Chapter 7Socioeconomic and Environmental InfluencesCopyright

Chapter 7
Socioeconomic and Environmental Influences
Copyright © 2019, by Elsevier Inc. All rights reserved.
Social status, economic conditions, and environment influence
our health and our response to illness.
One of the strongest and most consistent predictors of illness
and death is socioeconomic status.
The environment influences safety and well-being.
Introduction
2
The GI Generation commonly called the “Greatest
Generation”—born 1900 to 1924
The Silent Generation—born 1925 to 1945
The Baby Boomers—born 1946 to 1964
They shared certain experiences at similar stages of physical,
psychological, and social development that influenced the way
they perceive the world.
Age Cohorts
3
They are healthy and have resources to maintain their homes.
They have contributed to Social Security more than any other
age group because of their higher earnings.
3
Older adults receive income from five sources: Social Security,

assets, retirement, government pensions, and wages.
The age at which Social Security can be drawn is increasing
from age 65 to 67; the retirement benefit can slightly increase
for those who delay payment.
Supplemental Security Income (SSI) benefits are available for
the aged, disabled, or slightly impaired and those with few
assets and minimal income.
Income Sources
4
In peak earning years
Most married
Few have children younger than 18 still residing in the family
home.
53% are still employed.
Have completely or nearly paid for homes
Average annual income is more than $49,608.
Cohort 55–64 Years
5
5
Median income before taxes is $22,887.
Expenses related to medical care increase.
Face funeral expenses.
Veterans’ benefits are important to this age group because of
the increased risk of chronic disease and other acute health
problems.
6

Women outnumber men.
Health problems increase with age as do expenses for
prescriptions and assistive devices.
Quality of housing deteriorates.
Decreased strength and endurance reduce the ability to conduct
household chores.
7
Fastest growing segment of our population
At risk for an increase in chronic disease
Decreased ability to perform activities of daily living (ADLs )
Increased expenses for assistance, assistive devices, and
medication
Lowest annual income of all older Americans, and 10% live in
poverty
Social Security is primary income source
Cohort 85 Years and Older
8
8
In 2015, 8.8% of those age 65 or older were classified as poor
with income below the poverty level.
Affects the quality of life for older adults
Inadequate housing and diet
Delay seeking medical
Assistive aids are unaffordable luxuries.
Knowing the income level enables the nurse to direct the patient

to agencies and services to help those with limited resources.
Poverty
9
9
Shown to have a strong relationship to health risk factors
Influences earning ability and lifestyle behaviors
Greater access to wellness programs and preventive health
options
Education provides an opportunity to avoid stagnation and
isolation and adds to the enjoyment of later life (Erikson’s
seventh stage of development).
Education
10
10
Health status of older adults influences their socioeconomic
status.
80% of older adults have at least one chronic condition, 50%
have two.
44% consider their health to be excellent or very good.
Functional status is affected by chronic conditions.
This is an indicator of the adult’s ability to remain independent.
Health Status
11

11
Older Americans should review their insurance coverage often
to determine whether the coverage they have is necessary,
appropriate, and adequate.
Home, car, and life insurance
Health insurance is a necessity.
Medicare: federal health insurance program for those over 65
years old or persons of any age who are disabled or have
permanent kidney failure.
Parts A, B, and D
Insurance Coverage
12
Cost nothing for those who contributed to Medicare taxes while
working
If did not contribute to Medicare taxes while working, monthly
premium can be paid.
Home health care (including durable medical equipment)
Hospice care
Hospital inpatient stay
Mental health inpatient stays
Skilled nursing facility stay
Health Insurance:
Medicare Part A
13
For B: recipients pay a supplemental premium.
Home health services (including durable medical equipment)

Medical and other services (including inpatient doctor services
and outpatient therapies)
Outpatient mental health services and partial hospitalization for
mental health services
Outpatient hospital services
For D: must have Medicare
Prescription drug coverage
Health Insurance:
Medicare Parts B and D
14
The supplemental premium deducted from monthly Social
Security payment
14
Rules and benefits change often.
Many are confused by the paperwork, billing, and notices
regarding claims.
Medicare Part C—provides comprehensive care through a
variety of health care delivery models.
Supplemental insurance is secondary to Medicare, which is
primary.
Facts About Medicare
15
Federal and state funded, state managed program for low -
income individuals and their families
For eligible older adults residing in nursing facilities
Covers health-related care and other services not available in
the community because of their mental or physical conditions
Each state has different coverage and requirements.

