Abstract
Although the social structure of Turkish society has changed from a broad family order to a nuclear family, family relations still hold an important place, where traditional elements dominate. Still, elderly people are cared for by their family in their home environment. Thus, the role of family members is crucial in taking care of elderly individuals. In Turkey, the responsibility of care is largely on women; the elderly’s wife, daughter, or daughter-in-law most often provides the care. Family members who provide care need support so that they can maintain their physical, psychological and mental health. At this point, Antonovsky’s salutogenic health model represents a positive and holistic approach to support individual’s health and coping. The salutogenic understanding of health emphasizes both physical, psychological, social, spiritual and cultural resources which can be utilized not only to avoid illness, but to promote health.
With the rapidly increasing ageing population globally, health expenditures and the need for care are increasing accordingly. This increase reveals the importance of health-promoting practices in elderly care, which are important for the well-being and quality of life of older individuals and their families, as well as cost effectiveness. In Turkey, the emphasis on health-promoting practices is mostly focused in home-care services including examination, treatment, nursing care, medical care, medical equipment and device services, psychological support, physiotherapy, follow-up, rehabilitation services, housework (laundry, shopping, cleaning, food), personal care (dressing, bathroom, and personal hygiene help), 24-h emergency service, transportation, financial advice and training services within the scope of the social state policy for the elderly 65 years and older, whereas medical management of diseases serves elderly over the age of 85. In the Turkish health care system, salutogenesis can be used in principle for two aims: to guide health-promotion interventions in health care practice, and to (re)orient health care practice and research. The salutogenic orientation encompasses all elderly people independently of their position on the ease-/dis-ease continuum. This chapter presents health-promotion practices in the care of elderly home-dwelling people living in Turkey.
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1 Introduction
Exercising, quitting smoking, limiting alcohol consumption, participating in learning and physical activities, and being included in the community as well as preventing losses of functional capacity improve the quality of life and prolong people’s longevity [1,2,3]. Longer life is a valuable resource that provides the opportunity to reconsider not only what older age might be, but how our whole lives might unfold [4, 5]. Therefore, the decade of 2020–2030 has been declared as the “healthy ageing decade” by the World Health Organization (WHO) involving the importance of a healthy lifestyle at every stage of life [6,7,8,9]. After WHO emphasized the importance of health-promoting practices for all ages, people have increasingly begun to understand that a healthy lifestyle is important also among older people [5, 6, 9,10,11]. In many high-income countries, elderly people are spending their “extra years” in innovative and healthy ways, such as a new career, continuing education, life-long learning programs or pursuing a neglected passion, while the understanding of health promotion still is in its infancy in developing countries [5]. Turkey, as a developing country, slowly moves toward the transformation from a pathogenic or disease-oriented paradigm to a paradigm integrating pathogenesis and salutogenesis highlighting how to promote people’s health. That is, a health resource-oriented paradigm.
Antonovsky [4] developed the concept of sense of coherence (SOC) representing a person’s confidence in having the resources needed to cope with challenges. SOC is linked with personal strength and a person’s ability to cope in difficult situations [4, 8]. The first implication of adopting a salutogenic health orientation is the rejection of the dichotomy posited by a pathogenic paradigm: stating that people are either sick or healthy [4].
Despite the changes in the social structure of the Turkish society, family relations still hold an important place, where the traditional family structure prevails [1]. Thus, many older people still live at home and only a small number of elderly adults are staying in Turkish nursing homes [2]. Being able to continue living at home in old age provides a familiar environment within which to contend with the challenges and changes to lifestyle that occur due to the ageing process [8]. Social support, i.e., from the family, is one of the generalized resistance resources (GRRs) against stress that in turn contributes to the development of a strong SOC [7]. In the Turkish society, this means that elderly living together with their families have access to social support when facing life challenges. This represents a health-promoting resource for the elderly, as well as for their family.
On the other side, although it is a priority for the elderly to live in a society without being isolated from their own living environment, caring for elderly at home can also be experienced as a burden. A large part of the Turkish population considers elderly care as a duty [1]. The burden of care is largely on women; the wife, daughter, or daughter-in-law most often provide the care needed [2, 12]. This can be a demanding life situation to the caregivers. Knowledge of a person’s SOC might be one possible way to identify those who may be more vulnerable to stressful situations. Further, a strong SOC is related to quality of life, indicating that perceiving one’s life situation as comprehensible, manageable, and meaningful influences on family members’ coping strategies in care of older people [11]. SOC is a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available to meet the demands posed by these stimuli, and (3) these demands are challenges, worthy of investment and engagement ([7], p. 19). In this chapter, importance of the health-promoting practices for elderly people staying at home in Turkey are presented and discussed.
