or group discussion which resul ts in minimal act ion for change. One program wrote a proposal to acquire funding for out-reach a c t i v i t i e s however t h i s was vetoed by profess ionals . Senior volunteers from another program support the i r sponsors to take p o l i t i c a l act ion in the form of l e t te r wr i t ing and discussion with p o l i t i c i a n s , when relevant sen iors ' issues a r i se . However, rarely do they take th i s act ion themselves. Two programs address ageism by encouraging professionals and non-professionals to v i s i t t he i r programs and see how seniors funct ion, however, they appear to be preaching to the converted. C lea r l y , such underlying causes of s t ress for seniors in these communities as soc ia l 124 i s o l a t i o n , housing, ageism, transportat ion and poverty, though acknowledged, are given only super f i c ia l a t tent ion. The l i t e ra tu re on health promotion claims programs focus predominantly on indiv idual behaviour change e f fo r ts (Minkler & Pasick, 1986; Labonte, 1988; Smith, 1988). Many authors have expressed concern that although rhetor ic leg i t im izes the idea of developing health promotion programs within a wider context, the programs remain narrow in focus and thereby i m p l i c i t l y support the stance of indiv idual respons ib i l i t y for l i f e s t y l e . Though the theoret ica l basis of the programs studied i s "a socioecological model of health which recognizes the in te r re la t ionsh ip between soc ia l and environmental factors and defines health as encompassing the phys ica l , mental, soc ia l and personal domains," (Mart in, Robertson & Altman, 1988) the soc ia l and environmental factors are given l i t t l e recognit ion and e f fo r t . This focus on the indiv idual without an equal emphasis on the soc iost ructura l bases of health has led to much c r i t i c i s m of health promotion by authors who bel ieve the proponents of ind iv idua l ly -or ien ted behaviour change st rategies support a victim-blaming ideology (Becker, 1986; Crawford, 1979; Epstein, 1985; Guidott i ,1989; Kickbusch, 1989; Minkler & Pasick, 1986; Tesh, 1981). Ryan (1970), applied th i s process to North American soc ia l problems in h is book "Blaming the V ic t im" . In b r i e f , the steps involved in blaming the v ic t im are; (a) ident i fy ing a soc ia l problem; (b) studying those most immediately affected by t h i s problem and ident i fy ing how they are d i f fe rent from the rest of the populat ion; (c) def in ing the di f ferences as the cause of the soc ia l problem; and (d) assigning bureaucrats to develop 125 "humanitarian act ion programs" that w i l l "correct the d i f ferences" (Ryan, 1970, p. 7). I f these steps are applied to the high cost of i l l n e s s care, the v ic t im blamed i s the indiv idual suf fer ing from a chronic i l l n e s s or the aging process. Using Ryan's model, the fo l lowing scenario i s an example of how ind iv iduals can be blamed for the i r health problems: (a) A soc ia l problem which i s recognized as requir ing attent ion in our society today, i s the high cost of i l l n e s s care; (b) Those ind iv idua ls iden t i f i ed as most immediately affected by i l l health are people who smoke, lack regular exerc ise, have poor nu t r i t i ona l habits and do not manage the i r s t ress e f f ec t i ve l y ; (c) I t i s pr imar i ly those ind iv idua ls who do not pract ice responsible health and l i f e s t y l e s t rategies who become i l l and require i l l n e s s care; (d) Therefore, the provision of l i f es t y l e -o r i en ted health promotion programming could po ten t ia l l y a l l ev ia te t h i s soc ie ta l problem. Ryan noted that present-day v ic t im blaming i s very d i f fe rent from the "open prejudice and reactionary t a c t i c s " of e a r l i e r t imes, as now i t i s "cloaked in kindness and concern, and bears the trappings of s t a t i s t i c a l furbelows of scient ism (and) i s obscured by a perfumed haze of humanitarianism" (2, p. 7). Health promotion targeted to the indiv idual f i t s t h i s scenario form many ind iv idua ls . While basic e f fo r ts at problem solv ing the possible underlying causes of i l l health require major soc ios t ruc tu ra l , p o l i t i c a l and economic arrangements, the v ic t im blaming ideology encourages far more narrow st rategies which in turn develop more l imi ted ind iv idua l ly -or ien ted programs and p o l i c i e s . 126 In agreement with t h i s p e r s p e c t i v e , Crawford (1979, p. 256), s t a t e s t h a t those who advocate i n d i v i d u a l l y - o r i e n t e d programs support v i c t i m blaming which "serves as a l e g i t i m i z a t i o n f o r the retrenchment from r i g h t s and e n t i t l e m e n t s i n r e l a t i o n t o the s o c i a l causation of disease and i t f u n c t i o n s as a c o l o s s a l masquerade. The c o m p l e x i t i e s of s o c i a l causation are only beginning t o be explored. The ideology of i n d i v i d u a l r e s p o n s i b i l i t y , however, i n h i b i t s that understanding and s u b s t i t u t e s instead an u n r e a l i s t i c behavioural model. I t both ignores what i s known about human behaviour and minimizes the importance of evidence about the environmental a s s a u l t on h e a l t h . I t i n s t r u c t s people to be i n d i v i d u a l l y responsible at a time when they are becoming l e s s capable as i n d i v i d u a l s of c o n t r o l l i n g t h e i r t o t a l h e a l t h environment. Although environmental f a c t o r s are often recognized as " a l s o r e l e v a n t , " the i m p l i c a t i o n i s that l i t t l e can be done about an i n e l u c t a b l e , t e c h n o l o g i c a l , and i n d u s t r i a l s o c i e t y . What must be questioned i s both the e f f e c t i v e n e s s and the p o l i t i c a l uses of a focus on l i f e - s t y l e s and on changing i n d i v i d u a l behaviour without changing s o c i a l s t r u c t u r e and processes." The i n d i v i d u a l - r e s p o n s i b i l i t y r a t i o n a l e f o r hea l t h can be viewed as g r e a t l y b e n e f i t i n g the medical system, c e r t a i n p o l i t i c a l p a r t i e s and i n d u s t r y . This perspective which i s often r e i n f o r c e d by the media, redef i n e s i l l n e s s i n t o an i n d i v i d u a l problem which e f f e c t i v e l y i s o l a t e s i t from i t s s o c i a l context. As such, the need to address environmental and community h e a l t h c o n s i d e r a t i o n s i s e s s e n t i a l l y e l i m i n a t e d , l e a v i n g these i n t e r e s t groups f r e e from the r e s p o n s i b i l i t y of making heal t h enhancing 127 changes. When theo r i s t s , programmers and academics l im i t the determinants of i l l health to indiv idual respons ib i l i t y and indiv idual l i f e s t y l e , they can be viewed as a l l y i n g themselves with the se l f - i n te res ted biomedical, p o l i t i c a l and industry pos i t ion. (Mink ler & Pasick, 1986; Estes, Fox, Mahoney, 1986; Kickbusch, 1989) I f t h i s i s done to the v i r t ua l exclusion of environmental inf luences the v ic t im may have l i t t l e or no information and therefore maybe powerless to inf luence change except i nd i rec t l y through act ion (Epstein, 1985). As noted minimal environmental and community act ion for change has been taken by the programs under study. In one case when out reach programming was an ob ject ive, seniors were pushed back to the indiv idual behaviour change stance by profess ionals . The pro fess iona ls ' act ion undermined and negated the pos i t i ve act ion made by the seniors in attempting to address s o c i a l l y iso lated seniors in the i r community. This kind of narrow, int rospect ive approach to health promotion discourages concern for community and soc ie ta l wel l -being (Becker, 1986). What i s suggested i s that l i f e s t y l e change e f fo r ts remain secondary or at most equal to environmental approaches, and that approaches so le ly related to ind iv idual behaviour change may y ie ld marginal improvements in the soc ia l causes of heal th. Although th i s study does not provide d i rec t evidence for t h i s stance, i t must be noted that where environmental and community act ion was attempted gains were minimal. One i s tempted to bel ieve that t h i s i s an outcome from employing a health promotion approach which pr imar i ly focuses on indiv idual behaviour change. In response to the c r i t i c s of an ind iv idua l ly -or ien ted approach there are those who contend that few health promotion programs do focus 128 exc lus ive ly on indiv idual behavioural change, and further that programs which address indiv idual health and behaviour must eventual ly address system-change and the issue of con f l i c t i ng ideologies about health and health promotion (Green, 1984, 1986; Green and McAl is ter , 1986). Green's posi t ion i s p a r t i a l l y supported by workplace health promotion l i t e ra tu re (U.S. Department of Health and Human Serv ices, 1987; Walsh, 1988) which suggests that the introduction of health promotion a c t i v i t i e s in spec i f i c worksites led to health enhancing system-changes. The programs presently studied can not make th is claim and as yet have not addressed the issue of con f l i c t i ng ideologies. A lso , Green's perspective does not acknowledge the impact of the language and models used and how these i m p l i c i t l y suggest cer ta in types of approaches over others. Green (1984) pointed t h i s out himself when he suggested i t was perhaps regrettable that the predominance of contr ibut ions to the l i t e ra tu re are from psychology. "Even in large scale community intervent ions such as the Stanford three-community s tudies, the behavioral science contr ibut ions to planning the intervent ions have been made largely by psychologists. The resul t i s that the behavioral change intervent ions have tended to emphasize the ind iv idua l , and have been most useful in patient education. This concentration of behavioral science appl icat ions i s sometimes at the expense of act ion on needed change in the organ iza t iona l , i n s t i t u t i o n a l , environmental, and economic condit ions shaping behavior (Green, 1980, p. 217)." The use of terms such as ' L i f e s t y l e s ' and ' Ind iv idual Respons ib i l i t y ' a lso inadvertently serve to focus attent ion on changing the indiv idual rather than changing the underlying community and 129 environmental problems which maintain and reinforce unhealthy behaviour (Minkler & Pasick, 1986; Health Education Uni t , 1986). Widespread change through mult ip le mechanisms at a l l leve ls of society appears essent ia l i f the v ic t im blaming i m p l i c i t l y encouraged through the misuse of health promotion rhetor ic , language and narrow models i s to be avoided. Even i f professionals working in the health promotion arena are successful in incorporating environmental inf luences into programming, education at the micro, meso and macro-level w i l l be necessary to reverse the present impact a r i s ing from the indiv idual behaviour change stance. This focus on indiv idual respons ib i l i t y for health must be accompanied by an equal emphasis on the community and environmental factors which heavi ly inf luence indiv idual health pract ices. I f health care programmers, p o l i t i c i a n s , industry and the media continue to perpetuate a v ic t im blaming ideology i t i s feared society w i l l remain b l ind to the large-scale causal factors of the health problems i t seeks to address (Epstein, 1985; Becker,1986; Crawford, 1979; Kickbusch, 1989). Question 3 addresses those organizat ional inf luences which impact on program process and composition. QUESTION 3: What factors best contr ibute to explain program composition and var ia t ion? The composition and hence var ia t ion among the programs studied were most influenced by organizat ional factors inc luding: 1) the way a health promotion approach i s appl ied, 2) the structure of the program organizat ion, 3) program con t ro l , 4) program funding and 130 5) the impact of h i s t o r i ca l development on programming. As already noted the health promotion approach formally adopted by the programs in t h i s study i s a socioecological model of health (Mart in, Robertson & Altman, 1988). The degree to which pert inent indiv idual and environmental components are ref lected in program process and composition i s dependent on how much professionals and seniors adopt and incorporate i t s underlying p r i nc ip les . These p r inc ip les include senior pa r t i c i pa t i on , senior empowerment and partnership between seniors and professionals in program planning, organizat ion and process. I f sen iors ' issues are to be iden t i f i ed and addressed, i t would be ant ic ipated that seniors be given the opportunity to be act ive par t ic ipants in program planning and decis ion making, at a l l organizat ional l eve l s . This would require appropriate mechanisms be in place for regular and open communication between general par t i c ipan ts , f ront l i ne volunteer s ta f f and those s p e c i f i c a l l y involved in planning and organizat ion. Also those operating costs and manpower issues which af fect program composition would be viewed as pertinent organizat ional fac tors . Across programs the f indings were not re f l ec t i ve of t h i s ideal scenario. Only one program (Program B) adopted and incorporated the p r inc ip les of the socioecological model to any s ign i f i can t degree. This program was the only one that had mechanisms in place for regular open communication and decis ion making about program planning between the planners and the remaining par t i c ipants . In th i s program seniors planned, managed and organized the program while professionals functioned as f a c i l i t a t o r s , advocates and consultants. 131 A l l f i ve programs studied had seniors running program a c t i v i t i e s , however, two programs had no designated senior volunteers involved in program planning and decis ion making. Of the three programs that had seniors involved in committees and on boards, in two of these cases professionals c lea r l y undervalued sen iors ' input by e i ther monopolizing or completely preventing sen iors ' involvement in discussion and decis ion making processes. In three of the f i ve programs professionals and seniors complained that inadequate funding and/or s ta f f i ng l imi ted program expansion. In one program where funding was pursued by seniors, professionals interfered with the process and monies were not forthcoming. In one other program senior volunteers conducted annual fund ra is ing a c t i v i t i e s to purchase equipment. However, seniors and professionals in most programs did not venture beyond discussion to pursue solut ions to s ta f f i ng and funding concerns. A lso , the impact on programming of h i s t o r i c a l factors can not be underestimated. Although a socioecological model had been adopted since 1986, a l l these programs were modelled to some degree on a program which began in 1984. This program was developed by a health promotion consultant who employed an ind iv idual l i f es t y l e -o r i en ted health promotion approach. As noted program components vary l i t t l e among programs, and they predominantly address ind iv idual behaviour change which f i t s with t h i s behavioural model. Organizational factors that contr ibute to health promotion process and composition are mult i faceted and influenced great ly by macro, meso and micro- level inf luences and prac t ices . 