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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 o f 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 o f t h e r e q u i r e m e n t s f o r t h e degree o f M a s t e r s o f S c i e n c e in The F a c u l t y o f Graduate S t u d i e s (Interdisciplinary)  We a c c e p t t h i s t h e s i s as conforming t o t h e required standard  THE UNIVERSITY OF BRITISH COLUMBIA OCTOBER 1990 <g>  KIM CALSAFERRI, 1990  In  presenting this  degree at the  thesis  in  University of  partial  fulfilment  of  of  department  this or  thesis for by  his  or  requirements  British Columbia, I agree that the  freely available for reference and study. I further copying  the  representatives.  an advanced  Library shall make it  agree that permission for extensive  scholarly purposes may be her  for  It  is  granted  by the  understood  that  head of copying  my or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department The University of British Columbia Vancouver, Canada  DE-6 (2/88)  (Interdisciplinary)  -iTABLE OF CONTENTS ACKNOWLEDGEMENTS ABSTRACT LIST OF TABLES INTRODUCTION CHAPTER 1  REVIEW OF THE LITERATURE I. II. III. IV. V.  CHAPTER 2  iv v vi 1  DEFINING HEALTH PROMOTION THE EMERGENCE OF HEALTH PROMOTION THE EMERGENCE OF HEALTH PROMOTION FOR SENIORS THE FOCUS OF HEALTH PROMOTION PROGRAMMING FOR SENIORS RECENT RESEARCH ON HEALTH PROMOTION PROGRAMS FOR SENIORS  METHODOLOGY I.  E. II.  B. C. D. E. III.  RESEARCH TECHNIQUES EMPLOYED IN ETHNOGRAPHY SUMMARY  THE RESEARCH DESIGN  A.  18  25 28  32 37 37  41  THE SAMPLE 42 THE PROGRAM SELECTION PROCESS 43 THE SUBJECT SELECTION PROCESS 43 CONFIDENTIALITY AND RESEARCH CONSENT 44 THE ROLE OF THE RESEARCHER 45 DATA COLLECTION AND RESEARCH TECHNIQUES 47 The The The The The  G.  15  ETHNOGRAPHIC RESEARCH AND HEALTH PROMOTION FOR SENIORS 37 THE RESEARCH PURPOSE 39 THE RESEARCH GOALS 39 FORESHADOWED QUESTIONS 39 DEFINITION OF TERMS 40  THE RESEARCH METHODOLOGY  A. B. C. D. E. F.  12  THE ETHNOGRAPHIC RESEARCH TRADITION 18 THE HISTORICAL DEVELOPMENT OF ETHNOGRAPHY 20 THEORETICAL FOUNDATIONS OF ETHNOGRAPHY 25 Phenomenology Symbolic I n t e r a c t i o n i s m  D.  5 9 11  18  THE ETHNOGRAPHIC RESEARCH TRADITION  A. B. C.  5  F i e l d Diary F i e l d Notes Interviews Documents Protocols  DATA ANALYSIS  47 48 52 54 54  55  -iiCHAPTER 3  THE PLACES, THE PEOPLE AND THE EMERGING ISSUES  59  I.  PROGRAM A  59  A. B.  59 61  DESCRIPTION EMERGING ISSUES  Program O r g a n i z a t i o n and Process Attendance Community Issues Housing Out Reach Community  Involvement  Social Interaction and Support C.  II.  SUMMARY  PROGRAM B  69 69 70  C.  DESCRIPTION EMERGING ISSUES  Involvement  SUMMARY  70 71 73 73 73 74 75  PROGRAM C  75  A. B.  75 76  DESCRIPTION EMERGING ISSUES  Program Organization and Process Attendance Social Interaction and Support Community Issues C.  SUMMARY  76 78 79 80 80  PROGRAM D  80  A. B.  80 82  DESCRIPTION EMERGING ISSUES  Program Organization and Process Social Interaction and Support Community Issues Housing Community  Attendance C.  V.  67  A. B.  Community Out Reach  IV.  61 65 66 68  Program Organization and Process Attendance Social Interaction and Support Community Issues  III.  61 63 64  SUMMARY  Involvement  82 83 84 84 85  85 86  PROGRAM E  86  A.  86  DESCRIPTION  -"Miff. EMERGING  ISSUES  88  Program Organization and Process Attendance Community Issues Community Housing Out Reach  Involvement  Social Interaction and Support C.  CHAPTER 4  SUMMARY  88 89 90 90 91 92  92 93  PROGRAM FOCUS AND FACTORS CONTRIBUTING TO PROGRAM COMPOSITION  94  I.  PROGRAM FOCUS  95  A. B.  97  C.  II.  INDIVIDUAL BEHAVIOURAL CHANGE COMPONENTS UNDERLYING ENVIRONMENTAL AND COMMUNITY CHANGE COMPONENTS SUMMARY  99 102  FACTORS CONTRIBUTING TO PROGRAM COMPOSITION  102  A.  103  PROGRAM ORGANIZATION  AND PROCESS  Application of a Wellness/Health Promotion Approach 104 Varying Degrees of Structure 106 The Roles of Seniors and Professionals109 Program Funding 112 H i s t o r i c a l Development of Wellness/ Health Promotion 114 B.  CHAPTER 5  SUMMARY OF A PROGRAM ATTENDANCE SUMMARY OF B  RATIONALE  AND PATTERNS  115 116 120  CONCLUSIONS AND RECOMMENDATIONS  121  I.  121  THEORETICAL IMPLICATIONS OF THE STUDY A.  II. III. IV.  RESEARCH QUESTIONS  122  LIMITATIONS OF THE STUDY IMPLICATIONS FOR FUTURE RESEARCH PRACTICAL IMPLICATIONS FOR PROGRAM PROCESS AND ORGANIZATION  137 139  A. B.  140 141  INTERNAL EXTERNAL  INFLUENCES INFLUENCES  BIBLIOGRAPHY APPENDICES  140  143 A. B. C. D. E. F.  RESEARCH CONSENT FORMS OBSERVATION SCHEDULE EXAMPLES OF OBSERVATION PROTOCOLS INTERVIEW SCHEDULE INTERVIEW QUESTIONS EXAMPLE OF SENIOR AND PROFESSIONAL INTERVIEW PROTOCOLS  157 160 162 177 179 183  -i vACKNOWLEDGEMENTS  The completion of t h i s t h e s i s was made possible through the encouragement, support and generosity of f a m i l y , f r i e n d s , UBC f a c u l t y , and professionals and seniors of the health promotion programs studied. I would l i k e to thank my family whose influence has given me strength to believe 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 p a r t i c u l a r l y indebted to my "Gran" whose wisdom and grace have provided me with i n s i g h t into aging w e l l . My f r i e n d s have supplied me unending support and encouragement. They have s e n s i t i v e l y provided me with humour, hugs, company to e x e r c i s e , i n s i g h t s , meals, and most importantly, a b e l i e f in my a b i l i t i e s to complete t h i s t h e s 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 Vertinsky. Their commitment to the development of t h e i r students and to excellence in s c h o l a r l y 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 t h e s i s i s dedicated to the seniors and professionals whose b e l i e f in wellness and health promotion i s a confirmation that l i v i n g and dying well i s p o s s i b l e .  -vABSTRACT  The purpose of t h i s study i s to investigate the program focus and c o n t r i b u t i n g f a c t o r s to program composition of f i v e health promotion programs f o r s e n i o r s .  The programs are selected using opportunistic  sampling from f i v e d i f f e r e n t l o c a l areas in metropolitan Vancouver. f i v e areas together c o n s t i t u t e metropolitan Vancouver.  The  A theoretical  framework based on health promotion as a process which enables people to take control of t h e i r health promotion programming and recognizes that s o c i a l , p o l i t i c a l , and organizational interventions are as important as i n d i v i d u a l a c t i o n s , i s used to support the purpose of t h i s study.  An  ethnographic approach i s used to c o l l e c t o b s e r v a t i o n a l , interview and documentary data on program focus, process and o r g a n i z a t i o n .  The data are  analyzed q u a l i t a t i v e l y to f u r t h e r the understanding of health promotion as a process central to i n d i v i d u a l and group empowerment in program focus and organization.  The f i n d i n g s confirm that these programs focus  predominantly on i n d i v i d u a l behaviour change e f f o r t s and only minimally on underlying environmental and community change f a c t o r s .  In the process of  examining these health promotion programs f o r s e n i o r s , themes emerged which shed l i g h t on which f a c t o r s most influence program composition. Program organization and process which involves m u l t i p l e h i s t o r i c a l , t h e o r e t i c a l and organizational f a c t o r s are seen to most heavily influence program composition.  -vi-  LIST  OF TABLES  T a b l e 1:  Number and Type o f S u b j e c t s S e l e c t e d f o r  Interview  T a b l e 2:  I n d i v i d u a l Behavioural  T a b l e 3:  Environmental  T a b l e 4:  V a r y i n g Degrees o f Program  T a b l e 5:  The Program Funding S o u r c e s : Space, Equipment M i s c e l l a n e o u s S u p p l i e s , Manpower  Change Components  and Community Change Components Structure  44 96 97 107  113  1  INTRODUCTION  My  interest in t h i s study developed from my perspective as an  occupational  therapist, which requires that I view health from a h o l i s t i c  perspective.  When I work with individuals whose performance 1s impaired,  i t i s important to view them within the context of t h e i r environment. Also, as occupational  therapists highly value a client-centered approach  t h i s necessitates the involvement of each individual as an active participant in the planning and  intervention process.  I understood that  health promotion i s intended to foster the involvement of individuals in decision making processes about t h e i r health needs, and was health promotion philosophy recognizes environmental factors contribute to and  aware that a  that both individual behaviour and influence health and  well-being.  Health promotion i s 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;  1986;  U.S.  Lalonde, 1975;  International Conference on Health Promotion,  Department of Health, Education and Welfare, 1979).  There i s no d e f i n i t i o n of health promotion upon which everyone agrees, but the following two are frequently quoted, and are used in t h i s study: "Health promotion involves any combination of health education and related organizational, p o 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 i s the process of enabling people to increase control over, and to improve, t h e i r health" (World Health Organization, 1986).  As health promotion recognizes that s o c i a l , p o l i t i c a l  and  organizational conditions are as important as personal actions in determining health, the following two d e f i n i t i o n s are used in t h i s study: Individual Behavioural Change Components include programming that focuses upon personal health attitudes, self-management of chronic health conditions, n u t r i t i o n , 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 a f f e c t 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 i s o l a t i o n , poverty and  ageism.  Health promotion 1s viewed as having great potential f o r 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 f o r behaviour change,  3  and place l i t t l e or no emphasis on those underlying s o c i a l , p o l i t i c a l organizational factors that keep seniors impoverished, and disadvantaged. Pasick, 1986).  and  s o c i a l l y isolated  (Health Services and Promotion Branch, 1986;  Minkler &  Although the success of health promotion programs i s  viewed as dependent on the e f f e c t i v e 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 f i v e health promotion programs for seniors, in  the c i t y of Vancouver, B r i t i s h Columbia. Ethnographic  research i s viewed as p a r t i c u l a r l y well suited to t h i s  study as i t focuses on social organizations within s p e c i f i c contexts and provides a h o l i s t i c perspective without superimposing value system on the situation.  the researcher's  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  i s used to select one program from f i v e  d i f f e r e n t local areas of metropolitan Vancouver.  In the role of  participant as observer, the researcher conducts participant observation of  a l l f i v e programs, f o r a period of two months.  This i s followed by  4  i n t e r v i e w s w i t h two wellness  categories  the  professional  As w e l l ,  a n a l y s i s o f documents g a t h e r e d  s e n i o r p a r t i c i p a n t s and  wellness  coordinators  program components, the  p r o c e s s o f p r o g r a m d e v e l o p m e n t and  explains  coordinators.  o f s e n i o r p a r t i c i p a n t s and  program  This  study  theoretical  level  lends  and  the  change.  promotion.  1t  continue  i l l u s t r a t e s how  funding) markedly  the  play  i n h i b i t the  what  best  to concentrate  historical,  promotion approach) roles of  i n f l u e n c e program f o c u s ability  on  of the  and  seniors and  program t o  fulfill  promotion.  t h i s s t u d y f o c u s e s on  raises questions Influences  Further,  hence enhance o r  Finally,  about  promotion  f a c t o r s (varying degrees of s t r u c t u r e , the  intentions of health  p r o c e s s and  claim that health  r e m a i n n a r r o w i n f o c u s and  p r o f e s s i o n a l s , and  p r o c e s s and  support f o r the  (the a p p l i c a t i o n of a wellness/health  organizational  Insight  composition.  programs f o r s e n i o r s individual  provides  from  e x p l o r i n g program f o c u s ,  program  f a c t o r s which 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 , about the  r o l e t h a t m a c r o , meso, and  in perpetuating  narrowly-focused,  1t  also  micro-level  Individualistic  health  5  CHAPTER 1 REVIEW OF THE A s t u d y o f t h e f o c u s and  LITERATURE  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 e x a m i n a t i o n o f 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 : emphasis and  an  the s h i f t  1n  a c c e p t a n c e o f h e a l t h promotion as an i n t e g r a l p a r t o f h e a l t h  c a r e ; t h e emergence o f h e a l t h promotion programs f o r s e n i o r s ; t h e p r e s e n t f o c u s o f 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 program c o m p o s i t i o n and v a r i a t i o n . d e f i n e d and  In t h i s c h a p t e r ,  underlie  h e a l t h promotion  a s p e c t s o f h e a l t h promotion programs d e l i n e a t e d .  The  1s  factors  t h a t c o n t r i b u t e t o the emergence o f h e a l t h promotion programs are discussed  t o p r o v i d e a c o n t e x t w i t h i n which r e c e n t  h e a l t h promotion programs f o r s e n i o r s can be  I.  DEFINING  HEALTH  research of e x i s t i n g  explored.  PROMOTION  J u s t twenty y e a r s ago  h e a l t h promotion was  l i t t l e understood.  Today  h e a l t h promotion a t t r a c t s t h e s t u d y and a t t e n t i o n o f academics, h e a l t h c a r e p r o v i d e r s , p o l i c y makers, v o l u n t a r y and community o r g a n i z a t i o n s l a y people a l i k e .  and  T h i s i n t e r e s t has generated numerous a t t e m p t s a t  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. agreed-upon d e f i n i t i o n o f h e a l t h promotion and  i n p a r t i c u l a r of  promotion f o r t h e e l d e r l y (Duncan & G o l d , 1986; H e a l t h S e r v i c e s and  Promotion Branch, 1986).  As y e t t h e r e  Brown, 1982;  p h y s i c a l , mental and  Proponents o f t h i s concept  s o c i a l aspects of health.  health  Mullen,  1986;  However, consensus e x i s t s  t h a t h e a l t h promotion i s more t h a n t h e t r e a t m e n t o f d i s e a s e , t r a d i t i o n a l focus of biomediclne.  i s no  the consider  H e a l t h p r o m o t i o n , a broad  6  concept, i s concerned with the quality of l i f e .  Emphasis i s placed on  both individual and environmental determinants of health and well-being (Epp, 1986; Estes, Minkler, & Paslck, 1986; M o l l e n i l l , 1987; International Conference on Health Promotion, 1986; Kickbusch, 1989). Although the d e f i n i t i o n s offered have much in common, they d i f f e r in t h e i r emphasis on which factors are the appropriate targets f o r change efforts.  More s p e c i f i c a l l y , environmental factors are viewed as  p a r t i c u l a r l y 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 t h e i r environment," affirms Pender's (1982) d e f i n i t i o n of HEALTH PROMOTION as: " a c t i v i t i e s directed toward sustaining or increasing the level of well-being, s e l f - a c t u a l i z a t i o n and personal f u l f i l l m e n t of a given individual or group." This d e f i n i t i o n implies, that only i f the Individual or group takes r e s p o n s i b i l i t y f o r health promotion behaviours, w i l l enhancement of wellbeing follow (Thatcher, 1989). In contrast, Green et a l . (1986) defines HEALTH PROMOTION as: "any combination of health education and related organizational, p o 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 i s viewed  by many as o f f e r i n g a more sophisticated d e f i n i t i o n than more conventional health promotion concepts because of the focus on the s o c i a l , 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 not merely the absence of disease" (WHO, 1948).  well-being,  This d e f i n i t i o n 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 i s able on the one hand to r e a l i z e aspirations or needs and on the other hand, to change or cope with the environment." (WHO, 1984) HEALTH i s viewed as: "a resource f o r everyday l i f e , not the object of l i v i n g . " (WHO, 1984) HEALTH PROMOTION was defined as: "the process of enabling people to Increase control over, and to improve, t h e i r health." (WHO, 1986) and 1s seen as: "a mediating strategy between people and t h e i r environments, synthesizing personal choice and social r e s p o n s i b i l i t y in health." (WHO, 1986) This perspective emphasizes social and personal physical capacity.  resources as well as  Consistent with Green et a l . (1986) t h i s implies a  more positive and integrated look at health which recognizes environmental Influences.  This v i s i o n attempts to Integrate the Individual and social  components within an ecological framework.  Health promotion i s seen to  complement the e x i s t i n g health care system but 1s not viewed as synonymous with health care.  Of major s i g n i f i c a n c e i s 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 r e s p o n s i b i l i t y for health, i s reversed  (O'Neill,  1989/90). A federal publication e n t i t l e d "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 and p o l i c i e s within a broader context.  practices  Lalonde suggested that people's  health was influenced by a broad range of factors; human biology, lifestyle,  the organization of health care and the social and physical  environments in which people l i v e . Today t h i s 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  p u b l i c i z i n g t h i s new health promotion v i s i o n was the f i r s t  International  Conference on Health Promotion held in Ottawa in 1986. An important product of t h i s conference was the Ottawa Charter f o r Health Promotion (1986) which further expanded the World Health Organization's concepts by developing health promotion strategies to r e a l i z e i t s d e f i n i t i o n s 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 v i s i o n 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 s h i f t in emphasis from a biomedical well-being toward a broader conceptual  d e f i n i t i o n of health and  framework that encompasses  physical, s o c i a l , 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 health promotion now  choices, s i g n i f i e s the emergence of  exemplified by the WHO's ecological paradigm of  public health (Kickbusch,  1989).  Multiple factors have contributed to  health promotion as i t e x i s t s 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 n u t r i t i o n , changing personal  habits and sanitation, in achieving marked improvements in health status, and of Belloc and Breslow (1972), who  demonstrated an association between  l i 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  l i k e l y as more people survive Illness that previously  caused death e a r l i e r 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) a l t e r the aging  process;  b) improve the s o c i a l , 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". 1984)  (Fries, 1980;  1983;  10  Now that chronic disease i s a major precursor of death, many people believe the major emphasis of health care must s h i f t 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;  M o l l e n i l l , 1987; Larson, 1988; Evans, 1989; Kickbusch, 1989). The  1986 federal document "Achieving Health for A l l :  A Framework  for Health Promotion" reinforces t h i s emphasis and the necessity f o r developing health practices and policy within a broadened context.  The  fact that "health equity between high and low Income groups" was i d e n t i f i e d as "a leading challenge" indicates that t h i s framework has gone far beyond Lalonde's (1974) perspective (Epp, 1986). This document c a l l s f o r the Integration of Ideas from public health, health education and public p o l i c y and also for an expansion of the t r a d i t i o n a l use of the term health promotion.  Here, health 1s portrayed  as part of everyday l i v i n g and as an essential dimension of the quality of our l i v e s .  This view recognizes the role of Individuals and communities  in defining what health means and in s t r i v i n g to achieve, maintain or regain i t . The creation of healthy environments through a l t e r i n g or adapting the s o c i a l , 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, s o c i a l ,  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 t h e i r health and well-being.  Reduced Incomes, diminished  power and social standing, the threat of economic and social dependency, chronic i l l n e s s and d i s a b i l i t y , 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 health promotion a c t i v i t y .  and  Probable reasons for t h i s 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 d i s a b i l i t y , but the majority of seniors have lived beyond t h i s risk; c) youth, and are concerned with the individual's r e s p o n s i b i l i t y f o r reducing r i s k s , so that seniors are viewed as inappropriate participants; and d) absence or avoidance of disease, which i s an inappropriate goal for most seniors who  already suffer from at least one chronic health  problem (Estes, Fox & Mahoney, 1986; Promotion Branch, 1986;  Roadburg, 1985;  Health Services and  Somers, Kleinman & Clark, 1982).  The s h i f t in the causes of morbidity and mortality, the  Increased  proportion of people l i v i n g longer l i v e s and the increased costs of health care are some of the factors which have given r i s e to the  Increased  emphasis on health promotion as a legitimate component of health care (Labonte, 1988).  12  More s p e c i f i c a l l y , several reasons underlie the increasing emphasis on t h i s type of intervention among seniors: a) t h i s group 1s the fastest growing segment of t h i s nation's population; b) 86% have chronic conditions; c) the consequences of chronic health conditions t y p i c a l l y are disproportionately severe for seniors, resulting 1n r e s t r i c t i o n s on personal  independence and overall q u a l i t y 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 l i k e l y to need high cost personally r e s t r i c t i v e long term care (McDaniel, 1986; Promotion Branch, 1986;  Marshall, 1987;  S t a t i s t i c s Canada, 1985;  Health Services and 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 s p e c i f i c a l l y  highlight the e l d e r l y , together they have contributed to a conceptual framework f o r national health promotion a c t i v i t i e s f o r a l l Individuals.  IV.  THE FOCUS OF HEALTH PROMOTION PROGRAMMING FOR  To physicians, health promotion may  SENIORS  mean providing p r e s c r i p t i v e  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 l e v e l , i t might be expressed as concern in  13  terms of adequate f i n a n c i a l resources, transportation, housing and access to services (Labonte, 1988). To date, the l i t e r a t u r e suggests that health promotion programs f o r seniors, as f o r other groups in society, tend to focus on the Isolated individual as the target f o r behaviour change e f f o r t s (Estes, Kickbusch, 1989; Draper, 1988; Mlnkler & Paslck, 1986).  1983;  However, some  experts in the f i e l d believe that by focusing programming on individual change e f f o r t s , attention i s deflected from those environmental factors that heavily influence health practices and over which seniors may have 1 i t t l e control. Although these experts claim programs focus predominantly on l i f e s t y l e change and only minimally on the underlying environment  and  community change, no d i r e c t 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 f o r seniors in Canada (Taylor, 1983) and the U.S.  (Gilbert, 1986; Brown, 1982; Minkler & Paslck,  1986; Weiss & Sklar, 1983; Barbaro & Noyes, 1984; Dunn, 1985; GeshamKenton & 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, n u t r i t i o n awareness, stress reduction, promotion of f i t n e s s , 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 l i v e in a high crime area; t o l d which foods are n u t r i t i o n a l , but not how to afford them i f l i v i n g near or on the poverty l i n e ; and taught to identify and manage l i f e stresses but rarely encouraged or helped to work Individually or c o l l e c t i v e l y 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 r e s p o n s i b i l i t y f o r oneself and control over the s o c i a l , 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 t h e i r environment rather than simply helping them to cope with and adjust to l i f e s t y l e and health problems.  However, as these programs remain few in  number, the message i s clear; individual r e s p o n s i b i l i t y f o r 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 e x i s t s that would allow f o r an assessment of how comprehensive are senior center and health promotion a c t i v i t i e s and services (Krout, 1986), l e t alone t h e i r s p e c i f i c focus or how and why programs vary.  Almost without exception, research has focused  on the elderly individuals' socio-demographic c h a r a c t e r i s t i c s , the factors that d i f f e r e n t i a t e 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 i n the s p e c i f i c area of health promotion and the elderly, 1t i s extremely limited 1n scope and quantity.  The predominant  focus i s on program evaluation in the areas of  cost containment, health maintenance,  functional Independence, i l l n e s s  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 u t i l i z a t i o n and costs.  Some writers do claim that seniors health  promotion programs provide more cost e f f e c t i v e care and have potential to decrease excessive biomedical u t i l i z a t i o n 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  w i l l not decrease as t h i s necessitates broadened service delivery (Nelson et a l . , 1984; Russell, 1984; Gori, Ritcher & Yu, 1984). Those studies which address the benefits of health promotion f o r seniors focus predominantly on individual behaviour and l i 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 r e d u c t i o n 1n h e a l t h r i s k s (U.S. P u b l i c H e a l t h S e r v i c e and A d m i n i s t r a t i o n on A g i n g , 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 ) i n c r e a s e d p e r s o n a l 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.  Public Health  S e r v i c e and A d m i n i s t r a t i o n on A g i n g , 1984; Lalonde & F a l l c r e e k , Nelson e t a l . , 1984;  B a r b a r a & Noyes, 1984);  1985;  and  d) c o n s t r u c t i v e b e h a v i o u r a l changes toward h e a l t h i e r  lifestyle  b e h a v i o u r s and improved h e a l t h s t a t u s ( H i g g l n s , 1988; Jordon-Marsh N e u t r a , 1985; S m i t h , 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 e t a l . , 1984; B a r b a r a & Noyes, 1984; M i n k l e r , 1985; P u b l i c H e a l t h S e r v i c e s and A d m i n i s t r a t i o n on A g i n g ,  U.S.  1984).  Few documents and r e s e a r c h 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 f o c u s on i n d i v i d u a l h e a l t h b e h a v i o u r and  efforts  aimed a t e n a b l i n g s e n i o r s t o t a k e c o n t r o l o f h e a l t h d e c i s i o n s , t o c r e a t e h e a l t h y environments and c o o r d i n a t e h e a l t h y 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, e t a l . (1980).  Although the idea of  d e v e l o p i n g programming and r e s e a r c h w i t h i n a broader c o n t e x t has been l e g i t i m i z e d , t h e l i t e r a t u r e i n d i c a t e s I t s presence 1s e x t r e m e l y r a r e 1n practice.  Of two w e l l documented U.S.  programs, t h e W a l U n g f o r d  Wellness  P r o j e c t and t h e T e n d e r l o i n S e n i o r s Outreach P r o j e c t , o n l y t h e former undergone e m p i r i c a l s t u d y .  has  One outcome study c o n f i r m e d 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 f o r m a t i o n , a t t i t u d e and b e h a v i o u r change i n s e n i o r s o v e r 54 y e a r s o f age ( L a l o n d e & 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 t h e d e s c r i p t i o n c l e a r l y I n d i c a t e d a f o c u s on both I n d i v i d u a l b e h a v i o u r and e n v i r o n m e n t a l I s s u e s .  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 a t a suburban s e n i o r s ' c e n t e r , 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 ,  assessment o f t h e s e n i o r s needs and resources.  I n t e r e s t s and on a review o f community  A l t h o u g h e v a l u a t i o n has not y e t o c c u r r e d ,  d e s i g n e d w i t h t h i s i n mind.  The  the program  involvement of s e n i o r s and  community s e r v i c e s i n the program p l a n n i n g  envisioned  was  relevant  stage i s a noteworthy f e a t u r e .  From t h e l i t e r a t u r e reviewed, 1t 1s c l e a r t h a t the t y p e and of research  on  quantity  r e q u i r e d f o r knowledge development i n h e a l t h promotion as by Epp  considerably  (1986), WHO  (1986), and Green e t a l . (1980), d i f f e r s  from t h e l i f e s t y l e - o r i e n t e d r e s e a r c h t h a t has been the  trademark o f h e a l t h promotion u n t i l the process,  recently.  Research t h a t i n v e s t i g a t e s  f o c u s and v a r i a t i o n o f h e a l t h promotion programs, which  the i n t e n t i o n of t h i s present research, w i l l  add t o r e s e a r c h  1s  i n health  promotion. T h i s l i t e r a t u r e review has h e a l t h promoters, r e s e a r c h e r s ,  i n d i c a t e d t h a t much work l i e s ahead f o r  c a r e p r o v i d e r s , p o l i c y makers, the media  and o t h e r segments o f s o c i e t y 1f h e a l t h promotion 1s t o be a s s u r e d I n t e g r a l place i n the h e a l t h care  system.  an  18  CHAPTER 2 METHODOLOGY T h i s c h a p t e r i s d i v i d e d I n t o t h r e e s e c t i o n s f o r t h e purposes o f d e s c r i b i n g , d e f i n i n g and a p p l y i n g t h e e t h n o g r a p h i c r e s e a r c h methodology. .ethnographic  r e s e a r c h t r a d i t i o n as a  S e c t i o n one g i v e s a general account o f t h e  research t r a d i t i o n .  S e c t i o n two d i s c u s s e s t h e r e s e a r c h  d e s i g n , purpose, g o a l s and foreshadowed q u e s t i o n s o f t h i s s t u d y . three describes the a p p l i c a t i o n o f the ethnographic  Section  research t r a d i t i o n t o  t h i s study by p r e s e n t i n g t h e d a t a c o l l e c t i o n t e c h n i q u e s , t h e r o l e o f t h e r e s e a r c h e r and t h e p r o c e s s o f a n a l y s i s .  I. A.  THE ETHNOGRAPHIC  THE ETHNOGRAPHIC RESEARCH TRADITION RESEARCH  TRADITION  S o c i a l s c i e n c e r e s e a r c h has been d e s c r i b e d "as a c h o i c e between two c o n f l i c t i n g r e s e a r c h paradigms" (Hammersley & A t k i n s o n , 1983).  These  paradigms a r e 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, The  &  1979) and n a t u r a l i s m and p o s i t i v i s m (Hammersley & A t k i n s o n , 1983).  i s s u e between t h e two paradigms, i s t h e n a t u r e o f t h e s o c i a l w o r l d and  how i t s h o u l d be s t u d i e d . In r e c e n t y e a r s q u a l i t a t i v e r e s e a r c h has r e c e i v e d i n c r e a s i n g attention.  T h i s i s p a r t l y due t o t h e ongoing d i s c u s s i o n o f q u a l i t a t i v e  v e r s u s q u a n t i t a t i v e r e s e a r c h , but a l s o t o t h e r e a l i z a t i o n t h a t t h e r e a r e many problems i n t h e s o c i a l s c i e n c e s t h a t can b e s t be s t u d i e d w i t h 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 u s e r t o u s e r " (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, q u a l i t a t i v e research, interpretive  procedures, f i e l d research," (Burgess, 1984), n a t u r a l i s t i c inquiry and participant observation.  In t h i s study the term e t h n o g r a p h y w i l l be used  to identify the t r a d i t i o n . Ethnography has been associated with the c o l l e c t i o n 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 t h e i r experience and construct r e a l i t y " (Burgess, 1984) rather than on an objective r e a l i t y . fundamental  difference between ethnography  In t h i s way there i s a and positive science.  Ethnographers must understand the world as the participant does, unlike positive s c i e n t i s t s who study objective facts that exists outside the person. This t r a d i t i o n which goes back to the l a t t e r part of the nineteenth century, has i t s roots in more than one academic d i s c i p l i n e (anthropology, sociology, social psychology and education) and Includes p a r t i c u l a r 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 i s conducted in a wide variety of settings, confusion exists about what i t is.  In order to appreciate the usefulness of t h i s t r a d i t i o n , t h i s section  w i l l define and explore the d i f f e r e n t labels and describe the h i s t o r i c a l context and genesis of ethnography. This t r a d i t i o n 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.  