1.1 Aging in Turkey
In the twenty-first century, we now face a significant demographic shift towards an aging population in Turkey and worldwide [9]. Aging, which has been more prominent in developed countries, is now gaining importance also in developing countries; in Turkey, the older population is gradually increasing. While the percentage of population over the age of 65 in Turkey was 8% in 2014, it is estimated to be 10.2% in 2023, 16.3% in 2040, 22.6% in 2060 and 25.6% in 2080 [10]. Life expectancy at birth in 2020 was 73 years for men and 78 years for women in Turkey. According to the Turkish Statistical Institute (TÜİK), the population aged ≥65 was 5.7 million in 2012; this number will rise to 8.6 million in 2023, 19.5 million in 2050 and 24.7 million in 2075 [9, 10]. Due to the increasing rate of elderly people, from 2009 Turkey has established a pro-natalist population policy to increase the rate of young people in society; the social importance of having three children or more is emphasized [7, 9].
Social and cultural factors represent the basis for the perception of elderly care at home as the “basic duty of family members” [11]. Therefore, those who care for family members need to be supported and directed to maintain their physical and mental health [12, 13]. Salutogenic strategies represent health promoting approaches of supporting families and reducing the care-giving burden. Health is a human right. Thus, health promotion and health protection depend upon the promotion and protection of human rights and dignity [13]. Healthy aging seems to be achievable to a certain extent if the older individual can maintain or promote a strong SOC [4].
Prior to the 1950s, the dominant family type was large families due to the patriarchal social structure in Turkey [14]. However, during the recent years the socioeconomic and technological developments have accelerated a shift toward nuclear families. Resulting from changes in the social structure of the Turkish society, rural-urban migration has increased since the 1950s; young people move to urban areas, whereas the elderly remain in rural areas. Hence, the issue of elderly care has begun to emerge also in rural areas [7, 15]. This migration has affected the family structure and accelerated a change from the traditional large family toward the core family [2]. This change includes that the elderly (65 years and older), whom in the traditional large families were valued as a “wise” person in the family, increasingly are perceived as a “burden” to the family, causing the elderly to feel insignificant and lonely [4, 7].
In some ways, elderly people living in rural areas in Turkey have a greater need for health-promoting support compared to those living in urban areas [16]. Especially in villages, old people who are physically frail might be unable to conduct the needed work at the farm for different reasons; consequently, they are not able to earn money. Due to the migration of young people to the cities elderly people are left alone in villages. As a result, agricultural areas remain idle. Since the elderly people are unable to produce as they did before, they tend to buy ready-made products [7]. Due to population shortage, existing establishments (grocery, mill, coffee, etc.) and health institutions (health centers) are closing, public transport and flights are limited in the rural areas. Initially, the elderly who remain in the village become dependent on their children, relatives, and neighbors, i.e., their environment, for their many socioeconomic needs [7, 8].
With age, the prevalence of chronic diseases is increasing [17]. In recent years, researches and public health practices have shown that chronic diseases can be prevented in elderly individuals and their need of social and medical service can be reduced [14, 17, 18]. However, health promotion is still a relatively unfamiliar concept for health professionals. The most important way to fight chronic diseases in old age is successful aging and health-promoting activities and/or programs [14]. Successful aging is understood not only in terms of good physical health, but also psychologically and socially well-being [13]. Life length, biological and mental health, cognitive and social competence, productivity, personal control and enjoyment of life are common indicators of aging successfully [9, 14, 18]. In this context, successful aging means keeping the social environment and relationships alive while preparing oneself for old age, taking preventive measures to minimize health problems, making efforts to improve memory and physical functions and keeping a positive orientation toward life [6, 19].
Several conditions impact on older people’s health [19, 20]. The best-known types of health-related behaviors are smoking, alcohol use, physical exercise, eating, and lifestyle habits [2, 6]. In Turkey, health-promotion practices in the elderly can be financed and organized by donations from individuals or nongovernmental organizations or taxed by national governments [2]. In short, health-promotion activities and initiatives are heterogeneous as the providers of services and support differ by the contribution of the individual, the family, the immediate environment, society, and the local and central government [7]. Biological age is represented by the bodily and cellular changes seen with chronological age [6, 21]. In addition to the increased frequency of chronic diseases, some older people experience losses of functions followed by various degrees of disability [21]. When all these factors occur simultaneously, there is a significant increase in the need for health and social care; in the years to come the care needs of the elderly will continue to increase. Generally, development applications and health-promotion practices for older people in Turkey have three main objectives: (1) continuation and expansion of functional capacity, (2) protection or improvement of health, and (3) social network development and physical activity based in a social group [2].