132 Since the 1980's an expanded de f i n i t i on of health- promotion has been added to federal health rhetor ic which i den t i f i es both indiv idual behaviour and environmental inf luences as determinants of heal th. In consequence, national s t ra teg ies for health promotion now ident i fy a commitment to reorient health serv ices and the i r resources so as to address broader level health issues (Epp, 1986). However, major health po l icy in the form of l eg i s l a t i on and funding for health serv ices , continues to emphasize a cost ly acute care c r i s i s approach based on biomedical ideology which i s dominated by the medical establishment (Estes, Fox & Mahoney, 1986). This paradox i s an example of how health pol icy and hence pract ice often resul t from a process of negotiat ion between con f l i c t i ng ideologies. The introduct ion of health promotion ideology, while biomedical ideology i s strongly entrenched in present health po l i cy , has led to both intended and unintended consequences. On the one hand, federal health po l icy advocates community-based health promotion to improve the health status of a growing population of seniors and to reduce health care costs . Yet, i t openly supports biomedical approaches and pract ices by subsid iz ing the i n -place, high-tech medical system and fee- fo r -serv ice care. As such, when health promotion programs do ex is t they tend to adopt a c l i n i c a l l i f e s t y l e focus or operate without adequate funding (Estes, Fox & Mahoney, 1986; Health Services and Promotion Branch, 1986; Kickbusch, 1989; Marshal l , 1987; McKnight, 1978, 1987). This f a i l u r e to support health promotion with po l i c i es and funding that consolidate i t s ideals can only be expected to lead to ideological and pract ice di f ferences within health promotion programs themselves. 133 Although th i s study does not address these issues d i r ec t l y the data does ident i fy that ideological d i f ferences ex is t and these di f ferences appear to inf luence program process and composition. These di f ferences appear to stem from the attempt by professionals and seniors to combine two d i f ferent health promotion approaches. A l l f i ve programs studied have based the i r program content on a c l i n i c a l behavioural approach yet they attempt to organize program process using a socioecological approach. With a c l i n i c a l behavioural approach "the primary challenge ( i s ) to ass is t people in taking respons ib i l i t y for t he i r to ta l health" by adopting health enhancing l i f e s t y l e pract ices (Nelson, 1984). This approach focuses on modif icat ion of behaviour at the indiv idual level and the professional i s viewed as the program planner, leader and c l i n i c a l expert. In contrast the socioecological approach refocuses at tent ion, away from s t r i c t l y indiv idual factors and processes, and towards environmental determinants of health and group empowerment. This approach requires the d i rec t involvement of ind iv idua ls who ident i fy health needs and par t ic ipate in any necessary act ion to create health enhancing changes. Professionals are not viewed as experts and leaders, but rather they function as f a c i l i t a t o r s , advocates and resources in t h i s process (Mart in, Robertson & Altman, 1986; Mcleroy, Bibeau, Steckler & Glanz, 1988; Nelson,1984; Kickbusch,1989). The impact on program process and composition from these ideological d i f ferences, which stem from forces within the larger soc ia l system are fur ther compounded by those which stem from organizat ional inf luences. None of the seniors health promotion programs studied i s f ree-standing. Rather, as with many community health promotion programs for 134 seniors , the programs are a l l conducted within or sponsored by some type of community organizat ion or agency. I f the organizat ional s t ructures, missions and goals of the host and sponsoring organizat ions are incompatible with health promotion ideology i t i s l i k e l y t h i s w i l l impact on program process and composition. For example, the structure of most organizat ions i s based on a h ierarch ica l design establ ished to create control of people. On the other hand, the structure of progressive health promotion programs i s based on people act ing through consent. This di f ference i s c r i t i c a l because many health promotion goals can only be f u l f i l l e d through consent, and these are often the goals that w i l l be impossible to achieve through a h ierarch ica l system designed to control (Fr ied , 1980; Labonte, 1989; Mcknight,1987; Mcleroy, Bibeau, Steckler & Glanz, 1988; Ottoson & Green, 1987; Goodman & Steck ler , 1987; Kouzes & Mico, 1979; S h o r t e n , Kaluzny & Associates, 1988). Though data were not gathered s p e c i f i c a l l y from a l l the organizat ions in t h i s study, there were numerous examples that suggest ideological incompat ib i l i ty in organizat ional behaviour between the health promotion programs and the i r host and sponsoring organizat ions. These issues ser ious ly impact on program process and,ult imately af fect program composition. For example, the interference by professionals from one host organizat ion essen t ia l l y blocked a proposal which was to lead to the development of a seniors out reach program. These professionals believed that seniors should take respons ib i l i t y for th i s program themselves, while the seniors believed they needed the help of a paid coordinator. In another example professionals blocked seniors from par t i c ipa t ing on a 135 Seniors Advisory Board as they believed professionals should ident i fy seniors needs within the i r community, not the seniors. I f these ideological con f l i c t s are not given adequate attent ion through appropriate organizat ional processes, at worst, they could lead to program terminat ion. At best, organizat ional inf luences need to be addressed so that these health promotion programs can survive to become integrated parts of host and sponsoring organizat ions (Goodman & Steck ler , 1987). F i n a l l y , micro- level inf luences on program process and composition cannot be overlooked. Both seniors and professionals hold health promotion perspectives based on a l i fe t ime of h is tory within a par t i cu la r soc ie ty . Indiv iduals are affected by such factors as age, sex, occupational background, education, economic status, values and b e l i e f s . C o l l e c t i v e l y , soc ia l values, federal po l i c i es and the pract ices of the health system, industry and the media also have a tremendous impact on ind iv idua ls ' perspect ives. Hence, professionals may advocate for senior empowerment yet be heavi ly influenced by those c l i n i c a l methods which h i s t o r i c a l l y placed them in control of program process and composition. These c l i n i c a l methods assume that seniors require assistance to manage health promotion programming which lead professionals to make choices for them. This encourages psychological dependency and helpless behaviour on the part of seniors which diminishes the i r sense of control and empowerment and in turn , the i r impact on programming For example, soc ia l in teract ion and support are iden t i f i ed by a l l seniors as the primary reasons for program attendance yet few programs 136 legi t imate t h i s soc ia l health need by developing pert inent program a c t i v i t i e s . In a number of programs seniors come ear ly and leave late or ta lk qu iet ly amongst themselves while scheduled a c t i v i t i e s are in operat ion. Only one program legit imated th i s concern through the addit ion of new soc ia l a c t i v i t i e s . This program also provides a forum for a l l seniors to ident i fy the i r needs and par t ic ipa te in program development. Conversely, seniors may know that they have the knowledge and s k i l l s to take control of the i r own health promotion programming and be adversely affected by a soc ie ta l presumption that they have l i t t l e to of fer as they age. Ageism may have a negative impact on seniors sense of se l f worth and encourage an over-re l iance on professionals to make the decis ions for them. Consequently, seniors may re f ra in from ac t ive ly par t i c ipa t ing in the process of program planning, decis ion making and organizat ion (Easterbrook, 1978; Clark, 1969; Gaventa, 1980; Seligman, 1975; Maier & Seligman, 1976; Labonte, 1989; Schul tz , 1980). For example, in one of the programs studied, seniors were encouraged by one professional (wellness coordinator) to conduct exercises themselves as she f e l t they had the s k i l l s to do so. The seniors decided to each take a turn in running the exercises with each others support. However, another professional (from the host organization) believed a professional should run the program, and hence organized a f i tness inst ructor to run t h i s program component. The seniors readi ly backed off from running the program themselves, s ta t ing they f e l t the professional had more expert ise. In summary, although most of the health promotion programs studied focus pr imar i ly on indiv idual behaviour change, those programs where e f fo r ts are made to give seniors control of program process and 137 organizat ion were less l i k e l y to ignore those s o c i a l , o rgan izat iona l , economic and p o l i t i c a l factors that keep seniors s o c i a l l y i so la ted , disempowered, impoverished and undervalued in soc iety . When an ecological approach i s applied health promotion programs can more e f fec t i ve l y address pert inent needs of seniors and are more l i k e l y to recognize the impact of mul t ip le micro, meso, and macro-level inf luences on the health promotion programs themselves. I I . LIMITATIONS OF THE STUDY 1) The people interviewed were not necessar i ly representative of the whole group of ind iv iduals involved in each program, for several reasons: a) Only one senior who was involved in program planning and organizat ion was interviewed from three programs. b) Because few men attended these programs and i t was f e l t important by interview to represent both sexes proport ionately, in some programs the male perspective may be under-represented. c) although a l l coordinators were interviewed, no ind iv iduals from host organizat ions were represented in the sample of professional interviews. 2) Those seniors and professionals involved in program planning and organizat ion may be over-represented as they were asked more questions than senior par t i c ipants . 3) The more a r t i cu la te people may be over-represented in the data analys is and presentat ion, even though par t ic ipant observation was used in order to reduce th i s p o s s i b i l i t y . 138 4) The data gathered i s not necessar i ly representative of professionals involved with each program, for several reasons: a) Although a l l the coordinators adopted a broad perspective that recognized both indiv idual and environmental inf luences on heal th, and supported the p r inc ip le of senior pa r t i c i pa t i on , they may not f u l l y adopt the socioecological framework documented by the Health Department which i s s t i l l in draf t form. b) No data was gathered from professionals in host or sponsoring organizat ions about these organizat ions ' missions, goals and object ives. 5) General izat ion of the f indings w i l l be l imi ted for several reasons: a) Logical argument may provide j u s t i f i c a t i o n for general izat ion to a l l Health Department health promotion programs for seniors in the Vancouver area; however some bar r ie rs to t h i s genera l izabi1 i ty must be noted. These programs have some var ia t ions in terms of professional t ra in ing and philosophy, senior involvement in program planning and organizat ion, and the number of senior par t i c ipants , and the involvement from host and sponsoring agencies. The physical loca t ion , profess ional /sen ior r a t i o , and community charac te r i s t i cs also vary among groups. b) Genera l izabi1 i ty of data beyond t h i s sample of health promotion programs for seniors in Vancouver i s d i f f i c u l t to j u s t i f y . 6) R e p l i c a b i l i t y of procedures can be viewed as a l im i ta t i on . However, although only one researcher was involved, the use of mult ip le data co l l ec t i on procedures, along with t r iangu la t ion , enhances internal r e l i a b i l i t y . External r e l i a b i l i t y i s a matter of degree and some 139 qua l i ta t i ve researchers would argue that nothing can be repl icated exact ly . However, the deta i led descr ip t ion and discussion of both data co l l ec t i on and analys is procedures enhances the potent ia l of t h i s study being rep l i ca ted . III. IMPLICATIONS FOR FUTURE RESEARCH Despite the d i f f i c u l t i e s with genera l i zab i l i t y for many health promotion studies that adopt qua l i ta t i ve methods, fur ther research of t h i s type which s p e c i f i c a l l y explores health promotion program focus and organizat ion, can only add to the lack of research in th i s area. Although some authors claim programs continue to focus on indiv idual l i f e s t y l e change, too few documented research studies have been conducted to confirm t h i s . Without research that invest igates health promotion program focus and the underlying causal factors of program composition, there w i l l be an insu f f i c ien t quantity of studies to support the need for health promotion programming as envisioned by Epp (1988), Green, (1980) and,the World Health Organization (1984, 1986). In many instances, health promotion program research questions are wide-ranging and complex. Such i s the case with the present explorat ion of organizat ional inf luences on program process and composition. More indepth study needs to be undertaken in order to explore the ef fects of both the internal organizat ional mechanisms and those external organizat ional inf luences on program process and composition. Despite the d i f f i c u l t i e s with health promotion research, further studies are essent ia l to provide a f i rm foundation of information which i s readi ly ava i lab le to pol icy makers, health care planners, the media and 140 the general publ ic i f ' r e a l ' health promotion i s to be assured an integral part of the health care system. I V . PRACTICAL RECOMMENDATIONS FOR PROGRAM PROCESS AND ORGANIZATION This study of f i ve health promotion programs for seniors has attempted to capture the ex is t ing approach, process, and content of each program. Many issues need resolv ing i f these health promotion programs are to be successful as vehic les for enhancing the qua l i ty of l i f e of seniors l i v i n g in the community. Most of these issues are related to internal and external program inf luences. A. INTERNAL INFLUENCES 1) Health Promotion Approach. Professionals must se lect a health promotion approach which allows seniors to par t i c ipa te in def in ing the i r needs within the i r community; in pa r t i cu la r , an ecological approach would be more e f fec t i ve than a c l i n i c a l behavioural approach. 2) Involvement by Seniors in Health Promotion Planning and Decision Making. Seniors must be involved in every level of planning and decision making within programs that are i n i t i a t ed on the i r behalf. Only then w i l l these programs e f fec t i ve l y serve to address those needs iden t i f i ed by seniors. For example, a l l the seniors interviewed iden t i f i ed soc ia l support and soc ia l in teract ion as the primary reasons they attended the programs. However, l imi ted recognit ion was given to th i s aspect of the i r wel l -being by most programs. A lso , professionals expressed concerns that 141 seniors were not taking leadership ro les . However, without appropriate mechanisms for involvement, seniors w i l l not be inspired to exercise con t ro l , develop s k i l l s and take leadership pos i t ions. Only when they become involved, w i l l seniors take ownership of e f fo r t s made to improve the condit ions of the i r l i v e s . 