Discussion - Week 7Top of FormDiscussion Psychological Aspe

Discussion - Week 7
Top of Form
Discussion: Psychological Aspects of Aging
What does it mean to age “successfully”? Though the concept of
success is relative, theories of successful aging explain factors
that support individuals as they grow old. Factors such as
maintaining physical and mental activity and disengaging from
community obligations contribute to older adults’ ability to
function. As a social worker, you must understand these
supportive factors in order to address the needs of older cli ents
and their families.
As you will see in this week’s media, situations involving
Alzheimer’s or dementia, interpersonal conflict, and grief can
complicate the process of successful aging. For this Discussion,
you review one of two case studies involving an older woman
and apply a theory of successful aging to the case.
To Prepare:
· Review the Learning Resources on psychological aspects of
later adulthood, focusing on key life events and on theories of
successful aging.
· Access the Social Work Case Studies media and explore the
cases of Sara and of Francine.
· Select a theory of successful aging to apply to either Sara's or
Francine’s case.
By 01/12/2021Post a Discussion in which you:
· Identify whether you have chosen to analyze Sara's or
Francine's case for the Discussion.
· Explain key life events that have influenced Sara's or
Francine’s psychological functioning. Be sure to substantiate
what makes them key in your perspective.
· Explain how you as a social worker might apply a theory of
successful aging to Sara’s or Francine’s case. Be sure to provide

support for your strategy.
Bottom of Form
Required Readings
Zastrow, C. H., Kirst-Ashman, K. K., & Hessenauer, S. L.
(2019). Understanding human behavior and the social
environment (11th ed.). Cengage Learning.
· Chapter 15, "Psychological Aspects of Later Adulthood" (pp.
672–702)
Newell, J. M. (2019). An ecological systems framework for
professional resilience in social work practice. Social Work,
65(1), 65–73. https://doi.org/10.1093/sw/swz044
Teater, B., & Chonody, J. M. (2020). How do older adults
define successful aging? A scoping review. International
Journal of Aging and Human Development, 91(4), 599–625.
https://doi.org/10.1177/0091415019871207
Yousuf-Abramson, S. (2020). Worden’s tasks of mourning
through a social work lens. Journal of Social Work Practice, 1–
13. https://doi.org/10.1080/02650533.2020.1843146
Required MediaRequired Readings
Zastrow, C. H., Kirst-Ashman, K. K., & Hessenauer, S. L.
(2019). Understanding human behavior and the social
environment (11th ed.). Cengage Learning.
· Chapter 15, "Psychological Aspects of Later Adulthood" (pp.
672–702)
Chapter 15 Summary
The following summarizes this chapter’s content as it relates to

the learning objectives presented at the beginni ng of the
chapter. Chapter content will help prepare students to
LO 1 Describe the developmental tasks of later adulthood.
Older adults must make a number of developmental
psychological adjustments, such as adjusting to re-tirement and
lower income and to changing physical strength and health.
LO 2 Understand theoretical concepts about devel-opmental
tasks in later adulthood. Theoretical concepts about
developmental tasks in later adulthood include integrity versus
despair, shifting from work-role preoccupation to self-dif-
ferentiation; shifting from body preoccupation to body
transcendence; shifting from self-occupation to self-
transcendence; conducting a life review; the im-portance of
self-esteem; the significance of having a high level of life
satisfaction; the negative effects of low status and ageism; the
prevalence of depression and other emotional problems; and the
significance of spirituality and religion.
LO 3 Summarize theories of successful aging. Three theories of
successful aging are the activity theory, the disengagement
theory, and the social re-construction syndrome theory.
LO 4 Understand the impact of key life events on older people.
Significant life events for older people may include marriage,
death of a spouse, widowhood, remar-riage, parenting adult
children, grandparenthood, and great-grandparenthood.
LO 5 Understand guidelines for positive psycho-logical
preparations for later adulthood. Suggestions for positive
psychological preparations by younger adults for later
adulthood include engag-ing in good health practices, forming
close personal relationships, preparing financially, having
interests and hobbies, forming positive self-identities, looking
toward the future, learning to cope with crises, and learning to
cope with death.
LO 6 Summarize material on grief management and death
education.
Guidelines are presented on grief management and death
education, relating to a dying person, relating to survivors, and

becoming more comfortable with the idea of one’s own eventual
death
COMPETENCY NOTES The following identifies where
Educational Policy (EP) competencies and behaviors are
discussed in the chapter.
EP 6a. Apply knowledge of human behavior and the social
environment, person-in-environment, and other
multidisciplinary theoretical frameworks to engage with clients
and constituencies
EP 7b. Apply knowledge of human behavior and the social
environment, person-in-environment, and other
multidisciplinary theoretical frameworks in the analysis
of assessment data from clients and constituencies. (All of this
chapter.) The content of this chapter is focused on social work
students acquiring both of these behaviors in work-ing with
older persons.
EP 1. Demonstrate Ethical and Professional Behavior (p. 677,
678, 680, 684, 699, 700)
WEB RESOURCES
See this text’s companion website at www.cengagebrain.com for
learning tools such as chapter quizzes, videos, and more.
Copyright
Newell, J. M. (2019). An ecological systems framework for
professional resilience in social work practice. Social Work,
65(1), 65–73. https://doi.org/10.1093/sw/swz044
Teater, B., & Chonody, J. M. (2020). How do older adults
define successful aging? A scoping review. International
Journal of Aging and Human Development, 91(4), 599–625.
https://doi.org/10.1177/0091415019871 207

Yousuf-Abramson, S. (2020). Worden’s tasks of mourning
through a social work lens. Journal of Social Work Practice, 1–
13. https://doi.org/10.1080/02650533.2020.1843146
Required Media
Walden University, LLC. (2021). Social work case studies
[Interactive media]. https://class.waldenu.edu
· Navigate to Sara and to Francine.
Walden University, LLC. (2021). Models of grieving
Walden University, LLC. (2021). Social work case studies
· Navigate to Sara and to Francine.
Walden University, LLC. (2021). Models of grieving
Follow rubric
Initial Posting: Content
14.85 (49.5%) - 16.5 (55%)
Initial posting thoroughl y responds to all parts of the
Discussion prompt. Posting demonstrates excellent
understanding of the material presented in the Learning
Resources, as well as ability to apply the material. Posting
demonstrates exemplary critical thinking and reflection, as well
as analysis of the weekly Learning Resources. Specific and
relevant examples and evidence from at least two of the
Learning Resources and other scholarly sources are used to
substantiate the argument or viewpoint.

Follow-Up Response Postings: Content
6.75 (22.5%) - 7.5 (25%)
Student thoroughly addresses all parts of the response prompt.
Student responds to at least two colleagues in a meaningful,
respectful manner that promotes further inquiry and extends the
conversation. Response presents original ideas not already
discussed, asks stimulating questions, and further supports with
evidence from assigned readings. Post is substantive in both
length (75–100 words) and depth of ideas presented.
Readability of Postings
5.4 (18%) - 6 (20%)
Initial and response posts are clear and coherent. Few if any
(less than 2) writing errors are made. Student writes with
exemplary grammar, sentence structure, and punctuation to
convey their message.
ceciliahill
Sticky Note
You can stop reading here.
xxixxii-xxiiixxiv-xxv

• Read "How to Read Primary and Secondary Sources"
• Read "Preface" in MPLH
• Read the intro and your assigned essay in Chapter
1 of MPLH
◦ Essay 2 Ruiz
• Respond to the following prompt:
◦ After reading "How to Read Primary and
Secondary Sources," the primary source
analysis template, the Preface
to MPLH, intro to Chapter 1, and your
assigned Chapter 1 essay, reflect on your
learning in a 200- to 300-word
post. What have you learned about
Latinx history in the United States?
What have you learned about the skills
of historians? Why is it important to use
primary and secondary sources when
studying the history of marginalized
groups in the United States? How do
you think learning US history from the
perspective of Latinx people will disrupt
the master/traditional narrative of the
history of this country?
https://tcu.brightspace.com/d2l/common/dialogs/quickLink/quic
kLink.d2l?ou=191932&type=content&rcode=tcu-1395762
https://tcu.brightspace.com/d2l/common/dialogs/q uickLink/quic

Parker Family Episode 2
© 2013-2021 Walden University, LLC 1
Program Transcript
PARKER: Ever since my husband died, there's been no one to
talk to. It's just,
really, no one. And when Stephanie is home, I just feel so
alone.
FEMALE SPEAKER: What about the day center you go to? Isn't
that helping?
PARKER: I don't like it. What makes me really feel good,
though, is when I go
shopping, buying things. And my kittens. I love my cats. Oh,
have you seen
them? I have pictures. Just take a look. Look! These are so cute.
My babies.
FEMALE SPEAKER: Yes, they're very cute. And wow, you
have a lot of them.

PARKER: Oh, well, it's their home, too, not just Princess
Stephanie's.
FEMALE SPEAKER: The day program you're attending, are you
seeing a
psychiatrist there?
PARKER: Yes. Dr. Lewin.
FEMALE SPEAKER: May I ask how that's going?
PARKER: He says that I'm depressed.
FEMALE SPEAKER: In the pictures you showed me, you just
talked about the
cats, but I also saw all the things you keep around you, the
hoarding. I
understand how depressed you been since your husband passed
away. How
alone you've felt.
[SIGH] But I would like us to try and set up a plan to begin to
address the
hoarding. It's very clear that that's one of the big issues that's
affecting your
relationship with Stephanie and your life together. Can we try
that?
PARKER: I don't like it when we fight. She's still my baby, too.
Yes, I want to try.