Medicaid
16
You are hosting an educational Health Fair for senior citizens.
One booth answers questions on Medicare Health Insurance.
Which of the following are true statements? (Select all that
apply.)
You must be over age 65 to qualify for Medicare.
If you did not pay into Medicare, you cannot get
benefits at all.
Medicare part A covers hospitalization and
hospice care.
Medicare part D is for prescription drug coverage.
Quick Quiz!
17
17
17
Answer to Quick Quiz
ANS: C, D
18
Acquaintances, friends, and family
Schools, churches or synagogues, clubs, neighborhoods, and
towns

Act as buffers against the harmful effects that major life events
have on the health of older adults
To cope with losses of family members, friends, and a decline
in health and independence, individuals need a large social
network.
Role of Support Systems
19
19
A variety of benefits and entitlements are available to older
Americans.
Senior discounts
Subsidized housing
Supplemental Nutrition Assistance Program (SNAP)
Congregate meal sites/Meals on Wheels
Energy assistance
Veterans’ benefits
Benefits and Entitlements
20
20
Created in 1973―Amendment to the Older Americans Act
Purpose is to plan and implement social service programs at the
local level
Nutrition services through congregate meal sites and home-
delivered meals

Recreational opportunities
Chore service
Legal assistance
Transportation
Information and referral
Area Agencies on Aging
21
21
When no longer able to handle their affairs or make decisions a
conservator, guardian, or durable power of attorney may be
needed.
Conservator manages financial resources.
Does not necessarily indicate that older persons are incompetent
Guardian makes personal decisions not related to financial
matters.
Durable power of attorney is a document that names an agent to
act on behalf of a person for a specific function, like making
financial or health care decisions.
Conservators, Guardians, and
Power of Attorney
22
Environment contributes to a person’s perception of life.
Environmental factors such as adequate shelter, safety, and
comfort contribute to a person’s ability to function well.
Weather extremes can contribute to isolation.
Living in an urban or rural location affects access to services,
availability of support systems, and safety perceptions.

Environmental Influences and Geographic Location
23
An automobile is a symbol of independence.
2015—47.8 million older adults maintained their driver’s
license.
Driving is a form of independence and hard to give up.
Normal physical aging changes and effects of chronic health
conditions may require adaptations.
Each Administration on Aging (AAA ) is charged with ensuring
that transportation is available in its area.
Transportation
24
Home is a reflection of the individual, and for the older person
it signifies independence.
The home may be the only asset.
Safety can be a problem in any living situation.
A growing number of older adults are living a mobile life.
Many housing are options available for those who give up their
house.
Housing
25
25
Independent housing
Home matching programs

Living a mobile life
Retirement communities
Assisted living facilities
Board and care homes
Nursing care facilities
A segment of the older population is homeless.
Types of Housing
26
26
Elder victimization frequently goes unreported.
Often, the perpetrator of the crime is someone known to the
older adult.
Declining health and limited finances contribute to feelings of
vulnerability.
Those 85 years or older are abused and neglected at 2–3 times
their proportion of the older adult population.
90% of elder abuse and neglect cases with known perpetrator; a
family member.
Criminal Victimization
27
27
Older adults are good advocates for their own special needs and
interests.
Older adults are taking charge of their environment, their
resources, their mental and physical health, and the future of all

older adults.
The nurse’s advocacy for older adults is important for ensuring
that the older adults continue to control their lives.
Advocacy
28
Chapter 5
Cultural Influences
It is projected that by 2044 those persons from groups that have
long been counted as statistical minorities will become the
emerging majority.
Immigrant population is growing at a faster rate than that of the
native born.
Senior communities and health care facilities will need to
advance their cultural competence.
It is likely that many of these older adults will not speak the
same language as the nurse.
Diversity of the Older Adult
Population in the United States
2
Nurses are challenged to gain new awareness, knowledge, and
skills to provide culturally and linguistically appropriate care.
Culturally compassionate care reduces health disparities.
Culturally appropriate care begins with an increasing awareness
of our own beliefs and attitudes.
Conduct a cultural self-assessment

