The (WHO) World Health Organization (2010) defines health as a
state of complete physical, mental and social well-being, not only the absence
of disease. The health status does not merely focus on the physical fitness or
absence of diseases such as cancer, atherosclerosis, cardiovascular disease,
arthritis, hypertension, cataracts, type 2 diabetes, osteoporosis, and
Alzheimer's disease. Rather health status stresses upon both the mental
(absence of anxiety, depression, cognitive impairment, dementia and bipolar
disorders) and physical well being of the individual (World Health Organization,
2017). According to DSM V mental health refers to complete mental states that
facilitate a person performing their social, personal and occupational
functioning appropriately (American Psychiatric Association, 2013). According
to DSM V, the health refers to the appropriate social, occupational and
personal functioning of an individual. The mental health is fundamental for
productive and fit body and physical health status (World Health Organization,
2017). The quality of life is fundamental in elderly age, which can be achieved
with the fair Health Status (Frieden, 2010).
Health consciousness is imperative in the long-run of maintaining
good health status (Hubert et al., 2011). If a person is not aware of his
health status, he may find it difficult to adopt health-related behaviour that
is needed to develop according to his/her body need (Sidik, Rampal, &
Afifi, 2004). As a result, the health status would be low. Therefore the health
consciousness is imperative for people, to develop and follow the health-related
behaviour (Hubert et al., 2011). Health consciousness refers to an individual's
comprehensive mental orientation toward his or her health, being comprised of
self-health awareness, personal responsibility, and health motivation, as
opposed to being related to a specific issue (e.g., smoking, exercise, healthy
diet) or relying on the tendency to focus attention on one's health (Ashiq,
& Asad, 2017).
In other words, health-conscious individuals are likely to be aware
of their health condition by paying attention to and reflecting on their
health, as well as being responsible for their health and motivated to improve
or maintain their health given the high level of health value (Keyes, 2002).
Also, an individual's health consciousness is closely linked to the ways of
seeking and responding to health information (Moody et al., 2016). Research has
declared that 25% older people in community areas have plenty of health
knowledge and accordingly their health consciousness recorded in the range of 40.14%
to 73% (World Health Organization, 2017).
World Health Organization (2017) revealed that older people with
low self- health awareness had approximately three times higher risk factor for
mortality than those who thought of their health as excellent. Findings of
research suggest that a person‘s health consciousness may determine whether
he/she would engage in behaviours that may promote health such as
health-enhancing behaviour or health risk behaviour, the choice is his/her own
(Keyes, 2002). A literature review has indicated health consciousness as a
predictor of a range of health attitudes and behaviours (Bircher, &
Kuruvilla, 2014). Peoples who are highly health conscious are prepared to carry
out preventive health behaviours to attain the desired health outcomes.
Health behaviours are a key determinant of an individual's health
and well-being (Leslie, & Hankey, 2015). Therefore, Smoking, excessive
alcohol consumption, poor diet and physical inactivity are risk factors of
causality and disability in developed and under developing countries (WHO,
2009). The significance of health behaviours might not be disregarded for
adults and older people because health-damaging behaviours have been associated
with greater morbidity and mortality risk in the elderly population (Bircher,
& Kuruvilla, 2014). Thus, to improve the health behaviour of the elderly,
enhancing their health knowledge with limited literacy and increasing their
confidence in maintaining their health are important (Leslie, & Hankey, 2015).
The prevalence of functional dependency among older adults is high
in both, developed and underdeveloped countries (Ashiq, & Asad, 2017) and
one of the most important aspects of health outcomes in elderly with chronic
diseases in Pakistan. Non-communicable diseases share 20.5% the burden of
diseases in Pakistan and 2.5% are dependent (WHO, 2010). A functional
dependency is the outcome of many health determinants such as older age, female
sex, low literacy, disease burden (Leslie, & Hankey, 2015). The disease burden
such as cerebrovascular and other chronic diseases, depression, vision and
cognitive impairment, lower extremities functional limitation, poor
self-perceived health, low level of physical activity, smoking and low
frequency of social contacts (Bircher, & Kuruvilla, 2014).
Studies also found a significant relationship between physical activity, functional status and health status in the elderly (Ashiq, & Asad, 2017). The research investigated that physical inactivity is also related to the more behavioural problem and unhealthy lifestyles such as smoking and insufficient diet (Bircher, & Kuruvilla, 2014). Stranges et al. (2014) suggested detailed investigations into such health risks unhealthy diet, excessive alcohol and tobacco consumption, lack of regular physical exercise, etc. – for promoting health in the elderly and for a significant change in their lifestyle.
