Journal of Community Health Nursing, 31: 187–197, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.958390
Increasing Risk Awareness and Facilitating Safe Sexual Activity Among Older Adults in Senior Housing Tonii C. Gedin, DNP, RN and Barbara Resnick, PhD, CRNP, FAAN, FAANP University of Maryland, School of Nursing, Baltimore, Maryland
The prevalence of HIV in older adults is rising. This increase can be attributed to inconsistent condom use, low perceived disease susceptibility, and a sexual health knowledge gap found in older adults. Yet, little to no health promotion for older adults focuses on sex education. This study sought to determine the feasibility of a group-based educational program in senior housing settings and consider the utility of a self-efficacy based group education program on knowledge of disease risk and preventive techniques among older adults living in senior housing.
BACKGROUND AND SIGNIFICANCE According to the Center for Disease Control and Prevention (CDC) HIV diagnosis rates per 100,000 in Americans 50 and older increased from 8.2 in 2000 (CDC, 2003) to 8.5 in 2010 (CDC, 2013a). African Americans over 50 accounted for 46% of new diagnosis in 2010, a rate 10.7 times higher than Whites (CDC, 2013a). Nationally, the state of Maryland ranks second of all states for the highest rate of HIV diagnosis in those 55 and older (CDC, 2013b). Researchers have estimated, in older adults newly diagnosed with HIV, that half of them contracted the virus after age 50 (R. Smith, Delpech, Brown, & Rice, 2010). Within Baltimore City, trends of age at HIV diagnosis identified those 50–59 years of age as one of two age groups increasing from 2000 to 2010 (Maryland Department of Health and Mental Hygiene [DHMH], 2012). Exposure categories reported in Baltimore City also identify a rise in exposure through sexual activity compared to intravenous drug use, which has decreased (DHMH, 2012). The inconsistent use of condoms by older adults is one contributing factor to the rise in preventable sexual diseases. Studies have shown that older people with multiple sex partners and other risk behaviors were likely to report inconsistent condom use (Schensul, Levy, & Disch, 2003; K. Smith & Christakis, 2009; Ward, Disch, Schensul, & Levy, 2011). In a study exploring sexual behaviors of older unmarried women, 58% did not use condoms during their last sexual intercourse experience (Lindau, Leitsch, Lundberg, & Jerome, 2006). Among men, widowhood has been shown to significantly increase the risk of sexually transmitted infections (STI) in older adult men in the first year after death of a spouse (K. Smith & Christakis, 2009). This risk is even
Address correspondence to Tonii C. Gedin, DNP, RN, 3708 Hill Park Drive, Temple Hills, MD 20748. E-mail: tonii. [email protected]
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greater for men using erectile dysfunction drugs. It is anticipated that this increase is due to the fact that older men reentering the dating world are not using condoms. Inconsistent condom use and high-risk behaviors may be explained by the low perceived susceptibility of sexual disease contraction in older adults (Flavo & Norman, 2004; Lindau et al., 2006; Lindau et al., 2007; Maes & Louis, 2003; Schensul et al., 2003; Small, 2010; K. Smith & Christakis, 2009). The belief that one is susceptible to a particular illness or condition is a necessary component to health-related behavior such as consistent condom use (Rosenstock, Strecher, & Becker, 1988). Increasing their knowledge of condoms, and therefore their self-efficacy toward condom application, can influence older adults behavior toward condom use. Knowledge of condom use and STIs is lacking in older adults (Foster, Clark, Holstad, & Burgess, 2012; Goodroad, 2003; Nusbaum, Singh, & Pyles, 2004; Rodgers-Farmer, 1999; Ward et al., 2011). Research has shown 40% of older African American adults were uncertain about the effectiveness of condoms to protect one from STIs, with this uncertainty being even worse among women (Neundorfer, Harris, Britton, & Lynch, 2005; Rodgers-Farmer, 1999). Misconceptions about HIV and STI transmission are also common among older adults (Henderson et al., 2004; Hillman, 2007, 2008; Jackson, Early, Schim, & Penparse, 2005). For example, one 76-year-old African American man was quoted as stating, “he knows he’s safe [from infections] as long as he pours Jack Daniels on his genitals immediately after sex” (Ward et al., 2011, p. 32). The focus of education in the area of health promotion among older adults is most commonly geared toward cardiovascular health (diet and exercise), increasing physical activity, fall prevention, or cancer screening. Much less focus and emphasis has been placed on providing education around sexual health in older adults. Information received is not from health care providers, and the accuracy is questionable (Gott & Hinchliff, 2003; Henderson et al., 2004; Lindau, et al, 2006; Nusbaum et al., 2004; Slinkard & Kazer, 2011; Stewart & Graham, 2013). Older adults, however, have indicated that they would be willing to discuss sexual activity if this topic was initiated by their primary health care provider (Gott & Hinchliff, 2003; Lindau et al, 2006; Nusbaum et al., 2004; Slinkard & Kazer, 2011). Previous research found that older adults recommend education take place in community settings (Small, 2010). The rising prevalence of HIV, low perception of risk, inconsistent condom use, and knowledge gap in older adults in community-based settings supports a need for a targeted health education campaigns. Prior research (Jemmott, Jemmott, Hutchinson, Cederbaum, & O’Leary, 2008; Jemmott, Jemmott, & O’Leary, 2007) supports the use of brief, 30-min, intensive, multisession educational interventions conducted by nurses in clinical practice settings and STI clinics as a way to increase risk awareness, knowledge of STIs and change behavior (i.e., increase condom use among adults). Research also supports the use of group sex education in public housing and other community-based settings to change sexual risk behaviors (Carey, Senn, Vanable, CouryDoniger, & Urban, 2010; Sikkema et al., 2000). Specifically, prior research has demonstrated that brief interventions in clinical settings and group educational programs in public housing, focused on sexual health and associated risks, can help to increase knowledge and change behavior among adults. All of the prior work in sexual education has focused on middle-aged, rather than older, adults. This study seeks to explore effective teaching methods for increasing the self-efficacy of older adults toward safe-sex behaviors during brief educational interventions in senior housing. Older adult is defined in this study as individuals 55 years old or older.