Additional Content Attribution
MUSIC:
Music by Clean Cuts
© 2013-2021 Walden University, LLC 2
Original Art and Photography Provided By:
Brian Kline and Nico Danks
1
© 2021 Walden University, LLC. Adapted from Plummer, S. -
B., Makris, S., & Brocksen, S. M. (Eds.). (2014).
Sessions: Case histories. Laureate International Universities
Publishing.
Sara
Sara is a 72-year-old widowed Caucasian female who lives in a
two-bedroom apartment
with her 48-year-old daughter, Stephanie, and six cats. Sara and
her daughter have
lived together for the past 10 years since Stephanie returned
home after a failed

relationship and was unable to live independently. Stephanie
has a diagnosis of bipolar
disorder, and her overall physical health is good. Stephanie has
no history of treatment
for alcohol or substance use; during her teens she drank and
smoked marijuana but no
longer uses these substances. When she was 16 years old,
Stephanie was hospitalized
after her first bipolar episode. She had attempted suicide by
swallowing a handful of
Tylenol® and drinking half a bottle of vodka after her first
boyfriend broke up with her.
She has been hospitalized three times in the past 4 years when
she stopped taking her
medications and experienced suicidal ideation. Stephanie’s
current medications are
Lithium, Paxil®, Abilify®, and Klonopin®.
Stephanie recently had a brief hospitalization as a result of
depressive symptoms. She
attends a mental health drop-in center twice a week to socialize
with friends and
receives outpatient psychiatric treatment at a local mental
health clinic for medication

management and weekly therapy. She is maintaining a part-time
job at a local
supermarket where she bags groceries and is currently being
trained to become a
cashier. Stephanie has active Medicare and receives Social
Security Disability (SSD).
Sara has recently been hospitalized for depression and has some
physical issues. She
has documented high blood pressure and hyperthyroidism, she is
slightly underweight,
and she is displaying signs of dementia. Sara has no history of
alcohol or substance
use. Her current medications are Lexapro® and Zyprexa®. Sara
has Medicare and
receives Social Security benefits and a small pension. She
attends a day treatment
program for seniors that is affiliated with a local hospital in her
neighborhood. Sara
attends the program 3 days a week from 9:00 a.m. to 2:00 p.m.,
and van service is
provided free of charge.
A telephone call was made to Adult Protective Services (APS)
by the senior day
treatment social worker when Sara presented with increased

confusion, poor attention
to daily living skills, and statements made about Stephanie’s
behavior. Sara told the
social worker at the senior day treatment program that, “My
daughter is very
argumentative and is throwing all of my things out.” She
reported, “We are fighting like
cats and dogs; I’m afraid of her and of losing all my stuff.”
Home Visit
During the home visit, the APS worker observed that the living
room was very cluttered,
but that the kitchen was fairly clean, with food in the
refrigerator and cabinets. Despite
the clutter, all of the doorways, including the front door, had
clear egress. The family
lives on the first floor of the apartment building and could exit
the building without
difficulty in case of emergency. The litter boxes were also fa irly
clean, and there was no
sign of vermin in the home.
2

Publishing.
Upon questioning by the APS worker, Sara denied that she was
afraid of her daughter
or that her daughter had been physically abusive. In fact, the
worker observed that
Stephanie had a noticeable bruise on her forearm, which
appeared defensive in nature.
When asked about the bruise, Stephanie reported that she had
gotten it when her
mother tried to grab some items out of her arms that she was
about to throw out.
Stephanie admitted to throwing things out to clean up the
apartment, telling the APS
worker, “I’m tired of my mother’s hoarding.” Sara agreed with
the description of the
incident. Both Sara and Stephanie admitted to an increase in
arguing but denied
physical violence. Sara stated, “I didn’t mean to hurt Stephanie.
I was just trying to get
my things back.”
The APS worker observed that Sara’s appearance was unkempt

and disheveled, but
her overall hygiene was adequate (i.e., clean hair and clothes).
Stephanie was neatly
groomed with good hygiene. The APS worker determined that
no one was in immediate
danger to warrant removal from the home but that the family
needed a referral for
Intensive Case Management (ICM) services. It was clear there
was some conflict in the
home that had led to physical confrontations. Further, the house
had hygiene issues,
including trash and items stacked in the living room and Sara’s
room, which needed to
be addressed. The APS worker indicated in her report that if not
adequately addressed,
the hoarding might continue to escalate and create an unsafe
and unhygienic
environment, thus leading to a possible eviction or
recommendation for separation and
relocation for both women.
As the ICM worker, I visited the family to assess the situation
and the needs of the
clients. Stephanie said she was very angry with her mother and
sick of her compulsive

shopping and hoarding. Stephanie complained that they did not
have any visitors and
she was ashamed to invite friends to the home due to the
condition of the apartment.
When I asked Sara if she saw a problem with so many items
littering the apartment,
Sara replied, “I need all of these things.” Stephanie complained
that when she tried to
clean up and throw things out, her mother went outside and
brought it all back in again.
We discussed the need to clean up the apartment and make it
habitable for them to
remain in their home, based on the recommendations of the APS
worker. I also
discussed possible housing alternatives, such as senior housing
for Sara and a
supportive apartment complex for Stephanie. Sara and Stephanie
both stated they
wanted to remain in their apartment together, although
Stephanie questioned whether
her mother would cooperate with cleaning up the apartment.
Sara was adamant that
she did not want to be removed from their apartment and would
try to accept what

needed to be done so they would not be forced to move.
Sessions
Stephanie mentioned she was dissatisfied with her mother’s
psychiatric treatment and
felt she was not getting the help she needed. She reported that
her mother was very
anxious and was having difficulty sleeping, staying up until all
hours of the night, and
buying items from a televised shopping network. Sara’s
psychiatrist had recently
3
Publishing.
increased her Zyprexa prescription dosage to help reduce her
agitation and possible
bipolar disorder (as evidenced by the compulsive shopping), but
Stephanie did not feel
this had been helpful and wondered if it was contributing to her
mother’s confusion. I

asked for permission to contact both of their outpatient
treatment teams, and the
request was granted.
I then arranged to meet with Sara and her psychiatrist to discuss
her increased anxiety
and confusion and the compulsive shopping. I requested a
referral for neuropsychiatric
testing to assess possible cognitive changes or decline in
functioning. A test was
scheduled, and it indicated some cognitive deficits, but at the
end of testing, Sara told
the psychologist who administered the tests she had stopped
taking her medications for
depression. It was determined Sara’s depression and
discontinuation of medication
could have affected her test performance and it was
recommended she be retested in 6
months. I suggested a referral to a geriatric psychiatrist for
Sara, as she appeared to
need more specialized treatment. Sara’s psychologist agreed.
Because they had both stated that they did not want to be
removed from their home, I
worked with Sara and Stephanie as a team to address cleaning
the apartment. All

agreed that they would begin working together to clean the
house for 1 hour a day until
arrangements were made for additional help from family
members. To alleviate Sara’s
anxiety around throwing out the items, I suggested using three
bags for the initial
cleanup: one bag was for items she could throw out, the second
bag was for “maybes,”
and the third was for “not ready yet.” I scheduled home visits at
the designated cleanup
time to provide support and encouragement and to intervene in
disputes. I also
contacted Sara’s treatment team to inform them of the cleanup
plans and suggested
that Sara might need additional support and observation as it
progressed.
We then discussed placement for at least some of the cats,
because six seemed too
many for a small apartment. Sara and Stephanie were at first
adamant that they could
not give up their cats, but with further discussion admitted it
had become extremely
difficult to manage caring for them all. They both eventually
agreed to each keep their

favorite cat and find homes for the other four. Sara and
Stephanie made fliers and
brought them to their respective treatment programs to hand
out. Stephanie also
brought fliers about the cats to her place of employment. Three
of the four cats were
adopted within a week.
During one home visit, Stephanie pulled me aside and said she
had changed her
mind—she did not want to continue to live with her mother. She
requested that I
complete a housing application for supportive housing stating,
“I want to get on with my
life.” Stephanie had successfully completed cashier training,
and the manager of the
supermarket was pleased with her performance and was
prepared to hire her as a part-
time cashier soon. She expressed concern about how her mother
would react to this
decision and asked me for assistance telling her.
4

Publishing.
We all met together to discuss Stephanie’s decision to apply for
an apartment. Sara was
initially upset and had some difficulty accepting this decision.
Sara said she had fears
about living alone, but when we discussed senior living
alternatives, Sara was adamant
she wanted to remain in her apartment. Sara said she had lived
alone for a number of
years after her husband died and felt she could adjust again. I
offered to help her stay in
her apartment and explore home care services and programs
available that will meet
her current needs to remain at home.
An Ecological Systems Framework for
Professional Resilience in Social Work Practice
Jason M. Newell

The cumulative effects of chronic work-related stress
pervasively and persistently affect the
well-being of the human services workforce. As a preventive
measure, the ongoing commit-
ment to self-care strategies and resources is essential in
maintaining a healthy and resilient
professional quality of life. This article describes a holistic
approach to cultivating profes-
sional resilience through the ongoing practice of self-care. A
model for self-care using an
ecological systems framework with activities across the
biological, interpersonal, organiza-
tional, familial, peer-related, spiritual, and recreational aspects
of the biopsychosocial self is
proposed. Within this model, emphasis is placed on the role of
compassion satisfaction and
vicarious resilience as key components to fostering meaningful
and rewarding careers for
social workers.
KEY WORDS: burnout; compassion fatigue; compassion
satisfaction; professional resilience;
self-care
F or those who self-select the pursuit of acareer in human
services work, social workis far more than a career path, it is a
call to
embrace a professional life of deep, meaningful, and
rewarding service. Congruent with the mission,
values, and humanitarian spirit of the social work
profession (National Association of Social Work-
ers [NASW], 2009), social workers dedicate their
professional lives to providing services to those
who are poor, vulnerable, underserved, underpriv-
ileged, or otherwise suffering in some way. Yet
many social workers find themselves unprepared

