one sitting; exercising; sleeping seven to eight hours a night; maintaining desirable weight for height; avoiding snacks; and eating breakfast regularly. Inquiry ...
Health Practices of the Elderly Poor JAMES E. LUBBEN, MPH, DSW, PHILIP G. WEILER, MD, MPH, Abstract: The purpose of the present study was to describe the health practices of the elderly poor and to examine the association between specific health practices and subsequent hospital use. Data came from a sample of 931 Medicaid elderly living in California. Smoking, limited social networks, and lack of regular exercise
Introduction There has been increasing attention paid to health promotion and disease prevention activities in the elderly because of economic, medical, and social concerns. 1,2 With increasing life expectancy, a focus on preventive measures to decrease morbidity and improve quality of life in old age has also developed.3'4 To that end, health behavior and lifestyle have become important areas of concern over the last 20 years. In the early 1970s, Belloc and Breslow5 identified a list of seven health practices which were associated with health status: having never smoked; drinking less than five drinks at one sitting; exercising; sleeping seven to eight hours a night; maintaining desirable weight for height; avoiding snacks; and eating breakfast regularly. Inquiry regarding compliance with these practices has been included in the National Health Interview Surveys (NHIS) of the adult US population in 1977, 1983, and 1985.6 7 Additional investigations have substantiated the importance of the smoking, drinking, exercise, and weight control health practices.8'0 However, other practices have seldom been found to be significant. More recently, other general health practices have also been suggested as important: maintaining a balanced diet (fruits, vegetables, and whole grains but limits on caffeine and salt intake) has been suggested as an important health practice,' 11-13 and maintaining social networks.9'1 20 Current knowledge of specific health practices for elderly persons tends to be based on studies of younger populations. One of the few studies of an aged population reported that elderly who followed good health practices were not significantly advantaged in terms of mortality rates over a five-year period.2' However, another study affirmed the value of some health practices for an elderly population when they examined mortality rates over a 17-year period,'0 finding that not smoking, getting regular exercise, maintaining weight control, and regularly eating breakfast were associated with lower mortality rates. One aim of the present study was to evaluate the relative importance of specific health practices among elderly persons; another purpose was to explore differences in health practices of the elderly poor and the general elderly population.
AND
IRIS CHI, DSW
significantly increased the odds of subsequent hospital utilization. Implications of these findings, which could benefit health promotion
intervention and treatment programs for the elderly, were discussed. (Am J Public Health 1989; 79:731-734.)
Methods
Design The data were drawn from the California Senior Survey (CSS), a random sample of elderly Medi-Cal (Medicaid) recipients from eight representative communities within California. Eligibility for Medi-Cal includes those elderly on Supplemental Security Income (SSI) or with incomes of $550.00/month (single aged) or less after accounting for medical expenses. The CSS respondents were randomly selected from files which contain the names, addresses, and other basic demographic data for all Medi-Cal recipients. Only Medi-Cal recipients 65 years of age and older were sampled. CSS respondents were interviewed face-to-face in 1982 and paid $15.00 for their participation. Hospital utilization data were also obtained for one year following the interview. Comparisons between the survey data and statewide data indicated that respondents were typical of California's Medi-Cal elderly population. More complete descriptions ofthe sampling methodology and sample characteristics have already been published.22-24 For the present analyses, data from the interview were merged with those from other sources regarding a respondent's hospital use during the year following the interview. The hospital utilization data came from Medi-Cal paid claims computer tapes which were merged with data obtained from Medicare intermediaries.25 Combining these two sources provided complete data on number of days hospitalized for 90 per cent of the original CSS sample. To assure accuracy, the computer tapes were examined for any bills submitted for hospitalizations during the follow-up year to either Medi-Cal or Medicare intermediaries on behalf of CSS respondents. To overcome any problems that might have been caused by late billing, bills submitted up to two years following the interview were reviewed. No significant differences in characteristics were noted between survey respondents with and without complete hospital data. Only respondents with complete hospital data were used for the following analyses (N=931). The study relied upon self-report data regarding health practices using a questionnaire composed of several previously described instruments.22-24 Many of the questions on health practices were taken verbatim from the original Belloc and Breslow study.5 Participants
Address reprint requests to James E. Lubben, MPH, DSW, Assistant Professor, University of California-Los Angeles, School of Social Welfare, 247 Dodd Hail, Los Angeles, CA 90024. Dr. Weiler is Professor, Department of Community Health, School of Medicine, University of California-Davis. Dr. Chi is Lecturer, Department of Social Work, University of Hong Kong. This paper, submitted to the Journal January 28, 1988, was revised and accepted for publication September 26, 1988. © 1989 American Joumal of Public Health 0090-0036/89$1.50
AJPH June 1989, Vol. 79, No. 6
Reflecting the diversity of California's ethnic population, the sample included a sizable proportion of Blacks (17 per cent), Hispanics (13 per cent), and Asians (12 per cent) although a majority (58 per cent) were White. With respect to gender, there were approximately two females for every male. The average age was 77.2 years and a large majority (61 per cent) of the respondents lived alone. With respect to health, 36 per cent rated their health as good, 41 per cent rated 731
LUBBEN, ET AL.