Culturally Sensitive
Gerontologic Nursing Care
3
Cultural Concepts
Culture
Enculturation
Values
Acculturation
Race
Ethnicity and ethnic identity
Ethnocentrism
Racism
Cultural conflict
4
Are grounded in culture and influenced by past experience
Magico-religious theory
Health, illness, and effectiveness of treatment are believed to be
caused by the actions of a higher power.
Health is viewed as a blessing or a reward, and illness is
viewed as a punishment.
Treatments may involve religious practices such as praying,
meditating, fasting, wearing amulets, burning candles, or
establishing family altars.
Beliefs About Health and Illness
5

The right amount of exercise, food, sleep, evacuation,
interpersonal relationships, or geophysical and metaphysical
forces in the universe
Disturbances balance results in disharmony and subsequent
illness.
Interventions aim at restoring balance.
Yin/yang theory
Hot/cold theory
Balance and Harmony
6
The body is viewed as a functioning machine.
Health is a state of optimum functioning along with the absence
of microorganisms such as bacteria or viruses.
Treatment is directed at repair or removal of the damaged part
or administration of drugs to kill or retard the growth of the
causative organism.
The Biomedical or Western Perspective
7
Time orientation
Past
Perceive present health and health problems as the result of past
actions, from a past life, from earlier in this life, or from events
and circumstances related to one’s ancestors
Present
Perceive a new health problem to need attention in the
immediate present
Future
Holders of a future orientation accept that what we do now

affects our future health.
Transcending Cultural Concepts
8
Autonomy and individual responsibility are paramount.
Identity and self-esteem are bound to the self rather than to a
group.
Decisions should be made autonomously.
The Patient Self-Determination Act (PSDA)
The Health Insurance Portability and Accountability Act
(HIPAA)
Individualist Orientation
9
An individual derives identity from affiliation with and
participation in a social group such as a family or clan.
Needs of the group are more important than the individual, and
decisions are made with consideration of the effect on the
whole.
Collectivist Orientation
10
Theory that refers to the characteristics of relationships and
behaviors toward others
High context (universalism)
A more personal relationship is expected.
Body language is more important than spoken words.
Low context (particularism)
Task oriented

Individual identity is not as important
Direct approach is expected.
Context
11
The effective nurse is careful to follow correct etiquette with
his or her patients whenever possible
Handshake
Eye contact
Interpreters
Skills
12
Patients have the right to an interpreter.
The more complex the decision making, the more important it
is to have an interpreter.
Use only those trained in medical interpretation.
Avoid using children of patients.
Speak to the patient, not the interpreter.
Interpreters
13
The nurse works in a large metropolitan hospital that provides
care for older adults of many different cultures. Discuss the
ways a nurse can provide culturally competent care.
Case Study

14
Answers will vary
14
Theory of cultural care diversity and universality—
recommended for use with the older adult population
Theorizes three modes of action for the professional nurse to
provide culturally congruent care
Cultural care preservation or maintenance
Cultural care accommodation or negotiation
Cultural care repatterning or restructuring
Leininger
15
Kleinman, Eisenberg & Good (1978)
Suggested that to provide culturally sensitive and competent
care, the gerontologic nurse explores the meaning of the health
problem from the patient’s perspective.
The Explanatory Model
16
L—Listen carefully to what the older person is saying,
including the person’s perception of the situation, desired goals,
and ideas for treatment
E—Explain your perception of the situation and the problem(s)
A—Acknowledge and discuss both the similarities and the
differences between your perceptions and goals and those of the
older person
The LEARN Model (1 of 2)

17
R—Recommend a plan of action that takes both perspectives
into account
N—Negotiate a plan that is mutually acceptable
The LEARN Model (2 of 2)
18
E—Explanation
T—Treatment
H—Healers
N—Negotiate
I—Intervention
C—Collaboration
The Ethnic Model
19
Chapter 6
Family Influences
1
Families play a significant role in the lives of most older
persons.