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THEORETICAL MODEL Prior HIV knowledge and increased motivation to practice safe sex have both been associated with self-efficacy for safe-sex behaviors (Foster et al., 2012). In addition, among older adults, the relationship between self-efficacy for safe-sex behaviors was influenced by perceived effectiveness to perform safer sexual behaviors (Foster et al., 2012). In that study, as well as other studies focused on management of chronic illness, educational interventions have been shown to improve the self-efficacy in older adults (Beverly et al., 2013; Nguyen et al., 2013). The theory of self-efficacy (Bandura, 1977) was used to guide the development of a group educational program, Sexual Health for Older People (SHOP), which was provided for older adults in senior housing settings. The goal of SHOP was to strengthen confidence among older adults with regard to their knowledge of sexual health and safe sexual activities, and their confidence in using this knowledge to influence their sexual behavior. The theory of self-efficacy includes self-efficacy expectations, which are an individual’s judgment of his/her confidence to carry out specific behaviors, and outcome expectations, or the beliefs that carrying out a specific behavior will lead to a desired outcome. The stronger the individual’s perceived self-efficacy and outcome expectations, the more vigorous and persistent his or her efforts (Bandura, 1986). Self-efficacy can be strengthened using a number of approaches, including successful performance of the activity of interest, verbal encouragement to perform the activity, seeing like individuals successfully perform the activity, and eliminating unpleasant feelings and sensations associated with the activity (Bandura, 1977). Prior research has shown that self-efficacy-based approaches are effective in improving knowledge and behavior associated with safe sexual activity (Foster et al., 2012), as well as many other health behaviors related to physical activity (Resnick et al., 2007; Resnick et al., 2008). The purpose of this study was to determine the feasibility of a group-based educational program in senior housing settings and consider the utility of a self-efficacy-based group education program on knowledge of disease risk and preventive techniques among older adults living in senior housing. Specific aims were to learn from participants whether or not this type of approach was useful from their perspective and identify subsequent program revisions that could be used to guide ongoing development of educational programs specific to sexual health in older adults. To best explore the participants’ experience associated with this type of learning, a focus group approach was used. METHODS This was a qualitative study using a focus group approach. The study was approved by the University of Maryland Institutional Review Board and was conducted in two urban senior housing sites. Sample and Setting The SHOP sessions took place in two Baltimore City, low-income, senior-housing buildings. Inclusion criteria included living in one of these communities and being 55 years of age and older. To encourage participation and inform residents of the workshop, flyers were placed within the building a week prior to the class and attendance was encouraged by the site managers prior to and on the day of class.
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The SHOP Intervention The facilitator of the SHOP educational workshop was a Masters-prepared public health nurse with experience educating older adults on sexual health. Workshops were held in the multipurpose room within each of the facilities and lasted from 30 to 45 min. The workshops were set at a time that was determined to be the most conducive to attendance by the managers in each of the buildings. As shown in Table 1, multiple teaching methodologies were used to cater to various learning styles. Guided by self-efficacy theory, verbal encouragement was used to teach and encourage safe sexual behavior. Fundamentals of STI and HIV contraction were taught in lecture format with coordinating written materials. The lecture was done in an interactive format consistent with adult learning. Participants were encouraged to share their knowledge and beliefs and then accurate upto-date facts and information were presented. The information specifically included prevalence of STIs and HIV within the older adult population, modes of disease contraction, identification of high-risk behaviors, signs and symptoms of STI and HIV/AIDS, the importance of testing, and the ways in which to discuss sexual health with primary care providers (materials available from first author). Participants were shown how to perform skills such as application of a male condom and then given the opportunity to practice these skills via simulation experience (i.e., placement of a condom over a cucumber). In addition, to help address barriers to condom role-playing scenarios were developed. For example, a condom negotiation situation was conducted with participant TABLE 1 Description of Teaching Methodologies and Techniques Teaching Methodology
Description
Verbal Encouragement
Facilitator encouraged participants to start conversations about sexual health with their intimate partners. Facilitator encouraged participants to start conversations about sexual health with their primary care provider. Facilitator encouraged participants to get routine testing for STD’s and HIV/AIDS if they were sexually active. Facilitator encouraged participants to use condoms. Facilitator discussed the fundamentals of STD’s and HIV/AIDS. Facilitator discussed the prevalence of STDs and HIV within the older adult population, modes of disease contraction, identification of high-risk behaviors, signs and symptoms of STD and HIV/AIDS, the importance of testing, and the ways in which to discuss sexual health with primary care providers. Facilitator uses a cucumber for demonstration of male condom application. Facilitator discusses appropriate fit of male condoms. Facilitator discusses appropriate removal of male condoms. Facilitator provided examples of things to say when negotiating condom use with an intimate partner. Facilitator acted the role of new partner and the participant attempted to use condom negotiation techniques. Facilitator used a jeopardy style game with a board displaying point values of each question. Questions were asked in a true versus false format. Participants volunteered to answer questions and selected their question. A small prize was given to the winner of the game.
Lecture
Demonstration
Role-Play
Game
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volunteers and the educator. Last, to reinforce knowledge, the workshop incorporated a myth versus truth of STIs and HIV/AIDS jeopardy game. Focus Group Method and Measures The focus groups were held immediately following each educational workshop. Participants of the workshop were invited to stay and join in the focus group to provide feedback about the workshop and discuss their experiences. The educational facilitator led the focus groups and a research assistant took notes throughout the group discussion. Focus groups lasted approximately 30 min each. Total participation time for this study ranged from 1 hr to 1 hr and 15 min. The questions guiding the focus group are shown in Table 2. Questions asked during the focus group focused on how participants felt about the learning techniques used and whether or not the participant felt the knowledge gained would alter their sexual behavior in the future. Last, we explored with participants their recommendations for how the program could be improved. Data Analysis Data from the participants was analyzed using a constant comparison analysis (Strauss & Corbin, 1998). Two coders coded the data separately and then met to review codes and come to consensus. The codes were then developed into themes. Specifically, the three stages of constant comparison analysis identified by Strauss and Corbin were utilized in the analysis process. During the first stage, open coding was conducted, which involved each coder individually separating the data into small clusters and attaching a descriptive code to each cluster. In the second stage, axial coding the codes were categorized into groups. During the third and final stage of selective coding, the coders collaborated to establish themes that represent the content of each of the groups. Reliability and Validity of the Qualitative Data Credibility, dependability, and confirmability of qualitative data were examined. Credibility refers to the degree of believability, fit, and applicability of data to the inquiry (Lincoln & Guba, 1985). Because the focus groups were completed at different locations at different times the findings were coded independently. Findings from the first focus group were compared to the subsequent focus group to confirm or refute codes and emerging themes. Dependability refers to ability of the findings to be consistently found if methods are repeated (Lincoln & Guba, 1985). Dependability was demonstrated by implementing the same methods, in the same context, with the same population, in different sites with separate focus groups (Shenton,
TABLE 2 Focus Group Questions 1. 2. 3. 4.