for the chronic day-to-day exposure to clients and
the emotionally distressing narratives of their myr-
iad psychosocial problems.
The implications of nearly three decades of
practice research have demonstrated that the emo-
tionally challenging aspects of direct social work
practice have potentially deleterious and some-
times consequential psychological effects on social
workers themselves. This research bears particu-
lar relevance for students and newly degreed social
work professionals pursuing careers in child wel-
fare, clinical social work, disaster mental health,
military social work, and other forms of trauma-
related care (Gilin & Kauffman, 2015; D. Greene,
Mullins, Baggett, & Cherry, 2017; Knight, 2010).
It has been suggested that stress-related condi-
tions such as professional burnout, secondary trau-
matic stress, vicarious traumatization, and compas-
sion fatigue may be underestimated “occupational
hazards” for those providing social work services
(Pryce, Shackelford, & Pryce, 2007).
The wealth of evidence in the literature on
the emotional effects of direct social work prac-
tice clearly implies the need for well-developed
and comprehensive training and education on the
practice of self-care as an ongoing professional
behavior for all social workers (Strand, Abramovitz,
Layne, Robinson, & Way, 2014). Yet the emotional
and psychological risks associated with being in
direct practice with vulnerable populations, and the
essential utilization of self-care strategies to address
this important aspect of human services work, has
been an overlooked issue in the academy of social

work education (D. Greene et al., 2017; Newell &
MacNeil, 2010). The need for continued student
education, training, and professional development
at the undergraduate and graduate levels is sup-
ported by NASW, which encourages
the recognition by social work education pro-
grams of their critically important roles in edu-
cating social work students about the practice
of professional self-care by integrating such
content into existing student standards, poli-
cies, foundation and advanced curriculums,
field practicum, and assignments and projects.
(NASW, 2009, p. 270)
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Notwithstanding the evidence in the literature

supported by NASW, the most recent revision to
the Educational Policy and Accreditation Stan-
dards by the Council on Social Work Education
(CSWE) makes no direct mention of the im-
portance of including material on the practice of
self-care in social work educational curriculum or
course content (CSWE, 2015). The lack of re-
quired content on self-care as a component of
social work education at the BSW and MSW lev-
els of practice may be a contributing factor to the
higher rates of indirect trauma and professional
burnout in social work practice. It has been noted
that some social work students graduate from their
professional training programs with little knowl-
edge or ability to appropriately use self-care as an
ongoing and essential practice behavior (Gilin &
Kauffman,2015;Newell,2017).Furthermore,many
social work students may be exiting their programs
and entering the workforce without the profes-
sional training to recognize or address the signs
and symptoms of professional burnout, compas-
sion fatigue, and the indirect or vicarious effects of
trauma-related care (D. Greene et al., 2017).
To address this demanding issue for professional
social workers, this article conceptualizes profes-
sional resilience using a multidimensional frame-
work for the practice of self-care. Grounded in
the ecological systems perspective, a fundamen-
tal approach to social work practice, the proposed
framework conceptualizes self-care as a broader set
of practice behaviors pertaining to the whole per-
son, including the physical, interpersonal, organi-
zational, familial, and spiritual domains of the psy-
chosocial self. The model emphasizes self-care as
a holistic set of personal and professional prac-

tice behaviors cultivated through the positive and
growth-promoting aspects of direct practice. Fur-
thermore, the model offers an alternative approach
to addressing the inherent stress in social work
practice by focusing on the rewarding aspects of
the work, rather than the potentially deleteri-
ous effects, as described in the literature using
terms such as “vicarious traumatization,” “sec-
ondary traumatic stress,” “compassion fatigue,” and
“professional burnout.”
LITERATURE REVIEW
Conceptualizing Resilience
Human resilience is a broad construct that has been
studied as an adaptive response to stressful external
stimuli and as the use of coping skills as modera-
tors or buffers to the effects of stress and trauma
(Kent, Davis, & Reich, 2014; van der Walt, Suli-
man, Martin, Lammers, & Seedat, 2014; Yehuda,
Flory, Southwick, & Charney, 2006). The con-
cept of resilience has been examined as a func-
tion of healthy development across the life span
in infants, children, adolescents, adults, and fami-
lies (Masten, 2001; Walsh, 2015). From a cognitive
perspective, resilience has been studied as the vari-
ous ways human beings appraise, process, and regu-
late the emotions attached to external stimuli, with
emphasis on the application of positive thoughts
and emotions to promote psychological well-being
(Duckworth, Steen, & Seligman, 2005; Fredrick-
son, 2004). As a function of spirituality, resilience
has been examined in the form of demonstrating
compassion for the care of others, honoring one’s
own personal and spiritual sense of morality, and
adhering to personal and professional values and

ethics (Pyles, 2018; Seagar, 2014; Wicks & May-
nard, 2014).
The collective literature on the construct of re-
silience reveals no universally agreed-on opera-
tional definition for the term “resilience” (R. R.
Greene & Dubus, 2017). Studies examining resil-
ience often use the term interchangeably with
other similar personality attributes or character-
istics such as hardiness, personal growth, positive
adaptation, and psychological well-being (Luthar,
Cicchetti, & Becker, 2000). The American Psy-
chological Association (2016) described resilience as
“the process of adapting well in the face of adver-
sity, trauma, tragedy, threats or significant sources
of stress—such as family and relationship problems,
serious health problems or workplace and financial
stressors” (para. 1). A broader definition describes
resilience as a multifaceted process of well-being
demonstrated by “a sustained adaptive effort that
prevails despite challenge, as a bouncing back or
recovery from a challenge, and as a process of learn-
ing and growth that expands understanding, new
knowledge, and new skills” (Kent et al., 2014, p. xii).
Professional Resilience in Social Work
Practice
The term “professional resilience” has been used
across the fields of human services work including
counseling, social work, education, psychotherapy,
and other health-related professions to describe
the process by which those who provide services
66 Social Work Volume 65, Number 1 January 2020
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to vulnerable or at-risk populations thrive within
inherently stressful work conditions (Hegney, Rees,
Eley, Osseiran-Moisson, & Francis, 2015; Hernandez,
Gangsei, & Engstrom, 2007; Skovholt & Trotter-
Mathison, 2011). A recent shift in the trauma lit-
erature indicates a stronger focus on constructs
that define and measure the growth-promoting
aspects of both direct and indirect trauma expo-
sure, rather than the adverse effects. An example
of this paradigm shift from the direct trauma liter-
ature is the conceptualization of posttraumatic
growth (PTG) in comparison with posttraumatic
stress. Studies examining PTG in survivors of trau-
ma emphasize positive changes that occur in the
sense of self, in relationships with others, and in
overall quality of life perspective (Easton, Coohey,
Rhodes, & Moorthy, 2013; Saimos, Rodzik, &
Abel, 2012; Tedeschi & Calhoun, 2004).
Similar to the conceptual evolution of PTG,

research in the area of indirect trauma exposure
has revealed an attempt to bring balance to the
consequential effects of trauma treatment includ-
ing vicarious traumatization, secondary traumatic
stress, and compassion fatigue. Such constructs
have focused solely on the emotionally challeng-
ing aspects of providing direct services to those
who are vulnerable and suffering (Newell, Nelson-
Gardell, & MacNeil, 2016). In contrast, the term
“vicarious resilience” describes the process of trau-
ma recovery as having the potential to foster resil-
ience and growth, not only in the client, but in the
clinician as well (Hernandez et al., 2007). The pro-
cess of vicarious resilience occurs through prac-
tice with clients who, through the healing process,
overcome the effects of trauma through their redis-
covery of the meaningful aspects of life (Engstrom,
Hernandez, & Gangsei, 2008). A more commonly
cited term in this area is the concept of compassion
satisfaction, which refers to those aspects of human
services work that provide professional success,
reward, and fulfillment (Conrad & Keller-Guen-
ther, 2006; Stamm, 1999). Elements of compas-
sion satisfaction include positive interactions with
clients such as celebrating client successes, the for-
mation of meaningful and supportive relationships
with colleagues, the personal and spiritual satisfac-
tion of being in a helping profession, and the posi-
tive professional interactions that occur as benefits
of membership in a helping organization or com-
munity (R. R. Greene & Dubus, 2017; Kapoulistas
& Corcoran, 2015).
Self-Care as a Holistic Process: An
Ecological Systems Perspective

The term “self-care” is common to the discourse
of professional social workers; however, the actual
practice of professional self-care has not been oper-
ationalized in the ways of standardized approaches
to client treatment. Professional self-care has been
described as both a process and a defined set of
practice skills and strategies to mitigate the emo-
tionally challenging effects of providing services
to individuals, families, or communities (Skinner,
2015). Although there are no well-established or
rigorously tested models of self-care practice or
intervention, synthesis of the research literature
anecdotally suggests that the best approach to pro-
fessional resilience is an individualized combina-
tion of strategies at the personal and the organi-
zation levels (Cox & Steiner, 2013; Grise-Owens,
Miller, & Eaves, 2016; Lee & Miller, 2013). The
ecological systems perspective is useful in concep-
tualizing self-care as both a personal and a profes-
sional practice that includes aspects related to phys-
iological health behaviors, interpersonal coping,
organizational strategies, time with family and
friends, recreational activities, and spirituality (R.
R. Greene & Dubus, 2017). Taking a holistic ap-
proach to self-care allows for the application of
various strategies to promote positive professional
quality of life and an overall sense of physical and
emotional well-being.
One of the major premises of the ecological sys-
tems theory is the idea of homeostasis, which refers
to a human system’s drive and collective ability
to maintain its fundamental nature, even during
times of sudden or intense change (Payne, 2014;
Walsh, 2015). Another principle of systems the-
ory suggests that the collective system and all of its

domains naturally adapt and adjust to maintain bal-
ance or equilibrium as a homeostatic state. In terms
of self-care, as the occupational domain directly
influences all other domains in the collective sys-
tem, too much human energy expended in the
stress of work activities takes valuable energy and
resources away from other areas (positive health
behaviors, time with family and friends, spiritual
and recreational activities). Hence, maintainin g an
ongoing plan of self-care helps to create a healthy
work–life balance, which will hopefully recipro-
cally contribute to professional resilience and over-
all well-being.
Newell / An Ecological Systems Framework for Professional
Resilience in Social Work Practice 67
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Figure 1: Ecological Systems Framework for Holistic Self-Care