In the Action Plan of the Turkish Ministry of Health including activities of Health-Promotion and Development in 2009–2013, “reducing threats to the health of people and improving health” in health services were determined as the strategic objectives. For this purpose, the “Health Promotion Department” and “Non-Communicable Diseases and Chronic Conditions Department” were established and started their activities within the General Directorate of Basic Health Services of the Ministry of Health in 2008 [22]. Health professionals can advise and support health behavior of elderly people, improving their well-being and quality of life [9].
2 Health-Promoting Approaches in Older People Home Care in Turkey
In order to strengthen the health care system to meet with the increase of older people, the government aims to realize the targets and strategies in accordance with the WHO, European Healthy Aging Strategy and Action Plan (2012–2020) and Health 2020 targets [2]. With the aging population, health care spending and the need for care will increase rapidly, representing a serious responsibility to the future even in countries with a strong social security system [21]. In parallel with the increase of older people, the burden of chronic diseases as part of the total health expenditures is increasing gradually [14].
Maintaining independence and preventing disability among the older population are closely related to rehabilitation and ensuring quality of life [2]. In Turkey, quality of life in the elderly is related to maintaining life without social isolation, appropriate living conditions, timely and easy access to quality health services, maintaining relationships with friends and neighbors, and devoting time to meaningful activities of value to other people and the society [23]. Older adults are still capable of self-reflection, anticipation, and problem solving [24]. Health-promotion practices are an effective way to focus on people’s resources and capacities to create and maintain health [23, 24]. A health care approach focused on the individuals’ abilities for self-care that promote and maintain health is less costly than the management of diseases [25]. Meaningful relationships, social support, physical activity, healthy eating, vaccination, cessation of harmful habits such as smoking and alcohol, fight against obesity or malnutrition, preventive practices in falls, neurological and mental health protective activities represent areas for health-promotion initiatives [2, 26,27,28]. In the following, some central areas for health promotion directed to elderly in Turkey are presented.
Health-promotion initiative aims at involving and empowering individuals in the activities and decisions involving their health [6]. At any time during its lifetime, a living system must deal with and withstand negative forces that are on the verge of pushing it to maximum irregularity or entropy [19]. The salutogenic paradigm and practices contribute to health-promotion and public health in terms of quality of life, mental health, psychological resilience, coping with stress, maintaining and improving general health, well-being and healthy aging [6]. Healthy aging is stated as a process—it is the journey, not the end [14]. Fundamental to feeling good is to have a positive outlook on life [15]. Nutrition, lifestyle/habits, genetics, exercises, education, knowledge, skills, mental abilities, family, religion, self-esteem and ideology are social factors affecting healthy aging [8, 14]. The gero-salutogenic approach is shaped by SOC, which is an important factor in successfully coping with the stressful factors of daily life and improving the well-being and health of the elderly [19]. This approach considers the individual as a highly complex bio-psycho-social-spiritual living system, which is self-creating, self-organizing, and self-preserving [4, 19]. Older individuals have good prospects for positive development, if they manage to maintain or even improve their SOC [19]. Antonovsky [4] offered two explanations for the positive association between SOC and well-being, explicitly maintaining that it is not a causal one: (1) a strong SOC is shaped by life experiences that are characterized by the availability of general resistance resources; (2) there are certain resistance resources that contribute to both a strong SOC and well-being. SOC represents the gero-salutogenic core variable, which is fundamental to successful coping with the abundant stressors of everyday life and a key factor for determining an older individual’s well-being and health [19]. In this context, we aimed to examine three main aspects of positive aging and SOC among Turkish elderly people: subjective physical health, well-being, and psychological health.
2.1 Nutrition Problems and Health-Enhancing Practices
Adequate and balanced nutrition plays an active role in maintaining physical, mental development and functional status as well as preventing, treating and improving diseases in old age [20]. Nutrition problems can be one of the most important reasons underlying chronic diseases [28]. Elderly people living alone in Turkey are particularly at risk for malnutrition [28, 29]. Malnutrition occurs most often in the elderly as a result of insufficient intake or absorption of nutrients [29]. Other factors affecting nutritional status are physiological changes with age, acute and chronic diseases, dental problems, polypharmacy, economic issues, doing shopping alone, preparing meals, and inability to eat [26, 28].
There may be excessive (or unstable) intake of wrong food during old ages [25]. Another common unbalanced eating problem is obesity [30]. Assessment of abdominal obesity, glucose intolerance, hypertension, and dyslipidemia should be performed simultaneously [28]. Inadequate and unbalanced nutrition among elderly individuals is associated with obesity, cardiovascular diseases, cancer, diabetes, osteoporosis, all of which are correlated with high morbidity and mortality [31]. It is recommended that obese elderlies change their lifestyle by developing individual nutrition and physical activity programs [26]. Especially for the elderly with a chronic disease, a specific nutrition program should be developed to support well-being [25].