Describe your experiences and feelings associated with participation in this workshop. Describe the ways in which this workshop was helpful to increasing your knowledge of safe sex. Describe the ways in which your sexual behavior might change following this program. Tell me about the ways in which you might change this workshop to make it better in terms of the information provided or the ways in which you learn.
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2004). Comparison of separate findings indicated that the methods used produced consistent results when repeated. Confirmability refers to the extent to which the data is reflective of the focus group inquiry (Lincoln & Guba, 1985). Confirmability was established through the use of two reviewers being involved in the data analysis process. As noted, the reviewers coded the data independently and met to resolve any discrepancies until consensus was reached. Moreover, a transparent decision trail was created to increase confirmability. This trail supports the logical fit of the findings. RESULTS The SHOP workshops had a total of 21 participants combined. There were 5 participants at the first site, out of approximately 75 eligible residents (7%) living in the facility and 16 participants at the second site out of 100 eligible residents in the second setting (16%). A total of six codes were identified from the focus group data and these were reduced to 4 themes. Three of these themes focused on components that facilitated learning in the participants and included: (a) utility of games during education; (b) positive impact of a well-organized session; and (c) importance of the “teach back” approach. The fourth theme focused on the importance of tailoring the time of education to the audience and was labeled: (a) Timing is everything. Utility of Games During Education Participants described the jeopardy game as a key facilitator to their learning. The game was noted to be fun, enjoyable, and educational. Participants explained that the game helped them to process and recall what they had learned. The utility of games to increase learning was expressed by responses such as: “The lecture was logical and the game really helped to back up our knowledge. It was a fun way to learn and reinforce knowledge.” “I liked all parts of the class but the games were my favorite as they made me think.” Positive Impact of a Well-Organized Session Participants stated that the rigorous structure of the educational session was important to them. Participants expressed value in providing multiple teaching methodologies in an organized fashion during the single educational session. One participant reported, “All parts of the class went together really well and I learned something from all of it.” Participants felt that the organization of information increased not only their learning, but also their ability to stay engaged and interested in the session. Importance of the Teach Back Approach Participants reported that the opportunity to demonstrate learned skills increased their confidence in their knowledge about sexual health. Many expressed that they felt they could now educate others about this as well. In addition, some participants asserted that repeating information back to the group during the games helped them to clarify points and confirm the accuracy of information they were previously unsure about. One participant reported, “The game really backed up our knowledge. It was a fun way to ask questions and reinforce knowledge.”
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Timing is Everything Participants voiced that the time of the educational session directly impacts the number of participants likely to attend. Participants articulated specific days and/or times they felt would appeal to residents in their respective communities. Both workshops took place early in the afternoon. Participants at one location felt that the information would have reached a larger audience if it were offered in combination with another standing activity such as bingo. Participants at this same location felt participation would have been higher later in the day after 5pm. In contrast, the other location felt the time was perfect and stated they would not come out later in the evening.
DISCUSSION The older adults who participated in the focus groups provided support for the feasibility and utility of this method of teaching sexual health information. Participants were willing to attend the sessions and repeatedly noted that they learned a lot and appreciated the education. Implications for practice were identified by the focus group. Based on the focus group findings, the structure and organization of the educational sessions, the use of games, and timing of the intervention were all noted to have an important influence on the participants’ learning and engagement in the workshop. Organization Findings from this study reinforced the importance of being organized during educational workshops. As shown in prior studies, workshops and programs that organize and adhere to an appropriate teaching plan are more likely to be well received by older adults (Friedman, Cosby, Boyko, Hatton-Bauer, & Turnbull, 2011; Nussbaum & Coupland, 2004; Zurakowsi, Taylor, & Bradway, 2006). In addition to organization of information, based on information learned, it was helpful to prioritize the most important information to provide to the class participants to optimally assure learning. Previous research has noted that priority setting for information dissemination in older adults is needed particularly when providing health information (Best, 2001; Fenter, 2002; Zurakowsi et al., 2006). In the SHOP educational program, risk behaviors and the importance of condom use were presented prior to condom negotiation techniques. Our findings also confirm the recommended use of multiple teaching mechanisms to assure optimal learning (Agate, Mullins, Prudent, & Liberti, 2003; Friedman et al., 2011). As noted in prior education with older adults (Matsui, 2010; Rigdon, 2009), participants valued the use of multiple teaching methods that corresponded and supported each other. For example, written handouts that reiterated the facts stated and complimented the didactic information were greatly appreciated. Moreover, despite the increased use of technology and computers among older adults, our participants liked the written materials and indicated that they would use the written material and lecture information to share with family, friends, and church congregations. At the end of the formal session, several participants asked if they could take the extra copies of printed materials to share with others. Although printed, hard copies of educational material were greatly appreciated by the participants, we anticipate that the educational design may have been strengthened with the use
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of an audiovisual component such as a short video demonstrating a challenging sexual health interaction between two older individuals or other type of web-delivered intervention (Ammann, Vandelanotte, de Vries, & Mummery, 2012; Friedman et al., 2011). With increasing access to smart phones and tablets among older adults, inclusion of web-based educational materials for these individuals will become more accessible. Evidence is accumulating demonstrating that web-delivered educational interventions are effective in changing behaviors in older adults with chronic diseases (Ammann et al., 2012; Westlake et al., 2007) and web-based exercise interventions can improve physical function (Sparrow, Gottlieb, Demolles, & Fielding, 2011) and bone health (Nahm et al., 2010). Games As anticipated, the use of games was noted to be a particularly useful and an entertaining way to reinforce learning. Games provide a way in which to stimulate enthusiasm of the learner and thereby to promote the retention of information through repetition (Bastable, 2008; Billek-Sawhney & Reicherter, 2005; Fenter, 2002; Thomas, 2007). Games also provided the facilitator with a chance to correct misunderstandings or clarify information. Reinforcement and clarification of teaching is concurrent with prior findings of older adult education (Best, 2001). The questions asked during the games served as a fun way in which to provide ongoing education and repetition of information presented. The games were also used as a way for participants to teach each other as they expanded upon correct answers and clarified incorrect answers. That is, following their response to a quiz question, participants would explain to the group why the answer they provided was right or wrong. This teaching of information previously learned back to others has been referred to as the “teach back” technique (Weiss, 2007, p. 33). This method of demonstrating learning and demonstrating knowledge is recommended in the education of older adults (Best, 2001; Billek-Sawhney & Reicherter, 2005; Zurakowsi, Taylor, & Bradway, 2006) and useful in increasing retention of information (Fink et al., 2010). The SHOP workshop demonstrated that games can be used to facilitate teach back techniques and promote retention of learning and that this approach was greatly appreciated by the older learners. Previous research supports our finding that games facilitate learning (Blakley, Skirton, Cooper, Allum, & Nelmes, 2009: Gipson & Bear, 2013). These authors found that, in multiple studies, the use of games is associated with reinforcement and increased retention of information with nursing students and experienced nurses. In addition, previous research has shown that learning through games is equally as effective as traditional lecture (Gipson & Bear, 2013). Although the games were used in this study to facilitate learning on the part of the participants, the games also allowed the SHOP facilitator to evaluate what the participants had received in terms of information and what they understood following the session. Participants’ answers and teach back explanations provided the facilitator with evidence as to how well participants accurately recalled the information provided. Timing The timing of educational sessions for older adults living in senior housing persistently is challenging to establish as there are individual, cohort, and possibly even setting differences.