Given the breadth of the concept of stress and
its application across micro and macro domains,
the ecological systems perspective provides a use-
ful way of thinking about, understanding, and con-
ceptualizing the impact of stress on the personal
and professional lives of social workers. Using the
holistic approach proposed in the ecological sys-
tems framework, self-care activities across several
domains consisting of biophysiological, interper-
sonal, organizational, familial, peer-related, spiri-
tual, and recreational activities all contribute to a
comprehensive method of practice. Figure 1 pro-
vides an illustration of the ecological systems per-
spective as it applies to the practice of self-care.
Applying the Ecological Systems
Framework
Simple strategies for self-care at the individual
level range from maintaining positive health behav-
iors, spiritual activities, recreational activities, posi -
tive forms of self-expression, and connections with
family members and close friends. With regard to
the physiological domain of self-care, the most log-
ical place to begin is with “the basics” by assess-
ing activities related to physical well-being. Positive
health behaviors such as meal planning, sleep habits,
regular exercise and physical activity, and leisure
time are essential to the self-care process (Bush,
2015; Grise-Owens et al., 2016). If the need for an
improved meal plan and exercise routine is an iden-
tified area of self-care, it is best to start with one
reasonable health behavior goal or objective (that
is, avoid “pie in the sky” goals). For example, setting
a goal to complete a marathon is only reasonable
for someone who is interested in training to be a

marathon runner. Whereas completing a marathon
is a reasonable long-term goal, a reasonable short-
term goal is to make time to take a brisk walk at
least once each workday for one month. This is
also true when setting food intake and food behav-
ior goals. Healthy eating goals can be as simple as
making a commitment to buying healthy food
items and packing a sensible lunch rather than
relying on vending machines or fast food as daily
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sources of nutrition; substituting water for soda,
coffee, or other caffeinated beverages; or leaving
one’s office or computer space to eat lunch for a
mental break in a nonworking space.
Social workers understand the value and impor-
tance of human relationships in sustaining personal

and professional resilience and well-being over
time. When social workers allow work responsi-
bilities to take time away from family and friends,
there is potential for adding an additional layer of
stress from the guilt and shame that comes from
neglecting those who are most important in our
lives. In the absence of individual and familial self-
care, the chronic emotional demands of social work
practice may result in the depletion of empathy
resources to provide care for both the self and oth-
ers, leaving an empty reservoir of compassion and
empathy for families, friends, and other loved ones.
Therefore, part of the practice of self-care is to pre-
serve one’s natural empathy by valuing and pro-
tecting time for the experience of joy, laughter, and
compassion with family, friends, and other loved
ones (Giles, 2014; Pennebaker & Smyth, 2016).
The use of social support from family, pets, and
close friends has been shown to buffer the effects
of occupational stress, which ultimately contributes
to both the process of self-care and an over-
all sense of personal and professional well-being
(Grise-Owens et al., 2016; Viswesvaran, Sanchez,
& Fisher, 1999).
Organizational self-care begins with simple strat-
egies such as avoiding procrastination and allo-
cating sufficient work time to complete required
assignments, reports, or documentation. Protecting
calendar time, which for some is simply learning
to control one’s calendar, is an essential time man-
agement skill that includes not only setting reason-
able deadlines, but also actively prioritizing per-
sonal and professional obligations. Social workers
may find that taking a task-centered approach, by
setting specific goals and objectives for each day of

the week and remaining dedicated to these tasks
when possible, is useful in developing time man-
agement skills. A thorough assessment of out-of-
office calendar time (meetings, home visits, and so
on) and time spent working in the office may prove
useful in determining areas in which time may be
used more efficiently.
Before developing a formal strategy for orga-
nizational self-care, it is beneficial to examine
the impact of agency philosophy, culture, climate,
administrative structure, policies, and procedures
on agency providers and the clients they serve
(Lee & Miller, 2013). For example, the presence
of an agency culture that values the use of sup-
portive supervision, particularly for those new to
the social work profession, is useful in building
organizational resilience and professional efficacy
(Cox & Steiner, 2013). Social work practice is
grounded in the ability to develop healthy rela-
tionships through effective forms of communica-
tion. Supervisors play a vital role in cultivating pro-
fessional resilience by providing effective relational
guidance, support, education, and practice wisdom
during times of stress and professional insecurity
(Skovholt & Trotter-Mathison, 2011). Social sup-
port from professional colleagues through acts such
as assistance with administrative duties, insight into
difficult cases, or comfort during times of crisis
have been suggested as helpful for social workers
(Maslach, 2003).
Like the other components of the holistic ap-
proach to self-care, spirituality or having a spiri-
tual life is individually unique. Spirituality has been

defined as a “devotion to the immaterial part of
humanity and nature, rather than worldly things
such as possessions; an orientation to people’s reli -
gious, moral, or emotional nature” (Barker, 2014,
p. 409). Other components of spirituality include
self-perception, adherence to personal values and
ethics, belief in the existence and influence of a
higher power, and the formation of meaning-
ful relationships with others who are like-minded
subscribers to a common cause for social justice
and peace, a process described as “healing justice”
(Pyles, 2018). The presence of spirituality has been
shown to buffer the effects of workplace stress and
contribute to overall well-being as a vital source
of resilience and renewal for individuals and fam-
ilies (Brelsford & Farris, 2014; Csiernik & Adams,
2002).
The practice of spiritual self-care involves the
development and maintenance of spiritually or
religiously based practices as buffers to the effects
of personal and professional stress and as sources
of self-renewal and overall well-being. Strategies
for maintaining the religious component of spir-
itual self-care include regularly attending faith-
based services and activities, participating in reli -
gious observations and rituals, and praying (Falb
& Pargament, 2014). Nonreligiously based com-
ponents of spiritual self-care include engaging in
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Table 1: Suggestions for Developing a Comprehensive Plan of
Self-Care
Self-Care Domain Suggested Strategies
Biological Balanced diet and nutrition; adequate sleep schedule;
regular exercise regime; moderation
in alcohol use; utilization of health and mental health days to
recover from physical or
emotional illness, including grief work
Interpersonal Maintenance of professional boundaries with
clients; creating a healthy balance between
personal and professional obligations; use of adaptive rather
than maladaptive coping skills;
active engagement of anxiety associated with clients through
techniques such as
mindfulness, self-talk, and self-awareness; use of
psychotherapy, counseling, or support
group help (particularly for those with a personal trauma
history)

Organizational Seeking out organizations with missions
consistent with personal values and career
aspirations; ongoing participation in education, training, and
professional development
opportunities; active participation supervision and ongoing
mentorship; engaging in
supportive relationships with professional colleagues; setting
realistic goals and objectives
for the workday or workweek; using coffee and lunch breaks for
non-work-related
activities; participating in the celebration of client success and
fulfillment; maintaining a
realistic worldview about the impact of client work on the self
Familial Ongoing use of social support from family and close
friends; participation in nonstressful
family events; engaging in “no technology” dinners and family
time; scheduling family
and couples vacation time; participating in children’s activities,
school functions, and sports
events (if applicable); protecting time to celebrate special
family events, birthdays, or
anniversaries; scheduling nonfamily time to catch up with close
friends; caring for and
spending time with family pets
Spiritual Attending faith-based services regularly; engaging in
positive forms of self-expression and
self-revitalization, for example, yoga, meditation, philanthropic
activities
Recreational Reading; drawing; painting; sculpting; team
sports; cooking; hiking; swimming; movies;
other outdoor activities or forms of positive self-expression;
any activity personally or
professionally fostering the use of joy, humor, or laughter

positive forms of self-expression and revitalization
such as painting, journaling, inspirational reading,
and playing or listening to music (Baldwin, 1990;
Gladding, 2011; Pennebaker & Smyth, 2016). The
application of activities of healing and self-renewal
such as the use of conscious relaxation, yoga, and
meditation have also been suggested as positively
influencing spirituality and well-being (Richards,
Campenni, & Muse-Burke, 2010). Finally, recre-
ational activities that involve separation from the
work environment, particularly those involving a
deeper connection to a natural environment such
as hiking, swimming, or camping, may also be a
source of spiritual healing and self-care for some
direct practitioners (Falb & Pargament, 2014; Pearl -
man & Saakvitne, 1995). Table 1 provides sugges-
tions for developing a comprehensive plan of self-
care across the biological, interpersonal, organiza-
tional, familial, spiritual, and recreational domains
of the psychosocial self.
SOCIAL WORK PRACTICE AS SELF-CARE
Professional resilience represents the positive out-
comes of social work practice as they balance
the negative and sometimes deleterious effects of
human services work with those who are vulnera-
ble or suffering. Social workers garner the profes-
sional education, skills, and abilities to practice self-
care; it seems the biggest challenge is the pledge to
embrace self-care as an essential and ongoing prac-
tice behavior. For social workers who have dedi-
cated their lives to caring for others, practicing
self-care may seem counterintuitive. However, main-
taining a plan of professional self-care requires lit-

tle more than applying the basic theories, skills, and
knowledge used to facilitate consumers through
the process of case management and treatment
planning. Therefore, training in the practice of self-
care becomes a matter of commitment and culti-
vation. For example, fundamental to the practice
of social work is the assessment of human behavior
as it interfaces with the social environment; para-
doxically, this core competency can be applied to
the practitioner to gain valuable insights into both
personal and professional patterns of behavior.
Other mainstays of social work practice, such as the
utilization of problem-solving and task-centered
approaches, can easily be applied when creating a
useful, functional, and ongoing plan of professional
self-care. The use of strengths-based practice can be
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used to identify areas of professional or client suc-
cess as an analytic of the positive aspects of work-
ing within human services organizations. Finally,
the use of psychosocial assessment skills to com-
prehensively examine personal and professional
areas in need of improvement may prove helpful in
determining future self-care goals and objectives.
DISCUSSION
Professional awareness of the importance of self-
care in the practice community has been acknowl-
edged and supported by NASW, defining self-care as
a core essential component to social work prac-
tice [that] reflects a choice and commitment to
become actively involved in maintaining one’s
effectiveness as a social worker in preventing
and coping with the natural, yet unwanted, con-
sequences of helping. (NASW, 2009, p. 269)
The practice of self-care has been described as
the “key to professional resilience” (Newell, 2017),
generally in the form of “professional” self-care,
which fails to acknowledge that self-care is a holis-
tic practice with domains that move beyond the
professional setting. Although there are various
recommended components to developing and
maintaining self-care, and some suggested formu-
lations for how to prepare or construct a self-
care plan, the practice and process of maintain-
ing an ongoing plan of personal and professional
self-care is subjective to the individual practitioner
(Cox & Steiner, 2013; Lee & Miller, 2013). The
term “self-care” is in many ways defining, mean-
ing the approach to this practice is specific to the
interpersonal and physical needs of the individual,