3) Involvement by Professionals in Health Promotion Planning and Decision Making. Professionals must be involved in explor ing program approaches which meet sen iors ' needs rather than those that put a program in place. This requires that professionals should re l inquish control of programs and should funct ion more as senior advocates and consultants, where the i r primary role i s to provide knowledge, resources and s k i l l s that empower seniors "to run the i r own show." In conjunction with t h i s ro le , professionals must be involved in addressing those ideologica l c o n f l i c t s which hamper program process with host and sponsoring organizat ions. B. EXTERNAL INFLUENCES 1) Con f l i c t i ng Ideologies between Health Promotion Coordinators and Employers. Professionals must be empowered within the i r own organizations i f they are to e f fec t i ve l y empower seniors. For example, i f the pro fess iona l ' s health promotion ideology c o n f l i c t s with the i r employer's ideology t h i s could impact negatively on the qua l i ty and content of health promotion programming for seniors. 2) Con f l i c t i ng Ideologies between Programs and Host/Sponsoring Organizations. 142 Professionals must take an organizat ional role in gaining support for health promotion innovations from upper level management or appropriate personnel of host and sponsoring organizat ions. This may involve attending management meetings, encouraging management par t i c ipa t ion on health promotion program boards, and providing s ta f f education, material support and ongoing l i a i s o n . 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Health Po l icy and Health Promotion:  Towards a new conception of Publ ic Health. Vienna and Copenhagen: Proceedings of the f i r s t Vienna Dialogue on Health Promotion, WHO/EURO and the Austr ian Min is t ry of Health and Environmental Protect ion. Document RP-12 of the Eurosocial Research and Discussion Papers, European Centre For Socia l Welfare Training and Research, Vienna. 157 APPENDIX A RESEARCH CONSENT FORMS 158 Vancouver Health Department 5 North Unit #200-1651 Commercial Drive, Vancouver, B.C. V5L 3Y3 Telephone: 253-3575 Re: A qualitative research study - Community health promotion programs for seniors: Program components and contributing factors to their composition. Student investigator: Kim M. C a l s a f e r r i G r a d u a t e S t u d e n t ( M . S c . - H e a l t h P r o m o t i o n ) U n i v e r s i t y o f B r i t i s h C o l u m b i a I c o n s e n t to p a r t i c i p a t e i n a s t u d y b e i n g c o n d u c t e d by Kim C a l s a f e r r i o f h e a l t h p r o m o t i o n p r o g r a m s f o r s e n i o r s i n the V a n c o u v e r a r e a . I u n d e r s t a n d p a r t o f t h e s t u d y w i l l f o c u s on my p e r s p e c t i v e as a S e n i o r s W e l l n e s s C o o r d i n a t o r . I w i l l p a r t i c i p a t e b y : a ) a s s i s t i n g t h e r e s e a r c h e r to e s t a b l i s h a w o r k i n g r e l a t i o n s h i p w i t h one s e l e c t e d s e n i o r s program w i t h i n my c a t c h -ment a r e a ; b) making a v a i l a b l e p e r t i n e n t documents s u c h as p r o g r a m s c h e d u l e s , g o a l s and o b j e c t i v e s , m i n u t e s from program p l a n n i n g m e e t i n g s a n d ; c ) p a r t i c i p a t i n g i n a s e m i - s t r u c t u r e d i n t e r v i e w o f one h o u r s d u r a t i o n . I f I w i s h to w i t h d r a w from t h e s t u d y I know I c a n do so at a n y t i m e w i t h o u t j e o p a r d y . I u n d e r s t a n d a l l i n f o r m a t i o n w i l l be s t r i c t l y c o n f i d e n t i a l , no names a r e r e q u i r e d o r w i l l be r e c o r d e d and t h a t no i d e n t i f y i n g i n f o r m a t i o n w i l l be p l a c e d i n t h e f i n a l r e p o r t . I know a n s w e r s t o any q u e s t i o n s c o n c e r n i n g my p a r t i c i p a t i o n w i l l be g i v e n by t h e r e s e a r c h e r to e n s u r e t h a t I f u l l y u n d e r s t a n d t h e p r o c e s s . I have m a i n t a i n e d a c o p y o f t h i s c o n s e n t f o r m : Name _ _^  S i g n a t u r e ^ _ H e a l t h U n i t . Name ^ _ _ S i g n a t u r e _ — H e a l t h U n i t . Name S i g n a t u r e _ H e a l t h U n i t -Name t Name. - . S i g n a t u r e H e a l t h U n i t . S i g n a t u r e - . H e a l t h U n i t ~ , _ / l j b 89/4/10 CITY OF VANCOUVER 159 APPENDIX A SENIORS CONSENT FORM RE: A qua l i t a t i ve research study: COMMUNITY HEALTH PROMOTION PROGRAMS FOR SENIORS: PROGRAM COMPONENTS AND CONTRIBUTING FACTORS TO THEIR COMPOSITION. Student Invest igator : Kim Ca lsa fe r r l Graduate Student (M.Sc. Health Promotion) Univers i ty of B r i t i s h Columbia I CONSENT to par t i c ipa te 1n a study being conducted by Kim C a l s a f e r r l , of health promotion programs for seniors 1n the Vancouver area. I understand part of the study w i l l focus on my perspective as a senior member of one of these programs. I w i l l par t ic ipate in a semi-structured Interview of one hal f hour's durat ion. I know I can withdraw from the study at any time without 1t jeopardiz ing my future par t i c ipa t ion in the health promotion program. I understand a l l Information w i l l be s t r i c t l y con f i den t i a l ; no names are required or w i l l be recorded, and that no Ident i fy ing Information w i l l be placed 1n the f i n a l report. I know answers to any questions concerning my par t i c ipa t ion w i l l be given by the researcher to ensure that I f u l l y understand the process. I understand I w i l l receive a copy of t h i s signed consent form. Interviewee's Name: Program: Date: 1989 160 APPENDIX B OBSERVATION SCHEDULE 161 APPENDIX B OBSERVATION SCHEDULE FEBRUARY - JULY 1989 DATE TYPE TIME PROGRAM PROTOCOL Feb 22 Informal 10am-12pm A PAOB1 March 1 Formal 10am-12pm A PA0B3 May 1 Informal 10am-12pm B PB0B1 May 1 Informal 1pm-3pm C PC0B1 May 2 Informal 930am-12pm D PD0B1 May 3 Informal 1pm-4pm E PEOB1 May 6 Focused 11am-12pm D PD0B5 May 8 Informal 930am-12pm B PBOB2 May 8 Informal 1pm-3pm C PCOB2 May 10 Informal 10am-12pm A PAOB2 May 10 Informal 1pm-4pm E PE0B2 May 15 Focused 1030am-12pm E PE0B3 May 16 Formal 930am-12pm D PD0B3 May 17 Focused 12pm-1pm E PE0B4 May 17 Formal 1pm-4pm E PEOB5 May 23 Formal 945am-12pm D PDOB4 May 24 Formal 10am-12pm A PA0B4 May 24 Formal 1pm-4pm E PE0B6 June 7 Focused 1045am-12pm A PAOB5 June 12 Formal 930am-12pm B PBOB3 June 12 Formal 1pm-3pm C PC0B3 June 13 Focused 11am-12pm D PD0B6 June 14 Focused 11 am-12pm A PA0B6 June 19 Formal/Informal 10am-2pm B PB0B4 June 19 Focused 3pm-4pm C PC0B4 June 26 Formal/Focused 930am-115pm B PBOB5 June 26 Focused 130pm-230pm C PC0B5 June 28 Focused 11am-12pm A PA0B7 July 17 Focused 1030am-1pm E PEOB7 Key: P = Program OB = Observation 162 APPENDIX C EXAMPLES OF OBSERVATION PROTOCOLS 163 APPENDIX C EXAMPLES OF INFORMAL, FORMAL AND FOCUSED OBSERVATION PROTOCOLS INFORMAL OBSERVATION PCOB1-Program C, Observation 1 +PCOB1 +Name of researcher:Kim Ca lsa fe r r i +Date: May 1/89 +Time: 1:00-3:00 pm +Subject: Informal OB: Program C i s run out of a seniors centre in the down town core. When I entered the bui ld ing I noticed a woman s i t t i n g behind a table BR: I wondered i f she was a volunteer giv ing people info on what was happening in the bui ld ing as there i s a hive of a c t i v i t y . OB: I notice on the sign that there are a number of senior oriented services run out of t h i s bu i ld ing . I was surpr ised to bang into a senior from the Program B there. Then I saw (A) the fun and f i t ness inst ructor I had met las t week at Program C when I asked the Sen ior ' s for permission to observe. She i s of Scot t ish decent and recently was at S .F .U . completing her teachers diploma. She i s f u l l of energy and enjoys what she does here with the sen io r ' s a lo t BR: She to ld me t h i s when I was here l as t . OB: She hersel f i s a senior and i s involved as a volunteer here af ter doing the fun and f i tness inst ructors course. I introduce myself to another woman who s i t s behind a table with cards on i t . Her name i s (F) . She i s also a senior and a volunteer. I t i s more d i f f i c u l t to t e l l her age as her hai r i s black. BR: ?dyed OB: (F) gives me the schedule for May also I receive a hand out from (M) the coordinator of whole sen io r ' s center about special programs. 164 BR: I meet (M) Friday 22nd April to discuss my coming to the center to observe. He requested this-I suspect he over sees every thing and likes to keep his finger on the pulse of what is happening. OB: Music is now playing which (A) has put on. Seniors arrive and some go over to the table I asked the Senior Volunteer what happens at the table "this is for BP's". Apparently there is a RN who comes from the health dept to do these and people sign up 1st and are put on a lis t and when their turn comes up (F) lets them know. There is a scale by the table. BR: I was told by (F) this is so people can weigh themselves. Records are kept of this in a cardex which (F) organizes. OB: So far there are 7 people here- all are woman. (A) comes over and chats to me about the senior's strutt-she gives me a hand out on this event and also announces this to the group and gives interested people a pamphlet. This group are dressed in slacks and tops. All are well groomed, the majority wear nylons and shoes. Some wear sneakers Ethnic mix is 3 of Chinese decent and 6 Caucasian- one of these appears to have a German accent. BR: She's the one who told me to sit down so they could get started with exercises when I came to request to do research. OB: She share's her concerns about things not starting on time. (A) explains the exercises usually start at 1:15pm. She makes mention this isn't what's on the schedule. Exercises start at 1:15pm. She makes mention the Spanish teacher had lost two people her. The Wellness coordinator arrives and pops over to say hello to me and asks how things are going. People stand in front of chairs which are arranged in rows of approximately 5 and the group begins with arms. One woman hums to the music. (A) sings along. The music is gentle. 165 Exercises include; -shoulder ra ises -knee bends (A) reminds people they are gentle exercises and to hold onto the chai r i f they wish to . -marching on the spot "to ra ise your heart. Does anyone have medication and i f you do i t would be helpful i f you would le t me know." She points out that one lady has a pace maker, who has now sat down and continues to do the exercises with her feet seated in the cha i r . (A) asks spec i f i c people i f they are o.k. One she asks a number of t imes. Her name i s (G) and I notice she has a tremor of some kind and i s also one of the older members BR: This i s a guess-late 70's OB: # 2 i s ca l led by (F) for BP. The woman leaves the room and goes of f somewhere around the corner. This room although closed of f by three wal ls i s open at one end so I can hear ping pong b a l l s and people pop over now and again to look at what i s happening. The room i t s e l f i s on the 3rd f l oo r where seniors programs are held. I t has windows down two sides and i s approximately 30x15 feet . The table (F) i s at i s located at the end which i s open. The inst ructor i s in the middle of the group at the f ront . Two more woman ar r ive and move to the back and j o in i n . -ankle rotat ions - l e g rotat ions A man comes up to the table and gets a # for BP. (A) changes music to 'moon r i v e r ' -marching on the spot- some s i t - the rest remain standing - tw is t ing Another man ar r ives & then a woman. Only the woman jo ins in the exerc ises, the man i s here for BP. -walk in large c i r c l e around chairs (I am now in the center) . (J) pops over to ta lk to me and mentions she i s only here because the sen io r ' s l i k e 166 her to come by as i t makes i t more o f f i c i a l . BR: I wonder what t h i s means.. OB: She ta l ks to me about how they had a planning meeting in A p r i l . Z I ask when the next one i s and i f I can attend. She says i t w i l l be in June and i s usual ly held af ter the session. She also ta l ks about how she l i kes to see the program stop in the summer as bel ieves the volunteers need a break, or they get burnt out, yet often they want to continue. She also said she does to , to do other th ings, - f i ngers and feet in a seated pos i t ion Music i s very mellow now-piano (J) makes announcements-Weilness f a i r at Kerr isdale (a hand out i s given out labeled Seniors in Ac t ion) , she explains that d i f fe rent wellness groups w i l l be there and i t w i l l be a chance to see what others are up too. Every one chats about how to get the bus there. (J) apologizes for in terrupt ing the exercises and then leaves. -arms One of the women mentions t h i s i s what she had to do when she had a broken arm. - f i ngers - I t sy b i tsy spider -seated raise arms-arms out and in -eyes-up and down, side to side Another woman a r r i ves . I notice t h i s group looks re l a t i ve l y young-late 50's 60's except for a couple who look to me about 70-80. Another man ar r ives for BP. -s t re tch ing arms - face I t ' s now 2:00pm (A) f in i shes the session and thanks the group for coming. She mentions the seniors s t ru t t and gives pamphlets to those that don't have them. Seniors now chat together. Many leave, there are now 7 l e f t . The speaker i s here now. I t i s going to be a ta lk on 'dement ia /sen i l i t y ' by a coordinator of a S.T.A.T. Center. Two men jo in the group as 167 they are wait ing for BP. The ta lk continues for about one hour and during that time seniors ask questions about depression, alzheimer 's and del i r ium the top ic . At the end one member asks what other ta l ks t h i s coordinator gives and wonders i f she could come back again sometime. The program ends at 3:00pm The tone has been relaxed. BR: I did not ice however how a It of men came but how only two stayed for the ta l k and none went to the exerc ises. OB: This i s the end of t h i s observation. 168 FORMAL OBSERVATION PCOB3-Program C, Observation 3 +PCOB3 +Name:Kim Ca lsa fe r r i +Date: June 12/89 +Time: 1:00-3:00pm +Subject: Formal OB: I a r r ive at 1:05pm and see the table set up. There i s a TV set up. 7 senior women s i t in l i nes . ( I ) , a Senior Volunteer ar r ives & t e l l s 3 seniors s i t t i n g next to the coat rack that the RN won't be here today. FEMALE: (ar r ives) Hi ( I ) : No nurse here today- only exercise and lecture. OB: A young guy sets up the TV and puts on a video. There are 10 senior woman. MALE: What's on today. ( I ) : Eye disease. Are you going to come? MALE: No, my eyes are OK. OB: The video s t a r t s . I t i s a video from the Red Cross for Seniors-exerc ise, 1/2 hour. I understand (A) i s away r ight now so the video i s being used as a subst i tu te . I not ice on the table are two pamphlets from the St . John Ambulance: 1) Healthy Aging 2) Get Ready, Get Smart, Get a Handle On Your Retirement L i f es t y l e I notice that 1/2 of these people are regulars. Another woman a r r i ves , i t i s 1:22pm. She takes a seat and jo ins i n . I notice one woman doesn't j o i n i n . Another woman arr ives at 1:27pm. There are 13 women now. One of the woman sings as they do a rowing motion. FEMALE: Row row row your boat. OB: They do strengthening and st retching of both legs and arms. Another woman a r r i ves . Then the pace Increases. Heel, toe, polka. The woman on video s ings. They a l l laugh. They now move into a cool down. I notice a sign on a board: 169 Wellness CI in ic-d lscuss ions-your blood pressure taken-musical exercise-guest speakers. The video f in i shes at 1:45pm & (R) s ta r ts again. 2 more women a r r i ve . 