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Although both SHOP sites were inner city, low-income, senior housing communities, participants at each location had distinctly different preferences for intervention times. One site found the 1 o’clock time was very appropriate; the other felt that an evening session would be better attended. Tailoring the dates and times of workshops is critical to facilitating optimal participation in educational sessions for older adults. Thus, including these individuals in plans for the implementation of sessions is recommended (Agate et al., 2003). Partnering with the population to design the intervention may have allowed older adults to assess utility and relevance of SHOP (Doyle & Timonen, 2010) and identify pertinent differences in the population (Parker et al., 2012). In this study, we depended on the recommendation of the managers in the facilities and we recommend in future programming that interventionists work directly with residents to explore their preferences with regard to timing.
CONCLUSION This study was limited by virtue of design and the qualitative nature of this work. Moreover, it was done in only two settings. Despite these weaknesses, the findings provide support for the use of a self-efficacy based approach to teach older adults sensitive health information. In addition, the SHOP provided additional support for the use of multiple methods when educating lowincome older adults in senior housing. Further research is needed to explore the incorporation of technology into education sessions for these individuals. REFERENCES Agate, L., Mullins, J., Prudent, E., & Liberti, T. (2003). Strategies for reaching retirement communities and aging social networks: HIV/AIDS Prevention activities among seniors in South Florida. Journal of Acquired Immune Deficiency Syndromes, 33, 238–242. Ammann, R., Vandelanotte, C., de Vries, H., & Mummery, K. (2012). Can a website-delivered computer tailored physical activity intervention be acceptable, usable, and effective for older people? Health Education and Behavior, 40(2), 160–170. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 34, 191–215. Bandura, A. (1986). Social foundations of thought and action. Upper Saddle River, NJ: Prentice Hall. Bastable, S. B. (2008). Nurse as educator; principles of teaching and learning for nursing practice. Sudbury, MA: Jones and Bartlett. Best, J. (2001). Effective teaching for the elderly: back to basics. Orthopedic Nursing, 20(3), 46–52. Beverly, E., Fitzgerald, S., Sitnikov, L., Ganda, O., Enrique, C., & Weinger, K. (2013). Do older adults aged 60–75 years benefit from diabetes behavioral interventions. Diabetes Care, 36(6), 1501–1506. Billek-Sawhney, B., & Reicherter, E. (2005). Literacy and the older adult educational considerations for health professionals. Topics in Geriatric Rehabilitation, 21(4), 275–281. Blakely, G., Skirton, G., Cooper, S., Allum, P., & Nelmes, P. (2009). Educational gaming in the health sciences: systematic review. Journal of Advanced Nursing, 65(2), 259–269. Carey, M. P., Senn, T. E., Vanable, P. A., Coury-Doniger, P., & Urban, M. A. (2010). Brief and intensive behavioral interventions to promote sexual risk reduction among STD clinic patients: results from a randomized control trial. AIDS Behavior, 14, 504–517. doi:10.1007/s10461-009-9587-1 Centers for Disease Control and Prevention. (2003). AIDS Cases In Adolescents and Adults, by Age – United States, 1994–2000. Centers for Disease Control and Prevention. (2013a). Diagnoses of HIV infection among adults aged 50 years and older in the United States and dependent areas, 2007–2010. HIV Surveillance Supplemental Report, 18(3), 6.
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Nguyen, H., Donesky, D., Reinke, L., Wolpin, S., Chyall, L., Benditt, J., . . . Carrieri-Kohlman, V. (2013). Internetbased dyspnea self-management support for patient with chronic obstructive pulmonary disease, Journal of Pain and Symptom Management, 46(1), 43–55. Nusbaum, M., Singh, A., & Pyles, A. (2004). Sexual healthcare needs of women aged 65 and older. Journal of American Geriatrics Society, 52(1), 117–122. Nussbaum, J. F., & Coupland, J. (2004). Handbook of communication and aging research (2nd ed.). Mahwah, NJ: Lawrence Erlbaum Associates. Parker, S., Chen, E., Pillemer, K., Filiberto, D., Laureano, E., Piper, J., . . . Reid, C. (2012). Participatory adaptation of an evidence-based, arthritis, self-management program making changes to improve program fit. Family & Community Health, 35(3), 236–245. Resnick, B., Orwig, D., D’Adamo, C., Yu-Yahiro, J., Hawkes, W., Shardell, M., . . . Magaziner, J. (2008). Adherence to an exercise intervention study among older women post hip fracture. Journal of Clinical Sports Psychology, 2, 41–56. Resnick, B., Orwig, D., Yu-Yahiro, J., Hawkes, W., Shardell, M., Hebel, J. R., . . . Magaziner, J. (2007). Testing the effectiveness of the exercise plus program in older women post hip fracture. Annals of Behavioral Medicine, 34(1), 67–76. Rigdon, A. S. (2009). Development of patient education for older adults receiving chemotherapy. Clinical Journal of Oncology Nursing, 14(4), 433–441. Rodgers–Farmer, A. Y. (1999). HIV risk factors, HIV antibody testing, and AIDS knowledge among African Americans age 55 years and older. Social Work in Health Care, 29(3), 1–17. doi:10.1300/J010v29n03_01 Rosenstock, I., Strecher, V., & Becker, M. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15(2), 175–183. Schensul, J., Levy, J., & Disch, W. (2003). Individual contextual, and social network factors affecting exposure to HIV/AIDS risk among older residents living in low-income senior housing complexes. Journal of Acquired Immune Deficiency Syndromes, 33(2), 138–152. Shenton, A. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22, 63–75. Sikkema, K. J., Kelly, J. A., Winett, R. A., Solomon, L. J., Cargill, V. A., Roffman, R. A., . . . McAuliffe, T. L. (2000). Outcomes of a randomized community level HIV prevention intervention for women living in 18 low-income housing developments. American Journal of Public Health, 90(1), 57–63. Slinkard, M., & Kazer, M. (2011). Older adults and HIV and STI screening: The patient perspective. Geriatric Nursing, 32(5), 341–349. Small, F. (2010). What older adults know about HIV/AIDS: Lessons from an HIV/AIDS education program. Educational Gerontology, 36(1), 26–45. Smith, K., & Christakis, N. (2009). Association between widowhood and risk of diagnosis with a sexually transmitted infection in older adults. American Journal of Public Health, 99(11), 2055–2062. Smith, R., Delpech, V., Brown, A., & Rice, B. (2010). HIV transmission and high rates of late diagnoses among adults aged 50 years and over. AIDS, 24, 2109–2115. doi:10.1097/QAD.0b013e32833c7b9c Sparrow, D., Gottlieb, D., Demolles, D., & Fielding, R. (2011). Increases in muscle strength and balance using a resistance training program administered via a telecommunications system in older adults. Journal of Gerontology: Biological Sciences, 66A(11), 1251–1267. Stewart, A., & Graham, S. (2013). Sexual risk behavior among older adults. Clinical Advisor for Nurse Practitioners, 16(4), 28–38. Strauss, A., & Corbin, J. (1998). Basics of qualitative research, techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage. Thomas, C. M. (2007). Bullentin boards: A teaching strategy for older audiences. Journal of Gerontological Nursing, 33(3),45–52. Ward, E., Disch, W., Schensul, J., & Levy, J. (2011). Understanding low-income, minority self-perceptions of HIV risk. Journal of The Association of Nurses in AIDS Care, 22(1), 26–37 doi:10.1016/j.jana.2010.05.002 Weiss, B. D. (2007). Manual for clinicians health literacy and patient safety: Help patients understand. Chicago, IL: American Medical Association Foundation and American Medical Association. Westlake, C., Evangelista, L., Stromberg, A., Ter-Galstanyan, A., Yazirani, S., & Dracup, K. (2007). Evaluation of a webbased education and counseling pilot program for older heart failure patients. Progress in Cardiovascular Nursing, 22, 20–26. Zurakowski, T., Taylor, M., & Bradway, C. (2006). Effective teaching strategies for the older adult with urologic concerns. Urologic Nursing, 26(5), 355–360.
