Geriatric Nursing 38 (2017) 485e490

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Geriatric Nursing
journal homepage: www.gnjournal.com

Feature Article

A qualitative study to examine older adults’ perceptions of health:

a r t i c l e i n f o a b s t r a c t

Article history: Older adult health is often defined in clinical terms. Research has demonstrated that many older adults
Received 13 January 2017 self-report aging successfully regardless of clinical health status. This qualitative study used claims data
Received in revised form to identify older adults on three levels of health status: healthy and active, managing diseases, or very
14 February 2017
sick, to better understand how health is defined and maintained. In total, 32 participants from two cities
Accepted 20 February 2017
were interviewed. Interviews were audio- and video-recorded and then transcribed. Thematic analysis
Available online 22 March 2017
identified five themes: disconnectedness between objective and subjective health; health defined to
include psychological and social components; resilience and coping mechanisms indicative of successful
Keywords:
Successful aging
aging; social support systems integral to health; and the goal of maintaining functioning. These results
Health of older adults indicate the importance of individual perceptions of health rather than just counts of chronic diseases.
Resilience Health management programs should provide holistic approaches to maximize health outcomes and to
Social support promote successful aging.
Ó 2017 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Defining successful aging

Interest in optimizing older adults’ health and promoting Understanding how older adults evolve and adapt to life
successful aging has increased as this population grows due to both changes is best illustrated by successful aging theories. Success-
the aging of Baby Boomers and increasing life expectancy.1 ful aging was first defined by Rowe and Kahn3,4 as the absence of
Although older adults are living longer, they often face a number disease, sound physical and cognitive functioning, and social
of health conditions and chronic diseases. Therefore, supporting engagement. However, this definition limits the number of in-
older adults is of great importance as they strive to live healthy dividuals who can be considered successful agers and is
lives, while managing their chronic conditions. The National confounded by other factors such as income and education.5,6
Council on Aging (2014) reports that 92% of older adults have at Research demonstrates that older adults rate themselves as
least one chronic disease (such as heart disease or diabetes) and having aged successfully regardless of their clinical health sta-
77% have at least two conditions.1 The ability to manage these tus.5,7,8 Therefore, other successful aging theories integrate more
conditions and adapt to associated physical or psychological psychological and social resources.9e12 For example, other
changes is essential to the comprehensive understanding of suc- theories describe how older adults capitalize on their own
cessful aging. Furthermore, older adults who are able to manage individual internal and external resources and coping mecha-
and adapt are less likely to become high health care utilizers.2 nisms.9,11 These provide them with the ability to adapt to
stressors and compensate for losses in their lives as they age.9,11
As aging advances, older adults may be able to draw increasingly
from life experiences and resources, thus life satisfaction actually
increases with age.13 Integrating social and psychological re-
* Corresponding author. Advanced Analytics, Optum, 315 E. Eisenhower Parkway,
sources provides the ability to buffer potentially harmful
Suite 315, Ann Arbor, MI 48108, United States.
E-mail address: rifky.tkatch@optum.com (R. Tkatch). stressors that arise from disease and other factors that occur with

0197-4572/ Ó 2017 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.gerinurse.2017.02.009
486 R. Tkatch et al. / Geriatric Nursing 38 (2017) 485e490