2.2 Cigarette Consumption/Respiratory System Problems and Health-Enhancing Applications
With high age, a decrease in lung elasticity, increased chest wall stiffness, and decreased lung function due to the weakening of respiratory muscles are seen [26]. These changes result in significant progressive reductions in vital capacity, diffusion capacity, gas exchange, ventilation and respiratory sensitivity [32]. Smoking accelerates these changes considerably, and the prevalence of chronic obstructive pulmonary disease is known to vary between 2% and 9% [26, 32]. Respiratory infections, especially pneumonia, are an important cause of death in both developed and developing countries in people aged 65 years and older [33]. Sitting times in front of the television should be determined and the drawbacks of sitting still for a long time in terms of respiratory and circulatory system should be explained to older people [25]. The effect of smoking on respiratory infections should be explained and elderly people should be supported to quit smoking without creating stress [32]. Since drug use is widespread in the elderly and there may be pharmacokinetic and pharmacodynamic changes due to physiological changes, counseling approaches are recommended instead of pharmacological smoking cessation methods [34]. The health effects of exercising for 30 min every day should be explained [35]. Two hours of decongestant cough and deep breathing exercises should be done especially in bed-dependent individuals [26]. In bed-dependent and confused elderly people, frequent change of position is suggested as it will prevent stagnation in the lungs and the development of pneumonias [32].
2.3 Drug Management and Health-Enhancing Practices
The perspective of healthy aging in the medical model is focused on the absence of chronic illness, the ability to overcome chronic illness, or the elimination of risk factors that lead to chronic illness [14]. Unfortunately, globally as well in Turkey, the elderly constitute the majority of the population using drugs to cope with diseases [36, 37]. Polypharmacy drug side effects, drug-drug-disease interactions, treatment noncompliance, increase in cost, weight loss, falls, cognitive dysfunction: medication can lead to many health problems causing an increase in hospitalization and death [38]. Therefore, careful drug use is advised [36]. Older patients and caregivers should be informed about the medicines, vitamins, nutritional support products, and herbal medicines provided [39]. Written and oral information should be given about the preparations given, their frequency of use, their dosage as well as both their generic and market names [36]. Patients and caregivers should be educated about the common side effects of the drugs and informed about where to contact their physician [26]. Drug treatment should be simplified, especially to improve the adaptation to treatment among elderly people living alone [30]. The focus of the medical model on the absence of chronic illness and physical disabilities does not account for older individuals who, despite chronic illness, consider themselves as healthy and vital human beings [4, 8, 14]. It is well known that to achieve healthy aging, drug management is not enough; the individual must also maintain good exercise patterns, a healthy diet, and good lifestyle habits supporting people’s health [14]. Keys for successful and healthy aging are mental stability, social support, and social interaction rather than drugs [14, 30].
2.4 Physical Activity and Health-Promoting Practices
The “National Plan of Action on Aging and the Situation of Elderly People” was formed in Turkey in 2007. This national plan contains important recommendations and activities, such as emergency health care, day-care centers, cleaning services, social activities, food services to houses, repair and renovation services for the Turkish population showing increased longevity [40]. Physical activity and movement are seen as one of the most important health-promoting practices in maintaining health in elderly individuals, and the lack of it may set the stage for triggering the most dangerous chronic diseases such as cardiovascular diseases and cancer [34, 41]. Physical activity is found essential to older people’s quality of life, and is a therapeutic component in rehabilitation programs, as well as in the treatment and prevention of chronic diseases [20]. It is well known that in elderly individuals the mineral content of the skeletal system is decreasing, causing a decrease in muscle strength and muscle mass and therefore also a decreased ability to move [42]. Moreover, studies have shown a decrease in physical activity with advancing age [35, 43]. There is a direct relationship between increased inactivation with old age and cardiovascular diseases, osteoporosis, and colon cancer [38, 42].
WHO [5] asserts that mobility is the best guarantee of not losing independence and being able to overcome independency. Walking is the most accepted and recommended physical activity by physicians for older people [42, 44]. Walking takes place in social settings (e.g., parks, shopping centers, roads, neighborhood streets), often outdoors, both for leisure and exercise, as well as transportation [45]. In addition, walking or cycling for transportation purposes, dancing, playing, gardening, making housework and similar activities, sports, and physical exercises or activity are recommended [44, 46]. Health care professionals in Turkey recommend active sports, such as walking, slow running, dancing, swimming and cycling, or team games with their own age groups, for active aging [44].