the demands of the organization, balancing family
responsibilities, and other life dimensions. There-
fore, finding the right combination of activities to
promote a healthy balance between personal and
professional obligations should be the overarch-
ing goal in developing an ongoing plan of self-
care. The ecological systems framework described
in this article proposes a practical approach to
establishing, maintaining, and articulating self-care
practices. There is adequate research on the vari-
ous approaches to the practice of self-care, but few
models of this practice have been empirically vali-
dated. This is a logical next step for future research
and training initiatives.
Social work provides the great privilege of
focusing practice and research on the well-being
of others, with commitment that is unparalleled in
other professions. The reward for providing ser-
vices to those who are poor, vulnerable, under-
served, or suffering comes in the form of gratitude
and joy in knowing our consumers’ quality of life
improves because of the work that we do (Pooler,
Wolfer, & Freeman, 2014). The breadth of research
evidence on the effects of social work practice on
practitioners themselves has led the profession to
a place of understanding and acceptance that the
cumulative stress effects of social work practice
may negatively affect provider well-being. Hence,
committing to a plan of self-care as an ongoing
practice behavior is essential for social work profes-
sionals, not only for themselves, but for the better-
ment of the consumers of their services. Our pro-
fession has lost far too many earnest social workers
dedicated to the values, mission, and humanitarian

spirit of social work to the indirect effects of trauma
and professional burnout. To address this issue, the
social work profession and the academy of social
work education have a duty to promote the ongo-
ing practice of self-care through training and con-
tinuing education as an ethical imperative to both
future and current social worker practitioners. SW
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Sciences,
University of Montevallo, 737 Main Street, Station 6180,
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Article
How Do Older Adults
Define Successful
Aging? A
Scoping Review
Barbra Teater
1
and Jill M. Chonody
2
Abstract
Successful aging is a prominent theory that describes the aging
process and the
expected activities and behaviors older adults should engage in
or exhibit to age
successfully. Although this theory is used to gauge the extent to
which older adults
are aging successfully, older adults’ experiences and
perspectives of what successful

aging means to them are missing from the theory. A five-step
scoping review frame-
work was used to explore and synthesize the existing research
that investigated
older adults’ perspectives on successful aging. Twelve main
themes were found
and ranged from the importance of social relationships and
interactions to having
a good death. Findings indicated older adults do not define
successful aging as strictly
as is found in the literature. Old age and the aging process from
the views of older
adults provide future directions for theory development and
research.
Keywords
aging, successful aging, older adults, scoping review, aging
theory
1
Department of Social Work, College of Staten Island, City
University of New York, Staten Island,
NY, USA
2
Boise State University, Boise, ID, USA
Corresponding Author:

Barbra Teater, College of Staten Island, 2800 Victory Blvd. 2A,
201, Staten Island, NY 10314, USA.
Email: [email protected]
The International Journal of Aging
and Human Development
0(0) 1–27
! The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0091415019871207
journals.sagepub.com/home/ahd
Article
The International Journal of Aging
and Human Development
2020, Vol. 91(4) 599–625
© The Author(s) 2019
Article reuse guidelines:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0091415019871207
journals. sagepub. com/ home/ ahd

600 The International Journal of Aging and Human
Development 91(4)
Aging is a socially constructed phenomenon and how it is
perceived and expe-
rienced is influenced by culture, societal expectations, and
individuals’ lived
experiences (Brooks, 2010; Chonody & Teater, 2018). Old age
has historically
been defined through governmental policies by establishing a
specific chrono-
logical age to denote an “older person” and is used to determine
eligibility for
particular services (e.g., age 67 to receive Social Security
benefits in the United
States if born after 1960). Likewise, expectations and
explanations of behaviors
of people who are classified as “older” adults have been
presented through
sociological, psychological, and gerontological theories,
including disengage-
ment theory (Cumming & Henry, 1961), productive ageing
(Bass, Caro, &
Chen, 1993), activity theory (Havighurst, 1961), healthy ageing
(White House
Conference on Ageing, 2015), successful ageing (Rowe & Kahn,
1997), and
active aging (World Health Organization, 2002). However, over
the past 15 to
20 years, successful aging has become a prominent aging
paradigm in the sub-

stantive literature, yet a close examination of successful aging
reveals that the
voices of older adults are missing. This is a significant flaw in
theory develop-
ment in that older adults’ experiences and perspectives play an
essential role in
understanding and explaining aging. Therefore, this scoping
review aims to
review the literature to explore and synthesize the existing
research that inves-
tigated older adults’ views and definitions of successful aging.
Literature Review
Theories and Frameworks of Aging
Historically, the coming of old age was seen as a time
associated with disease
and disability and as disengagement theory proposed, a period
of withdrawal or
disengagement from social interactions and activities (Cumming
& Henry,
1961). Relatedly, activity theory purports that old age is a time
when older
adults adjust, redefine, and substitute their roles and activities
in an attempt
to maintain their sense of self (Havighurst, 1961). Over time,
theorists began
rejecting these premises, and positive theories of aging that
focused on health
and activity were proposed. Productive aging is one such theory

and argues that
older adults needed to remain active and productive through
engagement in
social activities and through the production of goods and
services via paid
and volunteer employment, thus reducing their reliance on
social services
(Bass et al., 1993). The more recent concept of healthy aging,
which is defined
as “living a long productive, meaningful life and enjoying a
high quality of life”
(White House Conference on Ageing, 2015), also aims to
maximize older adults’
physical, social, and mental well-being to promote
independence and reduce
burdens on others. Yet, both of these theories fail to consider
social and
2 The International Journal of Aging and Human Development
0(0)
Teater and Chonody 601
environmental factors that contribute to the extent to which one
can age
“healthy” (Mendes, 2013).
More current aging theories, such as active aging and successful
aging, were
developed as a counter response to theories that focused on
decline, loss, and

disengagement. Active aging is a positive policy framework that
focuses on the
connection of health and activity through six determinants:
health and social
services; behavioral; personal; physical; social; and economic,
with cross-cutting
determinants of culture and gender. Active aging was developed
by the World
Health Organization (2002) as a policy framework to assist
governments in
promoting and supporting active aging, which they defined as:
[T]he process of optimizing opportunities for health,
participation, and security in
order to enhance quality of life as people age [ . . . ] The word
‘active’ refers to
continuing participation in social, economic, cultural, spiritual,
and civic affairs,
not just the ability to be physically active or to participate in
the labor force. [. . .]
Active aging aims to extend healthy life expectancy and quality
of life for all people
as they age, including those who are frail, disabled, and in need
of care. (p. 12)
Finally, successful aging is achieved when individuals exhibit
the following: (a)
low probability of disease and disability, (b) high cognitive and
physical func-
tional capacity, and (c) high social activity and engagement in
social relation-

ships (Rowe & Kahn, 1997). Many argue that this theory pushed
too far in the
other direction whereby older adults are being held to
unrealistic standards in
order to be “successful” (Foster & Walker, 2015; Martinson &
Berridge, 2015;
Morell, 2003; Rubinstein & de Medeiros, 2015; Teater &
Chonody, 2017;
Walker, 2009). Furthermore, the focus on remaining free of
disease and disabil-
ity fails to acknowledge the natural changes that occur in an
aging body (Teater
& Chonody, 2017) and implies “hostility toward ageing bodies”
(Morell, 2003,
p. 69). In addition, successful aging assumes that “through
individual choice and
effort” one can age successfully and remain physically and
socially active (Rowe
& Kahn, 1997, p. 37). This individualist view supports
reduction in governmen-
tal policies that “provide social and other supports for [older
adults] . . . and,
notably, to address the social and structural inequalities that
create illness and
disability in the first place” (Martinson & Berridge, 2015, p.
63).
Although successful aging aims to take a more positive view of
aging by focus-
ing on health promotion, activity, and the positive features of
aging, it was devel-
oped without the input of older adults’ views and experiences or
an evaluation of
the extent to which the theory’s principles and premises
adequately depict the lived
experiences of older adults. Without exploring “how the social

meanings ascribed
to aging interact with individuals’ lived experiences of the
aging process,” aging is
being socially constructed and defined by culture instead
(Brooks, 2010, p. 238).
Development 91(4)
Measuring Successful Aging
Successful aging has been used to explain the aging process but
has also been
used as the basis for determining the extent to which older
adults are aging
successfully. For example, Kim (2008) developed a 31-item
instrument to mea-
sure successful aging on a 5-point Likert-type scale (1 ¼ never;
5 ¼ always),
which was comprised of items on autonomous life, self-
realization, active par-
ticipation in life, satisfaction with children, self-acceptance,
and acceptance of
others. Phelan, Anderson, LaCroix, and Larson (2004)
developed the successful
aging questionnaire where 20 factors of successful aging,

consisting of aspects of
psychological, social, physical, and functional health, were
identified from the
existing literature where older adults rated on a 3-point Likert-
type scale how
important they believed each attribute was to successful aging
(1 ¼ not impor-
tant, 2 ¼ neutral, and 3 ¼ important). The older adults in Phelan
et al.’s study
reported that health, freedom from disability, life satisfaction,
close personal
relationships, staying active and involved, maintaining
independence, meeting
needs, adapting to aging-related changes, self-acceptance, and
mastery were
most important, which supported the successful aging theory.
Both Kim and Phelan et al.’s studies assessed successful aging
by predefining
the factors versus asking older adults to define successful aging
themselves,
which may create an inaccurate picture of reality. Hilton,
Gonzalez, Saleh,
Maitoza, and Anngela-Cole (2012) highlighted a weakness in
Phelan et al.’s
study, which is the failure to include financial security and
religiosity/spiritual-

ity; factors older adults often mention as important to their
well-being. The
potential incongruence between predefining the factors of
successful aging and
self-assessment by older adults was underscored in a mixed-
methods study
where quantitative scores on physical, social, and
psychocognitive functions
indicated lower levels of successful aging among a group of
older adults who
qualitatively considered themselves to have aged successfully
(von Faber et al.,
2001). In addition, Montross et al. (2006) found 92% of
community-dwelling
older adults aged 60 years and older to perceive themselves as
aging successfully
despite experiencing a disease or disability. Such studies point
to the need for
more open-ended measures given that the current views on
aging are not
informed by older adults’ perspectives but, rather, by what
others—often
academic researchers—think older adults need (Clarke &
Warren, 2007).