85% of all senior citizens will need in-home assistance at some
point in their lives.
78% of in-home care is provided by unpaid family members and
friends.
Most of the care for the older adult is provided in the home
environment.
Role and Function of Families
2
Demographic and Social Trends That Affect Family Support
Increasing aging population
Living arrangements
Disability and activity
Decrease in birth rate
Increase in employment of women
Mobility of families
Increase in number of blended families
Older adult providing as well as receiving support
State of the senior housing industry
Caregiver workplace issues
3
3
Common Late-life Family
Issues and Decisions
Most common issues and difficult decisions families face
include:
Changes in living arrangements
Nursing facility placement
Financial and legal concerns

End-of-life health care decisions
Vehicle driving issues
Family caregiving
4
Family members struggle with allowing a person to be as
independent as possible and creating a more secure
environment.
Older person views loss of independence as “being closer to the
grave.”
As long as they have the mental capacity to make decisions,
they cannot be forced to accept help.
If an older adult is resistant to accepting other living
arrangements, nurses can help families ask crucial questions and
use the answers to guide the older adult to accepting a safer
alternative.
Changes in Living Arrangements
5
5
They are more options available than long-term care facilities
including assisted living and continuing care retirement
community.
The decision to move an older family member into any type of
care facility is difficult.
Decision is filled with guilt, sadness, anxiety, doubt, and
anger—even when the older person makes the decision.
Talk with family members about the potential benefits of a care
facility.

Care Facility Placement
6
Paying for long-term care
Nurses should know about the community resources that are
available and the eligibility requirements.
Financial and legal plans are necessary when the older adult
has been diagnosed with Alzheimer’s disease or related
disorders.
Durable power of attorney
Financial and Legal Concerns
7
A useful tool to help with end-of-life planning is “Five
Wishes”:
The person I want to make health care decisions for me when I
cannot
The kind of medical treatment I want or do not want
How comfortable I want to be
How I want people to treat me
What I want my loved ones to know
End-of-Life Health Care Decisions
8
Older drivers are more likely to get into accidents, receive
traffic violations, and suffer serious injury or fatality.
Factors that contribute to increased risk are as follows: Loss of
hearing acuity, loss of visual acuity, limited mobility and
increased reaction time, medications, dementia, or mental

impairment.
Families may need assistance assessing a person’s driving
ability and following a recommendation that their relative
should limit or discontinue driving.
Issue of Driving
9
Primarily provided by the adult children of the older adult
(daughters and daughter-in-law)
Types of family caregiving: Routine care, backup care,
circumscribed care, sporadic care, dissociation
More families are faced with long-distance caregiving.
Family member with Alzheimer’s disease will require
increasing levels of support and assistance as the disease
progresses.
Caregiver’s may feel a sense of failure when placement is
necessary.
Caregiving is stressful.
Family Caregiving
10
Few families are prepared to cope with the physical, financial,
and emotional costs of caregiving.
If the caregiver is employed, work relationships may be
compromised.
Many caregivers express frustration regarding the inequality of
the contributions of their siblings.
Caregiving can also be regarded as a beneficial opportunity
where the caregiving situation demonstrates love and
commitment.
Challenges and Opportunities of Caregiving

11
Caregivers may be unprepared for their new role so attending an
educational program may help
Caregiver information needs
Understanding the family member’s medical condition
Improving coping skills
Dealing with family issues
Communicating effectively with older persons
Using community services
Long-term planning
Education to Support
Family Caregivers
12
To provide caregivers with the confidence that they need to do a
task or take an action
It is critical to give caregivers an opportunity to practice skills
in a learning environment that is nonthreatening and
psychologically safe.
Discuss the barriers caregivers may confront in the real world
and ways to overcome these barriers.
Share printed information.
Goals of Caregiver Education
13
13