In addition, gardening is recommended as a health-promoting activity for older people staying at home [47]. Gardening provides an opportunity for the elderly to stay outdoors and is described by many as a pleasurable physical activity [47, 48]. In this process, opportunities can be provided for the elderly to care for plants and trees, to weed out leaves or to water plants and trees, to grow their own plants [49]. Seeing the growing of the plants and caring for them both provide physical activity and help to develop a sense of success, meaning, and self-confidence [44, 47]. If there is no garden possibility, plants or flowers grown in the house may also be an alternative [48]. It has been found that elderly individuals who engage in regular physical activity increase their independence and self-confidence, improve sleep quality due to reduced stress, modify depression, and decrease the incidence of chronic diseases [50]. Maintaining autonomy and physical activity are the most important factors of successful aging [14].
2.5 Home Accidents/Falls and Health-Promoting Practices
Falling is one of the most common and serious problems causing significant morbidity and mortality [42]. Age-related impairments in walking and cardiovascular function occur in the vestibular system (that is located in the labyrinth in the inner ear together with the cochlea, which is part of the hearing system) and in the ear vestibulum and provides motor coordination and sense of balance [35]. Falls are among the most common causes of injury/death in old age [51]. If looking at the fall rates of individuals over the age of 65 in Turkey, 60% of the falls occur in the home environment, 44% of home accident are on a dry ground and 4% on wet ground [52]. In community-based prospective studies, it is reported that the annual rate of falls in the elderly is between 30 and 60%, about half of the falls are repeated falls and two-third of them are preventable falls [35, 51, 53].
Knowing the risk factors causing falling is important for taking the necessary precautions [53]. Health-promoting activities preventing falls at home include regulating the physical environment of the elderly, teaching measures to prevent falls for the family and the elderly, providing assistance during activities that require skill and eliminating factors that may cause accidents [42, 43].
In Turkey, medical interventions, environmental regulations, training and exercise programs and auxiliary instruments are used to prevent and reduce the frequency of falls [35, 38]. The aim of these initiatives is to reduce the number of recurrent falls and reduce the rates of resulting diseases and deaths [42]. Decreasing the number of drugs in elderly people, especially reducing the number to be less than four, significantly reduces the risk [51]. In old ages, postural hypotension represents a risk of falling; thus, etiology is investigated, drugs are reviewed, diet of those with excessive salt restriction is reorganized and patients are asked to have adequate fluid intake [42]. Balancing arrangements include raising the head of the bed, getting up slowly from the bed, dorsiflexion exercises and pressure-enforcing socks [35, 42].
Environmental regulations are another important issue in preventing falling [35]. In this context, families and elderly individuals are informed about the use of non-slip tiles in the bathrooms, the use of non-slip floor covers and adhesive strips for the floor near the bathtub, washbasin and toilet, the use of slip resistant floor polish for the in-home safety in bathrooms [51]. Less furry carpets are recommended [42]. Lighting needs to be increased in stairs, bathrooms and bedrooms [51]. Dark painted material can be used on the windows for preventing excessive daytime brightness [54]. As there may be a problem of visibility in the dark, electric buttons should be placed on the top and bottom of the stairs, illuminated with night lights; colored adhesive strips should be placed on the step edges and step height should be no more than 15 cm [42, 51, 54]. On both sides of the steps, cylindrical, inward-facing end parts, easy to be grasped and some continuing handrails at the end of the step should be placed [53]. It is recommended to place holding bars on the wall next to the toilet [51], placing pads with non-slip adhesive rubber bands on the bathtub floor, holding bars in the bathtub and shower, as well as using a shower chair and a hand-held flexible shower head for those with reduced balance [54]. Information should be given to measure the distance from the kneecap to the floor for the bed height, not to use low chairs, and to keep the frequently used kitchen and toilet seats within reach [42, 51].
In addition to the regulations of elderly individuals’ home environment, there has been increased awareness on the importance of environmental arrangement in the external environment [35]. Research has shown that barriers on sidewalks are primarily responsible for falls happening in the external environment [35, 51, 54]. These barriers are easily damaged during winter months and high narrow-sidewalks, lack of crosswalks, slippery surfaces, stairs without handrails, poor lighting, and traffic seem to be the most important reasons for elderly individuals falling outside their home [45, 51, 53]. In recent years, awareness about the destructive effects of falls on elderly health has increased and interventions that can be made have been planned [51]. In this respect, elimination of architectural deficiencies and careful urban planning represent approaches that will prevent falling among older people [51, 54].