2 leave to go have coffee the others do i t a l l again. ( I ) : (to me) Come and jo in i n . (She jo ins the group) OB: One of the woman who ar r ives doesn't do i t . 2 more women ar r ive and 1 jo ins i n . (I) goes over to the other and encourages her to jo in i n . (E) : ( t e l l s me) Last week we had a lecture on AIDS and one by one a l l of them l e f t . I don't know why. The 2 men complained. I don't know why but one man was t e l l i n g us when he started having sex and that i t wasn't t i l l l a te . OB: Another woman a r r i ves . (I) goes over. FEMALE: Someone's supposed to come and speak about the eyes. ( I ) : Join 1n the exerc ises. FEMALE: I can ' t exerc ise. (She s i t s over by the coat rack) OB: I not ice when I look over that she has joined i n . ( I ) : I think tha t ' s him. Do you remember h is name? OB: She goes over to him. SP: I need a screen for s l i d e s . OB: The exercises end at 2:10pm. There are 20 people here. The ta lk i s ca l led "The Aging Eye" MALE: My name i s (P) . I'm an eye doctor in t r a i n i ng . I f i n i s h in 2 months at VGH. (P) : Please shout out i f you have questions. FEMALE: Can you speak a l i t t l e louder please. (P) : Do you know what legal blindness is? OB: Explains same. Shows a picture of the eye & expla ins. He mentions clouding of the eye-cataracts . FEMALE: I have that . (P) : What I'd l i k e to t e l l you today i s what happens to the eye when you 170 age, the diseases and what you can do. OB: Another man arrives. (P): Things that go wrong as you get older. D b a g g i e skin-simple surgery-take away extra skin 2) droppy l i d s - muscle that pulls eye c\open gets weak-can be in one eye or other. Fairly simple surgery. FEMALE: That's not a squint eye is 1t? (P): No and we won't talk about that because i t ' s more in younger people. 3) 1 id flops out 4) spotsoneye-skin tumour-not dangerous unless l e f t - important to treat and remove. Things that affect front of eye: 5) white ring- no problem 6) glaucoma- increased pressure in eye, the drainage of f l u i d out doesn't work- damage to peripheral vision (gradual loss) 2% of population Rx-drops in eye to decrease pressure 7) Cataract-lens gets cloudy -don't have to wait now t i l l "ripe" -90% chance of restoration of vision -local anesthesia only -surgery only Rx and lens implant or glasses or Macular Degeneration: -aging of back of eye -very common -50% over age 50 years -damages spot for fine vision -build up of white waste products -doesn't affect side vision -very l i t t l e can be done except laser Rx.x -only 1 type-leaking blood vessels Diabetes: -increased sugar levels -effects eyes-damages retina Detached retina: -aging, short sightedness, diabetes can cause same -retina detaches from blood supply -loose part of vision -a lot of black spots -flashing lights Optic Nerve Damage: -uncommon MALE: Is there 2 operations. One for dry eyes and wet eyes. 171 (P): Some of you may have dry eyes (he explains same). Rx not an operation but to use tear replacements. Can be plugged i f too much f l u i d . FEMALE: Last time I went to doctor he only changed one glass. (P): That's great i t didn't cost so much. FEMALE: What is a lazy eye. (P): The same as a squint eye, like cross eye. It's called lazy because it ' s not working. FEMALE:: Is that because you're over using. (P): That's a myth. You can't damage your eye from over use or lack of light- you just can't see. MALE: Night glare (P): Glare can be solved Do you have cataracts? MALE: Yes OB:: Many more questions are asked and (P) answers. FEMALE:: Why do you get sleepy when you read (P): Probably eye strain. OB: (I) and I talked at end as I needed to t e l l her I wouldn't be there next week but would see her at planning meeting. She thought i t was today so hasn't been f i l l e d in on changes. The session has been very interactive. (P) was very down to earth and approachable for questions. The talk ends at 3:15pm. This observation has had a very relaxed tone. This protocol ends. FOCUSED OBSERVATION PC0B6-Program C, Observation 6. +PC0B6 +Name:Kim Calsaferri +Date: June 26/89 +Time: 2:30-3:30pm +Subject: Focused OB: I arrive 1n the room next to the Wellness Clinic and 5 people are there. Sen Vol 1, Sen Vol 2, RN, Coord and Prof (connected to Seniors 172 Centre staff). We meet in another room off the Wellness Clinic at 2:30pm for the planning meeting for the Wellness Fair in f a l l . I heard about this meeting from the last planning meeting held on June 19/89. COORD: We talked about the possibility of a f a i r when we come back- explains what was discussed at last meeting. RN: On that day COORD: We could have films, speakers, games SEN VOL 1: You mentioned nutrition COORD: Yes the food wheel. She explains that i f i t stops meat area-they give out meat recipe. We have a couple of other games we could use and give out some prizes. She mentions two good films-Georgia and Rosia- a comedy about seniors. Mr. Nobody- one done in Toronto about individuals freedoms when they become older. A good film to e l i c i t discussion. "A House Divided"- another good film about elder abuse. There are others about seniors accomplishments PROF: We could cal l i t Fun and Wellness Day and advertise what will happen. COORD: We would be able to advertise your programs PROF: It would be good to start before the school board SEN VOL 1: How long for PROF: 10-3, the 2nd Monday, the 11th (M): (Arrives in) He asks the Sen Vol 2 to give out minutes from the June 19/89 meeting (SEE "Wellness Committee Meeting June 19/89" in the appendices) COORD: (M) we thought we could hold i t 10-3pm on the 11th PROF: And i t s going to be called Fun and Wellness- kick off day SEN VOL 1: Will we put balloons and streamers (M): I have balloons COORD: How should we do i t PROF: —BP and counselling in one area -popcorn COORD: And we could have exercise and the nutrition games 173 PROF: And why don't we invite Dr. Blatherwick to speak about AIDS OB: I wonder i f she is joking considering last time OB: They laugh (M): Suggests the living will SEN VOL 1: Wouldn't i t be better as a topic for the Wellness Clinic (M): He's a good speaker. Do you want speakers PROF: It's a kick off COORD: BP and maybe one of your counsellors could come down. PROF: You should just advertise yourself SEN VOL 1: What about the feet (M): Reflexology COORD: We need to get people involved SEN VOL 1: We need to get some of these people here involved COORD: What about the glee club PROF: 5 hours, 10-3pm. One room set up for films COORD: Fun films SEN VOL 1: I went down to the film festival some are long some are only 10 minutes COORD: Will you be here (M) to do BPs RN: Yeah but not a l l day COORD: We could slot i t in COORD: If you do i t a l l day your ears really k i l l you PROF: So BP What else do you do SEN VOL 2: Yes we should get a new weigher PROF: We could bring up the doctors on a trolley OB: COORD explains very expensive to fi x . The Prof says she'll look into i t PROF: I can but that no problem. By the time you start (M): COORD: We'll have some speakers, exercise and counselling, movies and massage. It would be really good to do massage (M): She stopped though We could talk to (V) COORD: We had a physiotherapist come in SEN VOL 1: There was too much before with massage, exercise, getting mixed with the talks 174 (M): Exercise- do you want me to approach the reflexologist and massage also COORD: I don't know how to do that unless we train someone (M): We can get (V) she's trained COORD: And then some fun games (M): Those nutrition games SEN VOL 2: He's a very good massager (M): As long as he does i t on the back SEN VOL 1: He did me and i t hurt a l l week COORD: We don't want a treatment massage we want a relaxation one (M): Should we divide up the tasks COORD: (M)'s afraid he'll get stuck (M): Someone on films from NFB, displays SEN VOL 1: They're very happy OB: People discuss this (M): (To Sen Vol 1) You want to pick up and preview SEN VOL 1: I don't want to COORD: I will discuss with you (M) and the Sen Vol 1 It's good i f we look at issues and fun Which means we need a skilled person to answer questions (M): That's why I said the Sen Vol 1 RN: A social worker COORD: Yes a social worker PROF: Maybe someone to speak on resources (M): I ' l l take care of demonstration, exercise and you COORD take care of speakers COORD: Dr. X, LTC and some one from police SEN VOL 1: Some one from Home Care COORD: Hard to get someone because they are so busy RN: Some one from LTC would know Who would you get (M.B.) COORD: Some nurse working down here someone from LTC, Health Unit (M): and (J) from information services COORD: And I can get (J.W.) to come with popcorn (M): I missed that COORD: She makes popcorn with Italian mix 175 PROF: The best thing is to give out things. Anything the Health Dept. can give away SEN VOL 1: The safety people gave out things (M): We had a barrage of calls after that for things as they said we could give things out RN: The Health Department give nothing COORD: We could organize popcorn and a water fountain PROF: I think that's pretty well organized. Should we have another meeting COORD: I'm away in August SEN VOL 1: We need to schedule and advertise in the West Ender (M): What do you think PROF: We're going to advertise classes RN: On TV that is COORD: (M) can organize that OB: Discuss exercise as important COORD: We could have carpet bowling using tins of food SEN VOL 1: We could have the Food Bank, after a l l i t is a wellness thing PROF: Very similar to our open day except focusing on Wellness RN: Have they set the date in August COORD: How about a meeting the middle of July and August (M): I ' l l be away in August COORD: Middle July (M): 3rd week COORD: About noon (M): Over lunch in the cafeteria. The 17th? COORD: A l i t t l e informal meeting PROF: You'll get speakers and films, we'll get the rest COORD: Line dancers SEN VOL 1: If you do line dancing you can't come to this COORD: Even i t you had dancing 1n one room. And crafts (M): We don't start that until 3rd week SEN VOL 1: Last time only one person came. You're supposed to focus on health. How far do you want to go 176 (M): Your physical well being SEN VOL 1: Yes OB: The Sen Vol 1 and (M) appear to be suggesting that wellness shouldn't include crafts. More discussion occurs about when the meeting should happen etc and this meeting closes around 3:30pm The tone of this meeting was f a i r l y relaxed. (M) looked to COORD a lot for answers. The Coord and Prof ran most of i t with occasional input from the Sen Vol 1 and 2. This protocol ends. 177 APPENDIX D INTERVIEW SCHEDULE 178 APPENDIX D INTERVIEW SCHEDULE July - August 1989 DATE TYPE SEX TIME PROTOCOL March 13 Sn.Part. M 12pm-1pm PAINT 1 July 1 Sn.Vol. F 1030am-12pm PEINT1 July 4 Sn.Part. F 11am-12pm PCINT1 July 5 Sn.Vol. M 11am-12pm PBINT1 July 5 Sn.Vol. F 2pm-3pm PAINT2 July 5 Sn.Vol. F 7pm-8pm PDINT1 July 5 Sn.Part. F 8pm-845pm PDINT2 July 10 Sn.Part. F 10am-1030am PBINT2 July 10 Sn.Part. M 1030am-11am PBINT3 July 10 Sn.Vol. M 1115am-12am PBINT4 July 10 Sn.Part. F 130pm-2pm PCINT2 July 11 Sn.Part. M 9am-930am PAINT3 July 12 Sn.Part. F 930am-10am PAINT4 July 12 Sn.Vol. F 2pm-3pm PEINT2 July 12 Sn.Part. F 3pm-330pm PEINT3 July 17 Sn.Part. F 930am-10am POINT3 July 19 Sn.Part. F 10am-1030am PAINT5 July 19 Sn.Vol. M 11am-1145am POINT4 July 24 Prof. F 930am-1030am PBINT6 July 24 Prof. F 11am-1230pm PCINT4 July 24 Prof. F 3pm-415pm POINT4 July 24 Prof. F 830am-930am PEINT6 July 26 Sn.Vol. F 930am-1015am PEINT5 July 26 Prof. F 2pm-315pm PAINT6 July 31 Sn.Vol. M 11 am-1130am PBINT5 Aug 1 Sn.Vol. F 11am-1145am PCINT3 Key: Sn.Part. = Senior Participant Sn.Vol. = Senior Volunteer Prof. = Professional P = Program INT = Interview 179 APPENDIX E INTERVIEW QUESTIONS 180 APPENDIX E EXAMPLES OF INTERVIEW QUESTIONS Seniors' Questions-Participants +Questions for Category 1 Seniors. +Across Programs +Date:July 3/89 +Questions: 1: What is the name of this program? 2: What is wellness/health promotion to you? 3: What is a wellness/health promotion program? 4: If you were to describe this program to someone, how would you? How long does the program run?- per year, per week, per session. 4: What are the goals/ philosophy of the program? 5: What is the history of the program? How did 1t start? 6: How do people find out about the program? 7: Who goes to the program? Who doesn't go? Why do people go? 8: What is the age range of people who go? 9: What is the ethnic mix? Socio-economic range? 10: Who runs the program? Who is in charge? 11: How are decisions made about the program content and activities? Who makes these decisions? 12: How is the program funded? Do people have to pay to attend? 13: What are the strengths of the program? What would you like to change/add? 14: Is community participation/ advocacy encouraged? 15: How would you describe this community? 16: I noticed certain issues are important to you as a group such as could you comment on these. Seniors' Questions-Volunteers and Program Planners +Questions for Category 2 Seniors +Across Programs +Date:July1/89 +HX-Wellness/Health Promotion Programs: 1: History of Seniors wellness in the city. 2: History of establishment of the Seniors Advisory Committee to Council-City Hall-How are committee members selected-are there other committees/different members -what is the mandate of these committees. Who where the founding members. 5: Funding sources-Advisory Committees,Programs. 181 6: One stop shop 7: Out reach-mentioned as "an eternal problem". What does this mean? 8: Housing-seems to be a major issue? 9: Toward a Better Age? +Specific Program: 1: Hx of same 2: What is wellness/health promotion to you? 3: What is a wellness/health promotion program? 4: How would you describe Program ? 5: How do people find out about this program? 6: How is i t funded/do people pay to attend? 7: What are the philosophy and goals of program? 8: Who goes/doesn't go/why more women than men/why do people go? 9: Who runs the program/who are the leaders-in charge/ 10: How are decisions made? 11: People go to different programs-why? 12: How involved is this program in community participation/ advocacy? 13: I noticed certain issues are important to the seniors such as could you comment on these? Professionals' Questions +Questions for Professionals Across Program +Date:23July/89 +General Health Promotion for Seniors in Vancouver: 1: What is the history of health promotion/wellness in this city for seniors? 2: Why/ how where the Wellness Coordinator positions established? 3: What is the mandate of these positions? 4: Who are you funded by? Who do you report to? What influence does this have on your decisions? 5: What is health promotion/wellness to you? How would you define it? 6: What is a health Promotion/wellness Program? How does i t operate? 7: Is there a framework by which you operate? Is there a philosophy/goals? Could you explain on these? 182 +Specific Health Promotion Programs. 1: What is the history of the program ? How did i t begin? How long has i t been in operation? 2: How would you describe this program to some one who hadn't been? What kind of components/activities occur/topics covered? 3: Who goes/why do people go/who doesn't go? 4: Men/women issue? 5: Who runs the program? Is there a leader(s)? 6: How are decisions made about program content/components? Who makes these decisions? Is this an active /passive process? 7: What i f any is the philosophy/goals of the program? Is this program meeting perceived goals? 8: How is the program funded? 9: Is community participation/advocacy encouraged? How? 10: How is this program funded? 11: What are the strengths of the program? 12: What i f any thing would you like to see changed/added? 13: How would you describe this community that this program in terms of cultural, social, and economic factors? +The following questions were asked as a result of the observations and the interviews with the seniors, (see in my dairy #2 pg 1&2) 14: Why are you involved/interested in:-housing? -outreach? -writing position papers? 