I t was the descriptive,  indepth documentation of t h i s social suffering by j o u r n a l i s t s , social workers, social surveyors and photographers, that l a i d the foundation f o r t h i s research t r a d i t i o n (Bogdin & Biklen, 1982). The term ethnography comes from anthropologists who studied foreign cultures in t h e i r natural settings.  Ethnography i s defined as "the branch  of anthropology that deals d e s c r i p t i v e l y with s p e c i f i c cultures" (Websters New World Dictionary, 1980). social anthropology.  This branch of anthropology i s known as  Ethnography i s the label given to the methodology  that generates the basic descriptive data on which social anthropology i s founded. Two anthropologists, Boas and Malinowski contributed much to t h i s field.  Boas and h i s 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, b r i e f  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 b e l i e f 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 s p e c i f i c 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 l i v i n g among and p a r t i c i p a t i n g in the d a i l y l i v e s of those primitive s o c i e t i e s he studied (Wax,  1960).  On a s i m i l a r search f o r meaning and understanding in human experiences, a s i g n i f i c a n t number of s o c i o l o g i s t s in the c l a s s i c a l t r a d i t i o n have recognized and stressed the importance of participant observation in methodology (Bruyn, 1962).  One of the f i r s t and c l a s s i c  statements on the technique and purpose of participant observation was made by Florence Kluckhohn  (1940: 331).  "Participant observation i s the conscious and systematic sharing, insofar as circumstances permit 1n the l i f e a c t i v i t i e s , and on the occasion in the interests and a f f e c t s of a group of persons.  Its  purpose 1s to obtain data about behaviour through d i r e c t contact and in terms of s p e c i f i c situations in which the d i s t o r t i o n that results from the investigator being an outsider,  i s reduced to minimum."  In the 1920s and 1930s the Chicago School, a group of s o c i o l o g i s t s at the sociology department f i e l d of multiple labels.  in Chicago, began contributing further to t h i s While these sociological researchers d i f f e r e d  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  r e l i e d on the study of a single case or unit such as an individual, a group, a neighbourhood,  or a community (Wiley, 1979).  Although the c h a r a c t e r i s t i c s of the Chicago School methodology are numerous, the following are frequently highlighted.  Researchers r e l i e d on  f i r s t hand data gathering, a technique that was heavily influenced by W.I. Thomas and Robert Park. had been untouched  Also, as by t h i s time few settings existed that  by contact with the west, these ethnographers turned to  the study of subcultures.  The emphasis on Intensive study of c i t y  life  provided the beginning of a trend, which continues to be the focus of those trained in the anthropological t r a d i t i o n today. works emerging from t h i s focus on subcultures include: The Slum (Zorbaugh,  Some important The Gold Coast and  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). all  As  these studies have a number of commonalties (e.g., meaning i s of  essential concern, the natural setting 1s used as the d i r e c t source of data, participant observation i s used as a data c o l l e c t i o n method, and descriptive data are analyzed inductively), 1t becomes apparent that these researchers have a similar understanding of what i s meant by ethnography and work from a common methodological t r a d i t i o n . The term n a t u r a l i s t i c I n q u i r y i s also used in conjunction with ethnography.  However, existing formulations of n a t u r a l i s t i c research  d i f f e r markedly.  N a t u r a l i s t i c theorists and practitioners have seldom  been in agreement on what they meant by t h i s method (Denzin, 1971). Catton (1966) views i t as a rigorous positivism. seen as humanism in disguise.  For Matza (1969) i t i s  In education q u a l i t a t i v e research i s often  23  c a l l e d n a t u r a l i s t i c inquiry as the researcher i s found where events occur naturally and the data i s 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), n a t u r a l i s t i c inquiry 1s equated with ecological psychology and/or ethology. Lofland (1971) describes naturalism as a deep commitment to the c o l l e c t i o n of r i c h and often atheoretical ethnographic specimens of human behaviour.  Denzin (1971) perceives a l l such formulations of n a t u r a l i s t i c  inquiry as d e f i c i e n t 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 c a l l t h i s version of the research act n a t u r a l i s t i c behaviourism and mean by the term that studied commitment to a c t i v e l y enter the worlds of native people to render those worlds understandable from the standpoint of a theory that i s grounded in the behaviours, languages, d e f i n i t i o n s and feelings of those studied" (Denzin, 1971:  168).  Once again an umbrella term, n a t u r a l i s t i c Inquiry, exists that refers not only to ethnography  but also to several other d i f f e r e n t  theoretical and methodological strategies. The term q u a l i t a t i v e research appears to have become more popular in the 1970s among educational ethnographers.  At t h i s time these methods  could not claim a central position in research methodology but they were no longer labeled fringe e f f o r t s .  As methodological debates continued  between quantitative and q u a l i t a t i v e factions, q u a l i t a t i v e evaluation research gained prominence (Guba, 1978; Patton, 1980), and some well known  24  researchers in quantitative c i r c l e s (Cronback, Bronfenbrenner,  1975; Glass,  1975;  1976), discovering that "hard science" was not adequate,  began exploring and advocating q u a l i t a t i v e approaches (Bogdin & Biklen, 1982). Although some q u a l i t a t i v e researchers (Wolcott, 1973; Metz, Rist, 1978)  1978;  in education were doing what they considered "fieldwork,  participant observation, indepth interviewing or ethnography-by spending extended amounts of time at the research s i t e 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 i s apparent that the exact use and formulation of labels associated with ethnography vary markedly from person to person and from d i s c i p l i n e to d i s c i p l i n e , 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 t h i s study.  Phenomenology Phenomenology, which represents the e f f o r t to describe human experience as i t i s lived (Merleau-Ponty,  1964), i s not just a research  method but i s also a philosophy and an approach  (Psathas, 1973).  I t has  been suggested that the f a i l u r e 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 i s "ambiguous and i l l - d e f i n e d and f u l l of cryptic yet pregnant slogans" (Koch, 1964).  Contrary to t h i s accusation,  phenomenology, as a research method , can be d i f f e r e n t i a t e d as a viable and useful q u a l i t a t i v e approach The phenomenological  (Ornery, 1983).  method i s both descriptive and Inductive.  Researchers who u t i l i z e t h i s mode attempt to understand the meaning of experiences, events and interactions to ordinary individuals in particular settings and situations (Bogdin & Biklen, 1982). phenomenological  The task of the  method i s to describe through investigation a l l those  phenomena, Including human experience as these appear " i n t h e i r f u l l e s t breadth and depth" (Spiegelberg, 1965).  In order to ensure that the  phenomenon i s Investigated as i t i s experienced or t r u l y 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 t h i s the individual must approach the  phenomenon with no anticipated expectations or categories. Also as the phenomenologist has no preconceived operational d e f i n i t i o n s and i s 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 s t r i v e to enter the conceptual  world of t h e i r subjects in order to appreciate the meaning individuals construct around a c t i v i t i e s and events in t h e i r d a i l y l i v e s  (Geertz,1973).  The concern, then, of the researcher i s both to understand the subjective perspective of the individual who has the experience and the e f f e c t that i t has on the behaviour or lived experience of that person (Morris, 1977).  The goal of the method i s to describe the t o t a l picture  of the lived experience, including the meanings those experiences have f o r individuals who take part in them.  Blumensteil (1973) describes the  method succinctly as "the t r i c k of making things whose meanings seem clear, meaningless  and then, discovering what they mean."  So where did t h i s phenomenological  method come from?  Phenomenology  as a method f o r the human sciences grew out of a philosophical movement that i s s t i l l  in a process of c l a r i f i c a t i o n .  sciences who gave form to the phenomenological not bound to phenomenological  philosophy.  Researchers in the social methods were inspired but  Edmund Husserl (Davis, 1973)  can largely be credited with the b i r t h of the phenomenological as a school of thought and as a method.  philosophy  I t appears that t h i s method began  to c r y s t a l l i z e in reaction to the denigration of philosophical knowledge  27  and the o b j e c t i f i c a t i o n of humans (Ornery, 1983).  The resultant method i s  a s o l i t a r y , introspective process that aims at "seeing the c l e a r apprehension of the evident giveness" (Kohak, 1978). Spiegelberg (1960,1970) i d e n t i f i e d s i x 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; c o n s t i t u t i v e phenomenology; reductive phenomenology; and hermeneutlc phenomenology.  Most phenomenological  researchers in the social sciences have been Inspired by, rather than d i r e c t l y applying, Spiegelberg's philosophical phenomenological method, and prefer not to r e s t r i c t the phenomenological approach to a sequence of steps or a structured methodology (Psathas, 1973; Morris, 1977; Swartz, 1979). The Impetus f o r the human sciences evolved out of what researchers perceived as the f a i l u r e of the method of natural sciences to adequately explain the phenomenon the human s c i e n t i s t s were investigating. Human science researchers believed the t r a d i t i o n a l methods of the natural sciences were too s i m p l i s t i c and demeaning (Ornery, 1983). impetus f o r t h i s methodological  The strongest  development was in psychology.  (1959, 1966) formulated the f i r s t approach.  Van Kaam  Two other much-utilized  phenomenological methods are those i d e n t i f i e d by Giorgi and associates (1975) and later C a l a i z z l (1979). It i s c l e a r that while researchers who advocate the use of phenomenology display theoretical and methodological share to some degree the goal of understanding  differences they a l l  human subjects from t h e i r  28  point of view and describing human experience as i t 1s l i v e d .  This 1s one  of the goals of t h i s study.  Symbolic Interactionism Symbolic interactionlsm, the dominant perspective  i n Social  Psychology, also guides the thinking and research of many s o c i o l o g i s t s . It i s a s o c i a l - s c i e n t i f i c perspective which takes a less deterministic view of human beings than quantitative perspectives approach to science. level.  and a more c r i t i c a l  Here, theorizing i s generally limited to the micro  Instead of focusing on the individual and t h e i r personality  c h a r a c t e r i s t i c s (as have c l a s s i c a l psychologists), or on the social structure or the s i t u a t i o n which causes individual behaviour (as have social psychologists  who draw from c l a s s i c a l sociology), symbolic  interactionlsm focuses on the nature of the interaction and on the dynamic social a c t i v i t i e s taking place between persons. (Wells, Biklen, 1982).  1978; Bogdin &  Symbolic interactionism emphasizes that the s e l f evolves  through the exchange of meaningful symbols with other human beings. Social l i f e and i t s rewards are viewed as an emerging product of interaction (Berger & Luckman, 1967). Other Important Ideas distinguishing t h i s perspective  and related to  i t s focus on interaction are the attention symbolic interaction pays to defining interaction, the present and the individual as an active rather than passive participant i n the world.  Interaction i s not simply defined  as what i s happening between people, but also by what i s happening within the person.  Each individual i s viewed as acting in the present.  only enters the present as i t i s recalled in the present.  The past  Finally,  29  s y m b o l i c 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 b e i n g u n p r e d i c t a b l e and active i n t h e i r world.  I n d i v i d u a l s a r e seen as making c o n s c i o u s c h o i c e s  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 o t h e r s , and t h e r e b y d i r e c t i n g and r e d i r e c t i n g t h e m s e l v e s a c c o r d i n g l y (Charon, 1985). Congruous w i t h phenomenology and b a s i c t o s y m b o l i c i n t e r a c t i o n i s m i s t h e assumption t h a t human e x p e r i e n c e 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 e x p e r i e n c e s a r e not viewed as  p o s s e s s i n g t h e i r own meaning; meaning i s g i v e n t o them.  People a c t as  i n t e r p r e t i n g , d e f i n i n g , s y m b o l i c a n i m a l s r a t h e r than on t h e b a s i s o f p r e d e t e r m i n e d responses t o p r e v i o u s i n t e r a c t i o n s o r t o p r e d e f i n e d o b j e c t s . I n t e r p r e t a t i o n i s a i d e d t h r o u g h i n t e r a c t i o n w i t h o t h e r s and t h r o u g h t h i s i n t e r a c t i o n t h e 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 a r e s p e c i f i c s c h o o l s w i t h i n s y m b o l i c i n t e r a c t i o n t r a d i t i o n , t h e most common d i v i s i o n b e i n g between t h e Iowa School and t h e Chicago School.  S o c i a l s c i e n t i s t s such as Koch i n t h e Iowa s c h o o l conduct  q u a n t i t a t i v e r e s e a r c h , w h i l e t h e C h i c a g o s c h o o l which 1s d e r i v e d  directly  from t h e work o f t h e f o u n d e r s o f s y m b o l i c 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 r e s e a r c h ( W e l l , 1979; Bogdin & B i k l e n , 1982).  Although  s y m b o l i c I n t e r a c t i o n i s m can c l a i m some h e r i t a 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 t h e work o f Americans George H. Mead, John Dewey, James W.I. Thomas and C h a r l e s Cooley ( M e l t z e r , P e t r a s & R e y n o l d s , 1975). Cooley i s b e s t remembered f o r h i s c o n c e p t s o f " p r i m a r y group" and " l o o k i n g g l a s s s e l f " - t h e n o t i o n t h a t each I n d i v i d u a l ' s s e l f p e r c e p t i o n emerges from how we b e l i e v e o t h e r s p e r c e i v e us.  Thomas i s known f o r h i s  emphasis on " t h e d e f i n i t i o n o f t h e s i t u a t i o n " - t h e i d e a t h a t i n terms o f  30  social consequences i t i s the person's perception of r e a l i t y , not the r e a l i t y 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 i s the  integration and interpretation of his work by s o c i o l o g i s t s such as Herbert Blummer.  He i s symbolic interactions leading exponent.  Blummer stresses  the symbolic nature of human interaction, the existence of s e l f and the conscious construction of the interaction within the social context (Blummer, 1969; Charon, 1985; Wells, 1979). Symbolic i n t e r a c t i o n i s t s are c r i t i c a l of the t r a d i t i o n a l social science, with i t s use of s c i e n t i f i c methodology f o r 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 s h i f t in thinking f o r  other s c i e n t i s t s who contend the past causes present action.  The symbolic  i n t e r a c t i o n i s t c a l l s f o r a d i f f e r e n t d i r e c t i o n , 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 d i r e c t 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 s c i e n t i f i c procedure, or with a picture of the world b u i l t up from p a r t i a l  31  and untested accounts of that world.  For symbolic i n t e r a c t i o n i s t s the  nature of the empirical social world i s to be discovered, to be dug out by a d i r e c t , careful and probing examination of that world." A central goal then of social science, viewed by the symbolic i n t e r a c t i o n i s t , i s the careful description of human interaction.  This i s  achieved through careful observation of social action, description of the important elements Involved, followed by description and r e d e f i n i t i o n of these elements.  Another important rule i s the gathering of data through  observing real l i f e situations (Charon,  1985).  Denzin, who has done s i g n i f i c a n t empirical work within the perspective of symbolic interactionism coined the term " N a t u r a l i s t i c Behaviourism" f o r a methodology which outlines the p r i n c i p l e s that he believes should govern s c i e n t i f i c inquiry within t h i s t r a d i t i o n (Denzin, 1971).  Both Denzin's description of n a t u r a l i s t i c 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, d e f i n i t i o n , meaning and social worlds.  This i s the case with the present study.  As such, they  a l l conform to a great extent to the s c i e n t i f i c p r i n c i p l e s 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 s o d a ! 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 f o r the purpose of description, or v e r i f i c a t i o n , and/or generation of theory" (Strauss, 1970). In the f i r s t stage of research, the ethnographer must gain access. c u l t i v a t e rapport, begin developing s e n s i t i z e r s and remain open to the participants and the s e t t l n g f s ) . 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). times, formal access i s obtained from an authority who participant in the setting(s) under study.  At  i s not a  Informal access i s the primary  mechanism f o r establishing rapport with the participants.  When the goal  of the research i s to achieve the participants' perspective, informal access i s of primary importance.  Once access has been gained and rapport  i s developed the research can proceed. The methods an ethnographer  uses to c o l l e c t 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 w i l l  be conducted. This schedule must be  33  comprehensive so as t o ensure t h a t o b s e r v a t i o n s w i l l the a c t i v i t i e s ,  events,  observation schedule  p l a c e s and  i s formulated  accordance w i t h the plan. I n f o r m a l and  Two  and  observations provide detailed activities, The  events  field  and  Two  important other  r e f l e x i v i t y and  in  means t h e p r o c e s s  notes, personal  events  r e f l e c t i o n s and  a s p e r c e i v e d by t h e techniques  research  1t.  of social  must t a k e  be a c c o m p l i s h e d  data collected  1n  researcher.  formal  r e c o g n i z e s t h a t we  inquiry,  we  the  by t e s t i n g  contains  Sensitizers  thoughts,  The  journal  are  reflexive  are part of the  social  can escape t h e s o c i a l  world  to this tradition  Sensitizers  the  and and  t h e r e f o r e are a l l a  R e f l e x i v i t y means  their effect  enable  recorded  feelings,  on t h e s e t t i n g .  hypotheses against other  the s e t t i n g ( s ) .  the  researcher, the p a r t i c i p a n t s  the s o c i a l world.  i n t o account  and  documented i n t h e f i e l d  are  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 by t h e  general  ethnographer.  T h i s i s a fundamental tenant  component i n u n d e r s t a n d i n g  can  r o l e on 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  ethnographers  in  recorded;  research process  s t u d y . T h e r e f o r e , t h e r e i s no way  the s e t t i n g  while  the development o f s e n s i t i z i n g concepts.  order t o study  observe  the  o b s e r v a t i o n s of s p e c i f i c a l l y chosen  a record of the  important  character of s o c i a l w o r l d we  will  Once  Informal observations b u i l d a  the p a r t i c i p a n t s ,  r e f l e x i v i t y of the ethnographers  i d e a s and  the ethnographer  reflect  people.  journal,  impressions, analytic  the s e t t i n g ( s ) .  types of observations are  formal observations.  d a t a base about t h e s e t t i n g  1n  people  thoroughly  This  information  ideas, concepts brought t o the  researcher t o develop  and and  research 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. the ethnographer  At t h i s time, the funnel i s wide open and  experiences a sense of confusion and bewilderment.  t h i s time, i t i s important that the ethnographer experiences and concepts. the ethnographer  At  remains open to ideas,  As research continues the funnel narrows and  becomes progressively more focused and c l 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 t h i s data. reflexive.  Ethnographic interviews are  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  r e f l e c t observations.  By now the ethnographer  be an accepted and unobtrusive part of the s e t t i n g ( s ) .  should  Sensitizing  concepts, ideas, hunches and analytic notes continue to be documented 1n the f i e l d journal.  I f the sampling plan i s 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. "going native" (Burgess, 1984).  At t h i s time there can be a danger of This only occurs i f the  ethnographer  becomes so involved with the participants that there i s an over i d e n t i f i c a t i o n with t h e i r 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 c a c y in analyzing the data.  The ethnographer should take a break from  the s e t t i n g from time to time (between processes such as observations, interviews and formal a n a l y s i s ) , to maintain perspective and to review the emerging s e n s i t i z i n g concepts. data.  This allows the theory to emerge from the  Now, the data i s reviewed f o r key words, phrases, ideas, t o p i c s ,  a c t i v i t i e s , patterns and themes in preparation for coding and a n a l y s i s . 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 s e t t i n g 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 follows upon and leads to generative questions; (2) f r a c t u r e s the data, thus f r e e i n g the researcher from d e s c r i p t i o n and f o r c i n g i n t e r p r e t a t i o n  to higher l e v e l s of a b s t r a c t i o n ;  (3) i s the p i v o t a l operation f o r moving towards the discovery of a core category or c a t e g o r i e s ; and so (4) moves toward ultimate integration of the e n t i r e a n a l y s i s ; as well as (5) y i e l d s the desired conceptual d e n s i t y " . The coding categories must allow f o r the Inconclusiveness of a l l the p a r t i c i p a n t s , a c t i v i t i e s , events and s e t t i n g ( s ) . A l s o , the s e n s i t i z i n g ideas, concepts and theory must be constantly reviewed f o r the inclusiveness of data.  As such the a n a l y t i c framework  that i s developed from t h i s process a r i s e s from the data.  The  ethnographer uses induction to develop a comprehensive a n a l y s i s of the data.  The data are coded through s e n s i t i z i n g concepts to develop  36  categories, themes and typologies which form a model f o r the a n a l y s i s of the data.  To check the a n a l y t i c framework the frequency, d i s t r i b u t i o n 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 f o r : "(1) comparing incidents applicable to each category; (2) i n t e g r a t i n g categories and t h e i r  properties;  (3) d e l i m i t i n g the theory; and (4) w r i t i n g the theory". This method provides a process where by the ethnographer can i n d u c t i v e l y develop theory from the data. At t h i s point the ethnographer i s ready to t r i a n g u l a t e the data and the model.  T r l a n g u l a t i o n e n t a i l s cross v a l i d a t i o n or comparison of data  to determine whether there i s corroboration between the m u l t i p l e data sources ( e . g . documents in and between s e t t i n g s ) and m u l t i p l e data c o l l e c t i o n procedures ( e . g . documents, interviews and observations). The f i n a l stage of ethnographic research i s l i n k i n g the researchers model to theory. research process.  This i s viewed as an important part of the ethnographic Glaser & Strauss (1967), who developed "grounded  theory", believed the emergence of theory from data ensures a between the theory and the s o c i a l phenomena being s t u d i e d .  "fit"  Grounded  theory requires that researchers i n d u c t i v e l y compare t h e i r data and theory, with other data and theory concerning the s o c i a l world. Theoretical integration i s important i f substantive and formal theory i s to be generated.  37  E.  SUMMARY  In recent years i n t e r e s t in ethnography has grown as a reaction to p o s i t i v i s m and as recognition that t h i s t r a d i t i o n i s better able to provide an adequate framework f o r s o c i a l research.  Ethnographers are  interested in the ways in which i n d i v i d u a l s construct r e a l i t y and they acknowledge the f a c t that the researcher i s also part of the s o c i a l world they study. The research process c o n s i s t s of d e f i n i n g the s o c i a l u n i t , gaining access to the s e t t i n g and developing rapport to e x p l i c a t e the p a r t i c i p a n t s ' perspective and t h e i r experience of the s o c i a l world (Hammersley & Atkinson, 1983; Strauss, 1987; Bogdin & B i k l e n , 1982, Strauss & Glaser, 1970).  II.  THE RESEARCH DESIGN  This section reviews ethnographic research as a methodology f o r t h i s research p r o j e c t .  The research design i s presented f o l l o w i n g which the  purpose, goals and foreshadowed questions of the study w i l l be o u t l i n e d .  A.  ETHNOGRAPHIC  RESEARCH  AND HEALTH PROMOTION FOR SENIORS  Despite a long standing t r a d i t i o n  in sociology and anthropology  (Becker, 1970; Blummer, 1969; Glaser & Strauss, 1967), q u a l i t a t i v e methods that attempt to understand the r e a 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 s o c i a l s e r v i c e research.  Most  research in t h i s f i e l d has r e l i e d on q u a n t i t a t i v e methodology which u t i l i z e s precise sampling s t r a t e g i e s and s t a t i s t i c a l a n a l y s i s , 1n an attempt to seek the f a c t s or causes of s o c i a l phenomenon and human  38  behaviour.  In c o n t r a s t , ethnographic research in the phenomenological and  symbolic i n t e r a c t i o n i s t t r a d i t i o n s , s t r i v e s to understand human experience and behaviour from the a c t o r s ' perspective.  Ethnographic methods  emphasize the i n d i v i d u a l and t h e i r perception of experiences, events and i n t e r a c t i o n s in the world, and t h e r e f o r e , produce data that i s r i c h , i n depth and d e t a i l e d (Patton, 1980). In the f i e l d of health promotion "research questions i d e n t i f i e d are wide-ranging and complex" and "as such they are not e a s i l y adaptable to narrowly focused short-term i n v e s t i g a t i o n s that use only methods" (Health and Welfare Canada, 1989/90).  quantitative  Many advocates of health  promotion f o r seniors believe health promotion research needs to place increased emphasis on q u a l i t a t i v e methods ( M o l l e n i l l , 1987; M a r t i n , Robertson & Altman, 1988; Minkler & Pasick, 1986). Ethnographic research i s p a r t i c u l a r l y well suited to the present study which emphasizes i n d i v i d u a l s ' perspectives about the program components and process in f i v e health promotion programs f o r seniors in the Vancouver area.  A health promotion program involves a s o c i a l  organization where groups of seniors i n t e r a c t with health promotion coordinators i n regular and structured ways.  P o t e n t i a l l y the behaviour of  seniors and coordinators are mutually influenced.  A l s o , both groups'  behaviour may be influenced by rules and r e l a t i o n s developed over time. In order to describe the components and f a c t o r s c o n t r i b u t i n g 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 vital.  As ethnographic inquiry focuses on organizations within s p e c i f i c  contexts and provides a h o l i s t i c perspective, without superimposing the  39 researcher's value system on the situation, i t 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. 1)  The specific goals are:  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. include:  Questions arise about these components which  40  1)  What i s the focus of program components?  (A t o p i c of i n t e r e s t to the researcher i s the balance of focus among programs between i n d i v i d u a l 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 a p p l i c a b l e , as the research proceeded.) 2)  Does the p r o f i l e of program components vary among health  promotion programs? 3)  What f a c t o r s best contribute to explain t h i s v a r i a t i o n ?  Some  possible explanatory f a c t o r s may be: - organizational s t r u c t u r e , e . g . , funding sources, program c o n t r o l , organizational goals and frameworks - perspectives of coordinators - perspectives of p a r t i c i p a t i n g seniors - program s i z e - c u l t u r a l , economic, and s o c i a l c h a r a c t e r i s t i c s of the community.  E.  DEFINITION  OF TERMS  Health Promotion Program:  A program which incorporates "any  combination of health education and related o r g a n i z a t i o n a l , p o 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" (Green, 1980).  A health promotion program  enables people "to increase control over and to Improve t h e i r health (World Health Organization, 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, selfhelp 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, i n i t i a l tentative questions may be abandoned i f subsequent data f a i l s to support them.  III.  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 t o explore the purpose of t h i s study the researcher i d e n t i f i e d s e n i o r s ' health promotion programs from a sample of Vancouver Health Department s e n i o r s ' health promotion programs.  The p a r t i c u l a r  programs were selected f o r the f o l l o w i n g reasons: 1)  These programs were s p e c i f i c a l l y labeled s e n i o r s ' health  promotion programs.  In f a c t , in November 1984 the Vancouver Health  Department established s e n i o r s ' wellness (health promotion) p o s i t i o n s i n each health unit in response to a request by the Council Committee f o r Seniors f o r s e n i o r s ' programming.  The s t a f f has been at work f o r s i x  years implementing s e n i o r s ' health promotion projects in conjunction with seniors and s e n i o r s ' i n t e r e s t groups in f i v e d i f f e r e n t areas of urban Vancouver. City.  Together these f i v e areas make up the parameters of Vancouver  Twenty three programs were in operation when t h i s research began.  The f i v e coordinators e i t h e r i d e n t i f i e d e x i s t i n g s e n i o r s ' i n t e r e s t groups or agencies i n the community, or were approached by them.  The development  of health promotion a c t i v i t i e s / p r o g r a m s was f a c i l i t a t e d through these community groups or agencies. 2)  S a t i s f a c t o r y 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 q u a l i t a t i v e methods which could describe the structures and dynamics of t h i s ongoing program process were deemed e s s e n t i a l to program e v a l u a t i o n .  A l s o , access to i n d i v i d u a l  programs and seniors appeared l i k e l y because a working r e l a t i o n s h i p  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. selected from each setting. with the program size.  Table 1 outlines the subjects  The number of senior interviewees increased  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  PROGRAM SIZE  T Y P E OF  PROFESSIONAL  S U B J E C T S S E L E C T E D FOR  CATEGORY 1 Female  INTERVIEW  SENIOR Male  CATEGORY 2 Female 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 i s t o r i a n s of the program.  Seniors in category two met only one  c r i t e r i o n ; they were program p a r t i c i p a n t s .  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 perspective.  D.  CONFIDENTIALITY AND RESEARCH CONSENT  In order to protect the i n t e g r i t y and r i g h t s of the p a r t i c i p a n t s , the names of the s e n i o r s , the coordinators, the programs and t h e i r locations have not been i d e n t i f i e d .  C o n f i d e n t i a l i t y was guaranteed to  everyone as part of the consent process f o r p a r t i c i p a t i o n in the research study. The coordinators were unanimous in t h e 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 s e n i o r s . L e t t e r s of research consent and agreement to p a r t i c i p a t e 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 p a r t i c i p a n t ' and the 'complete o b s e r v e r . '  Two other roles which f a l l between these are  the ' p a r t i c i p a n t as observer' and the 'observer as p a r t i c i p a n t '  (Gold,  1958; Junker, 1960; Hammersley & Atkinson, 1983; Williamson, Karp, Dalpin & Gray, 1986). The 'complete observer' and the 'complete p a r t i c i p a n t '  remain  t o t a l l y d i s g u i s e d , with the 'complete observer' observing from a concealed p o s i t i o n and the 'complete p a r t i c i p a n t ' observing by becoming almost f u l l y involved in the s e t t i n g , both emotionally and behaviourally.  