2.6 Vitamin D Deficiency and Health-Promoting Practices
Osteoporosis is one of the most threatening conditions in the older population with the progression of age; the most important factor that causes osteoporosis is vitamin D deficiency [55, 56]. Vitamin D is essential for calcium metabolism and bone quality [38, 57, 58]. Although the main source of vitamin D is exposure to sunlight, various factors such as latitude of the area experienced, season, hours of sunlight, and use of sunscreen influence the absorption of vitamin D [55, 57]. Especially elderly people who spend most of their time at home are at risk for vitamin D deficiency due to insufficient sunlight exposure and kidney synthesis of vitamin D and decreased absorption of vitamin D [59, 60]. In this case, calcium absorption decreases, parathyroid hormone works more to compensate this absorption, bone remodeling occurs, bone density decreases, and osteoporosis occurs [55, 60]. Although there is plenty of sunlight in Turkey, insufficient exposure to sunlight and wearing plenty of clothing due to sociocultural/religious beliefs are factors leading to vitamin D deficiency in the elderly [57]. Routine health-promoting practices in this group in Turkey are focused in education and counseling [56]. Recommendations are made to encourage the consumption of seafood, milk and dairy products, to supplement vitamin D and Calcium, and to increase the exposure to sunlight during the day [56, 60]. In particular, health professionals should enhance elderly people’s knowledge about the importance of vitamin D, the risks of vitamin D deficiency and the ways to prevent it as well as treatment options [55, 56, 60].
2.7 Well-Being, Mental Health and Health-Promoting Practices
Healthy aging is the process of slowing down, physically and cognitively, while resiliently adapting and compensating in order to optimally function and participate in all areas of one’s life (physical, cognitive, social, and spiritual) [14]. Individual lifestyle factors, social and community networks, living and working conditions, and general socioeconomic, cultural and environmental factors are some determinants of well-being [3, 4]. The salutogenic approach leads to a more profound understanding through reflection on life situations and a review of available resources and active adaptation to stress-rich environment, which promotes movement toward the “ease” part of Antonovsky’s health continuum [19, 61]. Over the life span, negative life events might reduce SOC which includes three interrelated components: comprehensibility of one’s world (cognitive aspect), manageability of one’s outcomes (behavioral aspect), and meaningfulness of one’s life (motivational aspect) [8, 15].
Antonovsky [4] stated that developing SOC requires internal and external generalized resistance resources, including ego identity, social network and social support. The social environment of the elderly individual’s such as spouse, family and friends are important support systems for feeling valuable, increased well-being, mental health satisfaction from life and coping with stress [61]. In Turkey, depression is the most important mental health problem that negatively effects SOC: perceived social support is significantly related with depression in old age [62].
The Turkish culture emphasizes the family as a core institution in the Turkish society; accordingly, older individuals live with their families and children [61, 63]. However, the number of elderly people living alone at home or in nursing homes has increased gradually as the nuclear family structure has become widespread in recent years [63]. If the older individual perceives aging as an isolated existence, he or she will tend to isolate him-/herself and begin to fail. However, if the older individual perceives aging as an integral part of the social structure in which he or she lives, thriving will be supported [14]. The quality of social support is considered a crucial resource for SOC and coping [4, 8]. Social support is significant for health and well-being for older people [8]; correspondingly, the physical, mental and emotional health of the elderly living with relatives are significantly better than among elderly living alone in Turkey [62,63,64]. Turkish Statistical Institute (TÜİK) [10] reported that family support in old age was closely associated with depression and suicide rates. Bozo et al. [62] found that perceived social support had no effect on life quality and depression: however, depressive symptoms decreased among older individuals with high daily life activity and adequate social support.
In Turkey, which predominantly is a Muslim country, worship and religion play an important role in dealing with loneliness, depression and psychosocial problems [65, 66]. In one study, elders stated that worship raised their morale and gave them peace [67]. Praying, reading the Qur’an, going to a mosque and worshipping with the community are among the most preferred coping methods among Turkish elderlies to fight against depression [66, 67]. According to the salutogenic health model, personal resources may include the following factors: (1) material resources (e.g., money), (2) knowledge and intelligence (e.g., knowing the real world and acquiring skills), (3) ego identity (e.g., integrated but flexible self), (4) coping strategies; (5) social support, (6) commitment and cohesion with one’s cultural roots, (7) cultural stability, (8) ritualistic activities, (9) individuals’ state of mind, (10) preventive health orientation, (11) genetic and constitutional GRRS, and (12) religion and philosophy (e.g., stable set of answers to life’s perplexities) [7, 67]. Just as recommended for many religions, it is an important responsibility for believers in Islam to take care of ones health, avoidance of substance use, healthy eating, and healthy living [66]. Religion might be a gatekeeper that can promote mental health and spirituality among older believers [65].
2.8 Sleep/Rest and Health-Promoting Practices
Sleep quality is a big challenge to many old people [68]. Elderly adults may experience daytime sleepiness, waking up earlier in the morning, difficulty falling asleep and maintaining sleep, and a decrease in night sleep time [69]. Sleep problems can cause troubles such as lack of attention, inability to perform daily tasks, falling and it seriously affects individuals’ quality of life [70].