183 APPENDIX F EXAMPLES OF SENIOR AND PROFESSIONAL INTERVIEW PROTOCOLS 184 APPENDIX F EXAMPLE OF SENIOR INTERVIEW PROTOCOL-CATEGORY TWO +PAINT1-Program A, Interview 1 +Senior Interview-Cat 2 +Name: M +DATE: July 5th,1989 OB: This interview was organized on Wed, June 28/89 following a focused observation. M was chosen as she is a designated leader and also has been involved with the program since i t s inception. She also assisted me in pin pointing other people who might be appropriate interviewees considering my c r i t e r i a KIM: OK. I suppose the f i r s t thing is what is the name that you have for you program? What is the name of it? M: At the center. KIM: Yeah. M: That's Keeping Well. KIM: It's called Keeping Well M: Yeah. But we're a f f i l i a t e d with uh Good Age. And the Good Age is uh Program A Community Center, School X and School Y. The 3 groups together are working with the seniors you see and we call ourselves the Good Age. And the Keeping Well Program came out of the Good Age. Do you know what I mean. KIM: So i t ' s kind of a co-sponsored type of thing is i t . M: No not really uh just some people came to the Good Age meetings and um (S) came along from the Health Unit and um -I put a name in-KIM: Oh that doesn't matter I won't put use names in, you can use names. M: And then she came to the community center and brought up the subject of Keeping Well Programs because she had done i t at other community centres. And so what started off, what started the Keeping Well Program was the people that were going to the Good Age and they met (S) there. And they came to the community center and we formed the Keeping Well and from there then I started getting hold of 185 neighbors and knocking on doors and delivering pamphlets and advertising our Keeping Well Program and i t expanded. KIM: OK. So how long has that program been running? M: Four years now. KIM: And you were kind of like a founding member, were you-M: Yeah, because I was in with the Good Age KIM: Where was the Good Age held? M: We had our open house at School Y. It was (G) from the community center and the 2 um I don't community workers I guess from the community schools that got together and formed the Good Age. KIM: OK. And how did they get people to come along to that? How did you hear about it? M: Word of mouth and advertising. They advertised that they were having-going to be holding this open house at School Y. Of course we a l l were a l l used to doing community work, volunteer work so we a l l pitched in. KIM: OK. Now I know i t ' s called Keeping Well. What is wellness to you. How would you define wellness? M: Wellness is uh uh a well rounded out person. Um um let me see now. Somebody that's active. Looks have them- and happy a happy person. And uh they like themselves so they look after themselves. And uh from there I guess i t just goes on and on and on. KIM: So what is a wellness program then to you? What does that mean to you? M: It's more social than anything. I've got to know so many people. And some of my old friends are there too that I contacted old friends to come to this. And then we've met a lot of new ones like the Chinese ladies and that. They're a l l new to me so uh I met them there. And i t ' s -that's why we start a half an hour- we get there an half an hour early to have a l i t t l e social before uh you know. A l i t t l e chat before we get into out exercise. 186 KIM: OK. So i f you were to describe this person to a new person. If you were te l l i n g someone about this program how would you describe i t to them. M: I would just t e l l them to come to uh you know -they want to meet a lot of nice people to come and then I would explain to him the things that we do. We have half an hour of uh light exercise and then we have a l i t t l e tea break and then we have um somebody come in and talk to us on different subjects. On health, on uh nutrition , um anything um law. We had a doctor that came from the Health Unit and his topic was "How to get the best out of your doctor" and that was very very interesting. Uh investments cause there are some seniors that have a bit of money and so i t ' s uh- I would explain a l l this to them i t ' s a real variety of things that we do during the year. KIM: OK. Now how long does the program run. Does i t run a l l year round? M: Right through we never stop. KIM: OK so i t ' s a year long thing and does i t always run right through. M: Yeah, the f i r s t year that we started uh (S) said look quite a few of the programs um stop for the 2 summer months July and August and she said what do you think. She asked us what do you think. So I spoke up f i r s t and I said well seeing i t ' s our f i r s t year let's run right through . Cause what I am afraid of is some of them who have been coming and i f they stay away for 2 months they just might decide to stay away you know, not come back. And this way i f we stay right through, you know they'll keep coming and we won't lose them. KIM: Sure. M: And so you know everybody showed up. We always had-even in the summer time we had such a good turn out that we decided to keep going a l l year. KIM: So what's the attendance like? How many people usually come? M: Uh average between um 18 and 20. 187 KIM: OK and you've got a core group that are pretty consistent? M: Yeah KIM: OK, now are there any goals that you have for this program? Do you have any- what are the goals that you try to achieve. M: What we want, what we want- my goal is to get a seniors room at the community center and we've been fighting the Parks Board for 6 years now. That we've trying to get this room and every year they promise us next year you're going to have your room cause we want to combine the 2 back rooms, we want to knock the wall off, we want to make i t one big room. We want to um move the south wall that faces the street. We want to move i t 6 feet towards the street, towards the side walk to make the rooms more square because they are long and narrow now. And we want to knock the 2 back rooms we want to knock the middle wall out and make i t one great big room and that would be like a seniors- form 9 in the morning to 5 in the afternoon would be s t r i c t l y seniors. And then- seniors don't go out very much at night so in the evening you know so uh well they have their bridge. But that's a different group but that's s t i l l seniors and um they have bridge 3 nights a week and so you know they're finished about 9 o'clock. And so from 9 in the morning until 5 in the afternoon would be st r i c t l y seniors that room and then after that they could use i t for other things- for exercise, an extra exercise room from the gym and KIM: So that must be the space issue that's been coming up, because I know that people have talked about space. Is that what that's a l l about? M: Yes. Because we're in Snowies Lounge now. But there are a lot of things that we can't do we can't do line dancing on account of the floor. We don't have the proper flooring and we can't get in the gym that has the proper floor. We can't get in the gym 188 because i t ' s being used a l l the time so i f we had our own room we could have so many more programs for seniors. KIM: So what's been the problem about getting the space? M: What the Parks Board I don't know-they keep promising to us and then they set money aside for that space and they turn around and give i t to some other community center and we're le f t . And now they t e l l us i t will be next year before we get our room. So i t ' s 6 years that they've been- so i t ' s kind of frustrating, very very frustrating. I am so frustrated that I want to get that Parks Board out of there, I'm working to have them a l l voted out of there and get a whole new group in there and then maybe we'd get our new room. KIM: So how do you work on something like that? How do you work on getting those out and getting new people in? M: Talk to the seniors. The seniors are the ones that- there are a lot of seniors in area A. And talk to the seniors every chance I get I talk to the seniors. Get those guys out of there. They've been in there too long. Get 'em out. KIM: So you say the program has been running for what- 4 year? M: Yeah KIM: And you've explained how that started. How do people find out about the program? How do people find out about the program? M: Word of mouth. Neighbors, you know person t e l l i n g their neighbors and then l i t t l e brochures that we have out they have a 1ittle calendar each month that gives the programs. KIM: Is that the community center is it? M: For the community center and uh we can take i t like when they have seniors day at Shopper's Drug Mart. We take a few of the calendars there and leave them on the table and people pick them up and 189 KIM: Do you ever use the newspaper or anything like that? M: No KIM: What about the local newspaper? M: They haven't bothered too much with that. It's just more or less word of mouth and you get your neighbors to come over, you know to come in and attend the meeting you know the gatherings. KIM: Who goes M? Who are the people that go? What's M: Active people, active people. The majority of them are between 60, 60 and up I guess we have some in their 80s- up there. KIM: What about ethnic mix in there? M: We were really surprised. (S) was really surprised you know, how well they fit t e d in when the Chinese people started to come and Wes who gives us our instructions now, he's Japanese. We get a long. They really f i t in nicely. We've had Greeks in there we've got uh you know. And we have a lot of people that come and v i s i t like our Indian lady from India who just le f t and uh she was so interesting. KIM: So how did the Chines ladies get involved then? M: I guess their neighbors told them to come. And they knew about the community center. There's a brochure that goes out twice a year. The spring one and the f a l l brochures that go out with the programs in there. And goes out in paper X. Everybody gets paper X so they get the programs and they come to the community center. KIM: So the rest of the group then-I've noticed they're Caucasian. Are most of those people of Canadian background of English or have you got a sense of where people are from? M: Yeah, well like (B) he's Scottish, you know. Uh (G) uh he's Canadian but his wife is Parisien French and she doesn't come because she's involved with other things, tennis and a l l this sort of stuff you know. So she doesn't come but um (J) 190 I believe he's French, he never speaks French but I believe he's French and um they just a l l f i t in. KIM: So i t ' s kind of a mixed bag. M: Yeah KIM: What about as far as people's socioeconomic status? Is i t people that are kind of - is i t a l l ranges or is i t -M: I think the majority of people that come there- I would call myself not poor but maybe middle class. If there was such a thing as lower middle class I would say because I'm fixed income. Nearly a l l of the people in here are on fixed incomes. And uh but some of the others they own their own home and that they're a l i t t l e better off. So they would be- but I would say the majority -middle class. KIM: Who runs the program? Who's in charge of and how are the decisions made about what happens. M: (S) actually- and works with the community center with the staff at the community center uh they have a seniors coordinator. (W) is the seniors coordinator and working together and then they consult us. KIM: So how-M: Like they lef t i t up to us today whether to cancel last-next weeks um program on account of the Stanley Park picnic for seniors. It's on next Wednesday- so he left i t up to us whether we wanted to cancel that program and go to the picnic and so the ones that aren't going to go the picnic are just going to stay home. Their won't be a program. It was voted that- but he left i t up to us to decide. KIM: Is that what happens around the types of activities that happen here. M: Yeah. They present them to us and they uh the bus trips and what have you we leave i t up to them cause they plan very good- we've never had any problems with the bus trips that they've planned for us. The kind of bus trips - the different places that we go. The majority of people have 191 been quite satisfied with that. KIM: And that's through the community center that's not part of the Keeping Well? M: No that's for a l l seniors. KIM: What about in the Keeping Well Program its e l f ? How do you make decisions about the topics and speaker and M: With (S), we discuss i t with (S) and the coordinator. KIM: How's the program funded? Do you have to pay to go? M: No that's free. KIM: OK so that's free. M: Yeah a l l you need is your membership which is $1.00. KIM: Because the space is supplied by the community center, they fund that right? M: Yeah KIM: What about the coffee and tea and M: Well they pay for i t KIM: The community center M: No no the seniors themselves we've got a l i t t l e box and they through their monies in their hot $.25 for a cup of coffee or tea and $.25 for a cookie or a slice or what ever we have there you know. And lots of times like I'm with The Chamber of Commerce as well and our meeting s is on a Monday and so we meet the seniors meet every Wednesday so sometimes there will be f r u i t and cheese and stuff like that le f t over from the Chamber and I stick i t in the fridge and then I bring i t to the seniors and always t e l l them that is was compliments of the Chamber of Commerce. So they benefit that way a l i t t l e bit. KIM: That's great. What do you think are the strengths of the program? What are the good things about it? What do you like about it? M: Pretty well everything that we do there I like. KIM: OK M: I can't find any fault with i t . KIM: OK that's great. Is there anything that you would like to add or change about the program? 