The two  remaining roles d i f f e r according to the emphasis placed on the amount of detached observation versus a c t i v e p a r t i c i p a t i o n .  The ' p a r t i c i p a n t as  observer' tends to p a r t i c i p a t e yet openly states h e r / h i s research intentions to those being studied.  The 'observer as p a r t i c i p a n t ' , on the  other hand, i s a more formal role and the contact with the p a r t i c i p a n t s tends to be b r i e f and e s s e n t i a l l y observation only. The ' p a r t i c i p a n t as observer' role was the goal of the researcher f o r t h i s study.  The researcher met with the coordinators and seniors to  explain the purpose of the study.  The researcher's  role c o n f l i c t was  minimal as she retained s u f f i c i e n t elements of 'the stranger' (Gold, 1958) yet was able to develop her r e l a t i o n s h i p s with informants to the point of intimate sharing. There was l i t t l e danger of o v e r - i d e n t i f y i n g or 'going n a t i v e ' ( M a l i n o s k i , 1922) with the s e n i o r s , because the difference in age and needs were s u f f i c i e n t to preclude the 'going n a t i v e ' dynamic.  The  46  r e l a t i o n s h i p between the researcher and coordinators was somewhat d i f f e r e n t f o r the p r o f e s s i o n a l s had s i m i l a r i t i e s with the researcher in age and s o c i a l r o l e .  However, the coordinators did not attend a l l  portions 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 e d to guard against the tendency to accept the ideas and opinions of the coordinators. The seniors and coordinators were briefed on the nature of the study and the role of the researcher.  A l l observations were openly recorded in  front of the p a r t i c i p a n t s The researcher had conducted a small p i l o t project f i v e months e a r l i e r in one selected s e t t i n g .  Due to the low turn over in coordinators  and seniors most i n d i v i d u a l s were f a m i l i a r with the researcher in t h i s setting.  The p i l o t project served to acquaint and s e n s i t i z e 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 i a r y , recorded f i e l d notes of observations, conducted audio-taped interviews, c o l l e c t e d pertinent documents, and typed the observations and interviews i n t o a computer in a protocol format f o r a n a l y s i s .  This process was s i m p l i f i e d with the use of  a computer program c a l l e d The Ethnograph ( S e i d e l , K j o i s e t h , Seymour, 1988) which a s s i s t e d the researcher with the mechanical tasks of protocol formatting and the c a t e g o r i z a t i o n of data.  It  in no way i n t e r f e r e d with  the a n a l y t i c a l process of the study.  The F i e l d 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.  It was used to record the researchers impressions, hunches, r e f l e c t i o n s , ideas and a n a l y t i c notes while in the s e t t i n g .  An example of an  impression, a r e f l e c t i o n 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 k e s to close things down in the summer as f e e l s the seniors need a break, I wondered who c l o s i n g down the program was f o r , her or the seniors and who makes t h i s d e c i s i o n ; p r o f e s s i o n a l s , seniors or both.  I made a mental note to observe the decision  making process in t h i s group as my hunch was professionals decide. The diary was also used to record and to monitor thoughts and f e e l i n g s about the researcher's r o l e and her r e l a t i o n s h i p s 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 f o r the a n a l y s i s of the data.  The Field Notes As a p a r t i c i p a n t observer the researcher kept f i e l d notes each time she was in each s e t t i n g .  As the researcher was involved in a l l aspects of  the programs, the f i e l d n o t e s recorded a l l a c t i v i t i e s and events that transpired in the programs during the informal, formal and focused observation periods.  (The observation schedule i s l i s t e d 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. each s e t t i n g ) .  These observations were noted in f i v e note pads (one f o r At the s t a 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. observations were conducted in each s e t t i n g .  Two informal  The researcher recorded the  format, a general d e s c r i p t i o n of the s e t t i n g s , the tone, d r e s s , and a c h e c k l i s t of d e s c r i p t i v e observations outlined by Spradley (1980, p. 78). The informal observations were general and d e s c r i p t i v e .  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 f o l l o w s : OB:  I a r r i v e at approx. 12:45 pm and  walk into the C C .  It  i s a very  large b u i l d i n g with many recreation activities.  I am instructed to move  u p s t a i r s 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 t e l l s 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 t h e i r s t a t i o n s 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 s e t t i n g and s e n s i t i z e d her to the s e n i o r s , the professionals and the program schedule. The formal observation notes were more s p e c i f i c . observations were conducted in each s e t t i n g .  Two formal  The researcher documented  format, routine, verbatim ' n a t i v e language' and any emotional responses that were expressed.  For example, a protocol from one program describes  an i n t e r a c t i o n 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  FEMALE:  No.  spoilt.  raining hard?  I go to get my n a i l s done.  I wasn't c u t t i n g them r i g h t .  The RN does a good job.  Then I go to  Eatons f o r a coffee. VOL:  And make a day of  it.  So your muscles are good. MALE: OB:  There you go.  Thank-you. Woman changes place with man.  I'm  51  FEMALE: OB:  I s n ' t she good.  She makes t h i s comment to me  FEMALE  I f e e l so good  a f t e r t h i s treatment.  I had my  shoulders done too. It was during these observations that a rapport between the researcher and p a r t i c i p a n t s seemed to heighten. The focused observation notes were the most s p e c i f i c . on program process and planning in each s e t t i n g .  These focused  For example, the  following from a protocol i s a segment of a planning meeting which was attended on J u l y 17th, 1989, were a professional i s d i s c u s s i n g senior p a r t i c i p a n t involvement in d e c i s i o n making about program content with the senior volunteers. PROF:  One thing I got to l e 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 k e to have at Program E.  Now we are t h i n k i n g of  things in terms of guest speakers but we might come up with some ideas i f you l i k e t h i s kind of impute f o r the a c t i v i t i e s and that kind of thing and they might even s u g g e s t . . . I t  sorta  w i l l be a chance to f i n d 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 v e r b a l i z i n g they think t h i s i s a good idea. No f u r t h e r comments are made from the s e n i o r s . PROF:  So that would be between 3:00 &  4:00 instead of a guest speaker. Two focused observations were conducted in each s e t t i n g .  In those  s e t t i n g s where s p e c i f i c committee meetings were h e l d , these were attended. Where planning meetings did not e x i s t , the portion 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 was used to maintain the f l e x i b i l i t y  interviewing  and spontaneity of responses.  The  common c h a r a c t e r i s t i c of a l l three ethnographic interviewing approaches 1s that they provide "a framework w i t h i n which respondents can express t h e i r own understandings in t h e i r own terms" (Patton, 1980, p. 205). The purpose of these interviews was to understand how seniors and coordinators viewed the program.  A l s o , i t was important to learn the  53  p a r t i c i p a n t s terminology and to capture t h e i r i n d i v i d u a l perspectives and experiences. P r i o r to the formalized interview p e r i o d , 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 t a l k i n g to the seniors and coordinators i n 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 l e v e l of generality to that of a more s p e c i f i c nature where a set of issues could be explored in the formal  interview  phase (Becker, 1954). Following the observation p e r i o d , the researcher conducted audiotaped, semi-structured interviews with a l l f i v e coordinators and 21 seniors.  The coordinators and seniors in category one were each  interviewed f o r one hour, and the seniors in category two for h a l f an hour.  These interviews combined the general interview guide approach with  a standard open-ended interview. to construct open-ended questions.  A set of t o p i c s served as a check l i s t Interviews conducted with coordinators  and seniors from category one allowed examination of the f o l l o w i n g t o p i c areas:  h i s t o r y of wellness/health promotion f o r seniors in Vancouver;  funding; program h i s t o r y ; program frameworks and goals; program focus and content; program process; senior and coordinator p a r t i c i p a t i o n in program planning and implementation; attendance patterns; and, s p e c i f i c program themes.  Topics d i f f e r e d s l i g h t l y f o r the seniors in category two, where  the focus was s p e c i f i c to each program  The t o p i c areas comprised:  program h i s t o r y ; program content and process; attendance patterns;  54  community c h a r a c t e r i s t i c s ; and, emerging program themes. schedule i s outlined in Appendix D.  (The interview  Interview Questions are l i s t e d 1n  Appendix E.)  The Documents  Documents which provided i n s i g h t 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 c o l l e c t i o n phase .  These included Health Department  and s p e c i f i c program conceptual frameworks, goals, schedules, funding sources and minutes of pertinent committee meetings.  The P r o t o c o l s  The w r i t t e n observations from the f i e l d notebooks and the data were typed i n t o protocol format.  interview  This allowed f o r ease of reading  and coding of the d e t a i l s and d e s c r i p t i o n s of the a c t i v i t i e s and i n t e r a c t i o n s in each s e t t i n g .  See Appendix C for examples of informal,  formal, focused observation p r o t o c o l s .  See Appendix F f o r 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 c o l l e c t i o n period.  The process of t r a n s c r i b i n g data was  useful in i t s e l f as i t provided the researcher with another opportunity reread the information thus increasing her f a m i l i a r i t y with the data. Ideas, hunches and i n s i g h t s were often added to the f i e l d journal t h i s process.  during  to  55  Once the protocols and the documentary data were reviewed for patterns, categories and themes t h 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 c o l l e c t i o n and the a n a l y s i s phases.  As  such, data a n a l y s i s was continual throughout t h i s research study. Like most ethnographic s t u d i e s , t h i s project did not begin with a theory or hypothesis to t e s t .  It should be noted however, that the  researcher was interested in the balance of focus among selected health promotion programs between i n d i v i d u a l behaviour change and environmental and community change components, which i s an idea brought to the research from the l i t e r a t u r e (Minkler & Pasick, 1986; Minkler, 1983).  However,  t h i s t e n t a t i v e 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 s e t t i n g and these data were analyzed to i d e n t i f y patterns, 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 a n a l y t i c notes were documented in the f i e l d diary as data was c o l l e c t e d from observations, interviews and documents.  The researcher used s e n s i t i z i n g ideas and  concepts to more f u l l y explain the p r o f i l e of program components and c o n t r i b u t i n g f a c t o r s to program composition. The constant comparison of data and s e n s i t i z i n g concepts resulted in the development of coding themes and categories (Glaser, 1964).  This  56  process of inductive a n a l y s i s produced themes and categories in two ways. Some emerged d i r e c t l y from seniors and coordinators e . g . s o c i a l i n t e r a c t i o n and support, housing, outreach, and from the program plan (initially  i d e n t i f i e d in the p i l o t p r o j e c t ) , while others that they did  not label or name were noted by the researcher e . g . program organization and process, attendance and community issues.  It should be noted that  s o c i a l support and attendance were unanticipated c a t e g o r i e s .  Social  support, a s i g n i f i c a n t theme to the s e n i o r s , 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 f u r t h e r explore t h i s as a theme in the research study.  Instead the comparison of program p r o f i l e s became important using  the s e n s i t i z i n g concepts ' I n d i v i d u a l Behaviour Change' and 'Environmental and Community Change Components,' brought from the  literature.  Program process and organization was the most frequently occurring category w i t h i n and across the s e t t i n g s . across the data sources.  It was also evenly d i s t r i b u t e d  This category became the core concept of the  developing model. Triangulation was used to cross v a l i d a t e 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 pertinent to the research. In s o c i a l research the researcher i s warned to avoid r e l i a n c e on a s i n g l e piece of data as there i s danger that undetected e r r o r i n the data production process could render the a n a l y s i s i n c o r r e c t .  In t h i s study  it  was j u s t as important and i l l u m i n a t i n g to look f o r d i f f e r e n c e s between the  57  types of data as to look f o r diverse kinds of data that lead to the same conclusion.  For example, a Health department document proposed a  framework f o r health promotion f o r older adults that would address both i n d i v i d u a l behaviour change and underlying environmental and community change components in health promotion programming for seniors (Martin, Robertson and Altman, 1988), yet s p e c i f i c program o u t l i n e s included no community and environmental change elements.  Similarly,  interviews  conducted with coordinators and seniors shed l i g h t on s i m i l a r i t i e s and differences in perspectives.  P a r t i c i p a n t observation allowed the  researcher to view which program components a c t u a l l y e x i s t e d .  In t h i s  example t r i a n g u l a t i o n promoted comparison of information between multiple data sources and among m u l t i p l e data c o l l e c t i o n procedures, as i t  involved  that which was documented, which was commented on through interview and which was observed by the researcher. It  i s an important technique in f i e l d research that theory must  a r i s e from and " f i t "  the data (Bogdin & B i k l e n , 1982; Burgess, 1984;  Hammersley & Atkinson, 1983).  The researcher reviewed the data and  categories to l i n k the t h e o r e t i c a l concepts emerging from the data to e x i s t i n g theory.  For example as concepts related to personal autonomy and  control were o u t l i n e d in documentary data and made reference to by coordinators and s e n i o r s , i t became evident that v i c t i m blaming, empowerment and helplessness were concepts emerging from the data.  Also  as s e n i o r s ' involvement in program process and organization was a c l e a r l y desired o b j e c t i v e , and as organizational goals are a facet of organizational behaviour, organization theory i s relevant to t h i s study.  58  The conclusions w i l l discuss l i t e r a t u r e and theory related to senior p a r t i c i p a t i o n in program process and organization of health promotion programs and how t h i s a f f e c t s s e n i o r s ' empowerment and c o n t r o l , and the focus of the programming.  I f however, the researcher was to conduct  a d d i t i o n a l a n a l y s i s of the substantive theory and acquire material from other studies which pertained to a data category, she could end up with a formal theory f o r a conceptual area such as how the d e c i s i o n making process a f f e c t s autonomy and control of groups within s o c i e t y . stage i s beyond the goal of t h i s present research.  This f i n a l  59  CHAPTER 3 THE PLACES, THE PEOPLE AND THE EMERGING ISSUES This chapter provides a d e s c r i p t i o n of f i v e wellness/health promotion programs from observation, interview and documentary data. d e s c r i p t i o n includes program h i s t o r y , content, funding,  Each  organizational  s t r u c t u r e , wellness/health promotion approach and the demographics of each l o c a l area in which the program i s located.  A d e s c r i p t i o n of the  p a r t i c i p a n t s and professionals involved i s given.  Emerging issues from  each program are discussed using the a n a l y t i c headings; program organization and process, attendance, s o c i a l i n t e r a c t i o n 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 o u t l i n i n g  pertinent  data from the d e s c r i p t i o n and discussion of emerging issues.  I. A.  PROGRAM A  DESCRIPTION  Program A began in 1987 at a l o c a l 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 older.  Although 85% of the residents have English as t h e i r mother tongue,  the ethnic d i v e r s i t y i s large.  Ethnic representation at Program A  i n c l u d e s ; E n g l i s h , S c o t t i s h , French, East Indian, Chinese and Ukrainian. The community contains a mix of low to high Income f a m i l i e s and s i n g l e residents.  Housing v a r i e s from s i n g l e to multiple d w e l l i n g s , of which 70%  are rented and 77% are apartment and duplex in type.  This i s a community  60  in t r a n s i t i o n where affordable m u l t i p l e resident dwellings are s t e a d i l y 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 inception.  its  Seniors were asked to i d e n t i f y health promotion needs at a  health forum.  Following t h i s a Seniors Advisory Committee was formed and  s e n i o r s , in partnership with Health Department s t a f f , began to plan and implement neighbourhood health programs.  Program A i s one of these.  Although t h i s program has no d i r e c t l y funded p o s i t i o n s , 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 t a 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 p r o f e s s i o n a l s .  The  community center provides an exercise i n s t r u c t o r and the wellness coordinator f a c i l i t a t e s d i s c u s s i o n s . The program i s a "free h e a l t h - r e l a t e d program f o r i n d i v i d u a l s 55 years p l u s . "  I t operates on Wednesdays 10:00 a.m. - 12:00 p.m.,  throughout the year. are men.  The average attendance i s 20 people, four of whom  Program components include; "fun and f i t n e s s e x e r c i s e " , "once a  month blood pressure monitoring"."refreshments", and " d i s c u s s i o n on health related t o p i c s , chosen by the p a r t i c i p a n t s . "  61  Although there i s no o f f i c i a l wellness/health promotion approach, the wellness coordinator adopts "A Framework for Health Promotion:  Older  A d u l t s " , a d r a f t document produced in 1988 by the Vancouver Health Department.  Here the goal i s to "promote the p h y s i c a l , mental, s o c i a l ,  and personal well-being of older a d u l t s , using s t r a t e g i e s a f f e c t i n g the i n d i v i d u a l and the environment."  both  Seniors support t h i s broad  perspective, though t h e i r primary focus i s on i n d i v i d u a l l i f e s t y l e change.  B.  EMERGING  ISSUES  Program Organization and Process Program organization and process, which concerns how seniors are involved in the d e c i s i o n making process and the running of the wellness program, i s the most t y p i c a l of a l l issues that emerged about Program A. The professionals and seniors d i f f e r  in t h e i r b e l i e f s .  Though seniors are  v e r b a l l y encouraged to be involved through mechanisms such as the Seniors Advisory Committee, a c t i v e p a r t i c i p a t i o n i s often blocked by professionals.  Conversely, seniors give a double message to  p r o f e s s i o n a l s ; while they say they want to be involved, t h e i r action often indicates they would rather not take on planning and leadership responsibi1ities. One professional gave the message that "seniors should be helped to f e e l l i k e they are getting control over programming," which can be "achieved by (us) s t a r t i n g 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 actions that do not support t h i s philosophy.  For  62  example, when a proposal f o r an Outreach Program was submitted to a federal funding agency by the s e n i o r s , 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-time 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. know what seniors need. Advisory Committee.  The message from professionals i s that they  This message i s also given by the Seniors  This committee though formed to act as a consulting  body on seniors needs, has not allowed senior leaders to share t h e i r perspectives. In t u r n , the seniors present a mixed message about t h e i r in program organization and process.  involvement  On the one hand some speak about how  they have t r i e d to be involved in program planning but are constantly disregarded by p r o f e s s i o n a l s . "got discouraged."  "We t r i e d to acquire outreach funding"  but  "We make suggestions to professionals l i k e what t o p i c s  we want to t a l k about, but as f a r as running the group we don't have any say."  One s e n i o r ' s perspective represented others on the functioning  of  the Seniors Advisory Committee by saying, "I get the impression that there are c e r t a i n professionals within that group who are making the decisions f o r people." The other common response from seniors was one of reluctance and lack of motivation to p a r t i c i p a t e  in program decision making.  Comments  varied from "seniors lack the commitment" and "seem reluctant to be  63  involved" to "we are supposed to make d e c i s i o n s " but "we only have so much energy" and "we don't want to give that much time."  Attendance Seniors and professionals agree that although there are m u l t i p l e reasons f o r senior attendance at Program A, s o c i a l i n t e r a c t i o n and support i s of primary importance.  Attendance patterns are influenced most by  gender differences and the i n d i v i d u a 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 b e l i e f that "there are men out t h e r e " , who could come but "are r e l u c t a n t . " One of the attending men believes "reluctance i s a psychological t h i n g .  I  think men are on the whole quite intimidated by large q u a n t i t i e s of women."  Other seniors believe "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 t h e i r  thing",  or that "they are too shy" and "not as motivated as women to j o i n t h i n g s . " Many seniors and p r o f e s s i o n a l s however are surprised at the number of men who do come.  It  i s i n t e r e s t i n g to note that t h i s program began with one  man and three women, and there has always been a man in the group. Another f a c t o r a f f e c t i n g attendance patterns i s the proximity of i n d i v i d u a l s to the program.  A number of people f e l t that the community  center i s "too f a r away f o r many to come" and that others are put off by "a big h i l l to climb when coming from a c e r t a i n d i r e c t i o n . "  Some seniors  had been keen to s t a 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 f o r t h i s group as seniors had  concerns about tax and rental increases, and f e l t t h e i r neighbourhoods were changing adversely.  Although professionals indicated seniors could  take control by "speaking out," seniors were l e f t f e e l i n g "discouraged" and "without a l t e r n a t i v e s . " The housing c r i s i s was viewed as a "very serious business".  "What  seniors are worried about i s how much t h e i r taxes have increased t h i s year", "rents doubled but incomes d i d n ' t " and "with taxes up what i s the s i n g l e 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 t e r n a t i v e s " and expression of " f e a r s and resentments" such as "to l i v e within our means a l o t of people are having to leave t h 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 h e i r places and having to go to another area altogether that i s affordable".  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  " w r i t i n g l e t t e r s to government", attending "housing forums" and making "phone c a l l s to a l o c a l number established to deal with tax and rental concerns."  Though some seniors followed through with these ideas many  f e l t the changes "were i n e v i t a b l e " and f e l t "discouraged" and helpless as there was l i t t l e they could do to e f f e c t change.  65  Out  Reach.  Out reach i s the process and programming involved in  reaching out to seniors who are not attending a wellness/health promotion program.  A group of s e n i o r s , with the support of one p r o f e s s i o n a l ,  submitted a proposal to a federal agency to fund a part-time p o s i t i o n to coordinate out reach a c t i v i t i e s .  P r o f e s s i o n a l s i n t e r f e r e d with t h i s  process and eventually 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-time out reach person, where that person could work with the group to f i n d out what programs seniors want.  In the middle of t h i s process along came a group  of p r o f e s s i o n a l s , and they a l l said they (the seniors) d i d n ' t need a programmer, that they could to i t themselves."  However the seniors  " d i d n ' t want to take the r e s p o n s i b 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 e d to get the grant and a l l we got was the run-around so we dropped i t for a w h i l e " , as the funding agency kept "changing the r u l e s " .  One senior said we "don't want to go  from door to door as we f i n d i t hard to knock on doors of perfect strangers".  This comment was made in support of an out reach coordinator  who would i n v e s t i g a t e how best to acquire information and u t i l i z e the seniors in the program i n a way they f e e l comfortable.  66  Although professionals were viewed as i n t e r f e r i n g in t h i s process, i t should be noted that there are those seniors that don't appear e n t h u s i a s t i c about out reach.  The f o l l o w i n g comments h i g h l i g h t t h i s :  "a  considerable number of people are happy to come on Wednesday but they are not p a r t i c u l a r l y concerned with having more people", or "they think  it  would be d e s i r a b l e but not e s s e n t i a l " and "so some are f o r 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  Community  it".  Involvement.  Community involvement includes s e n i o r s '  p a r t i c i p a t i o n in a c t i v i t i e s outside the wellness/health promotion program. Although community center s t a 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 s e n i o r s , such as volunteering and out reach, did not receive support by most p r o f e s s i o n a l s . 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 h e 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 t h a t ' s no l i f e . "  A number spoke of the importance of the s o c i a l component of  volunteering.  "Although we are working, so we don't have a chance to chat  that much, I've made a l o t of f r i e n d s there (Red C r o s s ) . "  67  It  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 professionals.  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 i n d i v i d u a l kept the p a r t i c i p a n t s  abreast of issues in the community that a f f e c t s e n i o r s , so they had information of meetings and forums in which they could p a r t i c i p a t e .  S o c i a l I n t e r a c t i o n and Support S o c i a l i n t e r a c t i o n and s o c i a l support are the primary reasons why seniors p a r t i c i p a t e in Program A.  Seniors come e a r l y and leave l a t e ,  taking time to chat on a one-to-one basis or in small groups.  Both  seniors and p r o f e s s i o n a l s acknowledge the importance of t h i s aspect of the program. "Friendship i s the primary component of the program" and " f r i e n d s are (viewed as) a health i s s u e . "  The program i s seen as a place for  " f e l l o w s h i p " , " s o c i a l support", "companionship" and "to make f r i e n d s . " The program i s considered to be important as i t provides "a place to t a l k " and " a chance to be with adults" f o l l o w i n g retirement.  Program A i s seen  to provide "a caring environment" where there i s "support when spouses d i e " and  "a l o t who are i s o l a t e d can come and met new f r i e n d s . "  It  seen as "more s o c i a l than p h y s i c a l " and that seems to explain "why we s t a r t a half hour e a r l y to have a l i t t l e chat before we get into the exercise."  I a l s o noticed that people stay l a t e and chat a f t e r the  is  68  program and some commented they "walk home" together and sometimes "go out f o r lunch".  C. SUMMARY Program A has operated for over three years at an urban community center.  On average twenty women and four men regularly attend a  predominantly l i f e - s t y l e oriented program.  Components include; e x e r c i s e ,  once monthly blood pressure checks, refreshments and h e a l t h - r e l a t e d discussion groups.  Seniors acknowledge the importance of a s o c i a l  component through t h e i r e a r l y a r r i v a l and staying a f t e r the program to chat.  The only community issue discussed was housing.  Although Program A  i s based on a wellness/health promotion approach which claims to promote senior involvement and p a r t i c i p a t i o n in program planning and implementation, professional dominance has negatively influenced seniors attempts to take control of, and to expand programming.  69  II. A.  PROGRAM B  DESCRIPTION  Program B began at a Unit of the Vancouver Health Department in the f a l l of 1984.  This unit i s i n a l o c a l area of Vancouver which contains a  population of 25,000 people of which 26% are s e n i o r s .  Here, there i s a  mix of low to middle income f a m i l i e s and s i n g l e r e s i d e n t s .  This community  has a v a r i e t y of ethnic populations of which E n g l i s h , Chinese, Punjabi, and German make up 88% of the population (Canada Census, 1986). of program attenders was as f o l l o w s ; E n g l i s h , German, Chinese, and one East Indian.  The mix Italian,  The housing mix i s predominantly single-detached  homes (76%) and m u l t i p l e family dwellings (13% duplex, 7% apartment).  68%  of these dwellings are owned (Canada Census, 1986). Program B i s j o i n t l y sponsored by the l o c a l Seniors Network Society and the Vancouver Health Department.  This program began a f t e r 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 e c t l y funded  p o s i t i o n s , 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 r o l e .  Senior volunteers provide  the manpower to maintain the weekly programming and the space i s furnished by a Health U n i t . The program i s free and operates every Monday, year round between 10:00 a.m.- 1:30 p.m. whom are men.  It  The average attendance i s 35 people, a t h i r d of  i s " f o r persons 55 years and better" and " i s based on  the b e l i e f that people who have access to health information and opportunities f o r physical f i t n e s s and getting to know each other, w i l l  70  f e e l better and have more energy."  Program components include:  blood  pressure and weight checks, neck, shoulder and foot massage, e x e r c i s e s , r e l a x a t i o n , a luncheon and a wellness t o p i c of Although there i s no o f f i c i a l  interest.  d e f i n i t i o n of wellness/health  promotion, both seniors and professionals embrace a " w h o l i s t i c " focus to health in which " p h y s i c a l , mental and s o c i a l aspects" are a l l important to " q u a l i t y of l i f e " . "self care",  The professionals add a focus on the  and the use of "community development s t r a t e g i e s " to " t r y  give seniors the s k i l l s to look a f t e r and maintain t h e i r  B. EMERGING  "environment", to  health."  ISSUES  Program Organization And Process Program organization and process, the most t y p i c a l theme of Program B, concerns issues of senior leadership, "cooperative decision making" and whether or not seniors are "encouraged to use and share t h e i r own resources."  In f a c t , decisions are made by seniors v i a volunteer  committees, and then presentation to the larger group where discussion and consensus occur.  