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Increasing Risk Awareness and Facilitating Safe Sexual Activity Among Older Adults in Senior Housing Tonii C. Gedin, DNP, RN and Barbara Resnick, PhD, CRNP, FAAN, FAANP University of Maryland, School of Nursing, Baltimore, Maryland
The prevalence of HIV in older adults is rising. This increase can be attributed to inconsistent condom use, low perceived disease susceptibility, and a sexual health knowledge gap found in older adults. Yet, little to no health promotion for older adults focuses on sex education. This study sought to determine the feasibility of a group-based educational program in senior housing settings and consider the utility of a self-efficacy based group education program on knowledge of disease risk and preventive techniques among older adults living in senior housing.
BACKGROUND AND SIGNIFICANCE According to the Center for Disease Control and Prevention (CDC) HIV diagnosis rates per 100,000 in Americans 50 and older increased from 8.2 in 2000 (CDC, 2003) to 8.5 in 2010 (CDC, 2013a). African Americans over 50 accounted for 46% of new diagnosis in 2010, a rate 10.7 times higher than Whites (CDC, 2013a). Nationally, the state of Maryland ranks second of all states for the highest rate of HIV diagnosis in those 55 and older (CDC, 2013b). Researchers have estimated, in older adults newly diagnosed with HIV, that half of them contracted the virus after age 50 (R. Smith, Delpech, Brown, & Rice, 2010). Within Baltimore City, trends of age at HIV diagnosis identified those 50–59 years of age as one of two age groups increasing from 2000 to 2010 (Maryland Department of Health and Mental Hygiene [DHMH], 2012). Exposure categories reported in Baltimore City also identify a rise in exposure through sexual activity compared to intravenous drug use, which has decreased (DHMH, 2012). The inconsistent use of condoms by older adults is one contributing factor to the rise in preventable sexual diseases. Studies have shown that older people with multiple sex partners and other risk behaviors were likely to report inconsistent condom use (Schensul, Levy, & Disch, 2003; K. Smith & Christakis, 2009; Ward, Disch, Schensul, & Levy, 2011). In a study exploring sexual behaviors of older unmarried women, 58% did not use condoms during their last sexual intercourse experience (Lindau, Leitsch, Lundberg, & Jerome, 2006). Among men, widowhood has been shown to significantly increase the risk of sexually transmitted infections (STI) in older adult men in the first year after death of a spouse (K. Smith & Christakis, 2009). This risk is even
Address correspondence to Tonii C. Gedin, DNP, RN, 3708 Hill Park Drive, Temple Hills, MD 20748. E-mail: tonii. [email protected]
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greater for men using erectile dysfunction drugs. It is anticipated that this increase is due to the fact that older men reentering the dating world are not using condoms. Inconsistent condom use and high-risk behaviors may be explained by the low perceived susceptibility of sexual disease contraction in older adults (Flavo & Norman, 2004; Lindau et al., 2006; Lindau et al., 2007; Maes & Louis, 2003; Schensul et al., 2003; Small, 2010; K. Smith & Christakis, 2009). The belief that one is susceptible to a particular illness or condition is a necessary component to health-related behavior such as consistent condom use (Rosenstock, Strecher, & Becker, 1988). Increasing their knowledge of condoms, and therefore their self-efficacy toward condom application, can influence older adults behavior toward condom use. Knowledge of condom use and STIs is lacking in older adults (Foster, Clark, Holstad, & Burgess, 2012; Goodroad, 2003; Nusbaum, Singh, & Pyles, 2004; Rodgers-Farmer, 1999; Ward et al., 2011). Research has shown 40% of older African American adults were uncertain about the effectiveness of condoms to protect one from STIs, with this uncertainty being even worse among women (Neundorfer, Harris, Britton, & Lynch, 2005; Rodgers-Farmer, 1999). Misconceptions about HIV and STI transmission are also common among older adults (Henderson et al., 2004; Hillman, 2007, 2008; Jackson, Early, Schim, & Penparse, 2005). For example, one 76-year-old African American man was quoted as stating, “he knows he’s safe [from infections] as long as he pours Jack Daniels on his genitals immediately after sex” (Ward et al., 2011, p. 32). The focus of education in the area of health promotion among older adults is most commonly geared toward cardiovascular health (diet and exercise), increasing physical activity, fall prevention, or cancer screening. Much less focus and emphasis has been placed on providing education around sexual health in older adults. Information received is not from health care providers, and the accuracy is questionable (Gott & Hinchliff, 2003; Henderson et al., 2004; Lindau, et al, 2006; Nusbaum et al., 2004; Slinkard & Kazer, 2011; Stewart & Graham, 2013). Older adults, however, have indicated that they would be willing to discuss sexual activity if this topic was initiated by their primary health care provider (Gott & Hinchliff, 2003; Lindau et al, 2006; Nusbaum et al., 2004; Slinkard & Kazer, 2011). Previous research found that older adults recommend education take place in community settings (Small, 2010). The rising prevalence of HIV, low perception of risk, inconsistent condom use, and knowledge gap in older adults in community-based settings supports a need for a targeted health education campaigns. Prior research (Jemmott, Jemmott, Hutchinson, Cederbaum, & O’Leary, 2008; Jemmott, Jemmott, & O’Leary, 2007) supports the use of brief, 30-min, intensive, multisession educational interventions conducted by nurses in clinical practice settings and STI clinics as a way to increase risk awareness, knowledge of STIs and change behavior (i.e., increase condom use among adults). Research also supports the use of group sex education in public housing and other community-based settings to change sexual risk behaviors (Carey, Senn, Vanable, CouryDoniger, & Urban, 2010; Sikkema et al., 2000). Specifically, prior research has demonstrated that brief interventions in clinical settings and group educational programs in public housing, focused on sexual health and associated risks, can help to increase knowledge and change behavior among adults. All of the prior work in sexual education has focused on middle-aged, rather than older, adults. This study seeks to explore effective teaching methods for increasing the self-efficacy of older adults toward safe-sex behaviors during brief educational interventions in senior housing. Older adult is defined in this study as individuals 55 years old or older.