aging.14 The integration of these theories provides a broader For older adults, self-reported health also includes the ability to
definition of health for older adults. take care of and manage oneself independently. Autonomy or in-
The key concepts of successful aging include self-perception of dependence is a key driver in maintaining health and successful
health, psychological and social resources, coping mechanisms, and aging for older adults.36,37 The ability to make health decisions,
the ability to adapt to life’s changes. Thus, the health of older adults perform activities of daily living (ADLs), continue to drive, and
can be conceptualized as a dichotomy between the objective and manage medications may significantly influence how older adults
subjective perspectives. The objective aspect of health is the clinical perceive their health and well-being.38,39
or medical status, such as number of chronic conditions or diseases,
while the subjective aspect is self-reported health. Although con- Statement of purpose
ditions and diseases are integral to health, the subjective compo-
nent, or perception of health, is important to consider as well, as it The purpose of this study was to better understand how older
is a powerful predictor of mortality regardless of clinical health adults across a spectrum of health describe their perceptions of
status.15 health, and to consider how their definitions may influence pro-
Little is understood about how to integrate the subjective and grams to support health maintenance. This approach attempts to
objective aspects of health and aging into practical, cost-effective move beyond the clinical model of health and instead provides a
interventions for delivery to older adult populations. Health pro- holistic insight into what older adults consider the determinants of
gram design requires an understanding of how older adults define health and their health needs over time. This qualitative viewpoint
their health, well-being, and the programs they might consider can provide an invaluable perspective of what older adults may
helpful to support their efforts. Older adults’ perceptions of health need from their own resources, families, communities, or support
as clinical health status changes over time could help researchers systems (including health plans) to maintain their health and well-
design more effective programs to help maintain and/or improve being over time and thus consider themselves as aging successfully.
health status. Thus the focus in this study incorporates a holistic
view of health including psychological and social determinants, Methods
coping skills, and maintaining health/functionality over time.
This study was the first phase of a larger multi-phase study to
Psychological and social determinants of health better understand the health-related issues of older adults with
AARPÒ Medicare Supplement plans insured by UnitedHealthcare
Psychological determinants of health generally refer to the in- Insurance company (for New York residents, UnitedHealthcare In-
ternal domains of quality of life, including levels of stress, anxiety, surance Company of New York). These plans are offered in all 50
depression, perceived social support, and locus of control.16 Social states, Washington DC, and various US territories. Of those with fee-
determinants of health relate to social structure, environment, in- for-service Medicare coverage (an estimated 34 million Americans),
come, and access to health care.17 Coupled together the psycho- about 27% (4.2 million) purchase a Medicare Supplement (i.e.
logical and social determinants of health significantly affect the Medigap) plan to help defray the out-of-pocket expenses from co-
health outcomes and mortality of older adults.18e21 Older adults payments, coinsurance, and deductibles that Medicare does not
who report high levels of life satisfaction, strong social networks, cover in entirety. Participants were recruited for in-person in-
and low stress tend to be lower risk, are more likely to utilize terviews from Phoenix, AZ and Chicago, IL. These cities were
preventive care services, and are thus likely to accrue lower identified based on their geographic location, enrollment in an
healthcare costs.18,22,23 Older adults with high levels of depression AARP Medicare Supplement plan, frequency of research conducted
and low social support have higher healthcare utilization and in these markets, and availability of facilities to conduct the in-
therefore higher costs.21e23 terviews. The goal of this first phase was to conduct individual
The ability to cope with life changes and stressors, such as loss of interviews with older adults to better understand their perceptions
friends or family, illness, or retirement, and maintain psychological of health, determinants of health, and resources they may use to
well-being demonstrates high levels of internal resources such as maintain health as they age. This study was approved by the New
resilience. Resilience is the ability to cope with challenges and England Institutional Review Board.
adapt to the demands in a psychologically healthy way24 and is
associated with high levels of social support and better health be- Participants
haviors.8,25,26 Research has found that high levels of resilience are
also associated with adaptive coping skills, optimism, spirituality, Participants were recruited to achieve a balance across gender
and social support.26,27 and clinical health status. To obtain a diversity of health-related
Other aspects of health for older adults include social support issues, participants were selected based on their Hierarchal Con-
and the ability to maintain independence. The health benefits of dition Category (HCC) risk scores.40 HCC scores are derived from
social support for older adults are profound.19,28,29 Social support is CMS based on medical claims and represent an individual’s medical
an important resource provided by one’s social network and pro- health status. For example, an HCC score of 2 means an individual
vides the sense that one will receive care in times of need.19 Older will likely have healthcare expenditures twice as high as the
adults derive health benefits both receiving and providing social average Medicare member. The sample was divided into three
support to members of their social networks.29,30 Pathways include categories based on these HCC scores: Healthy and Active (HA)
emotional support (providing comfort), informational support (HCC, 0.50 or below), At Risk (AR) (HCC, 0.51e2.80), and Very Sick
(providing information), and instrumental support (task-oriented (VS) (HCC, above 2.80). We oversampled the AR category, since
support such as being driven to a doctor’s appointment).19 Higher older adults often have multiple chronic conditions. We subdivided
levels of social support are associated with better health behaviors, the AR category into high and low risk (based on HCC scores) to get
higher self-rated health, better adherence to lifestyle modifications, health diversity within that group.
better cognitive functioning, and less loneliness.31e33 Social The research staff worked with a marketing company to recruit
support is also considered to be a positive coping mechanism as it participants. All participants were between the ages of 65e85.
relies on external resources to assist with health, stress, and Recruiters called members and followed a scripted screener. Eligi-
emotional regulation.34,35 bility to participate in this study included confirmation of
 R. Tkatch et al. / Geriatric Nursing 38 (2017) 485e490 487