A study examining sleep quality among 250 elderly people living at home in Turkey, found that 20.8% of individuals fall asleep within 30 min or longer after going to bed, that women complain more about sleep disorder than men, and that married older individuals pay more attention to sleep quality [68]. In another study, sleep quality was associated with fatigue and quality of life [71].
Elderly people need regular sleep in order to maintain their quality of life and body functions in the best way [72]. Solutions to sleep problems can be found with the correct use of pharmacological and non-pharmacological methods. Music has been widely used as a method for treating diseases in Turkish societies and in many civilizations [73]. Music relaxes the body by lowering heart rate as well as by regulating body temperature, blood pressure and respiratory rate [72, 74]; passive music therapy treatment has been widely used [74]. During passive music therapy people are resting, comfortably sitting or lying down, listening to a relaxing rhythm and the sound of water in accordance with the melody [72, 74]. Sleep and rest are physiologically needed in all individuals, and especially in elderly individuals. Therefore, creating a good sleep environment alongside music might improve older people’s sleep quality [75]. Noise should be reduced, and a quiet and safe environment should be provided. The atmosphere must be ventilated, the light should be reduced, the room temperature should be warm and the bed should be comfortable [68].
2.9 Quality of Life (QoL) and Health-Promoting Practices
Age, which is an inevitable biological and psychological development process, affects quality of life through changes in the human body such as vision, hearing, skeletal system, brain and prostate, menopause, and andropause periods [72]. In addition, an individual’s past experiences, health behaviors, habits, and genetic factors influence quality of life in late ages [76]. Elderly people should be supported to use resources optimally in order to maintain their health and quality of life [72]. The most common problems that affect quality of life associated with aging are changes in the cardiovascular system, respiratory system and the neurological system [64, 76]. In a salutogenic perspective, health, well-being and quality of life should be promoted throughout the life course [2]. The main purpose of preventive health services offered to the elderly in Turkey is to improve the individuals’ quality of life by supporting them to live independently and preventing obstacles [72, 76]. The main objective of the preventive health services offered to the elderly people is to improve their quality of life, allowing independent living and preventing disabilities [76].
One of the most important indicators of life quality is social relationships [77]. Developing SOC requires internal and external general resistance resources, including ego identity, social network, and social support [4]. Most elderly people ≥65 retire. As the children leave home, the family lessens, and thus shortening the elderly individuals’ social environment. Moreover, the elderly adults may experience physiological changes followed by loss of functionality and mobility. Hence, both social and functional restraints occur [78]. The loss of a spouse may be one of the most devastating factors in elderly individuals [79]. With retirement, the decrease in income causes a decline in social status among most of the elderly followed by a loss of many social activities [80]. WHO defines successful aging as a process of “age-in-place,” optimizing opportunities for health, continue to be involved in the community, maintain autonomy, independence and attain physical, social and mental well-being and quality of life [72, 75, 81]. Watching television, listening to the radio, chatting with people, and lounging represent common social activities among elderly people staying at home in Turkey [79]. Research demonstrates that although the elderly generally appreciate their current situation, some older individuals yearn for the activities they were doing while they were younger or healthier [82]. The salutogenic approach leads to a more profound understanding through reflection on life situations and a review of available resources and active adaptation to an irritating and stress-rich environment, which promotes movement toward the “ease” part of the health ease–dis-ease continuum [4, 72]. Aközer and colleagues [77] found that seniors in their free time gave priority to watching television, shopping and visiting family members and relatives. An elderly adult who lives a life isolated from the outside environment may tend to be closed, longing for the past, resistant to innovation and change [3, 83]. Therefore, the ability to maintain social interaction, relationship, autonomy and independence are important determinants of healthy ageing and quality of life [81].
3 Home Care Services
Physical, social, and spiritual changes occur with the progression of aging; the functional capacity of elderly individuals decreases and for some this situation causes older people to need help as well as care [78]. Health, welfare, housing, transport, and infrastructure are responsible sectors for healthy aging and quality of life of elderly people [81]. Although increasing needs are met by the families, relatives or communities of the elderly, long-term and regular assistance and services can be provided by health care services [12, 78]. The environment should support the individual’s SOC by means of available resources for health, enabling older people to live well despite their limitations [81]. The aims of the health care services are: (1) to support individuals with disabilities, the elderly, people with permanent illnesses during or after the disease recovery period in their environment, (2) to keep up with social life, (3) to ensure their integration with society by maintaining their lives happily and peacefully, and (4) to support the family members who care for the elderly person and especially women in the family [79, 84, 85].