A partnership e x i s t s between leaders (both professional  and senior) and seniors (both volunteers and non-volunteers), that f o s t e r s seniors drawing on t h e i r own resources to run the wellness/health promotion program themselves. Although one senior and one professional were i d e n t i f i e d as the principal  leaders or "the spark p l u g s " , the primary decision 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 f e r e n t 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 t h i n k . " viewed as i n t e r f e r i n g in t h i s process.  Leaders are not  "Well there i s a leader you know,  but the leader we can not c a l l a leader in the sense of s a y i n g , you do t h i s and t h a t .  The leader keeps every thing in order and keeps a l i n k  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 f o r the  r e g i s t e r i n g , massage, t a l k s and other j o b s . "  Cooperative decisions are  made about most aspects of the program i n c l u d i n g ; "volunteer involvement", "program changes", "problem s o l v i n g " , issues of space", "summer programs", planning the " t a l k s " and s e l e c t i n g and scheduling "summer t r i p s . "  As one  senior said "we kind of keep i t as democratic as p o s s i b l e . " Senior leaders and professionals play a d i f f e r e n t senior volunteers and general program p a r t i c i p a n t s .  role from the  The professionals see  themselves as " f a c i l i t a t o r s and advocates and hopefully stay out of the way so they (the seniors) can run t h e i r own show."  One year ago the  wellness coordinator encouraged the senior leader to ask the group f o r volunteers.  This resulted in the formation of the e x i s t i n g committees.  At t h i s time a s h i f t in process took place from a leader taking charge, to the creation of a partnership with s e n i o r s , where cooperative d e c i s i o n making r e s u l t s .  Attendance Although there are m u l t i p l e reasons f o r attendance at Program B, the "number one" given i s " f e l l o w s h i p . "  This program i s predominantly  72  attended by women.  Gender differences and seniors proximity to the  program have the most impact on attendance patterns. The most c i t e d reason for attendance was, " f e l l o w s h i p . " incorporates; the "company", because " i t  This  i s a f r i e n d l y p l a c e " , where  "there are nice people to t a l k to" and that people are "accepting" and "receptive to new people." " g e t t i n g out".  Another reason frequently mentioned was  In exploring t h i s i t appears that some f e e l "there i s  nothing f o r older people to do" and "they f e e l alone by themselves" so " i t gets them out" and provides "a place to pass the time".  The professionals  share t h i s perspective and believe some seniors attend because they have " l o y a l t i e s " to c e r t a i n volunteers. Gender d i f f e r e n c e s were viewed as having the most influence 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 difference in numbers between the sexes. include:  These  "we haven't got the pattern of a c t i v i t i e s they want" or "men  tend to be r e c l u s i v e " and are "more reserved" or "too shy".  Some believed  "the men in t h e i r 60's and 70's (who) come for B . P . s only" attend for break in routine" and "to c h a t . "  It was f e l t that "women are more  involved in things l i k e t h i s as are more s o c i a l . "  "the  73  S o c i a l Interaction and Support Seniors and professionals agree that s o c i a l i n t e r a c t i o n and s o c i a l support are the primary reasons why people attend.  Comments from seniors  support t h i s ; "number one i s f e l l o w s h i p " , and " t h e r e ' s an a t t i t u d e generated where everybody i s welcome."  The program provides an  a l t e r n a t i v e 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 a r e " .  Many said  "when you t a l k , you f i n d you have the same problems" and "you forget your troubles."  A couple of seniors mentioned that " s o c i a l i n t e r a c t i o n  is  important i f you are going to have physical h e a l t h " . Observation c l e a r l y indicted the importance of the s o c i a l aspect to people.  Seniors sat and chatted throughout the program in groups, over  cards, while waiting f o r blood pressure checks, over lunch and during the other a c t i v i t i e s .  Some spoke in t h e 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.  P a r t i c i p a t i o n in and c o n t r i b u t i o n to a  number of community a c t i v i t i e s and events i s supported by seniors and professionals. participate.  Volunteer work i s the primary means through which people This i s not s u r p r i s i n g 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 e l s e in the community."  The types of  74  a c t i v i t i e s mentioned were "meals on wheels", " d r i v i n g people to doctors" and running "exercises and r e l a x a t i o n " at other wellness programs. Information about community a c t i v i t i e s was d i s t r i b u t e d by leaders and non-leaders, usually 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 p a r t i c i p a n t s out into the community. It was generally f e l t that people were encouraged "to contribute" and "share t h e i r resources", however there are those who do not p a r t i c i p a t e and t h i s also appears acceptable.  Out Reach.  Out reach, although l i m i t e d , does e x i s t .  It was the  professional and senior leader who i d e n t i f i e d present out reach a c t i v i t i e s and could see the p o t e n t i a l f o r expansion in t h i s area. The phone t r e e , a form of s o c i a l support where seniors who don't attend f o r 2 or 3 weeks are contacted by phone, was the only outreach a c t i v i t y i d e n t i f i e d by s e n i o r s . were i d e n t i f i e d by p r o f e s s i o n a l s .  A l l other a c t i v i t i e s related to out reach For example senior volunteers share  t h e i r resources through running exercise and r e l a x a t i o n classes in two seniors b u i l d i n g s 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 f o r a short term project and the professional has suggested to the senior leader that the funds could be used "to t r a i n seniors to do bereavement c o u n s e l l i n g . "  75  C.  SUMMARY  Program B which i s located in a Unit of the Vancouver Health Department has been in operation f o r over f i v e years. seniors attend r e g u l a r l y , of whom a t h i r d are men.  On average 35  Though the program  components ( e x e r c i s e , r e l a x a t i o n , 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 r e c t program planning, implementation and s t a f f program activities.  Out reach, though l i m i t e d , i s conducted and the s o c i a l  component i s well integrated into program a c t i v i t i e s .  III. A.  PROGRAM C  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. residents.  Seniors aged 55 years and over make up 26% of the  The area contains a mix of low to middle income f a m i l i e s and  single residents.  Housing v a r i e s very l i t t l e with 98% of the dwellings  being rental apartments.  79% of the senior population l i v e alone.  l o c a l area contains a mix of ethnic populations i n c l u d i n g : Chinese, German, Ukrainian, Hungarian, P o l i s h and Dutch. make up the majority group (Canada Census, 1986).  This  French, English (72%)  Program C draws a mixed  c l i e n t e l e of "mostly Caucasian" ( E n g l i s h , S c o t t i s h , 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 f a c t that many attenders t r a v e l here on foot or by bus from other l o c a l areas.  76  The wellness program i s j o i n t l y sponsored by the Seniors Center and a Unit of the Vancouver Health Department.  It began when the wellness  coordinator was approached by an e x i s t i n g seniors group at the center. They wanted a wellness program s i m i l a r to that in another area of Vancouver.  Although t h i s program i s s t a f f e d and funded by the seniors  center, s e r v i c e s 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 l s o provide the  manpower to run the weekly program. The program i s free and operates on Mondays from 1:00- 3:00 p.m. P a r t i c i p a n t s are "55 years and b e t t e r . " i s 20 people, of whom 6 are men.  The average number of attenders  Program components include; weekly blood  pressure and weight checks, fun and f i t n e s s e x e r c i s e , and a health related presentation. There i s no o f f i c i a l w e l l n e s s / h e a l t h promotion approach at t h i s center.  However seniors i d e n t i f i e d "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 " b u i l d i n g leadership, providing information and working with professionals to teach them how to get seniors to p a r t i c i p a t e . "  B.  EMERGING  ISSUES  Program Organization and Process Program organization and process was the most t y p i c a l theme of Program C.  P r o f e s s i o n a l s believed seniors should " p a r t i c i p a t e in creating  a wellness program" through being given control of d e c i s i o n making and  77  ongoing program development; however a c t i v e p a r t i c i p a t i o n by general p a r t i c i p a n t s i s not encouraged. involvement.  Only one mechanism e x i s t s for senior  Seniors must become "volunteers" and then they can attend  monthly Wellness Committee meetings where program planning and decision making occurs. Indeed senior p a r t i c i p a n t s did not see themselves as involved in program d e c i s i o n making except f o r those who are designated as senior volunteers.  The f o l l o w i n g 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 h a t ' s a good idea and we should ask them i f they want to p a r t i c i p a t e in the volunteering, some of them c o u l d . "  A unilateral  decision was made by the p r o f e s s i o n a l s about c l o s i n g the program during summer as they f e e 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." only means for p a r t i c i p a n t involvement i s through the volunteers.  The  One  volunteer commented that " o c c a s i o n a l l y they (the p a r t i c i p a n t s ) w i l l come up to you and say I wish we had a program on such and such. O.K."  I'll  say  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 p a r t i c i p a t o r y and that "everyone gives t h e i r ideas."  However, cooperative brain storming and d e c i s i o n making was not  apparent during observation.  Seniors did make suggestions about  p a r t i c i p a n t involvement, content and timing of a c t i v i t i e s , but these were  78  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 p r i m a r i l y f o r the " f r i e n d s . "  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 f o r s o c i a l contact i s the most frequently mentioned. Seniors said they were "looking f o r f r i e n d s " , or they " l i k e d the f r i e n d s they'd made" and " l i k e d 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 i n t e r a c t i n g with the volunteer who runs t h i s segment of the program.  "Blood pressures" were thought to be the biggest drawing  card f o r the men.  Other reasons given f o r attending were, f o r "something  to do", to l i s t e n to "the speakers" and because "I Program C draws a mixed c l i e n t e l e .  "It's  l i k e to h e l p . "  a changing d r o p - i n . "  Even  though "most of the people who drop-in l i v e nearby", "there are people from K e r r i s d a l e " , the "North Shore" "and quite a few come from Burnaby." A number mentioned they also attend other wellness programs. influences who does and doesn't attend. over" or be "well enough to get the bus." men "has dropped o f f " . too many women." f e e l too shy."  Mobility  Seniors must be able to "walk Apparently the attendance of  One senior wondered i f i t was because "there are  Another said "men don't come for the exercise as they Apparently "a few men used to come and j o i n in the program  but then they dropped o f f and now a l o t play ping pong" instead.  Other  79  reasons given f o r non-attendance were; "some go to other places and prefer i t better",  "some people prefer to go to programs in t h e i r own area" and  one volunteer wondered i f the numbers " f e l l off when the nurse wasn't here and then a couple of times the speakers d i d n ' t show." numbers have increased since winter"  Although "the  (1988), i t i s f e l t by both  professionals and senior volunteers that "the program could f o l d at any time."  This b e l i e f leaves one with a sense of a tentativeness about the  future of the program.  S o c i a l Interaction And Support Program C provides a place f o r s o c i a l contact and i n t e r a c t i o n for seniors. Many said "I  l i k e to meet f r i e n d s and come to t a l k to them."  Others  mentioned "they need to mix around with people and t a l k otherwise they get lonely" or " t h e i r f r i e n d s 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 r e a l l y  talk."  Seniors and professionals both agree that the s o c i a l aspect of t h i s program i s of primary importance. One professional f e l t attendance was influenced by the exercise i n s t r u c t o r as "they r e a l l y enjoy her and so at t h i s point i f she l e f t , a l o t of people would stop coming."  It  i s also  i n t e r e s t i n g 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 j u s t around the corner from the open space used f o r 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 r u t " , and one professional l e t seniors know what other a c t i v i t i e s were scheduled in the center. components focus on i n d i v i d u a l  The program  l i f e s t y l e and behavioural change issues.  C. SUMMARY  This program has operated f o r over four years and i s one of many programs run at a seniors center. approximately s i x of whom are men.  Average attendance i s twenty people, Program components include; blood  pressure, weight checks, exercise and a health related presentations, which are l i f e s t y l e in focus.  Although professionals claim to  facilitate  senior leadership and p a r t i c i p a t i o n they dominate program d e c i s i o n making and planning.  No community issues are addressed by t h i s program.  IV. A.  PROGRAM D  DESCRIPTION  Program D began at a community center in 1988.  The l o c a l area in  which the community center i s l o c a t e d , 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 f a m i l i e s and s i n g l e residents.  79% of seniors here l i v e alone.  Most dwellings are owned  (85%), of which 88% are s i n g l e 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  f e e l t h i s i s changing the face of the neighbourhood.  The ethnic  combination of t h i s area i s p r i m a r i l y English (86%).  A l s o , small numbers  of Chinese, German, French, and Greek residents ( t o t a l 9%) l i v e in t h i s area.  The wellness program exemplifies t h i s mix with a l l attenders being  Caucasian except for one Chinese woman. Program D i s co-sponsored by the l o c a l community center and a Unit of the Vancouver Health Department. volunteer.  It was implemented by a senior  Shortly a f t e r i t ' s inception a wellness coordinator  approached the members of the program and the community center s t a f f , and became involved.  This wellness program has no d i r e c t l y funded p o s i t i o n s ,  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 t a f f input from the community center.  Senior volunteers and a r e t i r e d nurse o f f e r  their  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.  It serves seniors "55 years and b e t t e r . "  10 women attend each week.  An average of  Program components include: once monthly blood  pressure checks, shoulder massage, fun and f i t n e s s e x e r c i s e , refreshments, and a discussion section on a broad range of t o p i c s . This program has developed no o f f i c i a l d e f i n i t i o n of wellness/health promotion.  However, both senior and professional interviewees agreed,  that a w e l l n e s s / h e a l t h promotion approach considers; "body, mind, s p i r i t and companionship" as well as "using knowledge" as e s s e n t i a l ingredients The professional also adopts "A Framework for Health Promotion: Adults" as a health promotion approach.  Older  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 i n d i v i d u a l " e s t a b l i s h e s wellness or q u a l i t y of l i f e to be to them."  B.  1  EMERGING  ISSUES  Program Organization and Process Program organization and process i s the most t y p i c a l theme in t h i s setting.  Leadership roles and r e s p o n s i b i l i t i e s are not c l e a r l y  delineated, r e s u l t i n g in overt confusion and c o n f l i c t between one senior and a professional leader.  These i n d i v i d u a l s hold d i f f e r i n g perspectives;  the professional supports cooperative decision 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 d e n t i f i e d as an issue by the p a r t i c i p a n t s .  Seniors value  both leaders' c o n t r i b u t i o n to the program and f e e l they are involved. The designated leader started the program and views herself as the leader.  She f e e l s "we r e a l l y don't need the Department of Public Health"  and that the professional involved "has taken over" and " i s not r e a 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  u n t i l when the professional 'took i t over' and c l e a r l y indicates a preference f o r c o n t r o l l i n g the program independently without professional interference.  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 t u a t i o n quite d i f f e r e n 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  p a r t i c i p a n t s f o r the d e c i s i o n s " .  She would l i k e to see them more involved  83 in the program e . g . taking blood pressures, p a r t i c i p a t i n g more as volunteers w i t h i n the program and i n v o l v i n g themselves in out reach projects. The senior p a r t i c i p a n t s did not voice an opinion about the e x i s t i n g power struggle and strongly valued both leaders c o n t r i b u t i o n 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 s e c t i o n . They had taken on the role of s e l e c t i n g and organizing t o p i c s with encouragement from the p r o f e s s i o n a l .  There was no expression of concern  by seniors about t h e i r lack of involvement in other components of the program.  S o c i a l Interaction and Support Although seniors gave many reasons why they attend Program D i t  is  c l e a r that s o c i a l support and s o c i a l i n t e r a c t i o n are of primary importance to the group. perspective.  P r o f e s s i o n a l s agree and observations support t h i s Seniors tend to a r r i v e e a r l y and stay for the refreshments  a f t e r e x e r c i s e s . Both periods were busy with chatter.  The d i s c u s s i o n ,  though not personal per s e , does allow f o r seniors to t a l k about issues f o r which they need support e . g . housing. The s i g n i f i c a n c e of the s o c i a l element of the program to seniors was apparent by t h e i r comments; "a l o t come in to c h a t " , or " f o r the companionship", "the s o c i a b i l i t y " , and "the i n t e r a c t i o n with people." Another senior pointed out how t h i s support network i s s i g n i f i c a n 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 f o r 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 r e a l l y welcome".  Community Issues Housing.  The housing c r i s i s was a very s i g n i f i c a n t  Vancouver area while t h i s research was conducted.  issue in the  This l o c a l community  was affected as housing prices sky-rocketed leaving seniors concerned about large tax increases and the lack of housing a l t e r n a t i v e s , they choose to s e l l t h e i r homes.  The view held by the senior leader and  professional d i f f e r e d from the p a r t i c i p a n t s . non-issue to t h i s group.  should  They perceived housing as a  Seniors described the c r i s i s as "a traumatic  t h i n g " and stated they were " f r i g h t e n e d . " about the "increase in t a x e s " .  They said they were "angry"  They spoke about wanting to keep t h e i r  "own homes and that (they) almost f e l t pressured to s e l l . " expressed concerns about " l a c k of housing a l t e r n a t i v e s . " were "very worried about moving.  Where would we go?"  Also they Some of them  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 g h t . "  Others stated they "wouldn't subject themselves to  as t h a t ' s too u n c e r t a i n . "  The senior leader f e l t housing wasn't an issue  at a l l saying "I'm s i c k of l i s t e n i n g to i t . group."  renting  It's  not an issue for  this  I n t e r e s t i n g l y she stated she f e l t housing was only brought up as  an a issue because the professional was i n t e r e s t e d .  The professional  appeared to agree with t h i s s e n i o r , s t a t i n g that as "most owned t h e i r own homes, housing has never been an i s s u e . "  However, i t was apparent that  i n d i v i d u a l senior p a r t i c i p a n t s did hold fears about the housing c r i s i s and appreciated discussing  it.  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"; volunteering, out reach and community involvement were not encouraged through the program. Seniors agreed, saying "we are not r e a 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 " t h i s  group was ready f o r some out reach a c t i v i t i e s " saying "they r e a 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 p r i m a r i l y for " s o c i a l " reasons, by " a c t i v e " people a l l of whom are women. Although various reasons f o r attendance were s t a t e d - "they enjoy the a c t i v i t y and e x e r c i s e " , "the d i s c u s s i o n makes i t very i n t e r e s t i n g " ,  "it's  an opportunity to get out", and " i t ' s close and convenient"- the need for " s o c i a l support" and " s o c i a b i l i t y " were the ones most valued. The seniors and professional believe that  men don't come because  "they do not want to be involved in a program f u l l of women, because they f e e l overpowered, threatened and i n t i m i d a t e d . "  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 r e t i r e d or widowed, to come out in a group, i s r e a l l y a monumental t a s k . "  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 i s o l a t e d 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, e x e r c i s e , refreshments and health related d i s c u s s i o n s ) , community issues (housing, environmental hazards) are discussed.  Social components are well integrated into programming.  Though c o n f l i c t was apparent over leadership roles between one senior (who started the program) and a professional (who believes seniors in the program should be given greater opportunity to p a r t i c i p a t e in program planning and implementation), p a r t i c i p a n t s were s a t i s f i e d with the leadership and program content.  V.  A.  PROGRAM E  DESCRIPTION Program E, the f i r s t health promotion program f o r seniors in  Vancouver started at a downtown community center in 1984.  The l o c a l area  is a diverse s e l f - c o n t a i n e d community which has a population of about 37,000 (Canada Census, 1986) people of which 23% are s e n i o r s .  This area  contains a mix of low to high income f a m i l i e s and s i n g l e r e s i d e n t s . Although t h i s community comprises a v a r i e t y of ethnic groups, 77% are English.  French, German, P o l i s h , Chinese, Spanish and Hungarian make up  12% of the population.  This ethnic mix i s r e p l i c a t e d at Program E. 91%  87  of residents rent, and 99% l i v e in apartments.  One of the important  changes over the l a s t few years has been the demolition of more and more low cost accommodation. The wellness project developed out of the a r e a ' s Seniors Network. Seniors and Vancouver Health Department s t a f f organized a Health F a i r in June 1982 to promote s e l f - c a r e for s e n i o r s .  After the f a i r many seniors  expressed an i n t e r e s t to continue with a program.  Three wellness  workshops funded by the Health Promotion D i r e c t o r a t e , Health and Welfare Canada, were conducted by a wellness consultant between A p r i l 1983 and A p r i l 1984.  A number of i n d i v i d u a l seniors who attended these workshops  became wellness volunteers and with the assistance of Vancouver Health Department s t a f f , the program began. Program E remains a co-sponsored endeavor between the Seniors Network and the Vancouver Health Department. space.  Program E had no funded p o s i t i o n s .  A community center provides A wellness coordinator, a  nurse and a coordinator of volunteers, paid by the Vancouver Health Department, a s s i s t with the ongoing development and running of the program.  A number of wellness volunteers maintain the weekly functioning  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 t a f f member and three Health Department professionals also attend these meetings. The program i s a "a community program of s e l f - h e l p and support by seniors f o r 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. operates Wednesdays 1:00 p.m. - 4:00 p.m, a l l year except f o r August.  It  88  Program components include:  blood pressure checks, one-to-one hands on  relaxation (shoulder and f o o t ) , community resource information, refreshments, a c t i v i t y t a b l e , e x e r c i s e , weekly speaker s e c t i o n , peer counselling and consultation from occupational therapy, physiotherapy, nutrition,  pharmacy and nursing on a r o t a t i n g b a s i s .  Special events take  place throughout the year. The following o f f i c i a l d e f i n i t i o n of Program E was developed by the professionals and volunteers; "wellness i s the maximization of a person's p h y s i c a l , emotional, s o c i a l and s p i r i t u a l well-being both through i n d i v i d u a l e f f o r t and community a c t i o n . "  B.  EMERGING  ISSUES  Program Organization and Process Program organization and process i s the most t y p i c a l theme of t h i s program and addresses issues of s e n i o r / p r o f e s s i o n a l leadership, namely whether seniors u t i l i z e t h e i r own s k i l l s and resources and who i s involved in the running and d e c i s i o n making process of the program.  Although  seniors are encouraged to be involved, the only mechanism e x i s t i n g f o r t h i s i s to be a wellness volunteer.  This e n t i t l e s seniors to p a r t i c i p a t e  in running the program and attendance at the monthly Volunteer Meetings. Here, the majority of the decisions a f f e c t i n g programming are made.  The  meetings are attended by senior volunteers (both of Program E and the l o c a 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 p a r t i c i p a n t s have minimal input into program design and implementation, except through the occasional "brainstorming s e s s i o n " . Senior p a r t i c i p a n t s and volunteers view one senior and one professional as the primary leaders, but the other volunteers are also acknowledged for t h e i r leadership r o l e . run by p r o f e s s i o n a l s .  Planning meetings are generally  One senior volunteer (regarded as the senior  leader) was asked c o n t i n u a l l y for her opinion and the other wellness volunteers were encouraged by professionals to share t h e i r views and p a r t i c i p a t e in the decision making process.  Although volunteers and  professionals a l i k e believe attenders have input into the program, senior p a r t i c i p a n t s interviewed did not perceive t h i s , saying, "although we do make a comment o c c a s i o n a l l y , we don't give input because we are not volunteers." Professionals stated they "would l i k e to see more input from s e n i o r s " and "need more volunteers" to expand the program.  Professionals  noticed that at volunteer meetings "people t r y to r e f e r d e c i s i o n s " to them, but the professionals t r y to take r e s p o n s i b 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 s e n i o r s , predominantly "women."  They come f o r m u l t i p l e reasons, p r i m a r i l y f o r " s o c i a 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 l e a r that some of the  90  attenders do not have any other community involvement except for t h 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 v e longer"; i n d i v i d u a l s " s e t t l e d in t h i s a r e a " ; 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 f o r themselves."  This program also "reaches a l o t of people not involved in  other t h i n g s . " Although "blood pressure" i s viewed by many as a major drawing card e s p e c i a l l y f o r the men, many come f o r the "speaker" s e c t i o n , or "because they see t h i s as a l i n k to the community they don't otherwise have."  The  primary reason f o r 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 c a n ' t get out and get involved with any body or any t h i n g " that don't attend.  Men were viewed as non-attenders because  they are " a f r a i d to be amongst so many women", where "women are in charge" and  that they e i t h e r "tend to withdraw and i s o l a t e " or are "involved in  other t h i n g s . "  Community Issues Community  Involvement.  Program E's philosophy encourages seniors to  p a r t i c i p a t e in the community and partake in "community a c t i o n " .  However,  the focus on these concerns i s " l i m i t e d " to minimal volunteer involvement, the w r i t i n g of an occasional l e t t e r to government about s e n i o r s ' issues  91  and announcements during the program to p a r t i c i p a n t s .  On occasion senior  volunteers have spoken to l o c a l p o l i t i c i a n s about seniors issues. community action i s deemed necessary, t h i s program's  If  perspective i s  represented by the l o c a l Seniors Network. The general p a r t i c i p a n t s hear about community concerns, meetings and events through the occasional announcement ("Seniors in Action Day", "Environmental Action Conferences" and "Housing Forums").  Seniors are  "not pressured" to partake in community action and t h i s they are "pleased about."  Beyond "the one-on-one peer support" that the volunteers and  professionals o f f e r p a r t i c i p a n t s , " t h i s program tends to l i n k i t s e l f as part of the Network" when community action i s necessary, as professionals and senior volunteers " f e e l the larger number speaks volumes in comparison."  "On occasion we (professionals and volunteers) have w r i t t e n  l e t t e r s or a statement", about seniors issues.  Housing.  A "housing c r i s i s " e x i s t e d , which affected t h i s  program's r e s i d e n t s , while t h i s research was conducted.  Housing was  viewed as a major issue by both seniors and p r o f e s s i o n a l s , who f e l t " h e l p l e s s " and without " a l t e r n a t i v e s . " Housing was discussed by speakers and through announcements; also seniors could t a l k on a one-to-one basis with peer counsellor volunteers. "Anxiety" was apparent about the fear of " b u i l d i n g s being demolished" and the " s t r e s s of seniors being evicted not only from t h e i r homes but from t h e i r community."  "Enormous rental r a i s e s " and the s h i f t from rental  accommodation to "unaffordable" condominiums l e f t seniors with the b e l i e f  92  that there were "no a l t e r n a t i v e s . "  They f e l t "discouraged", "harassed"  and " h e l p l e s s . " Professionals and senior volunteers also expressed t h e i r impotence with t h i s matter with statements such a s , "I f e e l harassed, everyone wants housing and I c a n ' 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 l o s t t h e i r enthusiasm."  A pervasive f e e l i n g of helplessness was  apparent during t h i s period.  Out Reach.  Out reach emerged as a theme during the interview  (data  c o l l e c t i o n ) phase and was viewed as an issue only by professionals and senior volunteers.  They envision expansion of the e x i s t i n g program into  other areas of the l o c a l community, although f i n a n c i a l support and manpower are viewed as r e s t r i c t i n g t h i s v i s i o n .  Out reach was not  discussed by p a r t i c i p a n t s .  S o c i a l I n t e r a c t i o n and Support S o c i a l i n t e r a c t i o n and support are of primary concern to the seniors of Program E. this.  S e n i o r s , volunteers and professionals a l i k e acknowledge  Even though some seniors " s i t and stare while waiting for blood  pressures" or may not "make s i g n i f i c a n t r e l a t i o n s h i p s " with others in the program, a l l have an opportunity to i n t e r a c t with other seniors and receive support in a s o c i a l s e t t i n g . Seniors commented that they attend Program E "as much for the s o c i a l i z a t i o n and support as anything e l s e . " friends".  Some stated "we've made new  Others said "you've got someone to t a l k to every week about  93  what ever i s concerning you, l i k e housing  and finances" and that i t i s an  " o u t l e t when you can t a l k about your troubles and, once you're through you know that the senior volunteers keep an eye on you."  P r o f e s s i o n a l s agree  that seniors "can t a l k with people they f e e l are supportive" and even i f "they don't make f r i e n d s they do e s t a b l i s h s i g n i f i c a n t r e l a t i o n s h i p s . " A l l comments c l e a r l y indicate the importance of s o c i a l i n t e r a c t i o n 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 p r i m a r i l y l i f e s t y l e in focus, however  senior peer counsellors also address community issues such as housing, finances and s o c i a l i s o l a t i o n on a one to one basis with s e n i o r s .  