The Subjective Experience of Older Adults in Defining
Successful Aging
The incongruence found between predefined measures of
successful aging and
self-assessment may be related to variations among older adults
given they are a
heterogeneous group. Therefore, theories of aging should
incorporate differing
views of the aging experience based on gender, culture, health
status, and
other identities as such dimensions could help or hinder the
aging process
0(0)
(Martinson & Berridge, 2015). For example, older adults in non-
Western soci-
eties may not subscribe to the ideals of successful aging as they
may value
interdependence and family relations more than the promotion
of autonomy,
independence, and individual responsibility (Amin, 2017).
Moreover, accessibil-
ity to resources is not equitable, which can shape how people
age. Narrative or

life history research may be useful in further capturing how
aging is understood
among different groups of older adults, and “allow for the
examination of how
perceptions of aging may vary at different times and across the
shifting contexts
of people’s lives” (Dionigi, Horton, & Bellamy, 2011, p. 416).
Such knowledge
allows for a more accurate representation of experiences,
referred to as bio-
graphical aging, which enables older adults to adapt to or cope
with life chal-
lenges while also creating alternative meanings of the aging
process based on
experience and understanding of the self (Chapman, 2005;
Dionigi et al., 2011).
Acknowledging individual life stories allows for alternative
explanations of
aging and the aging process that can be valued and accepted
among different
groups of older adults, thus refuting the belief that all older
adults should be
held to one standard of “successful” aging.
This scoping review aims to begin this challenge by (a)
identifying any exist-
ing research that examined the perspectives of older adults on
their views of
successful aging, (b) summarizing the themes found in this
research, (c) com-
paring older adults’ views and definitions to successful aging,
and (d) providing
future directions for the conceptualization of old age and the
aging process
based on the views of older adults.

Methodology
A scoping review framework was used to explore existing
research on older
adults’ perspectives of successful aging. A scoping review is “a
form of knowl-
edge synthesis that addresses an exploratory research question
aimed at map-
ping key concepts, types of evidence, and gaps in research
related to a defined
area or field by systematically searching, selecting, and
synthesizing existing
knowledge” (Colquhoun et al., 2014, pp. 1292–1294). The aim
of a scoping
review is not to critique the methodology of the studies
reviewed but rather to
synthesize the evidence on a topic of interest (Arksey &
O’Malley, 2005).
The five steps in conducting a scoping review were followed as
described by
Levac, Colquhoun, and O’Brien (2010). The first step is to
identify the research
question, which was as follows: How do older adults define
successful aging?”
Given our interest in how participant driven research yields a
conceptualization
of successful aging, we delimited our research question to
exclude researcher-
driven ideas of successful aging. The second step in this process
was to identify
relevant studies. For this review, academic databases (Academic
Search Premier;
Abstracts in Social Gerontology; Family & Society Studies
Worldwide;
PsycINFO; Social Work Abstracts) were searched using the

following search
Development 91(4)
terms: successful aging, active aging, productive aging, healthy
aging, attitudes,
older adults. The positive aging theories of active aging,
productive aging, and
healthy aging were included in the search to review whether the
studies were
exploring successful aging in addition to these other positive
theories, for exam-
ple, asking older adults to define or provide examples of
successful aging (see
Lewis, 2013). Articles were limited to those available in
English and published
from 2002 to 2017. The search of the literature yielded 366
articles.
The third step in a scoping review is to determine whether each
of the studies
met the inclusion criteria. In addition to the parameters set
around publication
years and availability in English, the inclusion criteria included
research on
successful aging from the perspective of older adults through
open-ended ques-
tions to determine older adults’ definitions, experiences, and
perspectives of
successful aging (e.g., “What does successful aging mean to
you?”; “What is

involved in the process of successful aging?”). Articles where
the researchers
predefined successful aging were excluded, for example, when
researchers uti-
lized preexisting measures of successful aging or predefined the
possible key
elements of successful aging. Both researchers independently
reviewed all 366
abstracts identified in the search. Once this process was
complete, 56 articles
were identified for possible inclusion. The researchers
discussed this list together
and reviewed the abstracts again to resolve any uncertainties of
whether to
include or exclude the article. After this process, 42 articles
remained, and the
full articles were downloaded. Upon reviewing these articles, an
additional
12 articles were excluded primarily because upon closer
examination, it was
found that the researcher versus participants were delineating
the definition
for successful aging.
The fourth step involved charting the data or findings of the
review. For this
review, a data extraction form was created to chart the data,
which included
demographics of the sample, research design, instruments used,
questions asked,
sampling method, data analysis, and findings. The researchers
worked together
to develop this form, and then each researcher independently
extracted data
from the first two articles in the final list. This process helped
to determine

whether extraction was aligned with the research question
(Levac et al., 2010).
These extractions were discussed, and then the researchers
divided the remaining
articles for independent extraction. Once this process was
complete, researchers
discussed their extractions and once again explored how each
article aligned
with the purpose of the review. An additional eight articles were
found to be
slightly off topic; that is, the findings were focused on an
element of aging, such
as the meaning of death, but participants were not asked to
provide their per-
spective on successful aging. Thus, the final sample of articles
used in this review
was 22. Table 1 provides a summary of these studies.
The final fifth step involved collecting, summarizing, and
reporting the
results. To summarize and synthesize the findings, the
researchers each indepen-
dently reviewed all the data extraction forms and created a list
of themes found
0(0)
605
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h
e
a
lt
h
y
li
fe
st
y
le
;
th
in
k
in
g

p
o
si
ti
ve
ly
;
p
ro
m
o
ti
n
g
fa
m
il
y
a
n
d
in
te
rp
e
rs
o
n
a
l
re
la
ti
o
n

sh
ip
s;
b
u
il
d
-
in
g
u
p
fi
n
a
n
c
ia
l
re
so
u
rc
e
s;
p
re
fe
rr
e
d
li
v
in

g
a
rr
an
g
e
m
e
n
ts
C
o
ll
is
a
n
d
W
a
te
rf
ie
ld
(2
0
1
4
)
3
F
e
m

a
le
s;
3
m
al
e
s
M
e
an
a
g
e
¼
7
9
ye
a
rs
;
ra
n
g
e
:
7
5
–
9
0
E

n
g
la
n
d
C
o
m
m
u
n
it
y
d
w
e
ll
in
g
In
te
rv
ie
w
s
G
ro
u
n
d
e
d
th

e
o
ry
-o
p
e
n
c
o
d
in
g
;
a
x
ia
l
c
o
d
in
g
in
te
rv
ie
w
s;
E
x
p
lo
re

d
:
1
.
W
h
a
t
‘s
u
c
c
e
ss
fu
l
a
g
in
g
’
m
e
a
n
t
to
th
e
p
a
rt
ic

ip
a
n
ts
2
.
W
h
y
th
e
y
fe
lt
th
e
y
h
a
d
a
g
e
d
su
c
c
e
ss
fu
ll
y

U
n
d
e
rs
ta
n
d
in
g
p
a
in
;
p
e
rc
e
p
ti
o
n
s
o
f
a
g
in
g
(p
e
rc
e
p
ti

o
n
s
o
f
o
th
e
rs
;
a
tt
it
u
d
e
s
o
f
h
e
a
lt
h
c
a
re
p
ro
fe
ss
io
n
a

ls
;
d
is
a
b
il
it
y
;
a
d
a
p
ta
ti
o
n
)
(c
o
n
ti
n
u
e
d
)
7
606

T
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
A
u
th
o
r(
s)
D
e
m
o
g
ra
p
h
ic
s

D
e
si
g
n
/A
n
a
ly
se
s
Q
u
e
st
io
n
s
M
a
jo
r
T
h
e
m
e
s
(s
u
b
th
e
m

e
s)
3
.
R
e
c
o
ll
e
c
ti
o
n
o
f
p
a
in
fu
l
e
p
is
o
d
e
s
4
.
M
e
th
o

d
s
o
f
c
o
p
in
g
w
it
h
p
a
in
5
.
If
a
n
d
h
o
w
p
a
in
re
so
lv
e
d

6
.
H
o
w
th
e
y
th
o
u
g
h
t
th
a
t
p
a
in
d
if
fe
rs
w
h
e
n
yo
u
n
g
e
r

ve
rs
u
s
th
a
n
o
ld
e
r
7
.
C
u
rr
e
n
t
e
x
p
e
ri
e
n
c
e
s
w
it
h
o
f
p

a
in
,
if
a
n
y
8
.
H
o
w
th
e
ir
e
x
p
e
ri
e
n
c
e
o
f
p
a
in
c
o
m

p
a
re
d
w
it
h
th
a
t
o
f
o
th
e
r
o
ld
e
r
p
e
o
p
le
9
.
In
th
e
li
g
h

t
o
f
th
e
ir
u
n
d
e
rs
ta
n
d
in
g
o
f
su
c
c
e
ss
fu
l
a
g
in
g
,
h
o
w
th

is
m
ig
h
t
b
e
in
h
ib
it
e
d
b
y
p
a
in
D
io
n
ig
i
e
t
a
l.
(2
0
1
1
)

2
1
F
e
m
a
le
s
M
e
an
a
g
e
¼
8
3
.3
ye
a
rs
;
ra
n
g
e
:
7
5
–
9
2

M
id
d
le
c
la
ss
C
a
u
c
a
si
a
n
s
C
o
m
m
u
n
it
y
d
w
e
ll
in
g
In

-d
e
p
th
in
te
rv
ie
w
s
In
d
u
c
ti
ve
a
n
al
y
si
s
a
p
p
ro
a
c
h
;
n
a

rr
a
ti
ve
c
o
n
te
n
t
a
n
al
y
si
s
In
c
lu
d
e
d
:
1
.
D
o
yo
u
h
av
e
a

n
y
h
o
b
b
ie
s
o
r
re
g
-
u
la
r
a
c
ti
v
it
ie
s
th
a
t
y
o
u
e
n
jo
y
?