Studies also found a significant relationship between physical activity, functional status and health status in the elderly (Ashiq, & Asad, 2017). The research investigated that physical inactivity is also related to the more behavioural problem and unhealthy lifestyles such as smoking and insufficient diet (Bircher, & Kuruvilla, 2014). Stranges et al. (2014) suggested detailed investigations into such health risks unhealthy diet, excessive alcohol and tobacco consumption, lack of regular physical exercise, etc. – for promoting health in the elderly and for a significant change in their lifestyle.
It is highlighted in the literature (Stranges et al., 2014) that
people who are more health conscious and demonstrate healthy behaviours are healthier
and functionally independent. The article could be helpful in understanding the
possible relationship between these health variables, i.e., health-related
behaviours, health consciousness and functional status to promote health status
in the elderly population (Syed, and
Kiani 2003). Apart from that, it can be beneficial to identify the determinants
of health status among the elderly (Shrivastava, Shrivastava, & Ramasamy,
2013).
Social Model of Health Status
According to DSM V, the health refers to the appropriate social,
occupational and personal functioning of an individual (American Psychiatric
Association, 2013). Multiple factors play a significant role in maintaining the
good health status in elderly age. Dahlgren and Whitehead (1991) provided an
extensive framework in the form of layers that influence the health status.
They described a social, ecological theory to health and divided the health
model into five layers. They attempt to map the relationship between the
individual, their environment, disease, and health-related behaviours to
evaluate its impact on health status (Bircher, & Kuruvilla, 2014).
Individuals are at the centre with a set of fixed genes. Surrounding them are
influences on health that can be modified.
Figure 1.Dahlgren and Whitehead Social Model of Health
The first layer illustrates the social determinants or demographics
that play a crucial role in the development of health status among elderly
people. The gender, age, religion, number of children, family size, religion,
income, family system and expenditure are imperative in developing and
maintaining health-related behaviours among elderly peoples (Germov, 2014). The
socioeconomic status indicates that if a person does not have the finance to
bear his medical or balanced diet expenditure, his health behaviour would be
negative and consequently the health status would also be poor (Chan, Lee,
& Low, 2018). Poor socioeconomic status also contributes to the development
of risky health behaviour as the primary motive of such people revolves around
basic need, i.e. diet and shelter. For them, education, health literacy, and
preventive health behaviours become a secondary motive (Pogach, & Aron,
2018). As a result, they do not focus on such health-promoting behaviours
(Leslie, & Hankey, 2015).
Similarly, the family size and income are also another cause that
falls in the categories of socioeconomic statuses, such as for a poor large
family, it is difficult to pay attention to all family members and follow
healthy health behaviours within the limited income (Kraja, Kraja, Cakerri,
& Burazeri, 2016). The number of children covers a variety of aspect regarding
health status, the people who have the single child, or no child indicate
healthy health status as taken care by their younger one (Garko, 2018). Some
contradictory studies suggest that the parents who have no child or single
child encounter more psychological or health-related problems as they get the
least attention (Martínez-García et al., 2018). The parents either depends on
their child for all the tasks or neglected by their children even for necessary
care both these factors lead to poor health status or functional dependency
among elderly (Garko, 2018). The health literacy is very uncommon in
underdeveloped countries; people are not fully aware of their health status and
proper dietary plan to follow (Leslie, & Hankey, 2015). As a result, they suffer
from poor health status and functional dependency even in late adulthood. The
people do not consult doctors and miss or skip the appointments due to health
illiteracy. For them, the regular examination is extraordinary and unnecessary
for human health (Santoni et al., 2015).
Another aspect of health literacy is that people do not understand
the medical terminologies and recall the medicine name by their colour shape
and size instead of reading labels. These signs have been found to be common
even among literate and young people as well (Santoni et al., 2015).
Furthermore, these health behaviours become rigid and inflexible in older age.
The incomplete information on medical forms also indicates their negative
health-related behaviours. Other multiple social aspects affect the health
status among the elderly population. The belief, prejudice, discrimination and
social standards play a significant role in the development of risky health
behaviour (Liu, Liu, Li, & Chen, 2015).