Allow caregivers planned time away from their caregiving role.
Benefits to the patient may include interactions with others in a
similar situation; safe, supportive environment; and activities
that will match their needs and abilities.
Care receivers benefit from caregivers being more refreshed
after a break.
Nurses can educate on and encourage respite care.
Respite Programs
14
Lack of awareness
Apprehension
Caregiver attitudes
Timing
Finances
Care receiver resistance
Energy required to use the program
Program inflexibility and bureaucracy
Barriers to Access and Use of
Respite Services
15
Caregivers get advice.
Gain knowledge about their older relatives’ medical conditions
and problems.
Share experiences and feelings.
Develop new coping strategies.
Learn about community resources and care alternatives.
Caregiver Support Groups
16

Beliefs about what is best often differ, creating family
dissension so a meeting should be held early.
Everyone who is concerned/affected by decisions should be
involved, including the older person.
Hold in a neutral setting.
Create a feeling of support and confidentiality.
Acknowledge everyone has a different relationship, and
perspectives.
Family Meetings (1 of 2)
17
Give everyone the chance to express themselves and offer
suggestions.
Keep the meeting focused on current concerns.
Focus on the positive things family members do, and encourage
everyone to be honest about their limitations.
Prepare a written plan about decisions made, what each person
will do, and when he or she will do it.
Family Meetings (2 of 2)
18
Quick Quiz!
Being a caregiver for an older adult is challenging. Name three
things that nurses can do to help and support the caregiver in
this role.
19

Possible answers:
Educate them in understanding the older adult's medical
problem.
Give them a list of community services.
Inform them of respite care options and encourage their use.
Offer to hold a family meeting to help siblings express concerns
and manage their roles.
Provide written materials.
20
Identify who is the patient and who are the family members.
Assess the family, relationships, and dynamics.
Roles, loyalties, and obligations
Dependence and independence
Caregiver stress
Working With Families of Older Adults: Considerations and
Strategies
21
Help family members communicate their concerns honestly and
positively.
21
Planning requires anticipating negative situations like
dependency, disability, incapacity, and death, and exploring
actions to be taken.
Critical time for discussion is when a family member shows
signs of deterioration or has been diagnosed with a degenerative
disease like Alzheimer’s.
Talk about “what ifs.”

Express good intentions and a willingness to listen.
Help family members communicate their concerns honestly.
Advanced Family Planning
22
A person who is excluded from decision making is more likely
to become angry, demanding, helpless, or withdrawn.
Involvement in decision making provides greater assurance that
a person will accept and adapt to a change, even if the change is
not the person’s preferred choice.
Involve the Older Person in Decisions
23
Families experience many emotions when faced with difficult
decisions and caregiving: Grief, frustration, anger, resentment,
embarrassment, or guilt.
Family members may need to adjust their perception of the ill
person.
Feelings, beliefs, and attitudes influence behavior, so address
the belief systems and feelings of family members.
Deal with feelings of guilt since it reduces objectivity and the
ability to make decisions that are best for everyone.
Nurses can discuss and reinforce the “goodness of intent”
underlying their actions when the actual action taken may turn
out not to be the best choice.
Consider Feelings
24

Take care of yourself.
Maintain contact with friends.
Caregiving to adults very stressful.
It is okay not to love the older person who needs care.
Asking for help is a sign of strength.
Caregivers have a right to set limits and to say no.
Taking regular breaks early in caregiving is not selfish.
Make caregiving decisions based on the needs of everyone
involved.
Moving a family member into a care facility can be the most
loving step to take.
Caregivers should focus on what they have done well―and
forgive themselves.
Ten Important Things to Share With Caregivers
25
Recommend this six-step model to help families problem solve:
Gather information
Formulate options
Evaluate options
Create a plan
Implement the plan
Reassess
A Decision Making Model for Families
26
Chapter 8
Health Promotion and Illness/Disability Prevention

Health promotion: the science and art of helping people change
their lifestyle to move toward a state of optimum health
Primary prevention: seeking out services and education in order
to prevent disease
Secondary prevention: detecting early disease and seeking care
before the disease progresses or symptoms become apparent
Terminology (1 of 2)
2
2
Tertiary prevention: the care of established disease; attempts to
restore the person to their highest function, minimize the
negative effects of disease, and prevent disease-related
complications
Quaternary prevention: limiting disability while maintaining
functional ability or reducing loss of function through
adaptation
Terminology (2 of 2)
3
Transtheoretical model—progression through 6 stages of
behavioral changes—precontemplation, contemplation,
preparation, action, maintenance, and termination
Health belief model—determines certain behaviors that
attributed to and prevented participation in preventive measur es
Health promotion model—presumes an active role by the
participant in developing and deciding the context in which
health behaviors will be modified