P
le
a
se
d
e
sc
ri
b
e
.
2
.
W
h
a
t
d
o
e
s
su
c
c
e
ss
fu
l
a
g
in
g
m

e
a
n
to
yo
u
?
3
.
W
h
a
t
d
o
e
s
th
e
te
rm
o
ld
m
e
a
n
to
yo
u

?
4
.
P
le
a
se
d
e
sc
ri
b
e
yo
u
r
c
u
rr
e
n
t
h
e
a
lt
h
st
a
tu
s”
(4

0
6
).
P
e
rc
e
p
ti
o
n
s
o
f
b
e
in
g
o
ld
;
d
e
fi
n
it
io
n
s
o
f
su
c
c

e
ss
fu
l
a
g
in
g
G
u
e
ll
,
S
h
e
fe
r,
G
ri
ff
in
,
a
n
d
O
g
il
v
ie
(2

0
1
6
)
1
2
F
e
m
a
le
s;
1
5
m
a
le
s
1
0
w
e
re
6
5
–
6
9
ye
a
rs
o

ld
;
7
w
e
re
7
0
–
7
4
;
1
0
w
e
re
7
5
–
8
0
N
o
rf
o
lk
,
E
n
g

la
n
d
C
o
m
m
u
n
it
y
d
w
e
ll
in
g
S
e
m
i-
st
ru
c
tu
re
d
in
te
r-
v
ie
w

;
th
e
m
a
ti
c
d
a
ta
a
n
al
y
si
s
O
p
e
n
c
o
d
in
g
sy
n
th
e
si
ze
d
in

to
c
a
te
g
o
ri
e
s
E
x
p
lo
re
d
:
e
ve
ry
d
ay
a
c
ti
v
it
ie
s
a
n
d
m

o
ti
v
a
ti
o
n
s;
li
fe
st
y
le
o
p
p
o
rt
u
n
i-
ti
e
s;
c
h
o
ic
e
a
n
d
m
o

ti
v
a
ti
o
n
s
a
c
ro
ss
th
e
se
a
so
n
s
a
n
d
th
e
ir
li
fe
c
o
u
rs
e
;
a

sp
ir
at
io
n
s
in
to
o
ld
e
r
a
g
e
A
sp
ir
a
ti
o
n
s
o
f
a
c
ti
v
e
li
v
in
g

(p
o
si
ti
ve
a
tt
i-
tu
d
e
,
k
e
e
p
in
g
b
o
d
y
a
n
d
m
in
d
a
c
ti
v
e
,

te
n
si
o
n
b
e
tw
e
e
n
st
ay
in
g
b
u
sy
a
n
d
st
ay
in
g
a
c
ti
ve
);
p
ra

c
ti
c
e
s
o
f
a
c
ti
v
e
li
v
in
g
(b
e
in
g
o
u
t
a
n
d
a
b
o
u
t,
p
u
rp
o

se
fu
l
a
c
ti
v
it
ie
s,
a
d
a
p
ti
v
e
a
c
ti
v
e
n
e
ss
);
so
c
ia
l
c
o
n
te

x
t
o
f
a
c
ti
v
e
li
v
in
g
(s
o
c
ia
l
m
o
ti
-
v
at
o
rs
a
s
fa
c
il
it
a
to

rs
,
so
c
ia
l
li
m
it
a
ti
o
n
s
a
s
b
a
rr
ie
rs
)
(c
o
n
ti
n
u
e
d
)
8

607
T
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
A
u
th
o
r(
s)
D
e
m
o
g
ra
p
h

ic
s
D
e
si
g
n
/A
n
a
ly
se
s
Q
u
e
st
io
n
s
M
a
jo
r
T
h
e
m
e
s
(s
u
b

th
e
m
e
s)
H
il
to
n
e
t
a
l.
(2
0
1
2
)
3
8
F
e
m
a
le
s;
2
2
m
a
le
s

M
e
an
a
g
e
¼
6
1
;
ra
n
g
e
:
5
0
–
8
4
L
a
ti
n
o
(a
)
W
e
st
e
rn

st
a
te
s
in
th
e
U
n
it
e
d
S
ta
te
s
F
a
c
e
-t
o
-f
ac
e
in
te
rv
ie
w
s
to

fi
ll
o
u
t
q
u
e
st
io
n
n
ai
re
(m
a
in
ly
c
lo
se
e
n
d
e
d
q
u
e
st
io
n

s)
G
ro
u
n
d
e
d
th
e
o
ry
;
d
e
sc
ri
p
-
ti
v
e
st
a
ti
st
ic
s
D
e
m
o

g
ra
p
h
ic
s
a
n
d
h
e
a
lt
h
st
a
tu
s;
P
h
e
la
n
’s
sc
a
le
o
f
su
c
c
e
ss

fu
l
a
g
in
g
;
a
n
d
“
W
h
e
n
yo
u
th
in
k
a
b
o
u
t
a
g
in
g
w
e
ll
,

w
h
at
c
o
m
e
s
to
m
in
d
?
P
le
a
se
te
ll
u
s
w
h
a
t
su
c
c
e
ss
fu
l
a

g
in
g
m
e
a
n
s
to
yo
u
.”
G
o
o
d
h
e
a
lt
h
;
in
d
e
p
e
n
d
e
n
c
e
;

st
ay
in
g
a
c
ti
v
e
a
n
d
in
vo
lv
e
d
;
fa
m
il
y
a
n
d
so
c
ia
l
re
la
ti
o
n

sh
ip
s;
se
lf
-c
a
re
;
a
c
c
e
p
ti
n
g
th
e
a
g
in
g
p
ro
c
e
ss
;
p
o
si
ti
ve

a
tt
it
u
d
e
s;
c
o
g
-
n
it
iv
e
fu
n
c
ti
o
n
in
g;
fi
n
a
n
c
ia
l
w
e
ll
-b
e

in
g
;
sp
ir
it
u
a
li
ty
a
n
d
tr
an
sc
e
n
d
e
n
c
e
H
o
rd
e
r,
F
ra
n
d
in

,
a
n
d
L
a
rs
so
n
(2
0
1
3
)
9
F
e
m
a
le
s;
1
5
m
a
le
s
M
e
an
a

g
e
¼
8
1
;
ra
n
g
e
:
7
7
–
9
0
W
e
st
e
rn
S
w
e
d
e
n
C
o
m
m
u

n
it
y
d
w
e
ll
in
g
In
d
iv
id
u
a
l
in
te
rv
ie
w
s
C
o
n
te
n
t
a
n
al
y
si
s

E
x
p
lo
re
d
th
o
u
g
h
ts
a
n
d
fe
e
li
n
g
s
re
la
t-
e
d
to
su
c
c
e
ss

fu
l
a
g
in
g;
o
p
e
n
in
g
q
u
e
st
io
n
:
“
P
le
as
e
te
ll
m
e
w
h
a
t
su
c

c
e
ss
fu
l
a
g
in
g
m
e
a
n
s
to
yo
u
.”
(3
)
S
e
lf
-r
e
sp
e
c
t
th
ro
u
g
h

a
b
il
it
y
to
k
e
e
p
fe
ar
o
f
fr
a
il
ty
a
t
a
d
is
ta
n
c
e
(h
av
in
g
su
ff

ic
ie
n
t
b
o
d
il
y
re
so
u
rc
e
s
fo
r
se
c
u
ri
ty
a
n
d
o
p
p
o
rt
u
n
it

y
);
st
ru
c
tu
re
s
th
a
t
p
ro
m
o
te
se
c
u
ri
ty
a
n
d
o
p
p
o
rt
u
n
it
ie
s