192 M: Just the room, I'd like to have a better room for us to meet in so that we could do more programming for the seniors. KIM: Are the seniors there encouraged to participate in the community through the Keeping Well? M: Yes because quite a few of our Keeping Well people have volunteered to help out on the Tuesday afternoon when they have the special seniors. You know a bus picks them up from a nursing home and brings them and they do um ceramics and some will go in the kitchen and they'll look after the tea things and they make their own l i t t l e Christmas decorations and what have you. Stuff like that. They are quite a few of our Keeping Well people who have volunteered to do that and from there they volunteered to go and v i s i t another old senior that's house bound you know. KIM: Is there any Out Reach from this program? Is that something that i s -that you want to do or might want to do? M: We tried, yes. Well we tried I guess i t ' s s t i l l in abeyance there, we tried for a grant from the New Horizon and a l l we got was a run around so we dropped i t for a while. But (S) ants to start i t - would like to bring i t up again maybe in the f a l l . We might start working on i t maybe in September. And that's - we call that program Out Reach cause we want to reach out- we want to take programs to other parts of the area A. I'm thinking of - I ' l l use one area as an example, around school Z, using the school sort of a base. It wouldn't necessarily be in the school but the seniors would meet . It might be at the Legion, we might t get a room there. Or we might find a meeting place, but around there because they are so far away from the community center and even the ones that take the bus they s t i l l have a walk up a h i l l to get to the center and i f they come 193 along street B they s t i l l have a h i l l to climb. You know, that's why some of them stay away because of on account of we are not near a-we're not on a bus line KIM: So that kind of gets at my next question of who doesn't come? M: Yes the ones who don't come are people who are who have got in the habit of staying in the habit of staying in their homes and looking at their 4 walls. And they need, those are the ones that need encouragement to get them out. And I figure i f we brought a program closer to them so they wouldn't have i t wouldn't be such an effort for them then we could start getting them out and then gradually i t would expand and they would go out a l i t t l e further and-KIM: OK. One thing that came up when I was doing the observations was housing. That's been an issue in your group. Can you talk a l i t t l e about that. M: Well I'm involved quite a bit- the Chamber of Commerce is involved with quite a bit with what we call ATTACK right now, with the Assessment and what our seniors are really worried about are how much their taxes have increased this year. And I got involved through the Chamber of Commerce and I keep going to those meetings hoping that we achieve- we're trying to get them to squash this years assessments that are so high for the merchants but- I'm also hoping that through that the residents and some of our seniors you see have their own homes and they might benefit i f we can get the assessments squashed for this year. And they would pay the same taxes as they paid last year and reassess for 1990 and forget 1989 because they are going to be so many merchants that are going to have to close their doors and today's their deadline you see. KIM: So is the concern for the seniors-194 M: The seniors, the way - well we're watching Kerrisdale very closely what's happening in Kerrisdale and we're watching i t very closely that i t doesn't happen here because they are a lot of people who are renting so we're keeping a close watch on what happens and the outcome for Kerrisdale where the seniors are being kicked out of their places and having to go into a different area altogether that's affordable. And so uh- see with us here we're OK cause this is government owned these buildings and these were built - these were opened in 1946 for the veterans. KIM: But i t ' s a different story for some of the others. M: But now i t ' s open to the public but veterans s t i l l get preference, you know. And so this is owned by the government but there's been talk the last 5, 6 years that uh Central Mortgage is going to sell theses places to developers. And so we're watching that very closely and quite a few of our people that live in the block here belong to the Legion and so we've got the Legion and the DVA behind us that will fight for us. KIM: OK another thing that came up in your discussion was exercise instructors. M: Yes KIM: It sounds like you've quite a few-M: (Laughs) KIM: And there's been a few hassles with that. Like i t sounds like you're pretty happy with this last one but M: We were very very happy but I think that the thing is there is 2 ways of looking at i t . I like the l i t t l e g i r l I don't want to sound like I am against her cause I like her and she was very very good but she may have used us to get her certificate. She had to do so many hours of volunteer work to get her certificate. When she got her certificate and she's stayed on since her certificate maybe a month that she's done exercise with us and she has her own l i t t l e 195 business. She's got her l i t t l e bake shop. She does 2 other seniors groups that she gets paid for. See with us that was free- that was volunteer. Anyway we were very very happy with her except quite a few of our seniors said they wished she would change her music, her tape because the music didn't go with the exercise that she had. And they want to be able to keep time you know. They're not real rambunctious but they want to be able to keep time to the music i f they are marching and that. And her music didn't coincide with uh -so the other day I went up to her and I said while we were doing our exercise, I said to her very quietly do you- is that the only tape you have. And she said why are you getting tired of i t and I joking- I thought I knew her well enough and I'm laughing when I said to her "It's the shits" (Laughs) And she didn't say anything you see and she finished the program and she finished the exercises and that they told me they wanted to see me in the office and they accused me of -she told them that I had insulted her in front of everybody. So I do not know i f her being a business person and she's getting paid for the other 2 senior things . See there are 2 ways of looking at i t , maybe she is over sensitive and - but I said i t jokingly I was laughing when I said that to her and because I would never insult her. But I thought I knew here well enough to kid with her that way. The other hand maybe she used us to get her certificate and now that she's got her certificate couldn't very well quit as soon as she got her certificate so she went for the month and now she - this is her way out. And so we wrote her a letter and everybody signed i t and asked her to come back. And today (W) said that they mailed her the letter and also (H), who works in the office there, who's programmer met her on Friday and he gave her one of the letters that had been signed and that 196 had been sent to her. He handed her one and she read i t and she said she would think i t over and let them know. So i t ' s s t i l l standing. So we don't know. The other one was very very good but she has a bad back. I think she has art h r i t i s in her back and she had to quit plus her husband just retired and they wanted to do a l i t t l e bit of traveling cause she was free too. Before (P) we had (H) who uh does- who takes exercises from seniors but a l i t t l e more advanced, a l i t t l e more rambunctious - l i k e the younger seniors I would say. She takes lessons on that- she takes a class. KIM: Do you have a preference whether you have a young person or an older person? M: It doesn't matter to us. Just as long as they are you know-. Because she's young and they a l l liked her except for her music (LAUGHS) KIM: The only other thing I really want to ask you about is-I notice\ that there are very few men in the program. Have you got any idea why that might be/ M: Well men- I'm surprised that those guys come on their own. We have about 10 men a l l told but they don't a l l come at once. But we have about 10 men and according to (S) that is really to something because i t is mostly women that come out for exercise. Men don't normally come out. KIM: Why do you think that is? M: I don't know, I guess maybe they might think i t ' s sissyfied. They go down stairs and l i f t iron and what have you, you know and use the bicycles and stuff like that, that is more manly. But to exercise and to be with a bunch of women- this is why I'm really surprised you know at the ones who do show up. KIM: Well I think that's basically i t . OB: Tape clicks off. KIM: Go ahead and say that. M: What? 197 KIM: That social stuff. What you just said. That you think i t is more social than anything. M: Oh yeah, OB: Tape ends. 198 APPENDIX F EXAMPLE OF PROFESSIONAL INTERVIEW PROTOCOL +PAINT6-Program A, Interview 6 +Professional Interview +Date:July 26th, 1989 OB: I met with the professional at her office on the 26th July/89. Our interview took approx 90 mins. KIM: What is health promotion or wellness to you, how would you define it? PROF: Health promotion to me is really strategies to promote health in the definition that health is a means not and end, that health is a resource for every day living, then health promotion then becomes strategies to support people in their development of their health and increase their sense of control over their actions, over their, I think an example then is health could be housing for example and the housing c r i s i s , because people have a sense that they have no more control, and a health promotion program then with older people to help them feel like they are getting some control over the housing situation by either lobbying government or by letting the community know how the lack of affordable housing or lack of choice in housing is making them, giving them stress so for me health promotion is increasing a personal sense of control over their future and over their well being. KIM: So that moves me into the next question which is what is a health promotion program to you, what is i t about what is i t ' s purpose? PROF: A health promotion program then is i t ' s purpose then is to have people feel like they're increasing their own sense of control over their l i f e , over their future, over what's happening with them, so i f you use that as the base you start by working where they are. I mean i f they are going to increase control then they define the issues, they work with you on the 199 strategies, they are part of, i f we expect them to be responsible for health then they have to be responsible for the decisions around their health care, around health and then so i f i t ' s specifically about care then they should be involved some where in the decision making and know that i t is a much more of a partnership between health professionals and people and also that the health professionals are a resource to people and have something to bring to people but they don't have a l l the answers, so that the participants or citizens are helped in defining what the issues are and are much more involved in the process. KIM: As a Wellness Coordinator what kind of frame work do you work from, what is your kind of philosophy, your goals? PROF: Well I work from a very, 1st of a l l I don't consider i t wellness. Because to me wellness is a very narrow and has become in every day language a very narrow term and i t is really starting to focus much more on li f e s t y l e so I don't use that frame work I use a frame work of health promotion whether i t ' s health promotion fro younger or older people it ' s s t i l l back to what I have already defined which is what guides me is that he issues for older people and that they start to look at what they want ah and then the program has a number of different activities. It has the neighbourhood health program but i t has the West Side Seniors Advisory Committee, i t has the neighbourhood, i t comes from where the people are and where they start to define what they see as important for their sense of well being, so the frame work is always back to where older people now the other part of the frame work is to really understand that older people see that for them a sense of involvement or purpose and how they define that is important to their well being, so that that's a 200 major health issue for them. And the other aspect of i t is I just lost my train of thought here. KIM: Goals. PROF: The other major issue is that older people be seen as a resource being as they have experienced some s k i l l s and we are working with what they have rather than with what we think they need, so those are the kind of driving tenants of health promotion for me. KIM: I understand that these positions have been in place for some years now, can you give me a thumb nail sketch of the history of how these positions came into being or how the health promotion programs came into being? PROF: Well they came to be in different ways in different sections of the city because they where the f i r s t ah programs developed out of units, so each Health Unit went about i t a l i t t l e differently. Home Support, and the job was primarily community development working with seniors to develop alternate to home maker services or other options, so I was involved in getting Home Sharers developed and meals programs and Day Cares. While I was out there working with older people about these things they where talking to me about what they needed, they wanted more than L.T.C., quite a number of them were younger seniors and they weren't sure what they wanted but they wanted a prevention program, so sort of in the course over the years they did have these two drop ins. They weren't one end Kerrisdale was sort of done by prevention, but i t was sort of month to month whether the prevention program would continue and i t the one in Health Unit Y was done by L.T.C. and i t was the same thing L.T.C. wasn't sure whether there was any value in i t , and the mean time the older people are saying there is value and we would like more of these, we need a prevention program of people. They put together some ideas in Health 201 Unit X, you know we put them to the Prevention Program and they never, they really didn't have any manpower or time for any people, their whole focus in prevention at that time was children and their mothers so they said these are nice ideas but we don't have any staff. The older people where continually getting kin of cheesed off. The few that were involved in the 2 l i t t l e drop ins wanted them to continue and they were constantly facing the fact that staff were saying we don't know how long we can continue this so as a, working with older people the Director of the Health Unit asked me alright what would the program look like i f we had i t , what would i t look like for older people, and so I went out, he said take some time and do a bit survey about what is in the literature, what's available in the community. So I went and looked at the 2 that we had and then, which I wasn't directly involved in, and then looked at Program E that had started and I never did understand i t , some of i t was with the Health Department but some of i t was with the seniors down in the that area. I interviewed the professional coordinator and her view of Program E and went and looked at the whole Seattle Wallingford stuff and while I liked a lot of the stuff in the whole wellness what I was concerned about continually about i t and I was concerned even as I interviewed people what were the older peoples role in this. One of the things at that time the professional coordinator talked about was not being able to get older people to take control of the program. So what I wrote up the program in Health Unit X was I said we had to really look at that but I couldn't understand since I worked with people out here while developing hoe sharers why this, why older people wouldn't be interested in developing their own 202 neighbourhood health programs. Where was the discrepancy, was i t that we just had the bright more active ones out here running Home Sharers and Day Cares and the ones we met in the neighbourhood didn't have the s k i l l s or what? So when we wrote up the both of them from Health Unit X one of the big areas we wanted to look at was how do we involve older people, how would we go about that. The whole idea of peer to peer was very important and that l i f e style was one thing but what was the other dynamic and that we would . have to look into the literature and go further, we proposed that we would hire some one in Health Unit X who would work with the older people and plan a health program, a preventive program. S t i l l very vague as to what exactly would we do, we wouldn't, I wasn't quite sold on the wellness model that I saw. So they hired at that time a woman and she came in and she did that, took a long time before she went out in the community and did a whole l i t search and some of the areas that we really looked at was the whole thing of role and meaning for older people.. KIM: was she hired into a wellness position? PROF: Yes she was hired and she was the only non nurse and she was hired that what was f e l t in the unit what was we didn't need was another nurse, what we needed was a planner or developer, we needed some body that knew some thing we didn't know. We didn't want to replicate what was there. There was some thing missing there but we didn't know what, so she came and she did a l i t search and then we held health forums with older people in Health Unit Y and West unit because the unit was the Health Unit X Unit so we had the 2 sections. So we talked a lot to older