enrollment in an AARP Medicare Supplement plan. In addition, group was well-represented with 8 in the HA, 9 in the AR-Low, 8 in
potential participants (and household members) could not the AR-High, and 7 in the VS.
currently or formerly be employed by an advertising agency or a The coding team identified five distinct themes, defined below
marketing firm. Potential participants (and household members) with illustrative quotes for elaboration.
could not be current or former employees of UnitedHealthcare. A
total of 4000 individuals were randomly selected for the marketing
Thematic analysis
company to contact until they reached the goal of recruiting 40
participants. A large pool of participants was provided as it can be
1) Disconnect between objective and subjective status of health
difficult to reach participants for marketing interviews, the timing
was specific for the days of the interviews, and the study required
Participants were asked to rate their health on a scale of 1e10
specific breakdown based on the HCC scores. A total of 20 partici-
with 10 being the best health. Even though many fell into the
pants were recruited per city. Sixteen interviews were planned in
clinical category (as defined by HCC scores) of moderate to serious
each city: 4 HA, 8 AR (4 high and 4 low), and 4 VS. Other partici-
health issues, there was a pattern of higher than expected self-rated
pants were recruited as alternates and asked to fill in if someone
health. Almost all individuals with multiple chronic conditions
did not show up. Participants were paid $100 to participate in 1-h
described themselves as healthy and active, whereas many of those
interviews, which were audio- and video-recorded for transcrip-
with few to no chronic conditions rated their health lower than
tion and analysis purposes only.
expected. During the interviews it became clear that some of the
clinically healthier participants were not dealing with underlying
Data collection health issues and had poor coping mechanisms for changes
occurring in their lives (e.g., downsizing, dealing with adult chil-
A local facility was identified by the marketing research company. dren, and loss of a parent). Yet, those with multiple chronic con-
The interview room was set up in a neutral environment. The trained ditions were able to describe coping mechanisms for dealing with
moderator from the marketing firm and the participant were the conditions and/or disabilities and appeared to be more resilient to
only two individuals in the room although the research team was their social changes.
behind the one-way window. Interviews were conducted in English
using a discussion guide developed specifically for this project. “9 (health rating participant gave). I do have diabetes, but it’s under
This discussion guide (Table 1) asked questions relating to how control. Just feel that I try to take care of myself and so far have
participants defined their health, their health needs, and what they been able to. Doctor seems to be satisfied with my health.” (At Risk
felt necessary to maintain their health. The same moderator con- e High, Female, Age 75)
ducted all 32 interviews. Limited demographic information was “The only thing that bothers me is my back . I don’t think it would
collected in order to assure confidentiality. stop me from doing anything. Maybe from doing housework or
making a big meal. If I had to go out, I’d still go out. I power through
Analysis it. (At Risk e High, Female, Age 79)”
“I’ve been depressed lately. Some days are good, some days I don’t
Audio recordings were transcribed and de-identified for analysis get so much done. I just want to read and don’t want to deal with
purposes. The coding team consisted of eight members including things. I feel like I have a lot of pressure. Our house is too big.
the moderator. Thematic analysis was then conducted with a Financially, we need to move. I have trouble focusing and getting it
smaller subset of the coding team (four members). done.” (Healthy and Active, Female, Age 66)