it fair, and 22 per cent rated it poor. More than 75 per cent of the CSS respondents had seen a doctor within the past three months. Health Practice Variables
Appendix A describes the inquiry used to construct the health practice variables analyzed in the present study. Belloc and Breslow5 definitions of health practice for smoking, sleep, limited snacks, and regular breakfasts were used. Because alcohol consumption was so limited among the elderly in the present sample (68 per cent abstained), differences in this commonly examined health practice could not be evaluated. Hospital Use Variables
Two dichotomous variables measuring hospital utilization were used: whether a respondent had been hospitalized within a year following the interview, and whether a respondent experienced a hospital stay of six or more days in the year following the interview. The figure of six days was selected because it was slightly higher than the average length of stay for all respondents (mean length of stay = 5.2 days). Analysis
The present analysis involved a series of logistic regression models examining the relation of the 12 health practices with the two indices of subsequent hospital utilization. Controlling for age and self-reported health status at the baseline interview enabled us to compare our results with those from an earlier study which used a similar analytic model. o Results Prevalence of Risk Factors
Table 1 reports the percentage of the sample who did not comply with a specific health practice. Typically, 20 per cent to 25 per cent of the sample did not comply with any given health practice. Considerably higher non-compliance rates
observed for weight control (36 per cent), never smoking (43 per cent), regular physical exercise (50 per cent), and seven to eight hours of sleep (60 per cent). Only 12 per cent of the sample drank five or more cups a day of coffee or
were
tea.
Subsequent Hospitalizations Table 1 also shows how non-compliance with a specific health practice affected the odds of subsequent hospital use. The practices with the largest odds ratios were the two smoking items. Elderly who had limited social networks were half again as likely to be hospitalized and have extended stays as were elderly with larger networks. Similarly, a minimal level of physical activity reduced the odds of any hospitalization as well as the chances for an extended stay. Although almost all of the remaining odds ratios were in the expected direction, the 95 per cent confidence interval included 1.00. Separate analysis was conducted on underweight and overweight risk factors but neither was related to hospital use. Thus, based upon the present study, the most important health practices for elderly persons appeared to be not smoking (ever or currently), maintaining social networks, and engaging in some form of physical activity at least once a week. Since a major illness could have both changed an elderly person's health practices and also caused a hospitalization, the logistic regression models were modified to include a dummy variable indicating whether a respondent had been hospitalized in the year prior to the interview. The results of these additional analyses showed that maintaining social networks (OR 1.52; CI=1.08 2.12), not ever smoking (OR 1.59; CI=1.15, 2.21), and not currently smoking (OR 1.59; CI= 1.08, 2.33) continued to be related to risk of any subsequent hospitalization. However, the importance of regular physical exercise was diminished (OR 1.29; CI=.95, 1.76). Similar results were observed when considering the risk of a stay of six days or more in a hospital: maintaining social
TABLE 1-Association between Behavioral Risk Factors and One Year All Cause Hospitalizatlon Rates
Behavioral Risk Factors Smoking Ever Current Social Networks Limited networks Physical Activities Less than weekly Whole Grains