The  majority of s o c i a l i n t e r a c t i o n occurs while seniors and senior volunteers are engaged in a program a c t i v i t y . is limited.  Informal s o c i a l i z a t i o n between members  The seating arrangements are not conducive to s o c i a l  i n t e r a c t i o n between members.  On occasion, program leaders (professionals  and senior volunteers) advocate p o l i t i c a l , economic and s t r u c t u r a l changes they believe would enhance seniors p o s i t i o n in s o c i e t y .  Though volunteer  seniors are deeply involved in program planning and implementation t h i s i s l i m i t e d for p a r t i c i p a n t s .  94  CHAPTER 4 PROGRAM FOCUS AND FACTORS CONTRIBUTING TO PROGRAM COMPOSITION This chapter presents a cross a n a l y s i s and i n t e r p r e t a t i o n of data pertaining to program component focus and f a c t o r s c o n t r i b u t i n g to program composition. It  i s claimed that wellness/health promotion programs have tended to  focus p r i m a r i l y on i n d i v i d u a l behavioural f a c t o r s such as; personal health a t t i t u d e s , management of chronic i l l n e s s , d i e t , e x e r c i s e , s t r e s s management, personal support systems and personal community awareness and participation.  Minimal focus has been placed on those p o l i t i c a l , economic  and organizational f a c t o r s which keep seniors impoverished, s o c i a l l y i s o l a t e d and disadvantaged (Health Services & Promotion Branch, 1986; Minkler & Pasick, 1986).  The section below, PROGRAM COMPONENT FOCUS,  presents data that supports t h i s c l a i m .  Also the s i m i l a r i t i e s and  v a r i a t i o n s of program focus among the programs studied are presented.. Then the s e c t i o n , 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 v a r i a t i o n s of these f a c t o r s among the programs studied are presented.  95  I.  PROGRAM FOCUS  In order to promote health and implement a w e l l n e s s / h e a l t h promotion approach, Health Promotion Programs f o r 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 section analyzes the extent to which  Individual behavioural change and Underlying community change components are included in the programs studied.  In p a r t i c u l a r , i t e s t a b l i s h e s that  the components across a l l programs are predominantly focused on i n d i v i d u a l behavioural change.  It also presents the s i m i l a r i t i e s and v a r i a t i o n s of  program components among the programs.  96 TABLE 2 INDIVIDUAL BEHAVIOURAL CHANGE COMPONENTS PROGRAMS C D  A  B  PERSONAL SUPPORT SYSTEMS e . g . s o c i a l a c t i v i t y , luncheon, refreshment break, summer t r i p s  X  X  X  X  X  EXERCISE e . g . yoga, modified aerobics, dance  X  X  X  X  X  PERSONAL HEALTH ATTITUDES e . g . health related discussion  X  X  X  X  X  NUTRITION e . g . health related d i s c u s s i o n , weight checks  X  X  X  X  X  STRESS MANAGEMENT e . g . massage, r e l a x a t i o n , coping s k i l l development  X  SELF MANAGEMENT OF CHRONIC HEALTH CONDITIONS e . g . through health related sharing and d i s c u s s i o n , blood pressure monitoring, weight checks  X  X  X  X  X  PERSONAL SENSE OF PURPOSE e . g . volunteering, p a r t i c i p a t i o n in decision making, community projects  X  X  X  X  X  PERSONAL ENVIRONMENTAL AWARENESS AND PARTICIPATION e . g . summer t r i p s , discussion of environmental awareness, community p r o j e c t s , volunteering  X  X  X  E  X  X  X  X  97  TABLE 3 ENVIRONMENTAL AND COMMUNITY CHANGE COMPONENTS  A  PROGRAMS B C  COMMUNITY PROBLEMS e . g . housing, out reach transportation  D  E  X  X  COMMUNITY SUPPORT e . g . information sharing and referral SOCIAL ISSUES e . g . ageism ORGANIZATIONAL CONTROL  X  POLITICAL ACTION e . g . seniors issues  X  ECONOMIC e . g . poverty, program funding ENVIRONMENTAL HAZARDS e . g . crime, a r c h i t e c t u r a l b a r r i e r s , environmental concerns  A.  INDIVIDUAL BEHAVIOURAL CHANGE COMPONENTS  ' I n d i v i d u a l behavioural change components' are defined to include programming that focuses upon personal health a t t i t u d e s , self-management of chronic c o n d i t i o n s , n u t r i t i o n , e x e r c i s e , s t r e s s management, personal sense of purpose, personal support systems and personal environmental awareness and p a r t i c i p a t i o n . The welcoming, f r i e n d l y 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 f o r s o c i a l i n t e r a c t i o n and support amongst members, volunteers and p r o f e s s i o n a l s .  98  Exercise, run by senior volunteers (with the exception of Program A) i s an integral part of a l l the programs.  A p o s i t i v e image of senior  involvement in exercise i s presented which helps to d i s p e l ageist b e l i e f s commonly held by professionals and seniors about exercise and aging. Blood pressure monitoring, and health related d i s c u s s i o n which speak to personal health a t t i t u d e s , n u t r i t i o n ,  s t r e s s management and s e l f  management of chronic conditions are addressed by a l l the programs. S p e c i f i c s t r e s s management techniques are offered by a l l but one program (Program C) in the form of massage and r e l a x a t i o n exercises (Programs B, D, E) or coping s k i l l development (Program A ) . Senior volunteer p o s i t i o n s , which are a v a i l a b l e in a l l programs, provide an avenue f o r seniors to draw upon t h e i r own resources and engage in meaningful a c t i v i t y f o r others, thereby addressing personal sense of meaning. Some p a r t i c u l a r v a r i a t i o n s in programming are noteworthy.  The more  established 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 i n d i v i d u a l support systems and personal environmental awareness and p a r t i c i p a t i o n .  In p a r t i c u l a r Program E i s the  only one to o f f e r information, support and r e f e r r a l through the provision of peer c o u n s e l l i n g and a v a i l a b l e brochures.  Peer c o u n s e l l i n g i s a  s p e c i a l i z e d form of s o c i a l support which denotes intervention from a volunteer who i s a non-professional.  Rather than being formally trained  in c o u n s e l l i n g , peers o f f e r support through the depth of t h e 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 f e r a luncheon program.  Here, a  s o c i a l context for eating i s provided f o r those seniors who may have  99  apathy towards food, thereby addressing not only s o c i a l support but an underlying environmental cause of poor n u t r i t i o n in the senior population. Both Program E and B conduct projects and organize summer t r i p s which provide opportunity f o r the development of personal support systems and encourage personal environmental awareness and p a r t i c i p a t i o n . Two smaller programs (Program A and D) use i n t e r a c t i v e discussion groups to address issues of personal support, personal sense of purpose, personal health issues, and personal environmental awareness and p a r t i c i p a t i o n . Here, the professionals act as f a c i l i t a t o r s encouraging and supporting the p a r t i c i p a t i o n of a l l members in c o l l e c t i v e decision making and discussion of health related t o p i c s of i n t e r e s t s .  Program A f u r t h e r employs  p a r t i c i p a t o r y discussion to share ideas on stress management and s e 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 p a r t i c i p a t i o n 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  organizational f a c t o r s that a f f e c t promotion of immediate i n d i v i d u a l behavioural change components for example through the a v a i l a b i l i t y of community supports, s e l f - h e l p groups, out reach s e r v i c e s , information networks, and by addressing s o c i a l and economic f a c t o r s such as s o c i a 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 i n d i v i d u a l health behaviour with broader e f f o r t s aimed at helping seniors bring about changes in t h e i r environment.  It  i s i n t e r e s t i n g to note that t h i s i s the only program that  does not s e r v i c e a p a r t i c u l a r community.  It  i s located in the downtown  business core and the majority of i t ' s members t r a v e l from other l o c a l 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 s e r v i c e s 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 f o r t and on which elements, they focus. Some concentrate more on immediate community problems, while others focus on broader economic and s o c i a l issues such as s o c i a 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 a c t i o n . The housing c r i s i s was an immediate community issue in c e r t a i n 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 m u l t i p l e resident dwellings and apartments were being  demolished and replaced by expensive duplex and quadruplex condominiums leaving many seniors concerned about tax and rental increases, e v i c t i o n , and lack of affordable a l t e r n a t i v e s .  Two programs (A and D) shared ideas  on methods and avenues f o r community action through group d i s c u s s i o n . None of these programs took group a c t i o n , though seniors were encouraged to do so by the professionals who led the d i s c u s s i o n s .  Program E on the  other hand, has, on occasion, responded to s o c i a l and economic issues a f f e c t i n g s e n i o r s , but usually i t  l i n k s i t s e l f to a Seniors Network when  101  community action i s necessary.  Program E, peer counselors provide  information and r e f e r r a l on a one-to-one basis for seniors concerned about s p e c i f i c housing i s s u e s , however the focus i s on i n d i v i d u a l adaptation rather than community change. The s o c i a l support a v a i l a b l e to those who attend these programs i s not n e c e s s a r i l y a c c e s s i b l e to many i s o l a t e d seniors who need support to venture out, or who l i v e too f a r away and have no means of t r a n s p o r t a t i o n . 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 r e l a x a t i o n in a seniors b u i l d i n g in t h e i r l o c a l area. Seniors at Program A t r i e d unsuccessfully to acquire funding for t h i s purpose.  Though i n i t i a l l y e n t h u s i a s t i c to investigate the needs of  i s o l a t e d seniors in t h e i r area, t h i s group gave up a f t e r 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 t h e i r community but stated they needed funding and additional manpower to implement t h i s s u c c e s s f u l l y . The only program to address economic f a c t o r s that e f f e c t the promotion of i n d i v i d u a l 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 .  Also,  senior volunteers have been known to p a r t i c i p a t e in community action through l e t t e r s and d i r e c t dialogue with l o c a l p o l i t i c i a n s . P o t e n t i a l l y , senior p a r t i c i p a t i o n in formal and informal organizational structures provides a mechanism to address ageism. Ageism i s a presumption held by many professionals that older people have less to o f f e r as they age.  In f a c 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 ' l i p service' to senior input, while others (professionals involved with Program B) foster and encourage senior input at a l l 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 diseaseoriented 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 managed, and on the patterns and rationale for attendance.  and  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 contribute to program composition.  The emerging issues are addressed  under the f o l l o w i n g headings: Program organization and process (wellness/health promotion approach, organization and process) Program attendance patterns and r a t i o n a l e (attendance, s o c i a l i n t e r a c t i o n 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 influences program composition.  The  organizational structures of programs are expected to be based on a wellness/health promotion approach which highly values process in the form of s e n i o r s ' p a r t i c i p a t i o n , s e n i o r s ' empowerment and partnership between seniors and p r o f e s s i o n a l s . t h i s opportunity:  Three s t r u c t u r a l  l e v e l s among programs provide  as a general p a r t i c i p a n t in general planning meetings;  as a volunteer s t a f f member in formal and informal committees; and as a member of a seniors advisory board.  This section shows how the program  composition and v a r i a t i o n among the programs studied are influenced by: 1) 2)  the a p p l i c a t i o n of a wellness/health promotion approach; varying degrees of structure within the programs;  3)  the roles of seniors and p r o f e s s i o n a l s ;  4)  funding;  5)  and the h i s t o r i c a l development of w e l l n e s s / health promotion  programs f o r seniors in Vancouver.  104  A p p l i c a t i o n of a Wellness/Health Promotion Approach Seniors' p a r t i c i p a t i o n , s e n i o r s ' empowerment and partnership between seniors and p r o f e s s i o n a l s are i d e n t i f i e d as elements of the organization and process of wellness/health promotion programs in 'A Framework f o r Health Promotion: Older A d u l t s ' a d r a f 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 objectives of t h i s document which f o l l o w : "OBJECTIVES:  It  i s necessary to mobilize and coordinate community  resources, ( i n c l u d i n g Health Department resources), to accomplish the objectives of: 1)  d i s p e l l i n g the myths commonly associated with aging;  2)  enabling older adults to develop and/ or maintain p h y s i c a l ,  mental and s o c i a l well-being and autonomy;and 3)  encouraging and supporting older adults to draw upon t h e i r own  resources and take control of t h e i r own health promotion programming. In t h i s approach older people are p a r t i c i p a n t s in a dialogue with the health professional who presents ideas for consideration.  The  community group and the professional exchange t h e i r views on h e a l t h , allowing them to learn from each other while valuing t h e i r separate experiences and knowledge.  By including older people as partners in the  planning, development and implementation of programs, the process also provides opportunities f o r meaningful a c t i v i t y which increases the older  105  person's sense of c o n t r o l , t h e i r f e e l i n g s of effectiveness and t h e i r contacts with other people." However, in order f o r t h i s approach to be implemented seniors must be a c t i v e l y involved at a l l planning and s t a f f i n g l e v e l s .  The value and  implementation of senior p a r t i c i p a t i o n in volunteer s t a f f , committee and advisory board p o s i t i o n s w i l l be discussed l a t e r in t h i s section (Varying Degrees of S t r u c t u r e ) .  Here, the p a r t i c i p a t i o n of general senior members  i s discussed. Program B, i s the only program which has a system whereby general p a r t i c i p a n t s , 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 o r g a n i z a t i o n . This occurs at general planning sessions h e l d , when necessary, during weekly announcement periods.  One senior put t h i s w e l l , " d i f f e r e n t  seniors  form a group of people who run the speaker section 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 t h i n k . " Three programs have general member p a r t i c i p a t i o n which i s l i m i t e d to one program component, the speaker or discussion s e c t i o n .  Program E  involves p a r t i c i p a n t s in brainstorming discussion t o p i c s however, t h i s i s l i m i t e d to a yearly occurrence.  Programs A and D use group decision  making to formulate agendas f o r upcoming discussion groups.  In a very  informal atmosphere, both seniors and professionals present ideas for c o n s i d e r a t i o n , and consolidate planning. A number of seniors interviewed indicated they were not given adequate opportunity to p a r t i c i p a t e in program planning and decision  106  making unless involved at the volunteer l e v e l .  The f o l l o w i n g comments  support t h i s perspective: - "We make suggestions to professionals l i k e what t o p i c s we want to t a l k about, but as f a r as running the group we don't have any say "(Program A ) . -"I  S i m i l a r comments are made about Program E.  don't know who gets them(the speakers), I never get asked."  (Program C ) .  In t h i s program, no mechanism e x i s t s for input about  programming by senior members at a l l . -"Although we do pass a comment o c c a s i o n a l l y , we don't get asked (for input) because we are not v o l u n t e e r s . " (Program E ) . F i n a l l y , one other response should be noted.  Some seniors were  reluctant and lacked motivation to p a r t i c i p a t e in the decision 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 ) ,  articulate  t h i s point of view. Although professionals claim to support senior d i r e c t i o n and control of wellness/health promotion programs, the present lack of organizational structures (with the exception of Program B ) , l i m i t s t h i s process p a r t i c u l a r l y at the general p a r t i c i p a n t  level.  Varying Degrees of Structure The extent to which seniors are valued and p a r t i c i p a t e at the volunteer s t a f f , committee and advisory board member l e v e l s , d i f f e r s among programs.  Table 4 i s a schematic representation of the l e v e l s of  structure among programs.  107 TABLE 4 VARYING DEGREES OF PROGRAM STRUCTURE  A P a r t i c i p a n t planning meetings  B  PROGRAMS C D  health X topics only  Volunteer s t a f f meetings  X  Program Planning meetings Professionals and Seniors  X  Seniors Advisory Board meetings  X  health topics only  E  1x/ year  X X  X  X  Of the f i v e programs, Program E has the greatest degree of structure.  At the time of the study, t h i s program was characterized by  c l e a r formalized p o s i t i o n s and l i n e s of a u t h o r i t y .  These include: monthly  meetings which r e g u l a r l y include senior volunteers, Seniors Network representatives, Health Department s t a f f (wellness coordinator, volunteer services c o o r d i n a t o r ) , and community center program coordinator; a w r i t t e n agenda and minutes; and o f f i c e 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 p a r t i c i p a t i o n i s highly valued.  A l i m i t a t i o n however,  i s that general p a r t i c i p a n t s are not v i s i b l y involved i n program planning and d e c i s i o n 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 organizational structure i s s i m i l a r to Program A, but on a smaller s c a l e .  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 d e c i s i o n making.  The  same strengths and l i m i t a t i o n s apply as with Program E with the additional l i m i t a t i o n that input from senior volunteers was observed to be undervalued by p r o f e s s i o n a l s . In terms of s t r u c t u r e , committee and volunteer s t a f f members in Program B shun the notion of h i e r a r c h i e s and appear to avoid behaviours which may i n f e r formality or bureaucracy.  A l l seniors who attend are  involved in some capacity in the ongoing planning, decision making and s t a f f i n g 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 t h i s w e 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 t h i s and t h a t .  The leader keeps everything in order and keeps a l i n k  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 t h e i r community.  The corresponding l i m i t a t i o n s of such a loose  structure might include some d i s o r g a n i z a t i o n . Programs A and D could be described as l y i n g between the Program E and Program B in terms of t h e i r organizational s t r u c t u r e .  Seniors, in  partnership with p r o f e s s i o n a l s , are highly involved in planning the speaker section of these programs.  No other organizational  structure  e x i s t s in Program D, so there i s no forum f o r senior or professional p a r t i c i p a t i o n in other aspects of program development and implementation.  109  In Program A, other structures do e x i s t but permit l i m i t e d input from seniors.  For example, a S e n i o r s ' Advisory Committee was formed to act as  a consulting body on s e n i o r s ' needs in t h i s community, but t h i s body (predominantly p r o f e s s i o n a l s ) does not permit seniors who are regarded as experts to p a r t i c i p a t e .  Also a Professional Committee of the community  center in which t h i s program i s housed, was instrumental in vetoing a proposal for senior out reach programming developed by seniors in the program.  Overall the lack of p a r t i c i p a t o r y organizational structure  in  Programs A and D l i m i t s senior p a r t i c i p a t i o n in program planning and decision making a n d . c u r t a i l s any responsiveness to emerging seniors issues.  The Roles of Seniors and P r o f e s s i o n a l s In a w e l l n e s s / h e a l t h promotion approach, professionals hold up a mirror to the group so that seniors can see t h e i r health issues and decide which ones they want to address.  Seniors become partners with  professionals in the decision making process and, f u r t h e r , play a role in the planning, development and implementation of programs.  In order for  t h i s process to work e f f e c t i v e l y , regular and open communication must be maintained between general p a r t i c i p a n t s , front l i n e volunteer s t a f f and those responsible f o r planning and o r g a n i z a t i o n .  Mechanisms for program  r e c i p i e n t feedback are e s s e n t i a l i f seniors issues are to be adequately i d e n t i f i e d and addressed (see Table 4, p. 105). Program B i s the only program which provides opportunity f o r regular open communication about a l l aspects of programming between the general p a r t i c i p a n t s and those responsible for planning.  P r o f e s s i o n a l s 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 seniors) can run t h e i r own show."  (the  Here, seniors use professionals  p r i m a r i l y as resources and consultants.  The seniors function in two  r o l e s , as volunteer s t a f f and as p a r t i c i p a n t s .  It should be noted that  one senior i s a paid member of the Seniors Network with which t h 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 e x e r c i s e , massage, t a l k s or other jobs l i k e r e g i s t r a t i o n , or putting out the c h a i r s and preparing refreshments."  Those not involved in t h i s way are given the  opportunity  to p a r t i c i p a t e in program planning. Two of the smaller programs (A and D) have regular open communication between professionals and p a r t i c i p a n t s , but only in respect to decision making about the speaker/discussion s e c t i o n . Program A had no designated volunteer p o s i t i o n s though some seniors organize c h a i r set-up, s i g n - i n sheets and refreshments on a regular b a s i s . One community center s t a f f organizes the exercise i n s t r u c t o r ,  and the  wellness coordinator conducts blood pressure checks and f a c i l i t a t e s speaker/discussion s e c t i o n .  the  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 t a f f stepped in and organized i t f o r them.  This h i g h l i g h t s the d i f f e r e n t  approaches that professionals  involved with t h i s program hold. Program D have three senior volunteers who conduct e x e r c i s e , massage and blood pressure checks.  Neither professional nor s e n i o r - p a r t i c i p a n t s  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 r e s p o n s i b i l i t i e s are not c l e a r l y delineated here and t h i s r e s u l t s in role c o n f l i c t and confusion between the professional and one senior volunteer. Program E and C receive l i m i t e d input from p a r t i c i p a n t s unless seniors make i n d i v i d u a l comments.  In the case of Program E, however,  f r o n t l i n e volunteers work with professionals on program planning and organization.  Also two members of the seniors network, by whom t h i s  program i s sponsored, attend these meetings. volunteers run a l l program a c t i v i t i e s .  Some f i f t e e n senior  Senior p a r t i c i p a n t s on occasion  make comments about programming on a one-to-one basis to the senior volunteers.  Approximately once a year, senior p a r t i c i p a n t s 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 r y  to refer decisions to us (the p r o f e s s i o n a l s ) but we attempt to turn issues and decisions back to the group." Program C has four senior volunteers whose roles are to run e x e r c i s e , blood pressure checks and man the r e g i s t r a t i o n desk.  No  attempts are made to ask for more volunteers to p a r t i c i p a t e , 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 a u t o c r a t i c .  They run a l l  meetings and tend to make the decisions about programming with minimal input from the senior volunteers who attend yet these professionals advocate f o r increased senior leadership.  112  Program Funding  This section discusses how people in each program perceive funding questions and how funding i s seen to influence program composition. In general seniors at each center have l i m i t e d knowledge of funding issues.  Only one or two senior volunteers were able to a r t i c u l a t e the  funding needs and problems f o r t h e i r program.  However, a number of  s e n i o r s , though they knew nothing about t h i s area, stated they could "use more funds f o r program expansion (Program A and E ) . "  It was the  professionals who demonstrated the most intimate knowledge of funding concerns related to t h e i r programs. Table 5 i s a schematic representation of the program funding sources for space, manpower, equipment and miscellaneous c o s t s .  113 TABLE 5 THE PROGRAM FUNDING SOURCES SPACE, EQUIPMENT, MISCELLANEOUS SUPPLIES, MANPOWER PROGRAMS C D  A  B  SPACE  CC  HD  SC  CC  CC  EQUIPMENT  CC  HD  SC  CC  CC/ SP  MISCELLANEOUS SUPPLIES e . g . refreshments  SP  SP  SC  SP  SP  CC/ HD  HD  HD/ SC  HD/ CC  HD/ CC  SP  SP/ SN  SP  SP  SP/ SN  PROFESSIONAL STAFF VOLUNTEERS  CC SC HD SN SP  -  E  Community Centre Seniors Centre Health Department Seniors Network Senior P a r t i c i p a n t s  Several community organizations supply free space, use of equipment, and s t a f f hours but the primary funding source i s the Vancouver Health Department which supplies space, equipment (Program B) and s t a f f (wellness coordinators) to a l l programs; a volunteer coordinator and a nurse f o r Program B; and a volunteer and a nurse for Program E. out of l o c a l community centers.  Three programs run  In the case of Program A, space i s free  and a community center s t a f f member a l l o c a t e s time to the program because h i s p o s i t i o n involves senior program planning.  Program C, which operates  from a seniors center, i s one of many s e n i o r s ' programs f o r which the r e s p o n s i b i l i t y l i e s with the c e n t e r ' 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 f i r s t 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 s e l f - c a r e program for s e n i o r s , t h i s professional worked with a seniors network s o c i e t y , i n proposing a wellness project to the Health Promotion Directorate of Health and Welfare, Canada.  The  project was funded i n 1983 and was based somewhat on the Wallingford Wellness Project in S e a t t l e , Washington and the Growing Younger Program in Boise, Idaho.  It  i s important to note that both these programs focus  p r i m a r i l y on i n d i v i d u a l behavioural change (Dychtwald, 1986). A weekly program which developed into the e x i s t i n g program (E) began with the following components; blood pressure checks, health nurse c o n s u l t a t i o n , exercise and a health related presentation.  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 i d e n t i c a l components to those of the f i r s t health d r o p - i n . Program composition among a l l the programs studied have changed l i t t l e in the l a s t s i x years since the inception of Program E, c l e a r l y i d e n t i f y i n g the strong influence of h i s t o r i c a l f a c t o r s on present program composition.  SUMMARY  As has been shown program composition i s influenced by multiple h i s t o r i c a l , t h e o r e t i c a l and organizational f a c t o r s . combined these elements in various ways.  Each program has  A wellness/health promotion  approach i s r e f l e c t e d to varying degrees depending on how thoroughly seniors and professionals embrace the underlying p r i n c i p l e s of health promotion as outlined by the health department (Martin, Robertson & Altman, 1988).  Only one program (B) c a r r i e s t h i s out in a s i g n i f i c a n t  116  manner.  The degree of organizational structure has been shown to  reflect  a continuum where l i m i t a t i o n or f a c i l i t a t i o n of senior p a r t i c i p a t i o n , d i r e c t i o n and control e x i s t s .  Organizational safeguards which ensure  senior involvement at the p a r t i c i p a n t member l e v e l are l i m i t e d , fundamentally, to one program.  Role v a r i a t i o n 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 e v e l s .  The impact of the h i s t o r i c a l development on  these wellness/health promotion programs f o r seniors appears to maintain a focus on i n d i v i d u a l 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 i m i t s program expansion.  The  differences and s i m i l a r i t i e s among programs h i g h l i g h t how the program organization and process heavily influence program composition.  B.  PROGRAM ATTENDANCE  RATIONALE  AND  PATTERNS  S o c i a l i n t e r a c t i o n and support are i d e n t i f i e d by seniors and professionals as the primary reasons for s e n i o r s ' attendance at wellness/health promotion programs.  However, the number of s o c i a l  components v a r i e s greatly from program to program. patterns between men and women d i f f e r markedly.  A l s o , the attendance  In t h i s section i t  is  shown how the r a t i o n a l e for program attendance and the d i f f e r i n g attendance patterns between men and women in varying ways among the programs studied.  influence program composition  117  Program Attendance Rationale Loneliness and i s o l a t i o n are key issues for the senior population. Approximately 10% of seniors l i v i n g in the l o c a l areas studied are not l i v i n g in f a m i l i e s , and 45% l i v e alone (Canada Census, 1986).  Based on  discussion with seniors and professionals from a l l the programs studied, the consensus was that s o c i a l i n t e r a c t i o n and support i s a key element to health and w e l l - b e i n g , and the prime reason for attendance.  This need  influences program composition in d i f f e r e n t ways. At Programs A, B and D seniors a r r i v e e a r l y 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 u n t i l 1:00 p.m.  As Program E  provides no seating for those l i n i n g up outside, t h i s i s nonconducive to s o c i a l i n t e r a c t i o n .  viewed as  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 s o c i a l i z a t i o n once the program i s in process.  In c o n t r a s t , Program B conducts many  a c t i v i t i e s ( r e g i s t e r i n g , waiting f o r massages and blood pressure checks) in small groups and the seating arrangements ( i n small groups) are very conducive to s o c i a l i n t e r a c t i o n . Program A and D o f f e r s a refreshment break following e x e r c i s e .  This  allows seniors to mingle and chat f o r approximately f i f t e e n minutes p r i o r to the h e a l t h - r e l a t e d discussion component. Program B, i s the only program to o f f e r a lunch component.  Here  seniors s i t together f o r approximately half an hour and "shoot the breeze" while e a t i n g , p r i o r to the discussion s e c t i o n .  One senior leader  118  mentioned "many people who stay f o r t h i s l i v e alone and appreciate the opportunity to eat with o t h e r s . " A l l programs have senior volunteers who o f f e r d i f f e r i n g degrees of s o c i a l support to those who attend.  Seniors from a l l programs commented  that these i n d i v i d u a l s create a " f r i e n d l y , welcoming environment" that i s conducive to s o c i a l i n t e r a c t i o n .  For example, at Program C, seniors and  professionals believe that i f the exercise i n s t r u c t o r was to leave, attendance would drop markedly.  This senior takes the f i r s t  fifteen  minutes to chat with p a r t i c i p a n t s p r i o r to commencing e x e r c i s e s . program, no other provision for s o c i a l i n t e r a c t i o n i s made. the only program to provide peer c o u n s e l l o r s , who o f f e r  At t h i s  Program E i s  support,  information and r e f e r r a l on issues of bereavement, housing, f i n a n c e s , 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 i n d i v i d u a l s to t a l k with about problems has impacted on t h e i r l i v e s in very s i g n i f i c a n t ways. Although s o c i a l f a c t o r s have had an influence on program composition to some degree in some of the programs studied, most programs have paid l i t t l e a t t e n t i o n to the importance of a c t i v i t i e s that address the s o c i a l needs of s e n i o r s .  