Models of Health Promotion
4
4
Patient barriers unrelated to health beliefs include: lack of
transportation, financial limitations, lack of insurance coverage,
lack of availability, language barriers, and health illiteracy
Older Adults’ Barriers to
Health Promotion
5
Primary preventive measures
Yearly well visits
Immunizations
Smoking cessation
Alcohol consumption
Polypharmacy
Bone health
Disease Prevention (1 of 2)
6
Secondary preventive measures
Annual screening recommendations for older adults should be
made on an individual basis with the use of the guidelines and
evidence-based recommendations from USPSTF.
Tertiary preventive measures

Aims to prevent or reduce long-term effects of a disease by
helping patients manage their conditions and chronic symptoms
such as-stroke, cardiopulmonary disease, chronic pain, and
cancers
Disease Prevention (2 of 2)
7
Which of the following are secondary health prevention
measures? (Select all that apply.)
A. Mammogram
B. Cardiac rehab
C. Smoking cessation class
D. Stroke rehab
E. Colonoscopy
F. Annual flu shot
Quick Quiz!
8
ANS: A, E
9
Look for potential health hazards and contributing risk factors
Utilize Gordon’s typology of 11 functional health patterns
Subjective and objective assessment of each pattern
Within each pattern, identify the aging adult’s knowledge of
health promotion, ability to manage health-promoting activities,

and value given to activities of health promotion.
Assessment for Health Promotion and Disease Prevention
10
10
Self-perception/self-concept pattern
Encompasses a sense of personal identity; body language,
attitudes, and view of self in cognitive, physical, and affective
realms; and expressions of sense of worth and emotional state
Roles/relationships pattern
Encompasses the achievement of expected developmental tasks
Health perception/health management pattern
Encompasses the perceived level of health and current
management of any health problems
Gordon’s Typology (1 of 4)
11
Nutritional/metabolic pattern
Encompasses evaluation of dietary and other nutrition-related
indicators
Coping/stress-tolerance pattern
Encompasses the client’s reserve and capacity to resist
challenges to self-integrity and his or her ability to manage
difficult situations
Cognitive/perceptual pattern
Encompasses self-management of pain, the presence of
communication difficulties, and deficits in sensory function

12
Value/belief pattern
Encompasses elements of spiritual well-being that the older
adult perceives as important for a satisfactory daily living
experience and the philosophic system that helps him or her
function within society
Activity/exercise pattern
Encompasses information related to health promotion that
encourages the older adult to achieve the recommended 30
minutes daily of physical activity on most days of the week
13
Rest/sleep pattern
Encompasses the sleep and rest patterns over a 24-hour period
and their effect on function
Sexuality/reproductive pattern
Encompasses the older adult’s behavioral expressions of sexual
identity
Elimination pattern
Encompasses bowel and bladder excretory functions
14
Involves exploring the older adult’s ideas and beliefs
concerning health care needs
Reading current literature to keep abreast of the latest specific
health promotion recommendations
Understanding of behavior change and behavior change theories
such as the theory of self-efficacy

Planning in Health Promotion and Disease Prevention
15
15
Adopt proactive stance toward an action plan for health
promotion of the older individual
Seeking activities, locations, and means for disseminating
health promotion information to a group of older adults is an
example of implementing a proactive stance.
Evaluation
Determining the effectiveness of care plan
Implementation and Evaluation in Health Promotion and
Disease Prevention
16
Nurses can provide a bridge between the theory of health
promotion and the implementation of health promotion, health
protection, and preventive services.
Use an individualized approach.
Focus on providing appropriate education both formally in
health promotion classes and informally during health care
visits.
Provide current recommendations for health promotion
activities and help older clients decide what health behaviors
they want to engage in.
Supporting Geriatric Empowerment
17

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