Ageing Int (2014) 39:369–384 DOI 10.1007/s12126-014-9203-1
Perceptions of Healthy Aging among African-American and Ethiopian Elders Cheryl E. Waites & Durrenda N. Onolemhemhen
Published online: 11 October 2014 # Springer Science+Business Media New York 2014
Abstract This study explores healthy aging and health promotion preferences, practices and perceptions of African-American and Ethiopian older adults. Participants completed a questionnaire linked to three levels relevant to an ecological framework: individual, interpersonal and community or environmental. Results indicate that the ecological environments of African-Americans and Ethiopian senior were quite different. African-American elders’ conception of healthy aging related to preserving their independence while Ethiopian elders indicated a holistic view that included close ties with extended family members. Both groups reported high levels of spirituality and belief in God. Other similarities and differences are discussed. This study points to the importance of industrialized and developing countries understanding the needs and perfections of elders as they shape flexible and responsive policy and programs for global health promotion. Keywords Global . Aging . African American . Ethiopian . Healthy aging . Health promotion
A Comparison of the Perceptions of Healthy Aging for African-American and Ethiopian Elders Aging is a global phenomenon and in the coming decades we will see a demographic shift with a marked increase in the older adult population. This aging boom will also be true for persons of African descent in industrialized countries like the United States and developing countries in African (U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Aging 2007). The United Nations projections for the period 1980–2025, reports that African countries “will experience one of the largest increases in absolute numbers of persons C. E. Waites : D. N. Onolemhemhen (*) Wayne State University School of Social Work, 4756 Cass Ave., Detroit, MI 48202, USA e-mail:
[email protected] C. E. Waites e-mail:
[email protected]
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age 60 and above of any world region” and developing countries as a whole “should start to anticipate substantial increase in the proportion of their populations over the age of 60 in the 21st century” (Okojie 1988, p. 3). Countries in all parts of the world must prepare to accommodate the needs of an aging population, which is rapidly increasing (World Health Organization (WHO), HelpAge International and U.S. National Institute on Aging 2002). Preparation for this aging boom is significant because elders of African descent currently disproportionately suffer the ill effects of chronic illness and are in need of a host of health promotion services and supports to remain healthy as they age (Reid et al. 2003; Kirby and Kaneda 2006). Exploring healthy aging perceptions and practice will assist developing and industrialized countries in preparing for this aging boom by indentifying strategies and programs for health promotion for older adults. While there is scholarship regarding health disparities and healthy aging among African-Americans, little is known about healthy aging and health promotion in Africa. Also, the similarities and differences regarding healthy aging perceptions and practices among elders of African descent in both industrialized and developing countries have not been explored. This is a topic of increasing importance due to the coming global aging boom (Zimmer and Martin 2007), the prevalence of health disparities, the possibility of using lessons learned from industrialized countries and the need to plan effective health promotion policy and programs. This study focused on Ethiopia as well as North Carolina and Michigan largely due to other established research projects that the researchers were conducting.
Literature Review In examining the literature regarding healthy aging there is some research concerning the healthy aging and health promotion perceptions and practices of elders of African descent. However, very little can be found on people of African descent outside the United State (U.S.) and we found no studies regarding healthy aging for Ethiopian older adults. The U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Aging (2007) reported that in industrialized countries the demographic course and implications of aging are well known in contrast to developing countries where there is a dearth of information on the topic. This supported our findings during the literature review. As a result, we explored the literature on health promotion in African as a means of providing some insight regarding healthy aging in Ethiopia. The World Health Organization [WHO], n.d. points out that the onset of old age in industrial countries begins at age 65, while in other parts of the world, where the life expectancy is lower, old age can begin in the 50’s. Life expectancy rates show that older adults in the U. S. and other industrialized countries live on average 20 years longer than elders in the developing world most particularly in Sub-Saharan Africa. The life expectancy for African-Americans also continues to be lower than the national average in the U.S. (Satcher et al. 2005). African-American life expectancy is 70.2 years compared to an average of 76.5 years for all U.S. population groups (U.S. Census 2010). The life expectancy for African-American men, on average, is 66.1 years compared to the national average of 73.6 years for all men (Satcher et al. 2005). The
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literature points to disparities regarding old age and longevity among those of African descent. Both developing and industrialized countries must contend with the impact of an aging population, and comparative global longevity disparities. Unfortunately in Africa many countries are ill equipped to deal with the needs of an aging population in terms of healthcare and health promotion assistance (Darkwa 2006). The literature points out that the elders in Africa and developing countries of the world cannot easily provide for themselves during their older adult years because of poor health, and a lack of private savings (Bongaarts and Zimmer 2002). The average African income is approximately $1,000 a year while the worldwide average is over $6,500 (Faye 2007). The mean income level in Ethiopia has been reported at roughly equivalent to $710 in U.S. dollars (Sparks 2010). The median income of American adults age 65 and older in 2008 was $30,774 but incomes varied widely around this number (Purcell 2009; U.S. Census 2010). Although