The adaptation of the salutogenic approach as complementing the pathogenic approach is important to health-promotion among home-dwelling elderly individuals: the salutogenic approach highlights to utilize the individual’s resources for health in his or her social and physical environment [81] as well as helps to better understand the transitions in old ages and successful aging [4]. The salutogenic approach focuses on movement toward health, whereas the pathologic approach focuses on disease and identifies the person with the disease [4]. Both paradigms are equally important and should be integrated in a holistic salutogenic understanding of health. A central priority by the state should be to meet the needs of the older population including health-promotion and continuity of the social and health care facilities/policies for every individual without any discrimination [2]. A policy based on salutogenic approaches and comprehensive perspectives such as the “Active aging” concept could better improve the well-being of the older population. WHO states that “active aging allows people to realize their potential for physical, social, and mental well-being throughout the life course and to participate in society, while providing them with adequate protection, security and care when they need” [86]. With a strong SOC, people would be more confident about having control over their own choices and their situation by using their resources for health [81]. The European Region of WHO, in which Turkey is a member, has given priority to the facts like enjoying supportive, adapted social environments, having access to high-quality, tailor-made, well-coordinated health and social services, giving support to maintain the maximum health and functional capacity throughout life, and empowering individual while living and providing dignity through the entire life [2, 86].
The professional home-care in Turkey is still in it’s infancy; the first studies in this field started in the private sector [87]. Today, home-care services are supported by municipalities, private hospitals, private home-care centers and home-care units of public hospitals [79]. The “elderly-friendly cities” have gained increasing attention by policy makers over the last decade, since the WHO started to promote the concept [88]. In 2010, the Ministry of Health of the Turkish Republic started free home-care services including examination, treatment, nursing care, medical care, medical equipment and device services, psychological support, physiotherapy, follow-up, rehabilitation services, housework (laundry, shopping, cleaning, food), personal care (dressing, bathroom and personal hygiene), 24-h emergency service, transportation, financial advice and training services within the scope of the social state policy [12, 83, 86, 87, 89]. In Turkey, municipalities, social workers, public health workers, policymakers, and researchers work on many activities, facilities or services for older people to promote active ageing; nonetheless, access the to these services is sometimes low [87].
4 Conclusion
Ageing is a natural developmental dynamic process of human life and an individual’s triumph of accumulated life experiences [88]. As the proportion of older people in Turkey is increasing, the importance of health-promotion among the elderly is increasingly acknowledged. The WHO twenty-first century’s theme entitled “Health for all” was directly related to elderly’s health [75]. In this context, and in a health-promoting perspective, WHO focuses on strengthening the physical and mental capacities of seniors, as well as creating the environment to allow them to achieve their valued goals [88]. It is necessary to develop elderly friendly communities including aspects related to transportation, housing, public spaces, community and health services [90]. Healthy ageing is influenced by determinants such as social norms, living and working conditions, socioeconomic, cultural, and environmental factors [91]. Health-promotion initiatives in the older population should aim to increase or maintain elders’ functionality both socially, cognitively, emotionally, spiritually and physically, improving longevity and well-being. Enhancing functionality, maintaining strength as much as possible, living independently and facilitating well-being are main priorities of health-promotion [84, 92, 93]. Ensuring that older people remain healthy and active is a necessity, not a luxury. It is necessary to regulate the living space of elderly individuals aiming to support their quality of life and health, as well as to improve social relationships.
Take Home Messages
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Healthy ageing is influenced by a variety of interacting determinants, such as belief, living conditions, socioeconomic, cultural and environmental factors.
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There are health gains both for the elderly, their families and health care professionals by integrating a salutogenic orientation as part of the health policy, health care practices and research.
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The salutogenic model of health including the concept of sense of coherence should be implemented in health care practice, research, and health policy.
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Even if health-promotion practices still for most health care settings are limited in Turkey, existing evidence recommends an increased integration of salutogenesis into health care practices as well as a more systematic use of this approach in research on health care settings.
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In Turkey, elderly care is mostly provided by families in the home environment. Thus, there is a need to strengthen the care of the caregivers developed and organized as part of the home-care services.
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WHO has declared the period 2020–2030 as the “healthy ageing decade.” The importance of a healthy lifestyle and health-promoting practices during the entire life span is now increasingly understood among older people in Turkey.
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To fulfill the aim of making 2020–2030 “the healthy aging decade,” the development of nutritional and health care suitable for elderly people, programs supporting cigarette consumption, physical activity as well as adapting the physical environments to hinder accidents/falls, coping with vitamin D deficiency, supporting self-management of mental health, sleep/relaxation, quality of life and well-being are essential.
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The home-care services should be trained in health-promotion as well as in development and the implementation of health-promoting activities among elderly people in Turkey.
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Körükcü, Ö., Kabukcuoğlu, K. (2021). Health Promotion Among Home-Dwelling Elderly Individuals in Turkey. In: Haugan, G., Eriksson, M. (eds) Health Promotion in Health Care – Vital Theories and Research. Springer, Cham. https://doi.org/10.1007/978-3-030-63135-2_22
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