people and ah what we could see where really involved older people yet at the same time none of the places have been using the people in the real planning, 203 so. And interestingly enough a lot of the older people didn't see themselves as being involved in that, they would do any thing we asked but they couldn't see themselves planning any thing. So we decided to set up the a Seniors Advisory Committee and out of say a hundred older people about 20 came and started the development of the program and then we wrote the back ground paper on, before we would put a program out there we had to have a frame work to set i t in, so that was when we came around and i t was almost the beginning of that whole new look at health promotion, so we were coming at i t one way and i t almost, i t ' s like you think you've got the only view but it ' s out every where, well then almost simultaneously realized that what we where interested in they were also interested in Ottawa, you know everyone was starting to look at the area of control and involvement. So that was how we started in our area and one of the aspects of Health Unit X was the neighborhood health program but that wasn't the only aspect there was the West Side Seniors Advisory Committee. KIM: The Seniors Advisory Committee is that connected to any organization? PROF: No i t ' s just advising 2 areas. It started off by advising Health Unit X and eventually i t progressed. The Seniors Advisory Committee is to Health Unit on how would develop programs for older people. KIM: Is that an ongoing committee? PROF: Yes i t s t i l l exists. KIM: And does that met on an ongoing basis? PROF: Monthly, but i t , just to go back that was set up as part of the health promotion program then we also recognized that to reach a lot of people in the community we needed a similar kind of program to the Be Well program a more neighbourhood program. And what (A) did and by this time I was completely out of i t , (A) went to 204 where there were programs at Health Unit Y there was one that eventually became the Live Wires and one in Kerrisdale already. So those had been there before any one had thought about what and they were very much developed on health drop ins where you came and got your blood pressure so i t was very much on the c l i n i c a l model. And she just worked and built on those. Then I left Health Unit X and came here, there was a vacancy for a wellness person or health, wellness person here. I came to that position and when I here i t was agreed with (J) that i t would not be wellness i t would be same, i t had been set up the program in Burrard similar to other programs around the c l i n i c a l health wellness model and he and I agreed we would not call i t wellness but i t would be health promotion and that since I was starting with nothing much I would do health promotion similarly to what we had already developed in Health Unit X because that's where I was coming from. KIM: As related to PROF: The background.(this is the frame work) So he agreed to the back ground paper, so he agreed in having to expand into having the seniors, bring on seniors from another area onto the Seniors Advisory Committee, so that was what we have done. KIM: Your difference between wellness and health promotion, is that you see wellness as more of a c l i n i c a l thing PROF: Clinical thing, yes. KIM: And you see health promotion as PROF: The big difference is I see wellness, the c l i n i c a l model as s t i l l being professionally decided and controlled and I see the health promotion model as really working at least with the frame work that you're involving older people in the decisions and i t ' s works some places and i t doesn't work in other places. But you always recognize that older people have been really WELL TRAINED into having been passive receivers of 205 care. But the model that drives the health promotion model is to at least be expecting that older people can make decisions. In the cl i n i c a l wellness model we are s t i l l expecting some where or we are making an assumption that older people A) need to be taught about l i f e style, or B) need to have come to us for counseling or screening and we have decided that that's the program they should have and even i f we only decided i t ten years ago we s t i l l decided i t , so the assumptions are different and so the assumption that I work on is that a l l five of the programs I'm involved in look different because they come from what the older people want. So that Program X, they want blood pressures and the seniors take them there. Now in Program A they never have them because they never did want them. In Program Y they have them once a month because they want to do that. And then some times there are people who don't want blood pressure so there is no blood pressure, so the program comes much more from the people, the participants and looks more like them, so that the five are different. I'm starting one at Z and i t will look like they are in Z. Now the reality you are always dealing with is one of our problems that we are continually plagued with is some of the assumptions that I had at the beginning is that out of the groups would come the leaders and that eventually they would run the whole program, they would f a c i l i t a t e , they would take the blood pressures and I would be their resource on the telephone, well i t ' s only worked (she laughs) at Mt Pleasant. Which is fascinating, with the seniors with the less education, but they f a c i l i t a t e , but i t ' s just really the people that are there and because, when I'm really studying i t now i t ' s also because of the setting that they are in. They are in a neighbourhood house that expects that these people a l l can 206 contribute. So besides just the seniors there is a setting of belief or expectation that older people have s k i l l s and older people contribute and they s i t on their board and they run the finances and they make decisions about what their program looks like and so i t a l l leads into that the Keeping Well Program their. I haven't been there in 5 months. And (Je) who is one of the leaders and (K) phone me and they phone me i f they think there is anything that I can get them, like a resource person. They think they might the f i r e men to come and talk to them well do I know his number or I some times phone them because there is nutrition neighbors or some thing, but they run their whole program. Ah they sometimes lead their own exercises, some times they draw on the program there who will help them with their exercises. Over on the other end of i t is Program A which we started from nothing in the community center and they will almost do every thing but they won't do the f a c i l i t a t i n g . They will i f I'm going to be away and they will do i t for a while but then they want me to do the f a c i l i t a t i n g and so facil i t a t o r s have not just emerged out. We are interesting in Program A now we have no exercise person, i t ' s just sitting and I have said to them I can't come up with an exercise person, they have to find the exercise person and ah the community person eventually helped them and they found an exercise person who one of the people spoke not nicely to her i guess and she quit, though I had a feeling she was on a volunteer basis for eight weeks. She was getting her fitness ticket so she agreed to do i t , but maybe after eight weeks she decided she had too much to do. Any how they haven't got an exercise person and they keep looking for some one I say as a group and there's three women in the group who could lead the exercises, but they a l l hesitate but I'm just waiting to see 207 how they are going to resolve this. They want exercise, they'll pay for i t they've said, one of them (H) maybe she'll try this Wednesday, she's terribly shy and maybe with time she'll take i t on. But she used to teach exercise and now when she's older she feels she just too shy to exercise. Well we are just leaving i t now but the seniors are now saying they'll help her with the exercises i f only she will lead i t . Because they really like the group and they really like the exercises and they know i t ' s really important but previously we have found them or you know exercises but have found people through Red Cross to give them exercises but I thought this time they have to solve i t them selves because they have not emerged the same as Program Y. KIM: So how would you i f you where to describe that group, to someone who hadn't been coming how would you describe it? PROF: Well I just feel i t ' s very, they have a nice social network when you consider how none of them knew one another, when you consider when we started there where three seniors and over r the years i t has built up and they come back as they describe i t , what they come back for is one another. Their friendships that they have made there which is an important part of the whole health promotion as older people t e l l me one of their health issues is friendships, that support, social support. I think i t has really been worked that way ah there was a friendly open and welcoming and that they do follow up and walk home with one another and they do support one another and care about on another, so they have created a kind of a caring group, ah and I like the fact that there are different kinds of people in the group, there's Chinese, Japanese, any ones welcome and a woman came from India and they just open up and people feel immediately at home so I think i t ' s 208 open and excepting and they care a lot about one another and they have created a l i t t l e community there but the part that is kind of confusing me or making me wonder is they don't take on, like they would like line dancing but they can't seem to go beyond and create line dancing. Now I am beginning to think myself that i t ' s because the whole environment is in the community center and that there is an expectation in a community center that the programs will be provided because other wise they are a l l very capable and 2 or 3 of they now have gone to nutrition neighbours which, and have been working on i t , nutrition neighbours. At one point they wanted to do out reach and they organized a group to put together a proposal for New Horizons for out reach, a half time out reach person where the person could work with them to put on fairs and put on, go to McDonalds and put on coffee parties and talk to the seniors in the street and find out, one of the things that's a problem in area A is none of their programs are over subscribed they are a l l under subscribed for the amount of seniors that live in the neighbourhood. So they wanted to find out why. In the middle of their process came along a group of professionals ah, the teacher from the community school, a couple of the staff at the community center and they a l l said they didn't need a programmer, that they could do i t themselves, that they were a l l capable seniors and why didn't they just run the out reach program themselves and go ahead. And kind of got in the middle of this with New Horizons and New Horizons every body agreed that the seniors should do i t themselves. Now the seniors never agreed, they have always sen the need, they don't want to take on that kind of responsibility, they want to work with some one to do the out reach. So they a l l quit and they don't have an out reach program there because the 209 seniors there got so fed up with the different professionals at New Horizons that every time they put a proposal in New Horizons changed the rules and kept cutting them back and fin a l l y about five of them just took i t and gave i t to New Horizons and said keep i t , so they're interesting people, they make you think about what i t is about women and men who are fa i r l y middle class and have much better education than our people over on the East side and yet they don't seem to take the leadership role that you would expect would happen, so KIM: Are you the leader there? PROF: I'd suggest that (M) is probably the leader there, and she does try and some of them are coming like (D) and there are 2 or 3 of them who worked more like ( L ) who has a severe case of arthritis i f any one they would probably say (M) is the leader, but ah sometimes you would be hard pushed to know that, however KIM: How are the decisions made in that group then about what happens? PROF: I met with them on a regular basis and like they decided that this summer they wouldn't have a group discussion, they really wanted to have exercise, they didn't want to close they decided they would stay open, a l l summer and that they wanted to ah be pretty flexible have some exercise and they planned a picnic which they've had and organized themselves and other times they just want to s i t around and talk so some times I go over and they just s i t around and talk and other times they do their own thing. So they decided this summer they will do their own thing and be completely unscheduled by, but by the end of the summer we will me t again and we will usually set up what they want to discuss for the next 2 months, 2 or 3 months. Now in the spring some where in February March they decided that they really wanted to look at eh whole thing of attitude, depression, humour, so we set up about three months and 210 part of that group i t is not a laid on schedule so you're generally looking at attitudes but i f one week we go over and get into humour and want to know some thing more then that goes on the next week. So there is no schedule i t comes from what they are wanting but they will make up that schedule for, well we have been at i t for three years so we go through different cycles. Prior to that cycle on attitudes they did quite a lot on, they where concerned about heart attacks and how you manage that, blood pressure so we did a lot of work around more what signs do you look for, do you need to be on medications for hyper tension and why so they were looking at much more specific information around the body, that was last f a l l . Then sometimes what happens, we have a doctor who will come and answer questions about the body and so they schedule her in when she, they are asked would they like to have her and they agree and it ' s a mutual arrangement between them and KIM: Would you see that there are any goals for that group? Is there a philosophy by which they operate? PROF: Ah The philosophy I think is really more around involving other people. They had a hard time getting people in that center to the center so one of their major interests when they started was to really involve older people. Their other goal would be (the tape ends and I turn i t over and mention we are addressing goals). So their 2 goals are really to continue and they are really interested in reaching older people and involving them, the other area is to have a center for themselves in the community center either to have a room or a club house or to have some thing where they can have a focal point because they, that lounge they are in is not, and they have had the Parks Board down they have talked to them. One of the things that's happened to them is they 211 have been spun around by Parks Board a number of times, they've had a l l year kind of an on going disagreement with the staff there in that the coordinator f e l t that they needed nothing, they didn't need a seniors programmer. So they've been at the board and they have been arguing those things but they have been working on this too, one is to get more of a focus in area A and in that neighbourhood for seniors. They have had the Parks Board staff in, they've had the Parks Board politicians in, they've met with them they've talked with them, there is $65,000 in their bank account at area A but they can't seem to get, this is like working with an immorphous, everybody moves around them, which is very exhausting for, you