(s
a
ti
sf
a
c
-
ti
o
n
w
it
h
o
n
e
’s
fi
n
a
n
c
ia
l
si
tu
at
io
n
;
se
c
u
ri

ty
a
n
d
o
p
p
o
rt
u
n
it
ie
s
in
th
e
c
lo
se
st
c
o
n
te
x
t)
;
fe
e
li
n

g
v
a
lu
a
b
le
in
re
la
ti
o
n
to
th
e
o
u
ts
id
e
w
o
rl
d
(f
e
e
li
n
g
n

o
ti
c
e
d
a
n
d
a
p
p
re
c
ia
te
d
in
so
c
ia
l
re
la
ti
o
n
s;
e
n
g
a
g
e
m

e
n
t
in
a
c
ti
v
it
ie
s
th
a
t
p
ro
v
id
e
p
le
a
su
re
o
r
b
e
n
e
fi
t)
;
c

h
o
o
si
n
g
g
ra
ti
tu
d
e
in
st
e
a
d
o
f
w
o
rr
ie
s
(c
h
o
se
g
ra
ti
tu
d
e

fo
r
n
o
t
b
e
in
g
a
s
b
a
d
a
s
o
th
e
rs
;
d
e
n
y
in
g
d
if
fi
c
u
lt
ie
s;

a
c
c
e
p
ti
n
g
th
in
g
s
yo
u
c
a
n
n
o
t
c
h
a
n
g
e
)
H
su
(2
0
0
7

)
4
8
.1
%
fe
m
a
le
;
5
1
.9
%
m
al
e
(N
¼
5
9
4
)
3
0
.3
%
w
e
re

6
5
–
6
9
ye
a
rs
;
2
4
.7
%
w
e
re
7
0
–
7
4
;
2
4
.8
%
w
e
re

7
5
–
7
9
;
2
0
.2
%
w
e
re
8
0
þ
T
a
iw
a
n
C
o
m
m
u
n
it
y
d
w

e
ll
in
g
S
u
rv
e
y
s
c
o
n
d
u
c
te
d
v
ia
fa
c
e
-t
o
-f
ac
e
in
te
rv
ie
w
s

C
o
n
te
n
t
a
n
al
y
si
s;
fa
c
to
r
a
n
al
y
si
s
2
3
p
re
d
e
te
rm
in
e

d
it
e
m
s
a
b
o
u
t
su
c
-
c
e
ss
fu
l
a
g
in
g
a
n
d
“
W
h
a
t
d
o
yo
u

th
in
k
a
re
th
e
e
ss
e
n
ti
a
l
c
o
m
p
o
-
n
e
n
ts
o
f
a
n
id
e
a
l

a
n
d
sa
ti
sf
a
c
to
ry
o
ld
-a
g
e
li
fe
?”
P
h
y
si
c
a
l
h
e
a
lt
h
(4
7
.4
%

);
fa
m
il
y
a
n
d
so
c
ia
l
su
p
p
o
rt
(2
8
.7
%
);
e
c
o
n
o
m
ic
se
c
u
ri
ty

(1
7
.8
%
);
sp
ir
it
u
a
l
w
e
ll
-b
e
in
g
(1
6
.9
%
);
e
n
v
ir
o
n
m
e
n
t
a

n
d
so
c
ia
l
p
o
li
c
y
(1
1
.7
%
);
e
n
g
a
g
e
m
e
n
t
w
it
h
li
fe
(7
.5
%

)
(c
o
n
ti
n
u
e
d
)
9
608
T
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
A

u
th
o
r(
s)
D
e
m
o
g
ra
p
h
ic
s
D
e
si
g
n
/A
n
a
ly
se
s
Q
u
e
st
io
n
s

M
a
jo
r
T
h
e
m
e
s
(s
u
b
th
e
m
e
s)
Jo
p
p
e
t
a
l.
(2
0
1
5
)
N
¼

2
9
1
(1
5
1
A
m
e
ri
c
a
n
s;
1
5
5
G
e
rm
a
n
s)
;
g
e
n
d
e
r
w
a
s

n
o
t
sp
e
c
if
ie
d
U
.S
.
sa
m
p
le
¼
2
1
%
A
fr
ic
a
n
A
m
e
ri
c
a
n
;

7
%
A
si
a
n
A
m
e
ri
c
a
n
;
6
6
%
W
h
it
e
G
e
rm
a
n
sa
m
p
le
¼

1
0
0
%
W
h
it
e
A
g
e
ra
n
g
e
:
1
5
–
9
6
(1
0
3
“
y
o
u
n
g
p
e
o

p
le
”
;
9
2
“
m
id
d
le
-a
g
e
d
”;
a
n
d
9
6
“
o
ld
e
r
a
d
u
lt
s”
)
M

ix
tu
re
o
f
c
o
m
m
u
n
it
y
d
w
e
ll
in
g
a
n
d
re
si
d
e
n
-
ti
a
l
c
a

re
In
d
iv
id
u
a
l
in
te
rv
ie
w
s;
g
ro
u
n
d
e
d
th
e
o
ry
O
p
e
n
c
o
d

in
g
,
c
lu
st
e
ri
n
g
,
a
n
d
th
e
m
e
id
e
n
ti
fi
c
a
ti
o
n
1
.
W
h
a

t
is
su
c
c
e
ss
fu
l
a
g
in
g
in
yo
u
r
v
ie
w
?
2
.
W
h
a
t
is
in
vo
lv
e

d
in
th
e
p
ro
c
e
ss
o
f
su
c
c
e
ss
fu
l
a
g
in
g
?
H
e
a
lt
h
(8
1
7
%

);
so
c
ia
l
re
so
u
rc
e
s
(6
5
.7
%
);
a
c
ti
v
it
ie
s/
in
te
re
st
s
(5
5
.9
%
);
v
ir

tu
e
s/
a
tt
it
u
d
e
s/
b
e
li
e
fs
(5
1
.0
%
);
w
e
ll
-b
e
in
g
(4
9
.3
%
);
li
fe

m
a
n
a
ge
m
e
n
t/
c
o
p
in
g
(3
5
.9
%
);
fi
n
a
n
c
ia
l
re
so
u
rc
e
s
(3
1

.4
%
);
a
g
in
g
/a
g
e
a
s
a
to
p
ic
(2
5
.5
%
);
in
d
e
p
e
n
-
d
e
n
c
e
(1

7
.6
%
);
m
e
a
n
in
g
in
li
fe
(1
4
.7
%
);
g
ro
w
th
/m
a
tu
ra
ti
o
n
(1
4
.4
%
);

re
sp
e
c
t/
st
a
tu
s
(1
3
.7
%
);
e
d
u
c
a
ti
o
n
/k
n
o
w
le
d
g
e
(1
2
.1
%

);
m
ic
ro
e
n
v
ir
o
n
m
e
n
t
(9
.5
%
);
so
c
ie
ty
/m
ic
ro
e
n
v
ir
o
n
m
e
n

t
(8
.2
%
);
o
th
e
r
(2
.3
%
)
L
a
d
it
k
a
e
t
a
l.
(2
0
0
9
)
N
¼
3
9

6
7
4
.9
%
fe
m
a
le
s
D
iv
e
rs
e
p
a
rt
ic
ip
a
n
ts
,
in
c
lu
d
in
g
A
fr

ic
an
A
m
e
ri
c
a
n
s,
A
m
e
ri
c
a
n
In
d
ia
n
s,
C
h
in
e
se
,
H
is
p
a
n

ic
,
V
ie
tn
a
m
e
se
;
W
h
it
e
M
e
an
a
g
e
¼
7
1
.0
U
n
it
e
d
S
ta
te

s—
9
st
a
te
s
C
o
m
m
u
n
it
y
d
w
e
ll
in
g
4
2
fo
c
u
s
g
ro
u
p
s
C
o

n
st
an
t
c
o
m
p
a
ri
so
n
m
e
th
o
d
s
A
sk
e
d
to
p
ro
v
id
e
a
d
e
sc
ri

p
ti
o
n
o
f
“
so
m
e
o
n
e
w
h
o
yo
u
th
in
k
is
a
g
in
g
w
e
ll
”
L
iv
in

g
to
a
d
v
a
n
c
e
d
a
g
e
;
h
av
in
g
g
o
o
d
p
h
y
si
c
a
l
h
e
a
lt
h

;
h
av
in
g
a
p
o
si
ti
ve
m
e
n
ta
l
o
u
tl
o
o
k
;
b
e
in
g
c
o
g
n
it
iv
e
ly

a
le
rt
;
h
av
in
g
a
g
o
o
d
m
e
m
o
ry
;
a
n
d
b
e
in
g
so
c
ia
ll
y
in
vo
lv

e
d
L
e
w
is
(2
0
1
1
)
1
6
F
e
m
a
le
s;
1
0
m
a
le
s
1
0
0
%
A
la
sk
a

n
N
a
ti
ve
s
(A
N
)
A
g
e
ra
n
g
e
:
6
1
–
9
3
6
B
ri
st
o
l
B
ay
C
o
m

m
u
n
it
ie
s
In
te
rv
ie
w
s
th
a
t
u
ti
li
ze
d
th
e
“
e
x
p
la
n
a
to
ry
m
o

d
e
l
in
te
rv
ie
w
p
ro
-
to
c
o
l”
1
5
q
u
e
st
io
n
s
c
o
ve
re
d
th
e
se

to
p
ic
s:
“
h
o
w
A
N
E
ld
e
rs
d
e
fi
n
e
su
c
c
e
ss
fu
l
a
g
in
g
;

h
o
w
th
e
ir
a
g
in
g
p
ro
c
e
ss
a
ff
e
c
ts
th
e
ir
e
m
o
ti
o
n
a
l,
sp
ir

it
u
a
l,
F
o
u
r
e
le
m
e
n
ts
w
e
re
im
p
o
rt
a
n
t
to
e
ld
e
r-
sh
ip

(r
e
:
su
c
c
e
ss
fu
l
a
g
e
in
g
):
e
m
o
ti
o
n
a
l
w
e
ll
-b
e
in
g
;
c
o

m
m
u
n
it
y
e
n
g
a
g
e
m
e
n
t;
sp
ir
it
u
a
li
ty
;
p
h
y
si
c
a
l
h
e
a
lt

h (c
o
n
ti
n
u
e
d
)
10
609
T
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
A
u
th

o
r(
s)
D
e
m
o
g
ra
p
h
ic
s
D
e
si
g
n
/A
n
a
ly
se
s
Q
u
e
st
io
n
s
M

a
jo
r
T
h
e
m
e
s
(s
u
b
th
e
m
e
s)
(S
W
A
la
sk
a
)
C
o
m
m
u
n
it
y
d

w
e
ll
in
g
G
ro
u
n
d
e
d
th
e
o
ry
,
in
d
u
c
-
ti
v
e
a
p
p
ro
a
c
h
;
in

te
r-
ra
te
r
re
li
a
b
il
it
y
c
h
e
c
k
e
d
w
it
h
K
a
p
p
a
st
a
ti
st
ic
(M

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