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THEORETICAL MODEL Prior HIV knowledge and increased motivation to practice safe sex have both been associated with self-efficacy for safe-sex behaviors (Foster et al., 2012). In addition, among older adults, the relationship between self-efficacy for safe-sex behaviors was influenced by perceived effectiveness to perform safer sexual behaviors (Foster et al., 2012). In that study, as well as other studies focused on management of chronic illness, educational interventions have been shown to improve the self-efficacy in older adults (Beverly et al., 2013; Nguyen et al., 2013). The theory of self-efficacy (Bandura, 1977) was used to guide the development of a group educational program, Sexual Health for Older People (SHOP), which was provided for older adults in senior housing settings. The goal of SHOP was to strengthen confidence among older adults with regard to their knowledge of sexual health and safe sexual activities, and their confidence in using this knowledge to influence their sexual behavior. The theory of self-efficacy includes self-efficacy expectations, which are an individual’s judgment of his/her confidence to carry out specific behaviors, and outcome expectations, or the beliefs that carrying out a specific behavior will lead to a desired outcome. The stronger the individual’s perceived self-efficacy and outcome expectations, the more vigorous and persistent his or her efforts (Bandura, 1986). Self-efficacy can be strengthened using a number of approaches, including successful performance of the activity of interest, verbal encouragement to perform the activity, seeing like individuals successfully perform the activity, and eliminating unpleasant feelings and sensations associated with the activity (Bandura, 1977). Prior research has shown that self-efficacy-based approaches are effective in improving knowledge and behavior associated with safe sexual activity (Foster et al., 2012), as well as many other health behaviors related to physical activity (Resnick et al., 2007; Resnick et al., 2008). The purpose of this study was to determine the feasibility of a group-based educational program in senior housing settings and consider the utility of a self-efficacy-based group education program on knowledge of disease risk and preventive techniques among older adults living in senior housing. Specific aims were to learn from participants whether or not this type of approach was useful from their perspective and identify subsequent program revisions that could be used to guide ongoing development of educational programs specific to sexual health in older adults. To best explore the participants’ experience associated with this type of learning, a focus group approach was used. METHODS This was a qualitative study using a focus group approach. The study was approved by the University of Maryland Institutional Review Board and was conducted in two urban senior housing sites. Sample and Setting The SHOP sessions took place in two Baltimore City, low-income, senior-housing buildings. Inclusion criteria included living in one of these communities and being 55 years of age and older. To encourage participation and inform residents of the workshop, flyers were placed within the building a week prior to the class and attendance was encouraged by the site managers prior to and on the day of class.
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The SHOP Intervention The facilitator of the SHOP educational workshop was a Masters-prepared public health nurse with experience educating older adults on sexual health. Workshops were held in the multipurpose room within each of the facilities and lasted from 30 to 45 min. The workshops were set at a time that was determined to be the most conducive to attendance by the managers in each of the buildings. As shown in Table 1, multiple teaching methodologies were used to cater to various learning styles. Guided by self-efficacy theory, verbal encouragement was used to teach and encourage safe sexual behavior. Fundamentals of STI and HIV contraction were taught in lecture format with coordinating written materials. The lecture was done in an interactive format consistent with adult learning. Participants were encouraged to share their knowledge and beliefs and then accurate upto-date facts and information were presented. The information specifically included prevalence of STIs and HIV within the older adult population, modes of disease contraction, identification of high-risk behaviors, signs and symptoms of STI and HIV/AIDS, the importance of testing, and the ways in which to discuss sexual health with primary care providers (materials available from first author). Participants were shown how to perform skills such as application of a male condom and then given the opportunity to practice these skills via simulation experience (i.e., placement of a condom over a cucumber). In addition, to help address barriers to condom role-playing scenarios were developed. For example, a condom negotiation situation was conducted with participant TABLE 1 Description of Teaching Methodologies and Techniques Teaching Methodology
Description
Verbal Encouragement
Facilitator encouraged participants to start conversations about sexual health with their intimate partners. Facilitator encouraged participants to start conversations about sexual health with their primary care provider. Facilitator encouraged participants to get routine testing for STD’s and HIV/AIDS if they were sexually active. Facilitator encouraged participants to use condoms. Facilitator discussed the fundamentals of STD’s and HIV/AIDS. Facilitator discussed the prevalence of STDs and HIV within the older adult population, modes of disease contraction, identification of high-risk behaviors, signs and symptoms of STD and HIV/AIDS, the importance of testing, and the ways in which to discuss sexual health with primary care providers. Facilitator uses a cucumber for demonstration of male condom application. Facilitator discusses appropriate fit of male condoms. Facilitator discusses appropriate removal of male condoms. Facilitator provided examples of things to say when negotiating condom use with an intimate partner. Facilitator acted the role of new partner and the participant attempted to use condom negotiation techniques. Facilitator used a jeopardy style game with a board displaying point values of each question. Questions were asked in a true versus false format. Participants volunteered to answer questions and selected their question. A small prize was given to the winner of the game.