Program Attendance Patterns According to 1986 census data, women and men are s t i l l equal in number, up to age 50.  approximately  However, between 65 and 74, there are only  77 men to every 100 women; then between ages 75 and 84, the r a t i o drops to 50 men per 100 women; and among those aged 85 and o l d e r , there are only 44 men per 100 women.  As wellness/health promotion programs for seniors  119  predominantly address the 65 to 84 age group, where the r a t i o i s 63 men per 100 women, i t would be a n t i c i p a t e d that program composition among the programs s t u d i e d , would  r e f l e c t the needs of both gender groups.  This i s  not the case and a number of f a c t o r s 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 p a r t i c i p a n t s 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 r e c l u s i v e , " and " f e e l by large q u a n t i t i e s of women."  intimidated  Many seniors believe "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. blood pressure checks.  The component most attended by males i s  O c c a s i o n a l l y , men attend the discussion section  and, in the case of Program E, men do meet with peer c o u n s e l l o r s , though i t i s f e l t that more men would use t h i s s e r v i c e i f one of the counsellors was male.  Program A, i s the only program where the men p a r t i c i p a t e in a l l  program components. Also of i n t e r e s t , was Program C, where men come f o r blood pressure checks and then play ping-pong on a table set up j u s t around the corner from the open area where the program takes place. A number of men in Program B p a r t i c i p a t e as volunteers in the organization and s t a f f i n g of the program.  It  is  i n t e r e s t i n g that the  senior leader i s male and a t h i r d 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 p o s i t i o n s of i n f l u e n c e , and even i n 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 s o c i a l f a c t o r s are i d e n t i f i e d as the primary reason for program attendance, on the whole components which address s o c i a l i n t e r a c t i o n and support are given l i m i t e d recognition and support. Although some programs have established new components which f o s t e r s o c i a l i z a t i o n and provide support mechanisms to senior p a r t i c i p a n t s , others continue without recognizing the s i g n i f i c a n c e of t h i s need.  identified  Program composition does not to appear r e f l e c 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 v a l i d to focus on the i d e n t i f i e d 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  intimidating  number of women, i t may be important to explore men's health promotion needs f u r t h e r .  121  CHAPTER FIVE CONCLUSIONS AND RECOMMENDATIONS The purpose of t h i s chapter i s to l i n k the t h e o r e t i c a l concepts emerging from the findings of t h i s ethnographic research on health promotion programs for seniors with  e x i s t i n g theory and l i t e r a t u r e .  The  research questions are addressed, the l i m i t a t i o n s of t h i s project are discussed and the implications f o r future research are o u t l i n e d .  Finally,  p r a c t i c a l recommendations f o r future program focus and organization are discussed.  I.  THEORETICAL IMPLICATIONS OF THE STUDY  This study explores the concept of health promotion as i t relates to the program focus and organization of f i v e health promotion programs f o r 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 o r g a n i z a t i o n a l , p o l i t i c a l and economic interventions 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 i s one that enables people "to increase control over and to improve t h e i r health" (World Health Organization, 1986). Because health promotion i s a multifaceted strategy i t i s not s u r p r i s i n g that many t h e o r e t i c a l concepts emerged as the data and a n a l y t i c categories were developed and reviewed.  Individual behaviour change and  Environmental and community change components were used as a n a l y t i c categories as received support from the data and l i t e r a t u r e on health promotion.  Personal autonomy and control which were i d e n t i f i e d  in  122  documentary data were made reference to by seniors and coordinators.  As  the study progressed v i c t i m blaming, empowerment and learned helplessness emerged as relevant concepts to the research data.  A l s o , because the  promotion of senior involvement in program process and organization i s a r t i c u l a t e d as an objective of these health promotion programs, and because organizational goals are a facet of organizational behaviour, organization theory i s relevant to t h i s study.  A.  RESEARCH QUESTIONS  The research questions posed by t h i s study are restated, followed by a b r i e f d e s c r i p t i o n of the f i n d i n g s , which are then linked to theory and l i t e r a t u r e .  pertinent  As there are m u l t i p l e l e v e l s of influence on  health promotion programs these are divided into three i n c l u d i n g ; macrol e v e l influences w i t h i n the larger s o c i e t y , meso-level influences at the organizational l e v e l , and m i c r o - l e v e l influences at the i n d i v i d u a l  level.  Questions 1 and 2 are discussed together and address how macro and microlevel influences impact on health promotion program focus.  Question 3  discusses the impact of macro, meso and m i c r o - l e v e l influences on program organization and composition. QUESTION 1:  What i s the focus of the program components?  QUESTION 2:  Does the p r o f i l e of program components vary among  health promotion programs? D e t a i l s of the focus and v a r i a t i o n of program components are described in chapters three and four.  A l l programs o f f e r 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 a n a l y t i c categories of Individual Behavioural and underlying Environmental and Community Change  123  Components.  A l l f i v e programs concentrate predominantly on Individual  Behavioural Change Components which focus upon personal support systems, e x e r c i s e , personal health a t t i t u d e s , n u t r i t i o n , s t r e s s management, s e l f management of chronic health c o n d i t i o n s , personal sense of purpose and personal environmental awareness and p a r t i c i p a t i o n .  L i t t l e variation  e x i s t s among programs in respect to the a c t i v i t i e s offered to address these s p e c i f i c components although a broader array of a c t i v i t i e s  is  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 organizational f a c t o r s that a f f e c t the promotion of immediate i n d i v i d u a l behavioural change.  Although a l l f i v e programs provide mechanisms for  senior volunteers to p a r t i c i p a t e in program planning and d e c i s i o n making, there i s marked v a r i a t i o n in ' r e a l ' involvement by seniors among programs. Organizational f a c t o r s are discussed when question 3 i s addressed. Fundamentally, programming which addresses environmental f a c t o r s i s l i m i t e d to one-to-one and/or group discussion which r e s u l t s in minimal action f o r 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 p r o f e s s i o n a l s .  Senior  volunteers from another program support t h e i r sponsors to take p o l i t i c a l a c t i o n in the form of l e t t e r w r i t i n g and discussion with p o l i t i c i a n s , when relevant s e n i o r s ' issues a r i s e . themselves.  However, rarely do they take t h i s action  Two programs address ageism by encouraging professionals and  non-professionals to v i s i t t h e i r programs and see how seniors f u n c t i o n , however, they appear to be preaching to the converted.  C l e a r l y , such  underlying causes of s t r e s s for seniors in these communities as s o c i a l  124  i s o l a t i o n , housing, ageism, transportation and poverty, though acknowledged, are given only s u p e r f i c i a l  attention.  The l i t e r a t u r e on health promotion claims programs focus predominantly on i n d i v i d u a l behaviour change e f f o r t s (Minkler & Pasick, 1986; Labonte, 1988; Smith, 1988).  Many authors have expressed concern  that although r h e t o r i c l e g i t i m i z e s the idea of developing health promotion programs w i t h i n 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 i n d i v i d u a l r e s p o n s i b i l i t y f o r lifestyle.  Though the t h e o r e t i c a l basis of the programs studied i s "a  socioecological model of health which recognizes the  interrelationship  between s o c i a l and environmental f a c t o r s and defines health as encompassing the p h y s i c a l , mental, s o c i a l and personal domains," (Martin, Robertson & Altman, 1988) the s o c i a l and environmental f a c t o r s are given l i t t l e recognition and e f f o r t . This focus on the i n d i v i d u a l without an equal emphasis on the s o c i o s t r u c t u r a l bases of health has led to much c r i t i c i s m of health promotion by authors who believe the proponents of  individually-oriented  behaviour change s t r a t e g i e s support a victim-blaming ideology (Becker, 1986; Crawford, 1979; E p s t e i n , 1985; Guidotti,1989; Kickbusch, 1989; Minkler & Pasick, 1986; Tesh, 1981). Ryan (1970), applied t h i s process to North American s o c i a l problems i n h i s book "Blaming the V i c t i m " .  In b r i e f , the steps involved in blaming  the v i c t i m are; (a) i d e n t i f y i n g a s o c i a l problem; (b) studying those most immediately affected by t h i s problem and i d e n t i f y i n g how they are d i f f e r e n t from the rest of the population; (c) d e f i n i n g the differences as the cause of the s o c i a l problem; and (d) assigning bureaucrats to develop  125  "humanitarian action programs" that w i l l "correct the d i f f e r e n c e s " (Ryan, 1970, p. 7).  If these steps are applied to the high cost of i l l n e s s care,  the v i c t i m blamed i s the i n d i v i d u a l s u f f e r i n g from a chronic i l l n e s s or the aging process.  Using Ryan's model, the following scenario i s an  example of how i n d i v i d u a l s can be blamed for t h e i r health problems: (a)  A  s o c i a l problem which i s recognized as requiring a t t e n t i o n in our society today, i s the high cost of i l l n e s s care; (b) as most immediately affected by i l l  Those i n d i v i d u a l s  identified  health are people who smoke, lack  regular e x e r c i s e , have poor n u t r i t i o n a l habits and do not manage t h e i r stress effectively;  (c)  It  i s p r i m a r i l y those i n d i v i d u a l s who do not  p r a c t i c e responsible health and l i f e s t y l e s t r a t e g i e s who become i l l and require i l l n e s s care; (d)  Therefore, the  provision of  lifestyle-oriented  health promotion programming could p o t e n t i a l l y a l l e v i a t e t h i s s o c i e t a l problem. Ryan noted that present-day v i c t i m blaming i s very d i f f e r e n t from the "open prejudice and reactionary t a c t i c s " of e a r l i e r times, 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 scientism (and) i s obscured by a perfumed haze of humanitarianism" (2, p. 7).  Health promotion targeted to the i n d i v i d u a l  f i t s t h i s scenario form many i n d i v i d u a l s .  While basic e f f o r t s at problem  s o l v i n g the possible underlying causes of i l l health require major s o c i o s t r u c t u r a l , p o l i t i c a l and economic arrangements, the v i c t i m blaming ideology encourages f a r more narrow s t r a t e g i e s which in turn develop more l i m i t e d i n d i v i d u a l l y - o r i e n t e d programs and p o l i c i e s .  126  In agreement w i t h 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 t h o s e who  advocate i n d i v i d u a l l y - o r i e n t e d programs s u p p o r t v i c t i m  blaming which " s e r v e s as a l e g i t i m i z a t i o n f o r t h e 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 t h e s o c i a l c a u s a t i o n o f d i s e a s e 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 o f s o c i a l  c a u s a t i o n are o n l y b e g i n n i n g t o be e x p l o r e d . individual  The  ideology of  r e s p o n s i b i l i t y , however, i n h i b i t s t h a t u n d e r s t a n d i n g and  s u b s t i t u t e s i n s t e a d an u n r e a l i s t i c b e h a v i o u r a l model.  I t both  i g n o r e s what i s known about human b e h a v i o u r and m i n i m i z e s the importance o f e v i d e n c e about t h e e n v i r o n m e n t a l 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 t o be i n d i v i d u a l l y r e s p o n s i b l e a t a time when they are becoming l e s s c a p a b l e as i n d i v i d u a l s o f c o n t r o l l i n g t o t a l h e a l t h environment.  their  A l t h o u g h e n v i r o n m e n t a l f a c t o r s are o f t e n  r e c o g n i z e d as " a l s o r e l e v a n t , " t h e i m p l i c a t i o n i s t h a t 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  society.  What must be q u e s t i o n e d 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 o f a f o c u s 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  w i t h o u t changing s o c i a l s t r u c t u r e and p r o c e s s e s . " 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 h e a l t h can be viewed  g r e a t l y b e n e f i t i n g t h e medical system, c e r t a i n p o l i t i c a l industry.  as  p a r t i e s and  T h i s p e r s p e c t i v e which i s o f t e n r e i n f o r c e d by t h e media,  r e d e f 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 c o n t e x t .  As such, t h e need t o address e n v i r o n m e n t a l  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 t h e s e i n t e r e s t groups f r e e from t h e r e s p o n s i b i l i t y o f making h e a l t h  enhancing  127  changes.  When t h e o r i s t s , programmers and academics l i m i t the determinants  of i l l health to i n d i v i d u a l r e s p o n s i b i l i t y and i n d i v i d u a l l i f e s t y l e , they can be viewed as a l l y i n g themselves with the s e l f - i n t e r e s t e d biomedical, p o l i t i c a l and industry p o s i t i o n . ( M i n k l e r & Pasick, 1986; Estes, Fox, Mahoney, 1986; Kickbusch, 1989)  If t h i s i s done to the v i r t u a l exclusion  of environmental influences the v i c t i m may have l i t t l e or no information and therefore maybe powerless to influence change except i n d i r e c t l y through action ( E p s t e i n , 1985). As noted minimal environmental and community action for change has been taken by the programs under study.  In one case when out reach  programming was an o b j e c t i v e , seniors were pushed back to the i n d i v i d u a l behaviour change stance by p r o f e s s i o n a l s .  The p r o f e s s i o n a l s ' action  undermined and negated the p o s i t i v e action made by the seniors in attempting to address s o c i a l l y i s o l a t e d seniors in t h e i r community.  This  kind of narrow, i n t r o s p e c t i v e approach to health promotion discourages concern for community and s o c i e t a l well-being (Becker, 1986). What i s suggested i s that l i f e s t y l e change e f f o r t s remain secondary or at most equal to environmental approaches, and that approaches s o l e l y related to i n d i v i d u a l behaviour change may y i e l d marginal improvements in the s o c i a l causes of health.  Although t h i s study does not provide d i r e c t  evidence for t h i s stance, i t must be noted that where environmental and community action was attempted gains were minimal.  One i s tempted to  believe that t h i s i s an outcome from employing a health promotion approach which p r i m a r i l y focuses on i n d i v i d u a l behaviour change. In response to the c r i t i c s of an i n d i v i d u a l l y - o r i e n t e d approach there are those who contend that few health promotion programs do focus  128  e x c l u s i v e l y on i n d i v i d u a l behavioural change, and f u r t h e r that programs which address i n d i v i d u a l health and behaviour must eventually address system-change and the issue of c o n f l i c t i n g ideologies about health and health promotion (Green, 1984, 1986; Green and M c A l i s t e r , 1986). Green's p o s i t i o n i s p a r t i a l l y supported by workplace health promotion l i t e r a t u r e (U.S. Department of Health and Human S e r v i c e s , 1987; Walsh, 1988) which suggests that the introduction of health promotion a c t i v i t i e s in s p e c i f i c worksites led to health enhancing system-changes. The programs presently studied can not make t h i s claim and as yet have not addressed the issue of c o n f l i c t i n g i d e o l o g i e s . A l s o , 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 c e r t a i n 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 contributions to the l i t e r a t u r e are from psychology.  "Even in large scale  community interventions such as the Stanford three-community s t u d i e s , the behavioral science contributions to planning the interventions have been made l a r g e l y by psychologists.  The r e s u l t i s that the behavioral change  interventions have tended to emphasize the i n d i v i d u a l , and have been most useful in patient education.  This concentration of behavioral science  a p p l i c a t i o n s i s sometimes at the expense of action on needed change in the organizational, institutional,  environmental, and economic conditions  shaping behavior (Green, 1980, p. 217)." The use of terms such as ' L i f e s t y l e s ' and  'Individual  R e s p o n s i b i l i t y ' also inadvertently serve to focus a t t e n t i o n on changing the i n d i v i d u a l rather than changing the underlying community and  129  environmental problems which maintain and reinforce unhealthy behaviour (Minkler & Pasick, 1986; Health Education Unit, 1986). Widespread change through m u l t i p l e mechanisms at a l l l e v e l s of society appears e s s e n t i a l i f the v i c t i m blaming i m p l i c i t l y encouraged through the misuse of health promotion r h e t o r i c , language and narrow models i s to be avoided.  Even i f professionals working in the health  promotion arena are successful in incorporating environmental influences 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 i n g from the i n d i v i d u a l behaviour change stance.  This focus on i n d i v i d u a l r e s p o n s i b i l i t y for  health must be accompanied by an equal emphasis on the community and environmental f a c t o r s which heavily influence i n d i v i d u a l health p r a c t i c e s . 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 i c t i m blaming ideology i t i s feared society w i l l remain b l i n d to the l a r g e - s c a l e causal f a c t o r s of the health problems i t seeks to address ( E p s t e i n , 1985; Becker,1986; Crawford, 1979; Kickbusch, 1989). Question 3 addresses those organizational influences which impact on program process and composition. QUESTION 3:  What f a c t o r s best contribute to explain program  composition and v a r i a t i o n ? The composition and hence v a r i a t i o n among the programs studied were most influenced by organizational f a c t o r s i n c l u d i n g : 1)  the way a health promotion approach i s a p p l i e d ,  2)  the structure of the program o r g a n i z a t i o n ,  3)  program c o n t r o l ,  4)  program funding and  130 5)  the impact of h i s t o r i c a 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 s o c i o e c o l o g i c a l model of health (Martin, Robertson & Altman, 1988).  The degree to which pertinent i n d i v i d u a l and  environmental components are r e f l e c t e d in program process and composition i s dependent on how much professionals and seniors adopt and incorporate i t s underlying p r i n c i p l e s .  These p r i n c i p l e s include senior p a r t i c i p a t i o n ,  senior empowerment and partnership between seniors and professionals in program planning, organization and process.  If s e n i o r s ' issues are to be  i d e n t i f i e d and addressed, i t would be anticipated that seniors be given the opportunity to be active p a r t i c i p a n t s in program planning and decision making, at a l l organizational l e v e l s .  This would require appropriate  mechanisms be in place for regular and open communication between general p a r t i c i p a n t s , f r o n t l i n e volunteer s t a f f and those s p e c i f i c a l l y involved in planning and o r g a n i z a t i o n .  Also those operating costs and manpower  issues which a f f e c t program composition would be viewed as pertinent organizational f a c t o r s . Across programs the f i n d i n g s were not r e f l e c t i v e of t h i s ideal scenario.  Only one program (Program B) adopted and incorporated the  p r i n c i p l e s of the s o c i o e c o l o g i c a l model to any s i g n i f i c a n t degree.  This  program was the only one that had mechanisms in place f o r regular open communication and decision making about program planning between the planners and the remaining p a r t i c i p a n t s .  In t h 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 v e 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 decision making.  Of the three programs that had  seniors involved in committees and on boards, in two of these cases professionals c l e a r l y undervalued s e n i o r s ' input by e i t h e r monopolizing or completely preventing s e n i o r s ' involvement in discussion and decision making processes. In three of the f i v e programs professionals and seniors complained that inadequate funding and/or s t a f f i n g l i m i t e d program expansion.  In one  program where funding was pursued by s e n i o r s , professionals interfered with the process and monies were not forthcoming.  In one other program  senior volunteers conducted annual fund r a i s i n g 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 s o l u t i o n s to s t a f f i n g and funding concerns. A l s o , the impact on programming of h i s t o r i c a l f a c t o r s can not be underestimated.  Although a s o c i o e c o l o g i c a l 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 i n d i v i d u a l l i f e s t y l e - o r i e n t e d health promotion approach.  As noted program components vary l i t t l e among programs, and  they predominantly address i n d i v i d u a l behaviour change which f i t s with t h i s behavioural model. Organizational f a c t o r s that contribute to health promotion process and composition are multifaceted and influenced greatly by macro, meso and m i c r o - l e v e l influences and p r a c t i c e s .  132  Since the 1980's an expanded d e f i n i t i o n of health- promotion has been added to federal health r h e t o r i c which i d e n t i f i e s both i n d i v i d u a l behaviour and environmental influences as determinants of h e a l t h .  In  consequence, national s t r a t e g i e s for health promotion now i d e n t i f y a commitment to reorient health s e r v i c e s and t h e i r resources so as to address broader level health issues (Epp, 1986).  However, major health  p o l i c y in the form of l e g i s l a t i o n and funding for health s e r v i c e s , continues to emphasize a c o s t l y 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 p o l i c y and hence p r a c t i c e often r e s u l t from a process of negotiation between c o n f l i c t i n g i d e o l o g i e s . The introduction of health promotion ideology, while biomedical ideology i s strongly entrenched in present health p o l i c y , has led to both intended and unintended consequences.  On the one hand, federal health p o l i c y  advocates community-based health promotion to improve the health status of a growing population of seniors and to reduce health care c o s t s .  Yet,  it  openly supports biomedical approaches and p r a c t i c e s by s u b s i d i z i n g the i n place, high-tech medical system and f e e - f o r - s e r v i c e care.  As such, when  health promotion programs do e x i s t they tend to adopt a c l i n i c a l  lifestyle  focus or operate without adequate funding (Estes, Fox & Mahoney, 1986; Health Services and Promotion Branch, 1986; Kickbusch, 1989; M a r s h a l l , 1987; McKnight, 1978, 1987). This f a i l u r e to support health promotion with p o l i c i e s and funding that consolidate i t s i d e a l s can only be expected to lead to i d e o l o g i c a l and p r a c t i c e d i f f e r e n c e s within health promotion programs themselves.  133  Although t h i s study does not address these issues d i r e c t l y the data does i d e n t i f y that i d e o l o g i c a l differences e x i s t and these differences appear to influence program process and composition.  These differences  appear to stem from the attempt by professionals and seniors to combine two d i f f e r e n t health promotion approaches.  A l l f i v e programs studied have  based t h e 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 s o c i o e c o l o g i c a l approach. With a c l i n i c a l behavioural approach "the primary challenge ( i s ) to a s s i s t people in taking r e s p o n s i b i l i t y for t h e i r t o t a l health" by adopting health enhancing l i f e s t y l e p r a c t i c e s (Nelson, 1984).  This approach focuses on  modification of behaviour at the i n d i v i d u a l 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 s o c i o e c o l o g i c a l approach refocuses a t t e n t i o n , away from s t r i c t l y i n d i v i d u a l f a c t o r s and processes, and towards environmental of health and group empowerment.  determinants  This approach requires the d i r e c t  involvement of i n d i v i d u a l s who i d e n t i f y health needs and p a r t i c i p a t e any necessary action to create health enhancing changes. are not viewed as experts and leaders, but facilitators,  in  Professionals  rather they function as  advocates and resources in t h i s process (Martin, Robertson &  Altman, 1986; Mcleroy, Bibeau, S t e c k l e r & Glanz, 1988; Nelson,1984; Kickbusch,1989). The impact on program process and composition from these i d e o l o g i c a l d i f f e r e n c e s , which stem from forces within the larger s o c i a l system are f u r t h e r compounded by those which stem from organizational influences. None of the seniors health promotion programs studied i s f r e e standing.  Rather, as with many community health promotion programs for  134  s e n i o r s , the programs are a l l conducted within or sponsored by some type of community organization or agency.  If the organizational  structures,  missions and goals of the host and sponsoring organizations are incompatible with health promotion ideology i t on program process and composition.  is likely this will  impact  For example, the structure of most  organizations i s based on a h i e r a r c h i c a l design established to create control of people.  On the other hand, the structure of progressive health  promotion programs i s based on people acting through consent. difference i s c r i t i c a l  This  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 i e r a r c h i c a l system designed to control ( F r i e d , 1980; Labonte, 1989; Mcknight,1987; Mcleroy, Bibeau, Steckler & Glanz, 1988; Ottoson & Green, 1987; Goodman & S t e c k l e r , 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  organizations in t h i s study, there were numerous examples that suggest ideological incompatibility  in organizational behaviour between the health  promotion programs and t h e i r host and sponsoring organizations.  These  issues s e r i o u s l y impact on program process and,ultimately  program  composition.  affect  For example, the interference by professionals from one host  organization e s s e n t i a 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 r e s p o n s i b i l i t y f o r t h i s program themselves, while the seniors believed they needed the help of a paid coordinator.  In  another example professionals blocked seniors from p a r t i c i p a t i n g on a  135  Seniors Advisory Board as they believed professionals should i d e n t i f y seniors needs within t h e i r community, not the s e n i o r s . If these i d e o l o g i c a l c o n f l i c t s are not given adequate a t t e n t i o n through appropriate organizational processes, at worst, they could lead to program termination.  At best, organizational  influences need to be  addressed so that these health promotion programs can survive to become integrated parts of host and sponsoring organizations (Goodman & S t e c k l e r , 1987). F i n a l l y , m i c r o - l e v e l influences on program process and composition cannot be overlooked.  Both seniors and professionals hold health  promotion perspectives based on a l i f e t i m e of h i s t o r y within a p a r t i c u l a r society.  Individuals are affected by such f a c t o r s as age, sex,  occupational background, education, economic s t a t u s , values and b e l i e f s . C o l l e c t i v e l y , s o c i a l values, federal p o l i c i e s and the practices of the health system, industry and the media also have a tremendous impact on individuals'  perspectives.  Hence, professionals may advocate for senior empowerment yet be heavily 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 them in control of program process and composition.  placed  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 f o r them.  This  encourages psychological dependency and helpless behaviour on the part of seniors which diminishes t h e i r sense of control and empowerment and in t u r n , t h e i r impact on programming For example, s o c i a l i n t e r a c t i o n and support are i d e n t i f i e d by a l l seniors as the primary reasons for program attendance yet few programs  136  legitimate t h i s s o c i a l health need by developing pertinent program activities.  In a number of programs seniors come e a r l y and leave late or  t a l k q u i e t l y amongst themselves while scheduled a c t i v i t i e s are in operation.  Only one program legitimated t h i s concern through the addition  of new s o c i a l a c t i v i t i e s .  This program also provides a forum f o r a l l  seniors to i d e n t i f y t h e i r needs and p a r t i c i p a t e in program development. Conversely, seniors may know that they have the knowledge and s k i l l s to take control of t h e i r own health promotion programming and be adversely affected by a s o c i e t a l presumption that they have l i t t l e to o f f e r as they age.  Ageism may have a negative impact on seniors sense of s e l f worth and  encourage an o v e r - r e l i a n c e on professionals to make the decisions for them.  Consequently, seniors may r e f r a i n from a c t i v e l y p a r t i c i p a t i n g  in  the process of program planning, decision making and organization (Easterbrook, 1978; C l a r k , 1969; Gaventa, 1980; Seligman, 1975; Maier & Seligman, 1976; Labonte, 1989; S c h u l t z , 1980). For example, in one of the programs studied, seniors were encouraged by one professional (wellness coordinator) to conduct e x e r c i s e s 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 t n e s s i n s t r u c t o r to run t h i s program component.  The seniors r e a d i l y backed off from running the  program themselves, s t a t i n g they f e l t the professional had more e x p e r t i s e . In summary, although most of the health promotion programs studied focus p r i m a r i l y on i n d i v i d u a l behaviour change, those programs where e f f o r t s are made to give seniors control of program process and  137  organization were less l i k e l y to ignore those s o c i a l , o r g a n i z a t i o n a l , economic and p o l i t i c a l f a c t o r s that keep seniors s o c i a l l y i s o l a t e d , disempowered, impoverished and undervalued in s o c i e t y .  When an e c o l o g i c a l  approach i s applied health promotion programs can more e f f e c t i v e l y address pertinent needs of seniors and are more l i k e l y to recognize the impact of multiple micro, meso, and macro-level influences on the health promotion programs themselves.  II. 1)  LIMITATIONS OF THE STUDY  The people interviewed were not n e c e s s a r i l y representative of  the whole group of i n d i v i d u a l s involved in each program, for several reasons: a)  Only one senior who was involved in program planning and  organization 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 proportionately,  in some  programs the male perspective may be under-represented. c)  although a l l coordinators were interviewed, no i n d i v i d u a l s from  host organizations were represented in the sample of professional interviews. 2)  Those seniors and professionals involved in program planning and  organization may be over-represented as they were asked more questions than senior p a r t i c i p a n t s . 3)  The more a r t i c u l a t e people may be over-represented in the data  a n a l y s i s and presentation, even though p a r t i c i p a n t observation was used in order to reduce t h i s  possibility.  