there are policies and programs in place in the U.S. to promote health such as Medicare, health care facilities, social security retirement benefits, and advocacy organizations in 2004 24 % of African-Americans 65 and older were poor, compared to 8 % of white older adults (U.S. Census Bureau Fast Facts 2010). If not for Social Security, the poverty rate for older African-Americans would have more than doubled from 24 to 56 %. In addition, many African-American elders experience difficulties regarding access to health promotion services, (Kirby and Kaneda 2006; Quandt et al. 2009). Insufficient availability of ancillary services (transportation), difficulty traveling to programs, prohibitive cost, lack of consumer information (McKeehan et al. 2008) and culturally inappropriate or insensitive service provisions discourage potential users (Dancy and Ralston 2002). The literature points to problems related to access, cost, longevity, and economic and health disparities, for both U.S and African older adults. To address these issues it is important to hear the voices of elders in regard to their health promotion perceptions, practices and needs. African-American elders’ healthy aging beliefs and practices are documented in the literature. Alford and Nun’s (2004) identified healthy aging themes reported by African-American elders. In their study the African-American participants reported that family and social networks, health promotion activities and spirituality contribute to aging well. Collins et al. (2006) describe eight reoccurring themes related to good health: spirituality, being without pain/feeling good, positive attitude with good mentality, high priority on health, being independent/active, engaged in health promotion/ maintenance, socially active, and helping others. Corwin et al. (2009) later investigated African-American attitudes about aging well. Their findings supported earlier research and added that not being dependent on medications, traveling, being cognitively intact, free of serious mobility impairment or other health problems, and being independent all contributed to aging well. African-Americans did not commonly associate physical activity and nutrition with aging well. Research supports the notion that for AfricanAmerican elders healthy aging is perceived as multi-level interactions of individual behaviors and practices as well as interpersonal connections and access to community resources. There is limited research regarding healthy aging in Ethiopia. Not surprisingly, global connections regarding healthy aging issues for those of African descent in the U.S. and Africa have not been examined. A holistic comparison of health promotion
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beliefs, activities, and quality of life for elders of similar racial background who reside in industrialized countries as opposed to those who live in the developing world should be explored. A comparative examination of healthy aging through a multi-level, ecological lens provides a better understanding of healthy aging and health promotion. An Ecological Perspective This study employed an ecological perspective to healthy aging and focused on individual, social, cultural and environmental determinants of behavior (Marshall and Altpeter 2005; McLaren and Hawe 2005; McLeroy et al. 1988). Best et al. (2003) point out that there is a complex interplay among individual-family-organizational and community-level factors that influence health. These authors indicate the value of an ecological perspective is that it facilitates an integrated understanding of health perceptions, practices and outcomes. Three levels were the focal point for this study: individual, interpersonal and community/environmental. The individual level related to the beliefs, preferences, and practices of the respondents. The interpersonal level explored social engagement, family and cultural influences, how programs were communicated /marketed to potential participants. Finally, the community level looked at community amenities, resources and environmental supports. Environmental influences on individual preferences, practices and perceptions, as well as interpersonal interactions were integrated. This multi-level framework acknowledged the resulting healthy aging life course for elders. Study Questions The Intent of this cross-cultural comparison study was to use an ecological lens to explore and compare healthy aging and health promotion preferences, practices and perceptions of African-American and Ethiopian older adults. The research question was: what are the similarities and differences regarding healthy aging preferences and practices among African-American and Ethiopian elders.
Methodology This comparative study used similar methods and measures for both groups. Questionnaires with a demographic profile as well as focus groups for the AfricanAmerican elders were administered to participants. The results from both studies were analyzed and compared by merging the data files using the SPSS statistical package. The questionnaire and focus group data on the African-American elders were collected between 2007 and 2009. The Ethiopian questionnaire was completed for the Ethiopia participants during the summer of 2010. No identifiers were used for either group and the data were collected and reviewed in aggregate form. Both studies received IRB clearance to collect and analyze the data. There were three research sites in the United States, Southeast Raleigh (SE Raleigh) and Zebulon in Wake County North Carolina and the Detroit Metropolitan Area. The two communities in North Carolina were selected because of their high concentrations