Lecture
Demonstration
Role-Play
Game
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volunteers and the educator. Last, to reinforce knowledge, the workshop incorporated a myth versus truth of STIs and HIV/AIDS jeopardy game. Focus Group Method and Measures The focus groups were held immediately following each educational workshop. Participants of the workshop were invited to stay and join in the focus group to provide feedback about the workshop and discuss their experiences. The educational facilitator led the focus groups and a research assistant took notes throughout the group discussion. Focus groups lasted approximately 30 min each. Total participation time for this study ranged from 1 hr to 1 hr and 15 min. The questions guiding the focus group are shown in Table 2. Questions asked during the focus group focused on how participants felt about the learning techniques used and whether or not the participant felt the knowledge gained would alter their sexual behavior in the future. Last, we explored with participants their recommendations for how the program could be improved. Data Analysis Data from the participants was analyzed using a constant comparison analysis (Strauss & Corbin, 1998). Two coders coded the data separately and then met to review codes and come to consensus. The codes were then developed into themes. Specifically, the three stages of constant comparison analysis identified by Strauss and Corbin were utilized in the analysis process. During the first stage, open coding was conducted, which involved each coder individually separating the data into small clusters and attaching a descriptive code to each cluster. In the second stage, axial coding the codes were categorized into groups. During the third and final stage of selective coding, the coders collaborated to establish themes that represent the content of each of the groups. Reliability and Validity of the Qualitative Data Credibility, dependability, and confirmability of qualitative data were examined. Credibility refers to the degree of believability, fit, and applicability of data to the inquiry (Lincoln & Guba, 1985). Because the focus groups were completed at different locations at different times the findings were coded independently. Findings from the first focus group were compared to the subsequent focus group to confirm or refute codes and emerging themes. Dependability refers to ability of the findings to be consistently found if methods are repeated (Lincoln & Guba, 1985). Dependability was demonstrated by implementing the same methods, in the same context, with the same population, in different sites with separate focus groups (Shenton,
TABLE 2 Focus Group Questions 1. 2. 3. 4.
Describe your experiences and feelings associated with participation in this workshop. Describe the ways in which this workshop was helpful to increasing your knowledge of safe sex. Describe the ways in which your sexual behavior might change following this program. Tell me about the ways in which you might change this workshop to make it better in terms of the information provided or the ways in which you learn.
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2004). Comparison of separate findings indicated that the methods used produced consistent results when repeated. Confirmability refers to the extent to which the data is reflective of the focus group inquiry (Lincoln & Guba, 1985). Confirmability was established through the use of two reviewers being involved in the data analysis process. As noted, the reviewers coded the data independently and met to resolve any discrepancies until consensus was reached. Moreover, a transparent decision trail was created to increase confirmability. This trail supports the logical fit of the findings. RESULTS The SHOP workshops had a total of 21 participants combined. There were 5 participants at the first site, out of approximately 75 eligible residents (7%) living in the facility and 16 participants at the second site out of 100 eligible residents in the second setting (16%). A total of six codes were identified from the focus group data and these were reduced to 4 themes. Three of these themes focused on components that facilitated learning in the participants and included: (a) utility of games during education; (b) positive impact of a well-organized session; and (c) importance of the “teach back” approach. The fourth theme focused on the importance of tailoring the time of education to the audience and was labeled: (a) Timing is everything. Utility of Games During Education Participants described the jeopardy game as a key facilitator to their learning. The game was noted to be fun, enjoyable, and educational. Participants explained that the game helped them to process and recall what they had learned. The utility of games to increase learning was expressed by responses such as: “The lecture was logical and the game really helped to back up our knowledge. It was a fun way to learn and reinforce knowledge.” “I liked all parts of the class but the games were my favorite as they made me think.” Positive Impact of a Well-Organized Session Participants stated that the rigorous structure of the educational session was important to them. Participants expressed value in providing multiple teaching methodologies in an organized fashion during the single educational session. One participant reported, “All parts of the class went together really well and I learned something from all of it.” Participants felt that the organization of information increased not only their learning, but also their ability to stay engaged and interested in the session. Importance of the Teach Back Approach Participants reported that the opportunity to demonstrate learned skills increased their confidence in their knowledge about sexual health. Many expressed that they felt they could now educate others about this as well. In addition, some participants asserted that repeating information back to the group during the games helped them to clarify points and confirm the accuracy of information they were previously unsure about. One participant reported, “The game really backed up our knowledge. It was a fun way to ask questions and reinforce knowledge.”
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Timing is Everything Participants voiced that the time of the educational session directly impacts the number of participants likely to attend. Participants articulated specific days and/or times they felt would appeal to residents in their respective communities. Both workshops took place early in the afternoon. Participants at one location felt that the information would have reached a larger audience if it were offered in combination with another standing activity such as bingo. Participants at this same location felt participation would have been higher later in the day after 5pm. In contrast, the other location felt the time was perfect and stated they would not come out later in the evening.