138  4)  The data gathered i s not n e c e s s a r i l y representative of  professionals involved with each program, for several reasons: a)  Although a l l the coordinators adopted a broad perspective that  recognized both i n d i v i d u a l and environmental influences on h e a l t h , and supported the p r i n c i p l e of senior p a r t i c i p a t i o n , they may not f u l l y adopt the s o c i o e c o l o g i c a l framework documented by the Health Department which i s still  in d r a f t form. b)  No data was gathered from p r o f e s s i o n a l s in host or sponsoring  organizations about these o r g a n i z a t i o n s ' missions, goals and o b j e c t i v e s . 5)  G e n e r a l i z a t i o n of the f i n d i n g s w i l l be l i m i t e d for several  reasons: a)  Logical argument may provide j u s t i f i c a t i o n f o r g e n e r a l i z a t i o n to  a l l Health Department health promotion programs for seniors in the Vancouver area; however some b a r r i e r s to t h i s g e n e r a l i z a b i 1 i t y must be noted.  These programs have some v a r i a t i o n s in terms of professional  t r a i n i n g and philosophy, senior involvement in program planning and o r g a n i z a t i o n , and the number of senior p a r t i c i p a n t s , and the involvement from host and sponsoring agencies.  The physical l o c a t i o n ,  p r o f e s s i o n a l / s e n i o r r a t i o , and community c h a r a c t e r i s t i c s also vary among groups. b)  G e n e r a l i z a b i 1 i t y 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 i m i t a t i o n .  However, although only one researcher was involved, the use of multiple data c o l l e c t i o n procedures, along with t r i a n g u l a t i o n , enhances internal reliability.  External r e l i a b i l i t y  i s a matter of degree and some  139  q u a l i t a t i v e researchers would argue that nothing can be r e p l i c a t e d exactly.  However, the d e t a i l e d d e s c r i p t i o n and discussion of both data  c o l l e c t i o n and a n a l y s i s procedures enhances the potential of t h i s study being r e p l i c a t e d .  III.  IMPLICATIONS FOR FUTURE RESEARCH  Despite the d i f f i c u l t i e s with g e n e r a l i z a b i l i t y f o r many health promotion studies that adopt q u a l i t a t i v e methods, f u r t h e r 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 o r g a n i z a t i o n , can only add to the lack of research in t h i s area. Although some authors claim programs continue to focus on i n d i v i d u a l 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 investigates health promotion  program focus and the underlying causal f a c t o r s of program composition, there w i l l be an i n s u f f i c i e n 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 exploration  of organizational influences on program process and composition.  More  indepth study needs to be undertaken in order to explore the e f f e c t s of both the internal organizational mechanisms and those external organizational influences 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 e s s e n t i a l to provide a f i r m foundation of information which i s r e a d i l y a v a i l a b l e to p o l i c y makers, health care planners, the media and  140  the general public i f  ' r e a l ' health promotion i s to be assured an integral  part of the health care system.  IV.  PRACTICAL RECOMMENDATIONS FOR PROGRAM PROCESS AND ORGANIZATION  This study of f i v e health promotion programs for seniors has attempted to capture the e x i s t i n g approach, process, and content of each program.  Many issues need resolving i f these health promotion programs  are to be successful as v e h i c l e s f o r enhancing the q u a l i t y 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 influences.  A.  INTERNAL INFLUENCES  1)  Health Promotion Approach.  P r o f e s s i o n a l s must s e l e c t a health promotion approach which allows seniors to p a r t i c i p a t e in d e f i n i n g t h e i r needs within t h e i r community;  in  p a r t i c u l a r , an e c o l o g i c a l approach would be more e f f e c t i v e 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 w i t h i n programs that are i n i t i a t e d on t h e i r behalf.  Only then w i l l  these programs e f f e c t i v e l y serve to address those needs i d e n t i f i e d by seniors.  For example, a l l the seniors interviewed i d e n t i f i e d s o c i a l  support and s o c i a l i n t e r a c t i o n as the primary reasons they attended the programs.  However, l i m i t e d recognition was given to t h i s aspect of t h e i r  well-being by most programs.  A l s o , professionals expressed concerns that  141  seniors were not taking leadership r o l e s .  However, without appropriate  mechanisms for involvement, seniors w i l l not be inspired to exercise c o n t r o l , develop s k i l l s and take leadership p o s i t i o n s .  Only when they  become involved, w i l l seniors take ownership of e f f o r t s made to improve the conditions of t h e i r l i v e s . 3)  Involvement by P r o f e s s i o n a l s in Health Promotion Planning and  Decision Making. Professionals must be involved in exploring program approaches which meet s e n i o r s ' needs rather than those that put a program in place.  This  requires that professionals should r e l i n q u i s h control of programs and should function more as senior advocates and consultants, where t h e i r primary role i s to provide knowledge, resources and s k i l l s that empower seniors "to run t h e i r own show."  In conjunction with t h i s r o l e ,  professionals must be involved in addressing those i d e o l o g i c a l c o n f l i c t s which hamper program process with host and sponsoring organizations.  B.  EXTERNAL INFLUENCES  1)  C o n f l i c t i n g Ideologies between Health Promotion Coordinators and  Employers. Professionals must be empowered within t h e i r own organizations they are to e f f e c t i v e l y empower s e n i o r s .  For example, i f  if  the  p r o f e s s i o n a l ' s health promotion ideology c o n f l i c t s with t h e i r employer's ideology t h i s could impact negatively on the q u a l i t y and content of health promotion programming f o r s e n i o r s . 2)  C o n f l i c t i n g Ideologies between Programs and Host/Sponsoring  Organizations.  142  Professionals must take an organizational role in gaining support f o r health promotion innovations from upper level management or appropriate personnel of host and sponsoring organizations.  This may  involve attending management meetings, encouraging management p a r t i c i p a t i o n on health promotion program boards, and providing s t a f f education, material support and ongoing l i a i s o n . In some cases, however, not a l l the problems associated with e f f e c t i v e health promotion programming w i l l be solved, even given the s e l e c t i o n of appropriate approaches, the a c t i v e involvement of seniors and p r o f e s s i o n a l s , and the support of host and sponsoring organizations. Indeed, i t may not be p r a c t i c a l or possible to b u i l d consensus among a l l those a f f e c t e d .  A l s o , i t may take considerable time to develop  environmental and organizational support for program goals. many macro-level influences cannot be c o n t r o l l e d .  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Copenhagen:  World Health Organization. (1986). Health P o l i c y and Health Promotion: Towards a new conception of P u b l i c Health. Vienna and Copenhagen: Proceedings of the f i r s t Vienna Dialogue on Health Promotion, WHO/EURO and the Austrian M i n i s t r y of Health and Environmental P r o t e c t i o n . Document RP12 of the Eurosocial Research and Discussion Papers, European Centre For S o c i a l Welfare Training and Research, Vienna.  157  APPENDIX A RESEARCH CONSENT FORMS  158  Vancouver Health Department 5  Re:  North Unit #200-1651 Commercial Drive, Vancouver, B.C. V5L 3Y3  A qualitative research study - Community health promotion programs for seniors: Program components and contributing factors to t h e i r composition.  Student investigator:  K i m M. C a l s a f e r r i Graduate Student (M.Sc. - H e a l t h U n i v e r s i t y of B r i t i s h Columbia  I  Telephone: 253-3575  consent  to  participate  i n a study  of h e a l t h promotion programs understand part of the s t u d y Wellness Coordinator.  being  conducted  by  Promotion)  Kim C a l s a f e r r i  f o r s e n i o r s i n the V a n c o u v e r w i l l f o c u s on my p e r s p e c t i v e  area. I as a S e n i o r s  I w i l l p a r t i c i p a t e by: a) a s s i s t i n g the 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 p r o g r a m 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 program 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 f r o m p r o g r a m p l a n n i n g m e e t i n g s and; 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 duration. I f I w i s h t o w i t h d r a w f r o m t h e s t u d y I know I c a n do so a t a n y t i m e w i t h o u t jeopardy. 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 confidential, 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 researcher 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 the p r o c e s s . I  have m a i n t a i n e d  Name  _  Name ^ Name Name Name.  a copy  of  this  consent  _^  Signature  _  _ Signature  ^ _  Signature  t  form:  _  -.Signature Signature-.  ~  , _  /ljb 89/4/10  CITY OF V A N C O U V E R  _  Health  Unit  —Health  Unit  Health  Unit  Health  Unit.  Health  Unit  . . -  159  APPENDIX A SENIORS CONSENT FORM RE: A q u a l i t a t i v e research study: COMMUNITY HEALTH PROMOTION PROGRAMS FOR SENIORS: PROGRAM COMPONENTS AND CONTRIBUTING FACTORS TO THEIR COMPOSITION. Student I n v e s t i g a t o r :  Kim C a l s a f e r r l Graduate Student (M.Sc. Health Promotion) U n i v e r s i t y of B r i t i s h Columbia  I CONSENT to p a r t i c i p a t e 1n a study being conducted by Kim C a l s a f e r r l , of health promotion programs f o r 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 p a r t i c i p a t e in a semi-structured Interview of one h a l f hour's duration. I know I can withdraw from the study at any time without 1t jeopardizing my future p a r t i c i p a t i o n i n the health promotion program. I understand a l l Information 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 are required or w i l l be recorded, and that no I d e n t i f y i n g Information w i l l be placed 1n the f i n a l report. I know answers to any questions concerning my p a r t i c i p a t i o n 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  Feb 22 March 1 May 1 May 1 May 2 May 3 May 6 May 8 May 8 May 10 May 10 May 15 May 16 May 17 May 17 May 23 May 24 May 24 June 7 June 12 June 12 June 13 June 14 June 19 June 19 June 26 June 26 June 28 J u l y 17  Informal Formal Informal Informal Informal Informal Focused Informal Informal Informal Informal Focused Formal Focused Formal Formal Formal Formal Focused Formal Formal Focused Focused Formal/Informal Focused Formal/Focused Focused Focused Focused  10am-12pm 10am-12pm 10am-12pm 1pm-3pm 930am-12pm 1pm-4pm 11am-12pm 930am-12pm 1pm-3pm 10am-12pm 1pm-4pm 1030am-12pm 930am-12pm 12pm-1pm 1pm-4pm 945am-12pm 10am-12pm 1pm-4pm 1045am-12pm 930am-12pm 1pm-3pm 11am-12pm 11 am-12pm 10am-2pm 3pm-4pm 930am-115pm 130pm-230pm 11am-12pm 1030am-1pm  Key:  P = Program OB = Observation  PROGRAM A A B C D E D B C A E E D E E D A E A B C D A B C B C A E  PROTOCOL PAOB1 PA0B3 PB0B1 PC0B1 PD0B1 PEOB1 PD0B5 PBOB2 PCOB2 PAOB2 PE0B2 PE0B3 PD0B3 PE0B4 PEOB5 PDOB4 PA0B4 PE0B6 PAOB5 PBOB3 PC0B3 PD0B6 PA0B6 PB0B4 PC0B4 PBOB5 PC0B5 PA0B7 PEOB7  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 C a l s a f e 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 b u i l d i n g I noticed a woman s i t t i n g behind a table BR: I wondered i f she was a volunteer g i v i n g people info on what was happening in the b u i l d i n g 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 s e r v i c e s run out of t h i s b u i l d i n g . I was surprised to bang into a senior from the Program B there. Then I saw (A) the fun and f i t n e s s i n s t r u c t o r I had met l a s t week at Program C when I asked the S e n i o r ' s f o r permission to observe. She i s of S c o t t i s h 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 senior's a lot BR: She t o l d me t h i s when I was here last. OB: She h e r s e l f i s a senior and i s involved as a volunteer here a f t e r doing the fun and f i t n e s s i n s t r u c t o r s 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. It i s more d i f f i c u l t to t e l l her age as her h a i r i s black. BR: ?dyed OB: (F) gives me the schedule f o r May also I receive a hand out from (M) the coordinator of whole s e n i o r ' s center about s p e c i a l 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 l i s 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- a l l 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 s i t 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 r a i s e s -knee bends (A) reminds people they are gentle exercises and to hold onto the c h a i r i f they wish t o . -marching on the spot "to r a i s e your heart. Does anyone have medication and i f you do i t would be helpful i f you would l e 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 i n the c h a i r . (A) asks s p e c i f i c people i f they are o.k. One she asks a number of times. 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 c a l l e d by (F) f o r BP. The woman leaves the room and goes o f f somewhere around the corner. This room although closed o f f by three w a l l s 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 o o r where seniors programs are held. It has windows down two sides and i s approximately 30x15 f e e t . The table (F) i s at i s located at the end which i s open. The i n s t r u c t o r i s in the middle of the group at the front. Two more woman a r r i v e and move to the back and j o i n i n . -ankle rotations - l e g rotations A man comes up to the table and gets a # f o r BP. (A) changes music to 'moon r i v e r ' -marching on the spot- some s i t - the rest remain standing -twisting Another man a r r i v e s & then a woman. Only the woman j o i n s in the e x e r c i s e s , the man i s here f o r BP. -walk in large c i r c l e around c h a i r s (I am now in the c e n t e r ) . (J) pops over to t a l k to me and mentions she i s only here because the s e n i o r ' s l i k e  166  her to come by as i t makes i t more official. BR: I wonder what t h i s means.. OB: She t a l k s 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 usually held a f t e r the session. She also t a l k s about how she l i k e s to see the program stop i n the summer as believes the volunteers need a break, or they get burnt out, yet often they want to continue. She a l s o said she does t o , to do other t h i n g s , - f i n g e r s and feet in a seated p o s i t i o n Music i s very mellow now-piano (J) makes announcements-Weilness f a i r at K e r r i s d a l e (a hand out i s given out labeled Seniors in A c t i o n ) , she explains that d i f f e r e n t 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 f o r i n t e r r u p t i n g 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. -fingers - I t s y b i t s y spider -seated r a i s e arms-arms out and in -eyes-up and down, side to side Another woman a r r i v e s . I notice t h i s group looks r e l a t i v e l y young-late 50's 6 0 ' s except f o r a couple who look to me about 70-80. Another man a r r i v e s f o r BP. - s t r e t c h i n g arms -face I t ' s now 2:00pm (A) f i n i s h e s the session and thanks the group for coming. She mentions the seniors s t r u 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. It i s going to be a t a l k on ' d e m e n t i a / s e n i l i t y ' by a coordinator of a S . T . A . T . Center. Two men j o i n the group as  167  they are waiting f o r BP. The t a l k continues f o r about one hour and during that time seniors ask questions about depression, alzheimer's and d e l i r i u m the t o p i c . At the end one member asks what other t a l k s 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 notice however how a It of men came but how only two stayed f o r the t a l k and none went to the e x e r c i s e s . OB: This i s the end of t h i s observation.  168  FORMAL OBSERVATION PCOB3-Program C, Observation 3 +PCOB3 +Name:Kim C a l s a f e r r i +Date: June 12/89 +Time: 1:00-3:00pm +Subject: Formal OB: I a r r i v e at 1:05pm and see the t a b l e set up. There i s a TV set up. 7 senior women s i t in l i n e s . ( I ) , a Senior Volunteer a r r i v e s & 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: ( a r r i v e s ) Hi (I): No nurse here today- only exercise and l e c t u r e . 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 . It i s a video from the Red Cross f o r Seniorse x e r c i s e , 1/2 hour. I understand (A) i s away r i g h t now so the video i s being used as a s u b s t i t u t e . I notice on the table are two pamphlets from the S t . John Ambulance: 1) Healthy Aging 2) Get Ready, Get Smart, Get a Handle On Your Retirement L i f e s t y l e I notice that 1/2 of these people are regulars. Another woman a r r i v e s , i t i s 1:22pm. She takes a seat and j o i n s in. I notice one woman doesn't j o i n i n . Another woman a r r i v e s 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 s t r e t c h i n g of both legs and arms. Another woman a r r i v e s . Then the pace Increases. Heel, t o e , polka. The woman on video s i n g s . They a l l laugh. They now move into a cool down. I notice a sign on a board:  169  Wellness C I i n i c - d l s c u s s i o n s - y o u r blood pressure taken-musical exercise-guest speakers. The video f i n i s h e s at 1:45pm & (R) s t a r t s again. 2 more women a r r i v e . 2 leave to go have coffee the others do i t a l l again. (I): (to me) Come and j o i n i n . (She j o i n s the group) OB: One of the woman who a r r i v e s doesn't do i t . 2 more women a r r i v e and 1 j o i n s i n . (I) goes over to the other and encourages her to j o i n 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 late. OB: Another woman a r r i v e s . (I) goes over. FEMALE: Someone's supposed to come and speak about the eyes. (I): Join 1n the e x e r c i s e s . FEMALE: I c a n ' t e x e r c i s e . (She s i t s over by the coat rack) OB: I notice when I look over that she has joined i n . (I): I think t h a t ' s him. Do you remember h i s name? OB: She goes over to him. SP: I need a screen f o r s l i d e s . OB: The exercises end at 2:10pm. There are 20 people here. The t a l k i s c a l l e d "The Aging Eye" MALE: My name i s ( P ) . I'm an eye doctor in t r a i n i n g . 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 & e x p l a i n s . He mentions clouding of the eyecataracts. FEMALE: I have t h a t . (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 p u l l s eye c\open gets weak-can be in one eye or other. F a i r l y simple surgery. FEMALE: That's not a squint eye i s 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 v i s i o n (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 v i s i o n - l o c a l 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 f o r f i n e vision - b u i l d up of white waste products -doesn't affect side v i s i o n -very l i t t l e can be done except laser Rx.x -only 1 type-leaking blood vessels Diabetes: -increased sugar levels - e f f e c t s eyes-damages retina Detached retina: -aging, short sightedness, diabetes can cause same - r e t i n a detaches from blood supply -loose part of v i s i o n -a l o t of black spots -flashing lights Optic Nerve Damage: -uncommon MALE: Is there 2 operations. One f o r 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 i s a lazy eye. (P): The same as a squint eye, l i k e cross eye. I t ' s c a l l e d lazy because i t ' 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 l i g h t - 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 s t r a i n . 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 i n on changes. The session has been very interactive. (P) was very down to earth and approachable f o r questions. The t a l k 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 C a l s a f e r r i +Date: June 26/89 +Time: 2:30-3:30pm +Subject: Focused OB: I arrive 1n the room next to the Wellness C l i n i c and 5 people are there. Sen Vol 1, Sen Vol 2, RN, Coord and Prof (connected to Seniors  172  Centre s t a f f ) . We meet i n another room o f f the Wellness C l i n i c at 2:30pm for the planning meeting f o r the Wellness Fair i n f a l l . I heard about t h i s meeting from the l a s t planning meeting held on June 19/89. COORD: We talked about the p o s s i b i l i t y 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 n u t r i t i o n COORD: Yes the food wheel. She explains that i f i t stops meat areathey 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 f i l m to e l i c i t discussion. "A House Divided"- another good f i l m about elder abuse. There are others about seniors accomplishments PROF: We could c a l l i t Fun and Wellness Day and advertise what w i l l happen. COORD: We would be able to advertise your programs PROF: I t would be good t o start before the school board SEN VOL 1: How long f o r 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 o f f day SEN VOL 1: Will we put balloons and streamers (M): I have balloons COORD: How should we do i t PROF: — B P and counselling in one area -popcorn COORD: And we could have exercise and the n u t r i t i o n games  173  PROF: And why don't we invite Dr. Blatherwick to speak about AIDS OB: I wonder i f she i s joking considering last time OB: They laugh (M): Suggests the l i v i n g w i l l SEN VOL 1: Wouldn't i t be better as a topic for the Wellness C l i n i c (M): He's a good speaker. Do you want speakers PROF: It's a kick o f f 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 t o the f i l m f e s t i v a l 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 s l o t i t in COORD: I f you do i t a l l day your ears r e a l l y 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 t o f i x . The Prof says s h e ' l l look into i t PROF: I can but that no problem. By the time you s t a r t (M): COORD: We'll have some speakers, exercise and counselling, movies and massage. I t would be r e a l l y good to do massage (M): She stopped though We could t a l k to (V) COORD: We had a physiotherapist come i n SEN VOL 1: There was too much before with massage, exercise, getting mixed with the t a l k s  174  (M): Exercise- do you want me to approach the r e f l e x o l o g i s t and massage also COORD: I don't know how t o do that unless we t r a i n someone (M): We can get (V) she's trained COORD: And then some fun games (M): Those n u t r i t i o n 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 a f r a i d h e ' l l get stuck (M): Someone on films from NFB, displays SEN VOL 1: They're very happy OB: People discuss t h i s (M): (To Sen Vol 1) You want to pick up and preview SEN VOL 1: I don't want to COORD: I w i l l 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 s k i l l e d 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 t o 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.) t o come with popcorn (M): I missed that COORD: She makes popcorn with I t a l i a n mix  175  PROF: The best thing i s 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 c a l l s a f t e r that f o r 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 i s COORD: (M) can organize that OB: Discuss exercise as important COORD: We could have carpet bowling using t i n s of food SEN VOL 1: We could have the Food Bank, after a l l i t i s a wellness thing PROF: Very similar t o 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 i n August COORD: Middle July (M): 3rd week COORD: About noon (M): Over lunch i n the c a f e t e r i a . 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: I f you do line dancing you can't come t o t h i s COORD: Even i t you had dancing 1n one room. And c r a f t s (M): We don't s t a r t that u n t i l 3rd week SEN VOL 1: Last time only one person came. You're supposed to focus on health. How f a r 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 c r a f t s . More discussion occurs about when the meeting should happen etc and t h i s meeting closes around 3:30pm The tone of t h i s meeting was f a i r l y relaxed. (M) looked to COORD a l o t 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  March 13 July 1 July 4 July 5 July 5 July 5 July 5 July 10 July 10 July 10 July 10 July 11 July 12 July 12 July 12 July 17 July 19 July 19 July 24 July 24 July 24 July 24 July 26 July 26 July 31 Aug 1  Sn.Part. Sn.Vol. Sn.Part. Sn.Vol. Sn.Vol. Sn.Vol. Sn.Part. Sn.Part. Sn.Part. Sn.Vol. Sn.Part. Sn.Part. Sn.Part. Sn.Vol. Sn.Part. Sn.Part. Sn.Part. Sn.Vol. Prof. Prof. Prof. Prof. Sn.Vol. Prof. Sn.Vol. Sn.Vol.  Key:  Sn.Part. Sn.Vol. Prof. P INT  SEX M F F M F F F F M M F M F F F F F M F F F F F F M F = = = = =  TIME  PROTOCOL  12pm-1pm 1030am-12pm 11am-12pm 11am-12pm 2pm-3pm 7pm-8pm 8pm-845pm 10am-1030am 1030am-11am 1115am-12am 130pm-2pm 9am-930am 930am-10am 2pm-3pm 3pm-330pm 930am-10am 10am-1030am 11am-1145am 930am-1030am 11am-1230pm 3pm-415pm 830am-930am 930am-1015am 2pm-315pm 11 am-1130am 11am-1145am  PAINT 1 PEINT1 PCINT1 PBINT1 PAINT2 PDINT1 PDINT2 PBINT2 PBINT3 PBINT4 PCINT2 PAINT3 PAINT4 PEINT2 PEINT3 POINT3 PAINT5 POINT4 PBINT6 PCINT4 POINT4 PEINT6 PEINT5 PAINT6 PBINT5 PCINT3  Senior Participant Senior Volunteer Professional Program Interview  179  APPENDIX E INTERVIEW QUESTIONS  180  APPENDIX E EXAMPLES OF INTERVIEW QUESTIONS Seniors' Questions-Participants +Questions f o r Category 1 Seniors. +Across Programs +Date:July 3/89 +Questions:  1: 2: 3: 4: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: 15: 16:  What i s the name of t h i s program? What i s wellness/health promotion to you? What i s a wellness/health promotion program? I f you were to describe t h i s program to someone, how would you? How long does the program run?- per year, per week, per session. What are the goals/ philosophy of the program? What i s the history of the program? How did 1t s t a r t ? How do people find out about the program? Who goes to the program? Who doesn't go? Why do people go? What i s the age range of people who go? What i s the ethnic mix? Socio-economic range? Who runs the program? Who i s in charge? How are decisions made about the program content and a c t i v i t i e s ? Who makes these decisions? How i s the program funded? Do people have to pay to attend? What are the strengths of the program? What would you l i k e to change/add? Is community p a r t i c i p a t i o n / advocacy encouraged? How would you describe t h i s community? 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 f o r Category 2 Seniors +Across Programs +Date:July1/89 +HX-Wellness/Health Promotion Programs: 1: 2:  5:  History of Seniors wellness i n the c i t y . History of establishment of the Seniors Advisory Committee to Council-City Hall-How are committee members selected-are there other committees/different members -what i s the mandate of these committees. Who where the founding members. Funding sources-Advisory Committees,Programs.  181  6: 7: 8: 9:  One stop shop Out reach-mentioned as "an eternal problem". t h i s mean? Housing-seems to be a major issue? Toward a Better Age?  What does  +Specific Program: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13:  Hx of same What i s wellness/health promotion to you? What i s a wellness/health promotion program? How would you describe Program ? How do people find out about t h i s program? How i s i t funded/do people pay to attend? What are the philosophy and goals of program? Who goes/doesn't go/why more women than men/why do people go? Who runs the program/who are the leaders-in charge/ How are decisions made? People go to d i f f e r e n t programs-why? How involved i s t h i s program i n community p a r t i c i p a t i o n / advocacy? I noticed certain issues are important to the seniors such as could you comment on these? Professionals' Questions  +Questions f o r Professionals Across Program +Date:23July/89 +General Health Promotion f o r Seniors in Vancouver: 1: 2: 3: 4: 5: 6: 7:  What i s the history of health promotion/wellness in t h i s c i t y f o r seniors? Why/ how where the Wellness Coordinator positions established? What i s the mandate of these positions? Who are you funded by? Who do you report to? What influence does t h i s have on your decisions? What i s health promotion/wellness to you? How would you define i t ? What i s a health Promotion/wellness Program? How does i t operate? Is there a framework by which you operate? Is there a philosophy/goals? Could you explain on these?  182  +Specific Health Promotion Programs. 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13:  What i s the history of the program ? How did i t begin? How long has i t been in operation? How would you describe t h i s program to some one who hadn't been? What kind of components/activities occur/topics covered? Who goes/why do people go/who doesn't go? Men/women issue? Who runs the program? Is there a leader(s)? How are decisions made about program content/components? Who makes these decisions? Is t h i s an active /passive process? What i f any i s the philosophy/goals of the program? Is t h i s program meeting perceived goals? How i s the program funded? Is community participation/advocacy encouraged? How? How i s t h i s program funded? What are the strengths of the program? What i f any thing would you l i k e to see changed/added? How would you describe t h i s community that t h i s program in terms of c u l t u r a l , s o c i a l , 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 i s 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 i s what i s the name that you have f o r you program? What i s the name of i t ? M: At the center. KIM: Yeah. M: That's Keeping Well. KIM: I t ' 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 i s uh Program A Community Center, School X and School Y. The 3 groups together are working with the seniors you see and we c a l l 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 i s i t . M: No not r e a l l y 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 i n KIM: Oh that doesn't matter I won't put use names i n , 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 o f f , 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 l i k e 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 i t ? M: Word of mouth and advertising. They advertised that they were havinggoing to be holding t h i s 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 i n . KIM: OK. Now I know i t ' s called Keeping Well. What i s wellness to you. How would you define wellness? M: Wellness i s uh uh a well rounded out person. Um um l e t me see now. Somebody that's active. Looks have them- and happy a happy person. And uh they l i k e themselves so they look after themselves. And uh from there I guess i t just goes on and on and on. KIM: So what i s a wellness program then to you? What does that mean to you? M: I t ' 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 t h i s . And then we've met a l o t of new ones l i k e 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 s t a r t 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 t h i s person to a new person. I f you were t e l l i n g someone about t h i s 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 l o t 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 i n and talk to us on d i f f e r e n t subjects. On health, on uh n u t r i t i o n , 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 b i t of money and so i t ' s uh- I would explain a l l t h i s 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 f o r 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 l e t ' s run right through . Cause what I am a f r a i d of i s some of them who have been coming and i f they stay away f o r 2 months they just might decide to stay away you know, not come back. And t h i s way i f we stay right through, you know t h e y ' l l 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 t h i s program? Do you have any- what are the goals that you try to achieve. M: What we want, what we want- my goal i s 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 t h i s 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 l i k e 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 t h e i r bridge. But that's a d i f f e r e n t 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 u n t i l 5 in the afternoon would be s t 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 l o t of things that we can't do we can't do l i n e dancing on account of the f l o o r . We don't have the proper f l o o r i n g and we can't get in the gym that has the proper f l o o r . 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 f o r seniors. KIM: So what's been the problem about getting the space? M: What the Parks Board I don't knowthey keep promising to us and then they set money aside f o r that space and they turn around and give i t to some other community center and we're l e f t . And now they t e l l us i t w i l l be next year before we get our room. So i t ' s 6 years that they've been- so i t ' s kind of f r u s t r a t i n g , very very f r u s t r a t i n g . 