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of African-American elders. SE Raleigh, located in the city of Raleigh, includes a historically African-American embedded section, with a communal legacy represented by family homes, and longstanding historically Black Colleges (U. S. Census Wake County Demographic Population and Census 2000; U. S. Census 2010; American Fact Finder 2010). SE Raleigh has an urban/suburban context and 71.5 % of its population is African-American. Zebulon is a town located in the northeastern part of Wake County and began as an agricultural community. It has a more rural/suburban context and 39.7 % of the population is African-American. The third site was Detroit Michigan where 83 % of the population is Black or African-American (U. S. Census Bureau 2006–2008). This urban area is the 11th largest city in the U.S. Elders are contending with issues that many large urban cites face including urban decline and limited free and safe amenities for elders. These communities comprise the U.S. study sites. The other research site was in Ethiopia East Africa in the city of Awasa, located on the shores of Lake Awasa in the Great Rift Valley. It is 175 miles from Addis Ababa, the capitol of Ethiopia. It is a medium size city with a population of 119,623 bordered on all sides by unmapped, rural villages. We also went to rural community about 10 miles from Awasa to recruit participants. Awassa and its surrounding villages had access to a large lake, which was source of food for the community as fish is a dietary staple. The region is also a lush farming area and elders have access to food free of charge from their family farms. Awassa Referral Hospital is located within the city and there are a number of health clinics and health posts in the surrounding villages. Questionnaire Both questionnaires (African-American and Ethiopian) consisted of 28 items. This included demographic information specifically age, gender, employment, educational background and income. The remaining items addressed healthy aging environmental, interpersonal and individual factors. The questions were derived from the literature on what constitutes healthy aging (Campbell et al. 2000; Marshall and Altpeter 2005; Walcott-McQuigg and Prochaska 2001). The environmental factors addressed in the questionnaire included safe places to walk, transportation methods, and awareness of health promotion amenities, supportive groups, classes and activities in their communities (see Table 4). On the interpersonal level volunteer activity, social engagement with family and friends and participation in educational or supportive programs, and health promotion marketing was explored. The individual level practices and preferences addressed regular exercise, balanced diets, medical check-ups, use of humor, spirituality and a positive attitude toward ones health. In addition the questionnaire asked participants to rate their overall perception of their health status. The questionnaire was initially developed with Americans in mind but it was modified to accommodate the linguistic and cultural differences in Ethiopia. The questionnaire was translated and read in the Sidama language for the Ethiopian participants. Participants’ responses were recorded on the questionnaire by local research assistants and stored to maintain confidentiality. The African-American participants also took part in a 90 min focus group after completing the questionnaire. All of the U.S. focus group findings were not presented in this study. However, the responses and themes from three focus group questions are
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addressed and compared with the responses from the Ethiopian participants. The Ethiopian participants responded to three open-ended questions that were included in their questionnaire. The open-ended questions were equivalent (via translation) to the three focus group question in the U.S. study. This allowed for coding and analysis of the responses across both groups. The Participants A criterion sample was drawn for both groups; African-American and Ethiopian. The African-American sample was drawn first (data had collected from 2007 to 2009). The criteria for the U. S. participants was: 1) must be at least 62 years old, 2) must be a resident of the study areas (Wake County North Carolina, SE Raleigh North Carolina and the Detroit Michigan Metropolitan Area), and 3) must be African-American. For the Ethiopian participants the criteria was as follows: 1) must be at least 50 years old (life expectancy is 54 years old in Ethiopia), 2) must be a resident of Awassa or a village within 25 miles of Awassa and, 3) must be an Ethiopian citizen. Recruitment of Participants Purposive samples of African-Americans were recruited to participate in the U.S. portion of the study. Community leaders assisted researchers and invited members of their social network to participate in the study. In the Detroit sample participants were also obtained with the assistance from the Wayne State University Healthier Black Elders Center. A total of seven focus groups were held and information regarding informed consent was reviewed. All participants consented and complete the questionnaire and took part in a focus group. Four focus groups were held at local churches in SE Raleigh and Zebulon, and three at senior centers in Detroit. In Ethiopia researchers selected a rural community about 10 miles from Awassa and went from house-to-house soliciting volunteers. Volunteers were asked to meet at the center of the village close to the community well for interviews. Volunteer participants gathered at the research site and local research assistants questioned them to make sure they fit the study criteria of the study and read the informed consent recruitment document. In Awassa city, we recruited participants from the marketplace, in front of the post office and other public areas. The recruitment document was read to them prior to their interviews and they were invited to volunteer to participant in the study. This served as the informed consent for participation in the study. Data Analysis Two data sets, African-Americans and Ethiopian, were explored and analyzed. The researchers compared the demographic characteristics using SPSS statistical software package version 18. Chi-square tests were performed to compare descriptive variables; specifically gender, age, and employment status (see Table 1). Income and educational background information was also provided (see Table 2). The three qualitative questions were analyzed. These questions were: 1) What does healthier aging mean to you, 2) What do you do to stay healthy, and 3) Tell us about some of the places you can go to participate in physical activities? The audio tape data
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Table 1 Participant characteristics African-American Demographic
N
Gender
65
%
Ethiopian N
%
100
Female
51
78
54
54
Male
14
22
46
46
Age groups
64
50–60
2
3
67
67
61–70
20
31
17
17
71–80
27
42
11
11
81≥
15
24
5
5
Employment status
100
64
93
Working full-time
3
5
76
82
Working part-time
–
–
6
7
Retired working part-time
4
6
3
3
Retired not working
45
70
2
2
Retired volunteering
12
19
1
1
other
–
5
5
df
Chi-Square
P
1
10.1
.001*
3
67.8
.000*
7
126.6
.000*
1
83.9
.000*
2
24.9
.000*
1
23.2
.000*
4
59.7
.000*
Ecological comparisons Drive self
66
Yes
48
73
5
5
No
18
27
95
95
Family members drive me Yes No Use public transportation
100
66
100
15
23
51
77
66
–
–
100
100
100
Yes
5
8
42
42
No
61
92
58
58
Overall health
65
Excellent
2
100 3
8
8
Very Good
9
14
67
67
Good
37
57
22
22
Fair
17
26
2
2
Poor
–
–
1
1
P