now i t ' s not like the housing issue that can crystalize and they can get very angry over i t , they get i t a l l organized and then they get so much red tape that eventually they start to loose steam and then they think why are we fighting the Parks Board why don't we just enjoy ourselves. So i t kind of goes in tides, but the goal would be to have more of a center there and they have a general interest in out reach but they have had a lot interference by professionals who have really i f you looked at i t f e l t that they didn't know any thing. KIM: Professionals like who? PROF: Like I say the teacher from the community school, the coordinator at the community center, you see at the community center they relate to a couple of the community schools, and they kind of have a triangle and they do a lot of work with the youth and so they tried to set up in the community schools, there is one the Greek Program that I'm involved with but they have , they developed a, and this is kind of interesting they developed a group of professionals to look at the issues around older people in area A and 212 they never asked any older people and part of my thing is they have been so d i f f i c u l t some of the professionals that I have just let them do their thing and I haven't, I tried at one point to change their view of how older people work but the 2 school teachers and the coordinators were so negative, they knew in fact what was needed for older people and i t became such a poli t i c a l mess that I just receded and stayed with the seniors because they were so negative. I mean they do a continual model, they a l l knew what the older people wanted and what they needed was not a grant what they needed was to do the out reach themselves and nobody needed to take government money for this and this was really the prevailing view of 4 or 5 of the professionals. (K) from the Elders Network tried to t e l l them differently and they just, so they took the steam right out of them and the other reality for the seniors at area A is i f you are at Program C you have to raise the money to keep that place going and at area A you don't have to, they'll always have space there. So i t ' s not the same kind of focus, there isn't the same kind of fund raising. Ah at Program X the seniors get very active because Program X is another one that's not government reliant. They have the United Way helps and they are always fund raising, the seniors are very active and have to work collectively to keep that house going. But in area A the center is there but i t is always controlled by professionals. They can't even get right now space to do their line dancing in the gym because the gym is a l l booked up. There is a continual argument to get them, the staff to understand how the seniors have some say and they should be heard, so that's part of the problem at Program A. KIM: What do you see as the strengths of the program? PROF: At Program A? (I say yes) I think 213 the major strength is that i t i s , i t demonstrates that older people in many ways can run their own program and i t s a great net work developer. I mean for a lot of people who are very isolated at Program A, they come in there and they make friends. There is a number of those people over the years their spouses have died and the group has really supported them and they'll come back and t e l l you that they have no other kind of support. So I would say that friendship is probably the primary, where as at Program X a lot of is i t is involvement and purpose. At Program A probably the most successful part of i t is the friendships they have made. You would only see that i f you tracked i t , I mean those people as I say started out with three and then there was five and they i t built on, and now they have quite a large core group to met, new ones come back and forth. They get a lot of support from on another for a number of them has serious art h r i t i s and osteoarthritis, there are four or five of them who are care givers who come there, i t ' s not formalized, but that's the way they like i t . they s i t and talk about i t when they feel like talking about i t . Last week they where talking about how being older is not fun, and they feel very comfortable about talking about i t . Two people there have been in and out of hospital for depression and now they talk about coming there regularly, one woman was sent over maybe by a care team, hasn't been back into hospital for two years, so i t ' s really much more the social support with that group. KIM: What would you see as things you would like to change or add i f any thing? PROF: Well I don't know i f I need to change or add i t , i t ' s not my job, my job is to follow what they want and i f I had, what I would hope for is they s t i l l take on more leadership and go on and run i t themselves. But i t ' s 214 not my job to decide what the group is a l l about that is their job. My job is to follow what they want and sometimes too, to work in partnership and to throw some suggestions out but lots of times you throw out suggestions and they don't bother because that's not what they are interested in. I'm not in control of that group but I have a strong role as far as the f a c i l i t a t o r goes. KIM: Who doesn't go there? PROF: Well that's a question mark that we have not had a lot of people come and never come back. We have had people come who go on to other things and we will see them, you know I can think of some women, you know no body chases them, there's no body phoning them down. We have had people come onto he group who will then go off to come on to our Advisory Committee or get interested in some where else or we have a number of women who then start to volunteer who come there times but volunteer in Program A. Some times i t ' s just an entry point for them in Program A, but there are a lot of people in Program A who are not going any where and nobody knows what that is about or whether those people as the literature might t e l l you have a lot of resources have cars come and go to Brock House have a lot of resources. Then there are a lot of people who nobody ever sees and they are question mark in any of our neighborhoods about who are the isolated. Some I think and I would of i f I could have pushed i t would have liked to see them do, because what their out reach was looking at was really to go into the Safeway and ask that question of older people in the neighbourhood, what would they like to see in programs. Whether the people in area A just don't see themselves going to community centres, I don't know. Now we do have on of the neighborhood houses which is just across the street and it ' s a, i t draws on a l l the seniors 215 housing there, so who doesn't go I'm not sure. We have not really survey i t and know. I think that as I say when we started Program A we had three or four seniors going, they just couldn't get seniors to come to Program A at a l l so over the two or three years we have probably had about 100 come in there and we have a regulars, every week you'll notice there are some come and there some aren't there so they feel they don't have to be there every week, but they see i t as a resource for themselves and some times they come every week when things aren't maybe going so well or well, you also have people who have left because of frailness and have just gone on, we have several men, and we have had people move away, but I would think that i t has been one of the more successful programs at Program A. KIM: Why do you think that there are so many more women than men? PROF: In a l l of them? (I say yes). Oh because two thirds of the people over 65 are women, but I think that's the easy answer like 66% of the population are women. So i think that's one of the demographics, is one of them. But I think the other thing that interests me i s , and i t interests me at Program A we have more men than we do at most centres, I think that men are not that socially integrated. Like men will come i f they have a woman to bring them often, well at Program A that's not the way as the men who come on their own. I don't know i f men see exercise and socialization as their thing. I don't know and yet the men that do come to Program A really enjoy themselves, and a number of them are married and their wives don't come, but they just like to come and, one is an ex teacher, you keep wondering why he comes, he plays tennis, he cycles, he's married, he goes to Paris on a regular basis as his wife is French, but he comes every week and he just likes to come. He gets something from the group he's not getting from some 216 where else. Whether , well I don't know, but one of the things about men, the other thing is often the groups are made up of a l l women just who that's who comes out or that's who's there. In almost a l l of the groups except the neighbourhood house are new groups and they started with three or four women and then three or four more women come, now at Program A that's how we started but we started with three women and one man and we have always had a man in that group and we have always has men in that group because I think they come through the door and they don't see a man they don't come back. I haven't looked at i t extensively, the other thing is i t may be just to do with males and females, males will come on our advisory committees, males are very involved in the housing up in area B, but males are not very involved in the health drop ins or the neighbourhood health programs they just don't come. KIM: Another issue that seems to have emerged is housing, do you want to comment on that? PROF: Housing across the West side even though i t ' s more focused in area B is a great concern whether it ' s in Program A where they feel every day i f you have a house a Realtor comes to your door. Almost every day they have Realtors asking them to sell their houses ah and then there's a l l theat whole they don't' know i f they sel l their house where would they go, could, you know I have lived in this house for 60 years and they feel a bit harassed in area A and area F they are a l l in apartments they are suffering the same way as Program J. What a lot of those people have done is gone up to area J forums and they have taken interest and talked to (R) from, and used Program J as their resource. Now where housing isn't and issue is in Program X because they are already in subsidized housing or 217 already in low I mean poor housing, they have in some ways thought this was their lot I guess. So housing is a concern on the west side period, there are the 2 aspects of i t . If you sell your house there are very few alternates for you. You can buy some condominiums but there is not a lot of them and a lot of them are very expensive. You may sell your house for $400,000 but you are s t i l l looking at $200,000 and some thousand to buy a condominium and for people that age they just think the whole things ridiculous, they can't seem to, you know housing is continually there, they feel there whole neighbourhood changing in area A so that, and many of the people in the area at the Program A group are people who have lived in that neighborhood for 50 or 60 years and went to school there and so they see now a l l these new yuppie condominiums as they call them that don't have fences and people don't neighbor and both husband and wife work and some of them do not have children so they see there whole neighbourhood and often they are closed inward so they are not like housing where you , they feel there is no neighbors any more and they , there is some resentment at the size of the housing, but mostly there is kind of they see their whole area changing and that change is bothering them. But in area A you can not replace your house and another thing is a lot of older people like to rent at 75 they don't see buying any thing because they say at the most I have got 25 years and at the least I have got a year so why would I buy any thing and there is the whole values around leaving money for your children and their house is often their estate, particularly in area A. It is an issue at Program A they talk about i t a lot. But there is an area A planning committee and a number of our seniors are active in that, have on behalf of the group have come to the 218 group and we have talked about the Program A Planning Group. KIM: Is there any thing else you want to say? PROF: No I don't but I think the Health Promotion Program is more than the neighbourhood programs. I think that the neighbourhood programs have 2 or 3 purposes. One is they are a place where seniors can come back onto he community, so i f you are new to the neighbourhood, so i f you are newly bereaved or are newly retired i t is a place to come into the community or i f you've lost your best friends you can easily come into a program and get to know people and make new friends in the program and i t has a purpose of showing other programs what could be a program so that ah i t makes staff people around there is has worked some places but not others to recognize there are other ways of relating to seniors than just laying on programs and so that i t can demonstrate other kinds of principles. It's also a place where a number, the other purpose is for older people to take on other kinds of projects so in Program A i t would have been the out reach project i f i t had worked. In area J they did put together a big out reach project and did get funded for that and in area X they have the Neighbourhood project and an Out Reach Project so that i t ' s not just the program i t s e l f but identifying issues that they want to be involved in and taking i t and getting some funds and some staff to work with them on any development project so, but that's only one aspect of the Health Promotion we also have as I say the West Side Advisory who have done some work with housing and they have also done so work on a dialogue with L.T.C. ah te l l i n g L.T.C. staff how the f e l l about receiving service and how they could try and influence L.T.C. about this relationship and service delivery and those right off the top of my head. And the other big thing of 219 course is trying to influence professionals who relate to older people to see them rather than diseases and problems is to see older people as people with potential and s k i l l s . KIM: Are the seniors concerned about that issue? PROF: Well they talk about i t . they talk a lot about the whole Dr who doesn't listen to them and that's where they will focus in and they also will talk about the whole thing with age and they talk about that aging is not fun. But then I'm not sure any of us have understood how we have learned how to be passive receivers of advise and care, I think we have been conditioned to be dependant so I don't think older people are any different than a l l of us. they do talk about i t about the bag clerks who don't pay attention to them. But when you ask about ageism directly they will say there is no such thing, but i f you ask about attitudes they will talk about i t . Maybe when you say where are the seniors that don't come well they are the ones who don't want to be treated that way. So when you look at Lauds power you have got three choices, you can give up- you can not come, or you can fight with i t . And I think a lot of the seniors don't come and when you interview the seniors out side you find that the seniors don't come because they are not stupid or they have given up. And we have got that documented at area J where the seniors have said we just won't go back to that center because we just won't put up with that, we won't have her talk to us like that, they feel that they are important enough. OB: This inter view took approx 1 and a half hours. It flowed very easily and I f e l t that she was very frank and open. The tone was relaxed. 

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