DISCUSSION The older adults who participated in the focus groups provided support for the feasibility and utility of this method of teaching sexual health information. Participants were willing to attend the sessions and repeatedly noted that they learned a lot and appreciated the education. Implications for practice were identified by the focus group. Based on the focus group findings, the structure and organization of the educational sessions, the use of games, and timing of the intervention were all noted to have an important influence on the participants’ learning and engagement in the workshop. Organization Findings from this study reinforced the importance of being organized during educational workshops. As shown in prior studies, workshops and programs that organize and adhere to an appropriate teaching plan are more likely to be well received by older adults (Friedman, Cosby, Boyko, Hatton-Bauer, & Turnbull, 2011; Nussbaum & Coupland, 2004; Zurakowsi, Taylor, & Bradway, 2006). In addition to organization of information, based on information learned, it was helpful to prioritize the most important information to provide to the class participants to optimally assure learning. Previous research has noted that priority setting for information dissemination in older adults is needed particularly when providing health information (Best, 2001; Fenter, 2002; Zurakowsi et al., 2006). In the SHOP educational program, risk behaviors and the importance of condom use were presented prior to condom negotiation techniques. Our findings also confirm the recommended use of multiple teaching mechanisms to assure optimal learning (Agate, Mullins, Prudent, & Liberti, 2003; Friedman et al., 2011). As noted in prior education with older adults (Matsui, 2010; Rigdon, 2009), participants valued the use of multiple teaching methods that corresponded and supported each other. For example, written handouts that reiterated the facts stated and complimented the didactic information were greatly appreciated. Moreover, despite the increased use of technology and computers among older adults, our participants liked the written materials and indicated that they would use the written material and lecture information to share with family, friends, and church congregations. At the end of the formal session, several participants asked if they could take the extra copies of printed materials to share with others. Although printed, hard copies of educational material were greatly appreciated by the participants, we anticipate that the educational design may have been strengthened with the use
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of an audiovisual component such as a short video demonstrating a challenging sexual health interaction between two older individuals or other type of web-delivered intervention (Ammann, Vandelanotte, de Vries, & Mummery, 2012; Friedman et al., 2011). With increasing access to smart phones and tablets among older adults, inclusion of web-based educational materials for these individuals will become more accessible. Evidence is accumulating demonstrating that web-delivered educational interventions are effective in changing behaviors in older adults with chronic diseases (Ammann et al., 2012; Westlake et al., 2007) and web-based exercise interventions can improve physical function (Sparrow, Gottlieb, Demolles, & Fielding, 2011) and bone health (Nahm et al., 2010). Games As anticipated, the use of games was noted to be a particularly useful and an entertaining way to reinforce learning. Games provide a way in which to stimulate enthusiasm of the learner and thereby to promote the retention of information through repetition (Bastable, 2008; Billek-Sawhney & Reicherter, 2005; Fenter, 2002; Thomas, 2007). Games also provided the facilitator with a chance to correct misunderstandings or clarify information. Reinforcement and clarification of teaching is concurrent with prior findings of older adult education (Best, 2001). The questions asked during the games served as a fun way in which to provide ongoing education and repetition of information presented. The games were also used as a way for participants to teach each other as they expanded upon correct answers and clarified incorrect answers. That is, following their response to a quiz question, participants would explain to the group why the answer they provided was right or wrong. This teaching of information previously learned back to others has been referred to as the “teach back” technique (Weiss, 2007, p. 33). This method of demonstrating learning and demonstrating knowledge is recommended in the education of older adults (Best, 2001; Billek-Sawhney & Reicherter, 2005; Zurakowsi, Taylor, & Bradway, 2006) and useful in increasing retention of information (Fink et al., 2010). The SHOP workshop demonstrated that games can be used to facilitate teach back techniques and promote retention of learning and that this approach was greatly appreciated by the older learners. Previous research supports our finding that games facilitate learning (Blakley, Skirton, Cooper, Allum, & Nelmes, 2009: Gipson & Bear, 2013). These authors found that, in multiple studies, the use of games is associated with reinforcement and increased retention of information with nursing students and experienced nurses. In addition, previous research has shown that learning through games is equally as effective as traditional lecture (Gipson & Bear, 2013). Although the games were used in this study to facilitate learning on the part of the participants, the games also allowed the SHOP facilitator to evaluate what the participants had received in terms of information and what they understood following the session. Participants’ answers and teach back explanations provided the facilitator with evidence as to how well participants accurately recalled the information provided. Timing The timing of educational sessions for older adults living in senior housing persistently is challenging to establish as there are individual, cohort, and possibly even setting differences.
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Although both SHOP sites were inner city, low-income, senior housing communities, participants at each location had distinctly different preferences for intervention times. One site found the 1 o’clock time was very appropriate; the other felt that an evening session would be better attended. Tailoring the dates and times of workshops is critical to facilitating optimal participation in educational sessions for older adults. Thus, including these individuals in plans for the implementation of sessions is recommended (Agate et al., 2003). Partnering with the population to design the intervention may have allowed older adults to assess utility and relevance of SHOP (Doyle & Timonen, 2010) and identify pertinent differences in the population (Parker et al., 2012). In this study, we depended on the recommendation of the managers in the facilities and we recommend in future programming that interventionists work directly with residents to explore their preferences with regard to timing.
CONCLUSION This study was limited by virtue of design and the qualitative nature of this work. Moreover, it was done in only two settings. Despite these weaknesses, the findings provide support for the use of a self-efficacy based approach to teach older adults sensitive health information. In addition, the SHOP provided additional support for the use of multiple methods when educating lowincome older adults in senior housing. Further research is needed to explore the incorporation of technology into education sessions for these individuals. REFERENCES Agate, L., Mullins, J., Prudent, E., & Liberti, T. (2003). Strategies for reaching retirement communities and aging social networks: HIV/AIDS Prevention activities among seniors in South Florida. Journal of Acquired Immune Deficiency Syndromes, 33, 238–242. Ammann, R., Vandelanotte, C., de Vries, H., & Mummery, K. (2012). Can a website-delivered computer tailored physical activity intervention be acceptable, usable, and effective for older people? Health Education and Behavior, 40(2), 160–170. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 34, 191–215. Bandura, A. (1986). Social foundations of thought and action. Upper Saddle River, NJ: Prentice Hall. Bastable, S. B. (2008). Nurse as educator; principles of teaching and learning for nursing practice. Sudbury, MA: Jones and Bartlett. Best, J. (2001). Effective teaching for the elderly: back to basics. Orthopedic Nursing, 20(3), 46–52. Beverly, E., Fitzgerald, S., Sitnikov, L., Ganda, O., Enrique, C., & Weinger, K. (2013). Do older adults aged 60–75 years benefit from diabetes behavioral interventions. Diabetes Care, 36(6), 1501–1506. Billek-Sawhney, B., & Reicherter, E. (2005). Literacy and the older adult educational considerations for health professionals. Topics in Geriatric Rehabilitation, 21(4), 275–281. Blakely, G., Skirton, G., Cooper, S., Allum, P., & Nelmes, P. (2009). Educational gaming in the health sciences: systematic review. Journal of Advanced Nursing, 65(2), 259–269. Carey, M. P., Senn, T. E., Vanable, P. A., Coury-Doniger, P., & Urban, M. A. (2010). Brief and intensive behavioral interventions to promote sexual risk reduction among STD clinic patients: results from a randomized control trial. AIDS Behavior, 14, 504–517. doi:10.1007/s10461-009-9587-1 Centers for Disease Control and Prevention. (2003). AIDS Cases In Adolescents and Adults, by Age – United States, 1994–2000. Centers for Disease Control and Prevention. (2013a). Diagnoses of HIV infection among adults aged 50 years and older in the United States and dependent areas, 2007–2010. HIV Surveillance Supplemental Report, 18(3), 6.
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