The Affordable Care Act challenges the nation to move upstream and create healthcare to focus on wellness and not on illness. Creating a lens on populations that looks at developing skills and behaviors that can prevent diseases and their health consequences will be the key to a healthier nation and reduce staggering healthcare costs. New directions are also creating a closer link between physical health and behavioral health and creating a focus on overall wellness.
Prevention programs are developed through a scientific process to ensure effectiveness and to address the urgent needs of our communities. Developing a program to encourage older adults to stay healthier longer will save healthcare costs in the long run. The development of the Wellness Initiative for Senior Education (WISE) Program in New Jersey is a great example of how a program was thoughtfully developed into an evidence-based program recognized on the national level that has helped thousands of seniors in several states celebrate healthy aging.
In 1996, a local reporter editorialized a visit to his mother’s home within a local senior village in central New Jersey. He shared his concern over the many liquor bottles overflowing in the recycling cans that lined the streets in this senior housing complex. He logically linked his concerns with these seniors drinking excessive alcohol along with the many medications that are traditionally coupled with aging. He was describing a serious problem that was hiding in plain sight. When the article was published, complete with pictures of recycling containers overflowing with alcohol bottles, a call to action was issued. The New Jersey Prevention Network (NJPN) responded to this need and developed the framework of what is now one of the few evidence-based prevention programs specifically for older adults.
NJPN is a public health agency working to prevent substance abuse, addiction and other chronic diseases by building capacity among professionals, fostering positive collaboration among providers, and strengthening the field of prevention through the use of evidence-based practices and strategies. The organization began focusing attention on older adults in the mid-1990s.
Although WISE addresses the initial concern raised about alcohol use among older adults, it was ultimately developed to focus on overall wellness. The program’s goal is to celebrate healthy aging and educate older adults, so they are more likely to make positive lifestyle choices as they age and less likely to experience problems associated with alcohol and medication misuse. Participants gain the information and resources they need to maintain a healthy lifestyle and feel empowered about their health and the healthcare they receive. Topics range from such things as depression and how aging affects the body, risk factors for substance abuse, and medication use, misuse and management.
Substance Abuse in Later Life
Mention substance abuse prevention today, and most people will immediately think of youth. While young people certainly need evidence-based interventions, recent data confirms that they are not alone:
- According to the National Council on Alcoholism and Drug Dependence, alcohol and prescription drug problems among adults 60 and older is one of the fastest growing health problems facing the country.1
- Between 6 and 11% of seniors admitted to hospitals show signs of alcoholism.
- 80% of all senior substance abuse treatment admissions were for alcohol as the primary drug.
- Illicit drug use among seniors is projected to double by 2020.
- There are approximately 78 million baby boomers nationwide.2
- Many are taking the abuse of cocaine, heroin, marijuana, and other illicit drugs into their “golden years.”
- Although alcohol remains the top substance of choice among older adults, the aging baby boom cohort has resulted in illicit drugs accounting for a growing proportion of users and admissions to treatment facilities.
- People age 65 and older make up 12 percent of the U.S. population, but account for 34 percent of all prescription medication use and 30 percent of all over-the-counter medication use.3
- According to researchers, about 60 percent of older adults take their prescriptions improperly, and approximately 140,000 die each year as a result.4
To take these important statistics into consideration and provide rationale for including substance abuse prevention in an effective older-adult wellness program, the developers of WISE relied on the following hypotheses:
- Lifestyle choices have a significant impact on our overall health, particularly as we grow older. If individuals understand how their lifestyle choices and behaviors impact their health, they will make more positive choices and experience better health.
- Older adults have more health problems and therefore take more medications than any other age group. The more medications individuals take, the more likely they are to experience problems associated with their medications. If individuals have the tools and feel empowered to manage their healthcare, they will be less likely to experience problems with their medications.
- As we age, our bodies process alcohol and medications less efficiently, which puts older adults at increased risk of experiencing problems associated with their alcohol and medication use. If individuals learn how their bodies are changing as they grow older and how their bodies are affected by alcohol and medication, they will be less likely to use alcohol and medications problematically.
- Some older adults view aging as a negative experience, because they are struggling with declines in physical and mental function, quality-of-life issues, and significant life transitions, which can be stressful and lead to depression. Both depression and stress are risk factors for late-onset alcohol problems. If individuals learn to value generational diversity, celebrate growing older, and recognize the early signs and symptoms of depression, they will make more positive life choices and experience fewer alcohol problems.
Once the rationale for WISE was formally articulated, NJPN utilized the Health Belief Model as our guide in developing an appropriate intervention for this population.
Behavior Change Theory
Since the 1950s, health promotion professionals have used the Health Belief Model to design interventions to motivate individuals at risk for a particular health condition to change their behavior in order to remain healthy.