The second layer is ‘'personal behaviour and the ways of living''
that can promote or damage health. For example, the choice to smoke or not at
an elderly age is affected by friendship patterns and the norms of their
community (Chan, Lee, & Low, 2018). The choices to smoke or not, continuing
the morning walk and physical activity or not also indicate the health-related
behaviours of the elderly population (Ferrucci, Giallauria, & Guralnik,
2008). If they would choose appropriate
health-related behaviours such as quitting the smoke, it will enhance their
health status. Otherwise, they will suffer from low health status. The health
consciousness directs the health-related behaviours, as according to
Dutta-Bergman (2004) people who were not conscious of their health reported
more harmful health-related behaviour. It is imperative to be conscious of the
health status to develop positive health-related behaviours (Garko, 2018). For
example, if an individual is not conscious about his health status, what diet,
medication, habits and activities are harmful to his health, may not develop
good health-related behaviour (Chan, Lee, & Low, 2018). The activities,
diet medication, might be good for the health status of one person, but be
deadly alarming for another. Therefore, health consciousness is crucial and
strongly interlinked with health status.
The third layer is social and community influences, which provide
mutual support for members of the community in unfavourable conditions (Garko,
2018). The social and family support
adversely impact the health status of the elderly population such as if they do
not take care of the medication, dietary pattern, and hygienic conditions of
the elderly people, it will negatively impact their health status (Liu, Liu,
Li, & Chen, 2015). On the other hand, the physical dependency on younger is
due to a sedentary lifestyle also damage the health status as physical activity
is essential for life. A sedentary lifestyle is one the most significant aspect
of health-related behaviour, as the modern civilisation has made the human life
massively mechanical (Pogach, & Aron, 2018). People do not practice
physical activity rather they prefer indoor activities and remain seated for
several hours that adversely affected their health status (Garko, 2018). The
more the elderly population will depend on the community and family, either
financially, or functionally, their health status would be low accordingly
(Liu, Liu, Li, & Chen, 2015). The substantial body of researches indicates
a strong relationship between functional dependency and low self-esteem
(Colón-Emeric, Whitson, Pavon, & Hoenig, 2013). The social and community
influence in the form of discrimination regarding race, ethnicity, religion
also affect the health status of an elderly population. A cross-sectional study
has been conducted on 830 Chinese and 789 white respondents. The EQ-5D scale
was used to assess the health status of elderly populations. The results of the study indicated that the
Chinese people reported good health status and the white respondents reported
poor health status (Leung, Luo, So, & Quan, 2007). The white people
reported more discriminatory behaviours towards the non-ethnic group and
negative attitude as well, that affect their mental wellbeing.
The fourth layer includes structural factors: housing, working
conditions, access to services and provision of essential facilities, and
marital status (Flaskerud, & DeLilly, 2012). It covers all the
demographical characteristics of the health status (Chakravarty et al., 2012).
According to a study, the demographics characteristic found to be highly
associated with the health status of the elderly population (Liu, Liu, Li,
& Chen, 2015)). The marital status is also associated with health status,
according to this theory, in the elderly age the people become extremely
sensitive and need moral support and mental peace for maintaining a good health
status (Flaskerud, & DeLilly, 2012). The absence, isolation or death of the
partner leave a negative impact on the mental and physical health, as a person indulge
in risky health behaviour such as sitting idle, lack of attention to diet, lack
of physical activity, disorganized thoughts and dementia (Kraja, Kraja,
Cakerri, & Burazeri, 2016). The housing is very crucial in old age; the
people prefer to admit their parents in nursing homes, which negatively affect
the elderly people physical and mental health and they began to suffer from
isolation, grief, anxiety and stress (Ajzen, 1975). These symptoms lead to poor
health status (Flaskerud, & DeLilly, 2012).
The fifth layer
illustrates the socio-cultural variation and environmental conditions. For
example, one behaviour might be typical of one culture, might be considered
abnormal in another culture (Kaptein, Hughes, Murray, & Smyth, 2018). The
parental functional dependency is deemed to be accurate in collectivistic
cultures like Pakistan but considered as inappropriate in other western culture
(Flaskerud, & DeLilly, 2012).
The above model is the widely used model comprehensively explained
the health-related behaviours for a diverse health-related problem such as
functional dependency, lack of health consciousness, physical, mental illness
with the combination of multiple social determinants that leads to Health
Status, (Ajzen, 1975). The health-related behaviour may be positive or negative
that formulates the health status among elderly people. For example, the Health
Status positive increase performing positive behaviours, or actions, and
negative consequences caused by indulging in health risk behaviours etc.
(Santoni et al., 2015). The Social Health Model provides the detailed
description of all the factors that contribute to health status among elderly
people (Keyes, 2002). The current study included the related variable to
investigate its impact on the health status of elderly people in Pakistani
culture context following the above model methodology (Garko, 2018). The above model also provided the direction
regarding the methodology and analysis that would be incorporated in the study
to achieve the valid and reliable results.
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