Results 2) Health includes psychological and social well-being

Participants were between 66 and 80 years old (Mean ¼ 72). Of In describing their health, participants included details
the 32 participants 17 were female, 27 were married, 4 were wid- regarding their emotional and social well-being. This definition
owed, and 1 was living with a significant other. Each health status included how these components affected their daily lives and their

Table 1
Discussion guide.

Questions Prompts
Tell me a little about yourself. Where do you live? Who do you live with?
What does a typical “day in the life” for you look like? Do you have others that depend on you? How do you feel as you go about the
day?
How does a typical day change depending on your health? Pain, vision, hearing? On a scale of 1e10, how would you rate your health?
Tell me two-three words that describe your health.
Who supports you in all aspects of your life? People, online, agencies
What do these people provide for you?
What types of social activities do you engage in? Volunteer? Who do you spend time with?
What do you do when you need to talk about something e or when something is What types of things help you keep calm and peaceful?
bothering you?
How easy or difficult is it for you to bounce back or recover from a stressful or
difficult time?
Can you describe a good day? A bad day?
What does quality of life mean to you? What impacts this?
What types of things do you use to take care of your health? Financial, transportation, medication, personal needs?
What do you need that you currently don’t have to take care of your health or live in a Could an insurance company help with these needs?
healthy way?
How do you think your life will change in the future? Worries or fears as you grow older?
488 R. Tkatch et al. / Geriatric Nursing 38 (2017) 485e490