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 l i k e 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 l o t 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 f o r 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 t h e i r neighbors and then l i t t l e brochures that we have out they have a 1 i t t l e calendar each month that gives the programs. KIM: Is that the community center i s it? M: For the community center and uh we can take i t l i k e 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 l i k e that? M: No KIM: What about the local newspaper? M: They haven't bothered too much with that. I t ' 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 t h e i r 80s- up there. KIM: What about ethnic mix in there? M: We were r e a l l y surprised. (S) was r e a l l y surprised you know, how well they f i t 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 l o t of people that come and v i s i t l i k e our Indian lady from India who just l e f t and uh she was so interesting. KIM: So how did the Chines ladies get involved then? M: I guess t h e i r neighbors t o l d 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 thenI'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 l i k e (B) he's Scottish, you know. Uh (G) uh he's Canadian but his wife i s Parisien French and she doesn't come because she's involved with other things, tennis and a l l t h i s sort of s t u f f 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 i n . KIM: So i t ' s kind of a mixed bag. M: Yeah KIM: What about as f a r as people's socioeconomic status? Is i t people that are kind of - i s i t a l l ranges or is i t M: I think the majority of people that come there- I would c a l l myself not poor but maybe middle class. I f 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 t h e i r 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 s t a f f at the community center uh they have a seniors coordinator. (W) i s the seniors coordinator and working together and then they consult us. KIM: So howM: Like they l e f t i t up to us today whether to cancel last-next weeks um program on account of the Stanley Park picnic f o r seniors. I t ' s on next Wednesday- so he l e f t 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. I t was voted that- but he l e f t i t up to us to decide. KIM: Is that what happens around the types of a c t i v i t i e s that happen here. M: Yeah. They present them to us and they uh the bus t r i p s 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 t r i p s that they've planned f o r us. The kind of bus t r i p s - the d i f f e r e n t places that we go. The majority of people have  191  been quite s a t i s f i e d with that. KIM: And that's through the community center that's not part of the Keeping Well? M: No that's f o r a l l seniors. KIM: What about in the Keeping Well Program i t s 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 i s your membership which i s $1.00. KIM: Because the space i s 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 t h e i r monies in t h e i r hot $.25 for a cup of coffee or tea and $.25 for a cookie or a s l i c e or what ever we have there you know. And lots of times l i k e I'm with The Chamber of Commerce as well and our meeting s i s on a Monday and so we meet the seniors meet every Wednesday so sometimes there w i l l be f r u i t and cheese and s t u f f l i k e that l e f t over from the Chamber and I s t i c k i t in the fridge and then I bring i t to the seniors and always t e l l them that i s was compliments of the Chamber of Commerce. So they benefit that way a l i t t l e b i t . KIM: That's great. What do you think are the strengths of the program? What are the good things about i t ? What do you l i k e about i t ? M: Pretty well everything that we do there I l i k e . KIM: OK M: I can't find any f a u l t with i t . KIM: OK that's great. Is there anything that you would l i k e to add or change about the program?  192  M:  Just the room, I'd l i k e to have a better room f o r 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 w i l l go in the kitchen and t h e y ' l l look after the tea things and they make t h e i r own l i t t l e Christmas decorations and what have you. Stuff l i k e 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 t h i s program? Is that something that i s that you want to do or might want to do? M: We t r i e d , yes. Well we t r i e d I guess i t ' s s t i l l in abeyance there, we t r i e d f o r 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 s t a r t i t - would l i k e 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 c a l l 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. I t wouldn't necessarily be in the school but the seniors would meet . I t 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 t h e i r homes and looking at t h e i r 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 e f f o r t f o r 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 andKIM: 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 b i t - the Chamber of Commerce i s involved with quite a b i t with what we c a l l ATTACK right now, with the Assessment and what our seniors are really worried about are how much t h e i r taxes have increased t h i s 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 t h i s 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 t h e i r own homes and they might benefit i f we can get the assessments squashed f o r t h i s year. And they would pay the same taxes as they paid last year and reassess f o r 1990 and forget 1989 because they are going to be so many merchants that are going to have to close t h e i r doors and today's t h e i r deadline you see. KIM: So i s the concern f o r 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 t h e i r places and having to go into a d i f f e r e n t area altogether that's affordable. And so uh- see with us here we're OK cause t h i s i s government owned these buildings and these were b u i l t - these were opened in 1946 for the veterans.  KIM: But i t ' s a d i f f e r e n t story f o r 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 t h i s i s owned by the government but there's been talk the last 5, 6 years that uh Central Mortgage i s going to s e l l theses places to developers. And so we're watching that very closely and quite a few of our people that l i v e in the block here belong to the Legion and so we've got the Legion and the DVA behind us that w i l l fight for us. KIM: OK another thing that came up in your discussion was exercise instructors. M: Yes KIM: It sounds l i k e you've quite a fewM: (Laughs) KIM: And there's been a few hassles with that. Like i t sounds l i k e you're pretty happy with t h i s last one but M: We were very very happy but I think that the thing i s there i s 2 ways of looking at i t . I l i k e the l i t t l e g i r l I don't want to sound l i k e I am against her cause I l i k e her and she was very very good but she may have used us to get her c e r t i f i c a t e . She had to do so many hours of volunteer work to get her c e r t i f i c a t e . When she got her c e r t i f i c a t e and she's stayed on since her c e r t i f i c a t e 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 f o r . 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 q u i e t l y do you- i s that the only tape you have. And she said why are you getting t i r e d 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 s h i t s " (Laughs) And she didn't say anything you see and she finished the program and she f i n i s h e d the exercises and that they t o l d me they wanted to see me in the o f f i c e and they accused me of -she t o l d 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 i s 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 c e r t i f i c a t e and now that she's got her c e r t i f i c a t e couldn't very well quit as soon as she got her c e r t i f i c a t e so she went for the month and now she - t h i s i s her way out. And so we wrote her a l e t t e r and everybody signed i t and asked her to come back. And today (W) said that they mailed her the l e t t e r and also (H), who works in the o f f i c e there, who's programmer met her on Friday and he gave her one of the l e t t e r s 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 l e t 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 a r t h r i t i s i n 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 t r a v e l i n g 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: I t 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 i s - 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 t h e i r own. We have about 10 men a l l t o l d but they don't a l l come at once. But we have about 10 men and according to (S) that i s really to something because i t i s mostly women that come out f o r exercise. Men don't normally come out. KIM: Why do you think that i s ? M: I don't know, I guess maybe they might think i t ' s s i s s y f i e d . They go down s t a i r s and l i f t iron and what have you, you know and use the bicycles and s t u f f l i k e that, that i s more manly. But to exercise and to be with a bunch of women- t h i s i s why I'm r e a l l y surprised you know at the ones who do show up. KIM: Well I think that's b a s i c a l l y i t . OB: Tape c l i c k s o f f . KIM: Go ahead and say that. M: What?  197  KIM: That social s t u f f . What you just said. That you think i t i s 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 o f f i c e on the 26th July/89. Our interview took approx 90 mins. KIM: What i s health promotion or wellness to you, how would you define it? PROF: Health promotion to me i s really strategies to promote health in the d e f i n i t i o n that health i s a means not and end, that health i s a resource for every day l i v i n g , then health promotion then becomes strategies to support people in t h e i r development of t h e i r health and increase t h e i r sense of control over t h e i r actions, over t h e i r , I think an example then i s 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 l i k e they are getting some control over the housing situation by either lobbying government or by l e t t i n g the community know how the lack of affordable housing or lack of choice in housing i s making them, giving them stress so f o r me health promotion i s increasing a personal sense of control over t h e i r future and over t h e i r well being. KIM: So that moves me into the next question which i s what i s a health promotion program to you, what i s i t about what i s i t ' s purpose? PROF: A health promotion program then i s i t ' s purpose then i s to have people feel l i k e they're increasing t h e i r own sense of control over t h e i r l i f e , over t h e i r 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 f o r health then they have to be responsible f o r the decisions around t h e i r health care, around health and then so i f i t ' s s p e c i f i c a l l y about care then they should be involved some where in the decision making and know that i t i s 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 c i t i z e n s 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 i s 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 i s a very narrow and has become in every day language a very narrow term and i t i s really s t a r t i n g to focus much more on l i 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 f r o younger or older people i t ' s s t i l l back to what I have already defined which i s what guides me i s that he issues f o r older people and that they s t a r t to look at what they want ah and then the program has a number of d i f f e r e n t a c t i v i t i e s . 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 s t a r t to define what they see as important f o r t h e i r sense of well being, so the frame work i s always back to where older people now the other part of the frame work i s to r e a l l y understand that older people see that f o r them a sense of involvement or purpose and how they define that i s important to t h e i r well being, so that that's a  200  major health issue for them. And the other aspect of i t i s I just lost my t r a i n of thought here. KIM: Goals. PROF: The other major issue i s 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 i n place f o r 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 d i f f e r e n t ways in d i f f e r e n t sections of the c i t y 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 d i f f e r e n t l y . Home Support, and the job was primarily community development working with seniors t o 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 i n i t , and the mean time the older people are saying there i s value and we would l i k e 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 r e a l l y didn't have any manpower or time f o r any people, t h e i r whole focus in prevention at that time was children and t h e i r mothers so they said these are nice ideas but we don't have any s t a f f . The older people where continually getting kin of cheesed o f f . 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 s t a f f were saying we don't know how long we can continue t h i s so as a, working with older people the Director of the Health Unit asked me a l r i g h t what would the program look l i k e i f we had i t , what would i t look l i k e f o r older people, and so I went out, he said take some time and do a b i t survey about what i s in the l i t e r a t u r e , what's available in the community. So I went and looked at the 2 that we had and then, which I wasn't d i r e c t l y involved i n , 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 i n the that area. I interviewed the professional coordinator and her view of Program E and went and looked at the whole Seattle Wallingford s t u f f and while I liked a lot of the s t u f f 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 t h i s . 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 r e a l l y look at that but I couldn't understand since I worked with people out here while developing hoe sharers why t h i s , why older people wouldn't be interested in developing t h e i r 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 l i t e r a t u r e 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 i n and she did that, took a long time before she went out in the community and d i d a whole l i t search and some of the areas that we r e a l l y looked at was the whole thing of role and meaning f o r 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 r e p l i c a t e 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 i n 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 l o t 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 l o t 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 i n , 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 l i k e you think you've got the only view but i t ' 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 s t a r t i n g 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 i s that connected to any organization? PROF: No i t ' s just advising 2 areas. It started o f f by advising Health Unit X and eventually i t progressed. The Seniors Advisory Committee i s to Health Unit on how would develop programs f o r 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 l o t of people i n the community we needed a similar kind of program to the Be Well program a more neighbourhood program. And what (A) did and by t h i s 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 b u i l t on those. Then I l e f t Health Unit X and came here, there was a vacancy f o r 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 c a l l i t wellness but i t would be health promotion and that since I was starting with nothing much I would do health promotion s i m i l a r l y 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 i s 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, i s that you see wellness as more of a c l i n i c a l thing PROF: C l i n i c a l thing, yes. KIM: And you see health promotion as PROF: The big difference i s 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 r e a l l y 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 i s to at least be expecting that older people can make decisions. In the c l 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 s t y l e , or B) need to have come to us f o r 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 d i f f e r e n t and so the assumption that I work on i s that a l l f i v e of the programs I'm involved in look d i f f e r e n t 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 i s no blood pressure, so the program comes much more from the people, the participants and looks more l i k e them, so that the f i v e are d i f f e r e n t . I'm starting one at Z and i t w i l l look l i k e they are in Z. Now the r e a l i t y you are always dealing with i s one of our problems that we are continually plagued with is some of the assumptions that I had at the beginning i s 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 t h e i r resource on the telephone, well i t ' s only worked (she laughs) at Mt Pleasant. Which i s 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 r e a l l y the people that are there and because, when I'm r e a l l y studying i t now i t ' s also because of the setting that they are i n . They are in a neighbourhood house that expects that these people a l l can  206  contribute. So besides just the seniors there i s a setting of b e l i e f or expectation that older people have s k i l l s and older people contribute and they s i t on t h e i r board and they run the finances and they make decisions about what t h e i r program looks l i k e and so i t a l l leads into that the Keeping Well Program t h e i r . I haven't been there in 5 months. And (Je) who i s one of the leaders and (K) phone me and they phone me i f they think there i s anything that I can get them, l i k e a resource person. They think they might the f i r e men to come and talk to them well do I know h i s number or I some times phone them because there i s n u t r i t i o n neighbors or some thing, but they run t h e i r whole program. Ah they sometimes lead t h e i r own exercises, some times they draw on the program there who w i l l help them with t h e i r exercises. Over on the other end of i t i s Program A which we started from nothing in the community center and they w i l l almost do every thing but they won't do the f a c i l i t a t i n g . They w i l l i f I'm going to be away and they w i l l do i t f o r a while but then they want me to do the f a c i l i t a t i n g and so f a c i l 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 s i t t i n g and I have said to them I can't come up with an exercise person, they have to f i n d 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 f e e l i n g she was on a volunteer basis f o r eight weeks. She was getting her f i t n e s s t i c k e t 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 t h i s . They want exercise, t h e y ' l l pay f o r i t they've said, one of them (H) maybe she'll t r y t h i s Wednesday, she's t e r r i b l y shy and maybe with time she'll take i t on. But she used to teach exercise and now when she's older she f e e l s she just too shy to exercise. Well we are just leaving i t now but the seniors are now saying t h e y ' l l help her with the exercises i f only she w i l l lead i t . Because they really l i k e the group and they r e a l l y l i k e 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 t h i s 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 i t ? 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 b u i l t up and they come back as they describe i t , what they come back f o r i s one another. Their friendships that they have made there which i s an important part of the whole health promotion as older people t e l l me one of t h e i r health issues i s friendships, that support, social support. I think i t has r e a l l y been worked that way ah there was a f r i e n d l y 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 l i k e 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 l o t about one another and they have created a l i t t l e community there but the part that i s kind of confusing me or making me wonder i s they don't take on, l i k e they would l i k e l i n e dancing but they can't seem to go beyond and create l i n e dancing. Now I am beginning to think myself that i t ' s because the whole environment i s in the community center and that there i s an expectation in a community center that the programs w i l l be provided because other wise they are a l l very capable and 2 or 3 of they now have gone to n u t r i t i o n neighbours which, and have been working on i t , n u t r i t i o n neighbours. At one point they wanted to do out reach and they organized a group to put together a proposal f o r New Horizons f o r out reach, a half time out reach person where the person could work with them to put on f a i r s 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 i s none of t h e i r programs are over subscribed they are a l l under subscribed for the amount of seniors that l i v e in the neighbourhood. So they wanted to find out why. In the middle of t h e i r process came along a group of professionals ah, the teacher from the community school, a couple of the s t a f f 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 t h i s 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 r e s p o n s i b i l i t y , 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 d i f f e r e n t professionals at New Horizons that every time they put a proposal in New Horizons changed the rules and kept cutting them back and f i n a l l y about f i v e 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 i s about women and men who are f a 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) i s probably the leader there, and she does try and some of them are coming l i k e (D) and there are 2 or 3 of them who worked more l i k e ( L ) who has a severe case of a r t h r i t i s i f any one they would probably say (M) i s 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 l i k e they decided that t h i s 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 f l e x i b l e 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 t h e i r own thing. So they decided t h i s summer they w i l l do t h e i r own thing and be completely unscheduled by, but by the end of the summer we w i l l me t again and we w i l l usually set up what they want to discuss f o r 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 i s not a l a i d 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 i s no schedule i t comes from what they are wanting but they w i l l make up that schedule f o r , well we have been at i t for three years so we go through d i f f e r e n t cycles. Prior to that cycle on attitudes they did quite a l o t on, they where concerned about heart attacks and how you manage that, blood pressure so we did a l o t 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 s p e c i f i c information around the body, that was last f a l l . Then sometimes what happens, we have a doctor who w i l l come and answer questions about the body and so they schedule her in when she, they are asked would they l i k e to have her and they agree and i t ' 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 i s really more around involving other people. They had a hard time getting people in that center to the center so one of t h e i r 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 t h e i r 2 goals are really to continue and they are r e a l l y interested in reaching older people and involving them, the other area i s to have a center f o r 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 i s not, and they have had the Parks Board down they have talked to them. One of the things that's happened to them i s 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 s t a f f 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 t h i s too, one i s to get more of a focus in area A and in that neighbourhood f o r seniors. They have had the Parks Board s t a f f i n , they've had the Parks Board p o l i t i c i a n s i n , they've met with them they've talked with them, there i s $65,000 in t h e i r bank account at area A but they can't seem to get, t h i s i s l i k e working with an immorphous, everybody moves around them, which i s very exhausting f o r , you now i t ' s not l i k e the housing issue that can c r y s t a l i z e 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 l o t interference by professionals who have r e a l l y i f you looked at i t f e l t that they didn't know any thing. KIM: Professionals l i k e 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 t r i a n g l e and they do a l o t of work with the youth and so they t r i e d to set up in the community schools, there i s one the Greek Program that I'm involved with but they have , they developed a, and t h i s i s 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 i s they have been so d i f f i c u l t some of the professionals that I have just l e t them do t h e i r thing and I haven't, I t r i e d at one point to change t h e i r view of how older people work but the 2 school teachers and the coordinators were so negative, they knew in fact what was needed f o r older people and i t became such a p o l i 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 f o r t h i s and t h i s was really the prevailing view of 4 or 5 of the professionals. (K) from the Elders Network t r i e d to t e l l them d i f f e r e n t l y and they just, so they took the steam right out of them and the other r e a l i t y f o r the seniors at area A i s 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, t h e y ' l l 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 i s another one that's not government r e l i a n t . They have the United Way helps and they are always fund r a i s i n g , the seniors are very active and have to work c o l l e c t i v e l y to keep that house going. But in area A the center i s there but i t i s always controlled by professionals. They can't even get right now space to do t h e i r l i n e dancing in the gym because the gym i s a l l booked up. There i s a continual argument to get them, the s t a f f 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 i s that i t i s , i t demonstrates that older people in many ways can run t h e i r own program and i t s a great net work developer. I mean for a l o t of people who are very isolated at Program A, they come in there and they make friends. There i s a number of those people over the years t h e i r spouses have died and the group has really supported them and t h e y ' l l come back and t e l l you that they have no other kind of support. So I would say that friendship i s probably the primary, where as at Program X a l o t of i s i t i s involvement and purpose. At Program A probably the most successful part of i t i s 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 f i v e and they i t b u i l t 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 a r t h r i t i s and o s t e o a r t h r i t i s , there are four or f i v e of them who are care givers who come there, i t ' s not formalized, but that's the way they l i k e i t . they s i t and talk about i t when they feel l i k e t a l k i n g about i t . Last week they where talking about how being older i s not fun, and they feel very comfortable about talking about i t . Two people there have been in and out of hospital f o r 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 f o r two years, so i t ' s r e a l l y much more the social support with that group. KIM: What would you see as things you would l i k e 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 i s to follow what they want and i f I had, what I would hope for i s 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 i s a l l about that i s t h e i r job. My job i s 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 i n . 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 l o t of people come and never come back. We have had people come who go on to other things and we w i l l 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 w i l l then go o f f 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 f o r them in Program A, but there are a l o t of people in Program A who are not going any where and nobody knows what that i s about or whether those people as the l i t e r a t u r e might t e l l you have a l o t of resources have cars come and go to Brock House have a l o t 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 t h e i r out reach was looking at was r e a l l y to go into the Safeway and ask that question of older people in the neighbourhood, what would they l i k e 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 i s just across the street and i t ' 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 r e a l l y 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 l e f t because of f r a i l n e s s 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 l i k e 66% of the population are women. So i think that's one of the demographics, i s 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 s o c i a l l y integrated. Like men w i l l 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 t h e i r own. I don't know i f men see exercise and s o c i a l i z a t i o n as t h e i r thing. I don't know and yet the men that do come to Program A r e a l l y enjoy themselves, and a number of them are married and t h e i r wives don't come, but they just l i k e to come and, one i s 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 i s French, but he comes every week and he just l i k e s 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 i s 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 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 i s i t may be just to do with males and females, males w i l l 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.  we  KIM: Another issue that seems to have emerged i s housing, do you want to comment on that? PROF: Housing across the West side even though i t ' s more focused in area B i s a great concern whether i t ' 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 s e l l t h e i r houses ah and then there's a l l theat whole they don't' know i f they s e l l t h e i r house where would they go, could, you know I have lived in t h i s house f o r 60 years and they feel a b i t 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 l o t of those people have done i s gone up to area J forums and they have taken interest and talked to (R) from, and used Program J as t h e i r resource. Now where housing isn't and issue i s in Program X because they are already in subsidized housing or  217  already in low I mean poor housing, they have i n some ways thought t h i s was t h e i r l o t I guess. So housing i s a concern on the west side period, there are the 2 aspects of i t . I f you s e l l your house there are very few alternates f o r you. You can buy some condominiums but there i s not a l o t of them and a l o t of them are very expensive. You may s e l l 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 f o r people that age they just think the whole things ridiculous, they can't seem to, you know housing i s 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 f o r 50 or 60 years and went to school there and so they see now a l l these new yuppie condominiums as they c a l l 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 l i k e housing where you , they feel there i s no neighbors any more and they , there i s some resentment at the size of the housing, but mostly there i s kind of they see t h e i r whole area changing and that change i s bothering them. But in area A you can not replace your house and another thing i s a l o t of older people l i k e 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 i s the whole values around leaving money f o r your children and t h e i r house i s often t h e i r estate, p a r t i c u l a r l y in area A. I t i s an issue at Program A they talk about i t a l o t . But there i s 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 i s more than the neighbourhood programs. I think that the neighbourhood programs have 2 or 3 purposes. One i s 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 i s a place to come into the community or i f you've lost your best friends you can e a s i l y 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 s t a f f people around there i s 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 p r i n c i p l e s . It's also a place where a number, the other purpose i s f o r 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 s t a f f 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 t e l l i n g L.T.C. s t a f f how the f e l l about receiving service and how they could t r y and influence L.T.C. about t h i s relationship and service delivery and those right o f f the top of my head. And the other big thing of  219  course i s trying to influence professionals who relate to older people to see them rather than diseases and problems i s to see older people as people with potential and skills. KIM: Are the seniors concerned about that issue? PROF: Well they talk about i t . they talk a l o t about the whole Dr who doesn't l i s t e n to them and that's where they w i l l focus in and they also w i l l talk about the whole thing with age and they talk about that aging i s 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 d i f f e r e n t 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 d i r e c t l y they w i l l say there i s no such thing, but i f you ask about attitudes they w i l l 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 l o t 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 l i k e that, they feel that they are important enough. OB: This inter view took approx 1 and a half hours. I t flowed very e a s i l y and I f e l t that she was very frank and open. The tone was relaxed.  

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