The National Cancer Institute’s publication Theory at a Glance: A Guide For Health Promotion Practice5 explains that, according to the model, people are ready to act if they:
- Believe they are susceptible to the condition (perceived susceptibility),
- Believe the condition has serious consequences (perceived severity),
- Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits),
- Believe the costs of taking action (perceived barriers) are outweighed by the benefits,
- Are exposed to factors that prompt action—for example, a television ad or a reminder from a physician (cue to action), and
- Are confident in their ability to successfully perform an action (self-efficacy).
In order for older adults to engage in a wellness program that addresses a highly stigmatized issue such as substance abuse, NJPN developed a program that applies the following approaches:
- Demonstrate that a condition normally associated with adolescents had relevance for them and that this issue had significant negative consequences that were readily addressable with the proper tools.
- These tools would be easy and fun to learn.
- The program would need to be presented in a setting that older adults would likely include in their normal activities, and provide the opportunity to practice the new tools before they actually needed to be put to use.
Program at a Glance
WISE is a six-lesson curriculum facilitated by trained substance abuse prevention specialists once per week over a six-week period. Each lesson is two hours in length and is generally offered at senior centers, community centers, and houses of worship—places older adults already go on a regular basis. As a result, participants aren’t necessarily making a major change in their schedules to take part in the program.
Participants learn through interactive exercises that include small group discussions and projects. They are also given tools and resources to take home, increasing the likelihood that they will put into practice and share what they have learned. The content is organized in a manner that promotes the understanding and value of generational diversity in a format that excites and energizes participants to share what they have learned with family, friends and peers.
A multiyear, independent evaluation was conducted by the Institute for Families, an applied social science research and training center affiliated with the School of Social Work at Rutgers, the State University of New Jersey. Efforts to implement and evaluate the program were supported by the New Jersey Department of Human Services, Division of Mental Health and Addiction Services. The evaluation included pre- and post-tests, intervention and control groups, and focus groups. Based on evaluation results, the program as well as the pre- and post-tests were changed over the years, and after almost ten years of implementation and evaluation, the program is clearly having a positive impact on seniors. Through the Program’s rigorous evaluation, the evaluators found that:
- Participants had statistically significant improvements in knowledge. They knew more about how their bodies age, how the aging process affects their ability to metabolize alcohol and medications, and how to recognize the early signs and symptoms of depression.
- Participants made more positive changes in their health behavior over time. They were more likely to improve health behaviors related to lifestyle choices, healthcare empowerment, and use of prescription and over-the-counter medications.
- Participants reported greater increases in social support over time. They were more likely to report a greater sense of social guidance and social integration. Specifically, they reported that they had:
- Felt more confident in their ability to manage their health issues,
- Adopted a more assertive relationship with their physician and were more likely to ask their doctor questions,
- Developed a more positive outlook on aging and coping with aging issues,
- Changed their doctor and/or their pharmacy, got more involved with their doctor, and were more careful about taking their medications,
- Felt the lessons provided an open and comfortable atmosphere to express their feelings, including things they don’t usually talk about.
These outcomes suggest that by educating older adults about the issues and celebrating healthy aging, WISE is encouraging individuals to make more positive lifestyle choices. In doing so, they are more likely to enjoy a better quality of life moving forward.
Nationally Recognized as an Evidence-based Program
WISE, an evidence-based program, has been implemented nationally in diverse communities to thousands of older adults. The program was accepted into the Substance Abuse and Mental Health Services
Administration’s (SAMHSA) Service to Science Academy in 2006, receiving free technical assistance to help further NJPN’s evaluation efforts. The program’s impact received national recognition in 2009, receiving the National Exemplary Award for Innovative Substance Abuse Prevention Programs, Practices and Policies from the National Association of State Alcohol and Drug Abuse Directors (NASADAD), an organization that fosters and supports the development of these programs. In 2012, the program was approved and listed on SAMHSA‘s National Registry of Evidence-based Programs and Practices (NREPP). The program is available nationally and has been successfully implemented in rural, urban and suburban environments and is a great example of how prevention programs, when grounded in science, can promote positive lifestyle changes and improve health.
As physicians and other healthcare workers move their focus from curing illness to preventing illness, prevention programs such as WISE can be part of their options to maximize the health and wellness of their patients and improve community linkages to support healthier lifestyles.
- www.ncadd.org/images/stories/PDF/factsheet-alcoholismanddrugdependence amongolderadults.pdf
- www.socialworktoday.com/archive/012312p8.shtml and Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set (TEDS) and the National Survey on Drug Use and Health, 2010, 2011.
- “The State of Health and Aging in America 2004,” Merck Institute of Aging and Health and Centers for Disease Control, 2004.
- “Seniors should take a dose of precaution,” Ivanhoe Broadcast News, http://www.news8austin.com/content/living/health_beat/?ArID=120301&SecID=169
5. National Cancer Institute. (2005, September). Theory at a Glance: A Guide For Health Promotion Practice (second edition). Washington DC: US Department of Health and Human Services, National Institutes of Health. NIH Publication No.