health. Although physical health and medical issues were part of daughter-in-law . My friend. She lives a mile from me. I can call
the description, participants viewed their health in a holistic way her and talk to her about anything. I don’t worry it might not be
reflecting quality of life, more in terms of basic needs and comforts. confidential.” (Very Sick, Female, Age 74)
“Being able to do what and when you want to do it, physically and “I don’t usually talk to others about my health, except my wife .
mentally. Basically good health.” (At Risk-Low, Male, Age 72) My wife looks for healthy stuff for her. I might have chicken and
fish. She’s gotten away from hamburgers and pasta, etc . She
“How well and comfortable one can live the remainder of their life.
makes sure I don’t slip up and order something that’s not healthy.”
All needs are met; life is enjoyable, sense of well-being and joy.”
(At Risk-Low, Male, Age 72)
(Very Sick, Female, Age 70)
“Independence e the ability to participate in daily activities. I have 5) Maintaining day-to-day functioning is a priority for successful
a friend who everything is a chore for her. She has multiple physical aging
problems, so even getting up in the morning is a problem for her.
And her husband is ill, and she has to take care of him, so there’s Participants discussed the importance of maintaining indepen-
things that she can’t do because of her own health and his. Her dence, which they considered the primary way to stay healthy.
quality of life is on the kids . The key is remaining healthy more When contemplating their future needs, the fear of losing inde-
than anything else.” (Healthy and Active, Female, Age 70) pendence was a priority. In addition, participants talked about the
significance of having good days (versus bad days). When asked to
3) Resilience was indicative of aging successfully and coping describe a good day participants reported the importance of
mechanisms were key in defining well-being enjoying spiritual time, family time, and being calm and peaceful.
They included descriptions on enjoying adult children and grand-
Participants talked about “bouncing back” from difficulties and children, going where they wanted (even with limitations), and
not letting hardships get the best of them. They described illness as enjoying hobbies. Some participants clearly wanted to be needed
something they just had to deal with but would not let their ill- by others as that seemed to give them a sense of purpose and
nesses define them. In addition, many participants had suffered a fulfillment. Bad days included feeling out of control, stressful, angry
number of losses or challenges in life such as the death of close and alone, or disorganized. Frustrations with physical limitations
family members, illiteracy, estranged adult children, adult children could severely impact their day-to-day health.
with special needs, and loss of limbs. Participants talked about their
“To enjoy the activities that I’ve always enjoyed. I don’t want to feel
faith in God as a key source of coping. Other coping mechanisms
that since I’m getting older that I can’t do things because I’ve hurt
included relying on their family and friends as a support system and
myself. It’s to be able to keep doing things. Being able to exercise
looking at the positive things in their lives. Interestingly, a common
and watch what I eat. Getting out and being with friends . Keeps
thought was as simple as “you deal with it”.
me feeling healthy.” (Healthy and Active, Female, Age 66)
“My buddy passed away. I really miss him. He was always the one
“There are some days. There was one last weekend. I just didn’t feel
to keep me on my toes. He was really sick for eight months before he
good. Didn’t feel as productive as I would have been. But not
died and that was tough. It hits me hard when something happens
generally. I pretty well go, doing something every day. It’s rare for
but then I can get over it because I look at the positive. . But I take
me to be at something like this. I don’t know why I wasn’t busy and
bad situations and turn them into a positive. I thought if this
listened to that guy when he called, or the girl, but anyhow, usually
interview turns out to be a scam I’ll go to the Mercedes-Benz
home by about this time.” (At Risk-High, Male, Age 74)
dealership and have them wash my car and I’ll feel better.” (At
Risk-Low, Male, Age 82)
Discussion
“As life goes on, it’s a judgment call. You’ve got to deal with a lot of
the negatives that happen in the most peaceful way you can. To get
The purpose of this study was to better understand how older
the answers, to get yourself some help. By me going to Him (God),
it’s a way to help.” (At Risk-High, Male, Age 74) adults across a spectrum of health describe their perceptions of
health, and to consider how their definitions may influence pro-
4) Support systems impact current and future health grams to support health maintenance. The older adults in this study
gave unique perspectives of health with five themes emerging: the
disconnect between objective and subjective health status; health
The support of family and friends was an important component
has psychological and social components; social support is key in
to staying healthy. Many men viewed their wives as their primary
maintaining health; high levels of resilience and coping are needed
support but women also included their adult children, other close
to deal with challenges; and maintaining independence is a
family members, and friends. The supports did not necessarily need
priority.
to live in close proximity with the participant in order to be sup-
These themes were consistent with a holistic description of
portive providing emotional support for the participants, particu-
health, which fits well within successful aging theory. The first
larly as it related to their physical health. In addition, these
theme, reflecting inconsistency between clinical health status and
individuals provided instrumental support, such as taking them to
self-rated perceived health (objective vs. subjective) was expected.
appointments or helping around the house if there were physical
Many with multiple health conditions may still perceive them-
limitations. Importantly, the interviewees received much of their
selves as healthy and aging more successfully than they appear
health information from the support systems, as well. In addition,
from a clinical perspective.5,8 In this study, the reverse view was
physicians with whom participants had a long relationship were
also apparent for some of the objectively healthy participants, who
also considered a form of support.
unexpectedly seemed to be struggling with their health and health
“Encouragement. When I’m struggling with something physically needs. During the interviews it became clear that objectively
or emotionally, my husband. My best friend we can encourage each healthy participants were not necessarily as healthy as originally
other. My son. My youngest son is very much support. My thought. It appeared that for some participants who had been
 R. Tkatch et al. / Geriatric Nursing 38 (2017) 485e490 489

healthy for most of their lives, it was confusing and frightening to research to support that activity trackers such as a Fitbit do
deal with “newer” concerns and health conditions. Conversely, encourage physical activity and include online trackers that older
many of the objectively unhealthy participants had been dealing adults find useful.50 Other resources to improve physical activity
with multiple health issues for years and had developed strong include reduced-price gym memberships offered as a value-added
coping mechanisms. In interventions, healthier individuals are service by Medicare Supplement insurance plans.
often overlooked as it is assumed that they may not need services. Other sources of independence centered on the empowerment
These interviews demonstrated that interventions are needed for of older adults making their own health decisions. Many older
both healthier and sicker older adults to help them learn to adapt to adults already successfully use online and mobile application re-
new health concerns as they age. sources to get health information and to promote health behavior
The second theme focused on defining health to include psy- changes.51,52 Similarly, participants in this study reported frequent
chological well-being. Research confirms the importance of psy- use of their mobile devices and online resources especially related
chological components of health to successful aging, yet they are to their health. Therefore, adapting an online or mobile application
not always considered in the clinical model of health. This over- to specifically suit their needs, regardless of their health status,
sight is frequently attributed to the debate around both efficacy could be feasible. This approach should be holistic in nature and
and cost of delivering psychological services or interventions.41 include health behavior modifications, medication management,
Research has demonstrated that health outcomes such as pain education, and an online support group. Interventions should also
and functioning can improve when treating the psychological address various levels of literacy and provide assistance to those
components of health.42 Knowledge is still limited in what can be who are not computer literate. The opportunity to have simple yet
delivered in an efficacious and cost-effective way. Promising new wide reaching touch points could provide older adults of any health
research demonstrates the effectiveness of using mobile applica- status the support they may need to maintain their health and well-
tions for psychological intervention or stress reduction.43 Mobile being.
applications include a mindfulness intervention, coaching, and
cognitive behavioral therapy applications. Studies report success Limitations and future directions
with additional touch points (e.g. in-person, phone calls), and
participants report high levels of satisfaction with these mobile These qualitative interviews may not be generalizable to all
applications.43 segments of the older adult population. Participants interviewed
The third theme centered on resilience and adaptive coping. for this study may not be representative of the older adult popu-
Specifically, resilience and the ability to deal with life challenges lation, Medicare, or other Medicare Supplement insureds, and may
were consistent among those who seemed to have the “worst” differ in their demographics, socioeconomics, and health status.53
clinical health issues. Their coping mechanisms seemed to explain However, the participants in this study provided significant
why they perceived themselves as healthy and active. This view is insight on a holistic perspective of health that can provide re-
consistent with research demonstrating the benefits for those with searchers and clinicians with an understanding of what older adults
high levels of resilience including greater life satisfaction and well- may need to maintain their health. Future research should consider
being.26 Thus it is worthwhile to consider interventions to improve expanding these insights through a survey with a large generaliz-
resilience among those who may need it the most, such as those able sample. In addition, since perceived health and successful
with serious life stressors among the clinically healthier in- aging is multifaceted in nature, a more complex analysis of survey
dividuals. Unfortunately, research on interventions to improve data would be necessary in order to develop the appropriate health
resiliency among older adults is limited.26 interventions that may be needed in order for older adults to
The fourth theme described how older adults perceived their maintain their health in the future.
support networks and their relationship to their health. Many of
the participants appreciated social support from others and the Conclusions
ability to in turn provide support to some of the same people. This
perspective supports research on both the benefits of social support This study provided older adults with the opportunity to discuss
and the reciprocity of social support exchanges, or being able to their health, how they perceived their health, and how they could
both give and receive, as having significant benefits for older best adapt to changes in the future. Their responses demonstrated
adults.30 Opportunities to improve social support exchanges, such that older adults may be healthy and active regardless of their
as online resources, should be explored. Low-cost online in- conditions or diseases, have strong social and psychological re-
terventions to improve social support exchanges have demon- sources and coping mechanisms, and value their ability to take care
strated small but positive improvements in health behaviors and of themselves. Therefore, interventions or programs that address
well-being.44 These interventions primarily focus on creating an their needs from a holistic perspective, integrating psychological
online support network for individuals dealing with similar health and social components, could promote successful aging.
issues or concerns. In addition, since the reciprocity of exchanges
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