1) An appreciative education approach was compared to a social cognitive theory approach in promoting health behavior change and hypertension control in older adults. Quantitative results found significantly faster gait speeds in the appreciative education group, while qualitative findings identified differences in peer influence and health relationship perspectives between the groups. 2) Both approaches were effective in reducing BMI, blood pressure, and encouraging healthier food choices. Participants enjoyed learning aids like food samples and label reading. Behavior changes included increased fruits/vegetables, water intake, and blood pressure control. 3) Future research should measure long-term intervention effects, include food preparation, and conduct long-term case studies to better understand lifestyle behavior maintenance in older adults. Limitations included

1. Hypertension and Health
Behavior Change in Older Adults:
The Effect of an Appreciative Education Approach
Dissertation Defense
University of South Carolina
Department of Physical Education and Athletic Training
June 17, 2015
Mary Katherine Benya, MA, Gerontologist, Phd(c)

2. 10,000 baby boomers turn
65 daily between 2011-13
Cohn & Taylor, 2010; Passel & Cohn,
2008; Vincent & Velkoff, 2010
adults over 55
90% lifetime risk
of hypertension
Chobanian et al., 2003
life expectancy over
78 years
Murphy, Xu, & Kochanek, 2012
coronary heart disease
leading cause of death in US
& 81%US deaths over age 65
Murphy et al., 2012; Statistics, 2011
hypertension gateway chronic disease
preventable & controllable with lifestyle changes
Dagogo-Jack, Egbuonu, & Edeoga, 2010;
I. Hajjar, Appel et al., 2006, Kotchen, & Kotchen, 2006
Older Adults Hypertension Control

4. Community-based Interventions
1st generation
CHAD Program, West Jerusalem
Abramson et al., 1981; Parker & Assaf 2005
2nd generation
Stanford Five Cities Project
Farquhar et al., 1977
3rd generation
South Carolina Cardiovascular Disease
Prevention Project
Health, Fuchs, Croft, Temple & Wheeler, 1995
4th generation
WISEWOMAN Program
CDC, 2011b; Khavjou, Finkelstein, & Will, 2007

5. Lifestyle University Intervention
≈ Community program focused on adults with risk factors
for or conditions of hypertension, obesity, and diabetes
≈ 6 sessions (2.5 hours each)
≈ Content Areas
1) Nutrition 4) Stress Management
2) Physical Activity 5) Medical Knowledge
3) Social Support 6) Pharmacy
≈ Classes offered at no cost to participant
≈ Individuals must be motivated to make
lifestyle behavior changes
Hajjar et al., 2005

6. Social Cognitive Theory
Personal
Factors
BehaviorEnvironment
Self-efficacy
≈ Vicarious experiences (modeling) ≈ Mastery experiences
≈ Social persuasion
≈ Modeling of coping strategies to
reduce or eliminate the stressful reaction
Reciprocal Determinism
Bandura, 1986, 1989

7. Appreciative Cycle
disarm
discover
dream
design
deliver or
destiny
don't
settle
Bloom et al., 2011; Bloom et al., 2008

8. Theory Comparison

9. Research Questions
1) Is the Appreciative Education approach more
effective than the Social Cognitive Theory
approach in promoting health behavior change
when applied to an educational intervention in
older adults to control hypertension?
2) How do participant perspectives and health
behaviors after the intervention differ between
the Appreciative Education approach and
Social Cognitive Theory approach?

10. Mixed-methods
≈ Pretesting during required orientation one week prior
to the start of each course
~ 6 Lifestyle University courses
3 control Social Cognitive Theory
3 courses Appreciative Education
modified during last 50 minutes of four classes 2-5
~ 6 bi-weekly classes per course
on either Tuesday or Thursday
~ Older adults, aged 50 and older
≈ Post-test 1 part of class 6
≈ Post-test 2 at least 6 weeks after class 6
≈ Post-intervention interviews 34

11. Quantitative Measures
≈ descriptive statistics
≈ repeated measures group x time ANOVA
7 dependent variables
1) systolic blood pressure
2) diastolic blood pressure
3) body mass index
4) fruits & vegetables, avg daily – EATS
5) physical activity, avg METS/wk– IPAQ
6) self- selected gait – 10-meter gait
7) fast gait – 10-meter gait

12. Demographics

13. Control (SCT†) Intervention (AE≈)
Pre Post1 Post2 Pre Post1 Post2
Variable n Mean SD Mean SD Mean SD n Mean SD Mean SD Mean SD F p-value
Systolic blood pressure (mm Hg) 29 142.89 (26.56) 132.15 (21.73) 133.62 (22.53) 13 148.02 (29.23) 130.61 (24.61) 128.40 (20.86) (2, 80) 2.02 0.140
Diastolic blood pressure (mm Hg) 29 75.68 (11.02) 69.54 (9.54) 69.69 (9.05) 13 78.87 (9.95) 73.40 (8.86) 71.63 (7.20) (2, 80) 0.26 0.773
BMI (lb/m2) 29 31.34 (6.86) 31.07 (7.05) 30.87 (6.95) 13 28.17 (6.43) 28.05 (6.57) 27.74 (6.63) (2, 80) 0.86 0.150
Self-selected gait speed (meters/sec) 29 1.20 (0.28) 1.07 (0.19) 1.07 (0.20) 13 1.02 (0.12) 1.12 (0.13) 1.06 (0.14) (2, 80) 9.80 0.0002*
Fast gait speed (meters/sec) 29 1.54 (0.39) 1.36 (0.32) 1.42 (0.29) 13 1.39 (0.22) 1.42 (0.26) 1.44 (0.30) (2, 80) 6.67 0.002*
†Social Cognitive Theory (SCT)
≈Appreciative Education (AE)
* significant
Note: all individuals with missing data were dropped from the analysis
Quantitative Results

14. Mean Self-selected & Fast Gait Speed
Pre Post1 Post2
SCT 1.2 1.07 1.07
AE 1.02 1.12 1.06
0.9
0.95
1
1.05
1.1
1.15
1.2
1.25
Self-selectedGaitSpeed(m/sec)
Mean Self-selected Gait Speed
Pre Post1 Post2
SCT 1.54 1.36 1.42
AE 1.39 1.42 1.44
1.25
1.3
1.35
1.4
1.45
1.5
1.55
1.6
FastGaitSpeed(m/sec)
Mean Fast Gait Speed

15. Pre-test to Post-test 2
Changes
Pre Post1 Post2
SCT 142.89 132.15 133.62
AE 148.02 130.61 128.4
115
120
125
130
135
140
145
150
SystolicBP(mmhG)
Systolic Blood Pressure
Pre Post1 Post2
SCT 75.68 69.54 69.69
AE 78.87 73.4 71.63
64
66
68
70
72
74
76
78
80
DiastolicBP(mmhG)
Diastolic Blood Pressure

16. Qualitative Results
3 Perspective themes & sub-themes
1) Peer Influence (SCT)
~ advice & ideas
~ challenges & support
~ successes
2) Health Relationships (AE)
~ bucket list
~ reflection
~ taking action
~ noticing the connections
3) Enjoyment
4 Health Behavior themes & sub-themes
1) Accountability
~ food
~ physical activity
~ blood pressure
2) Consumption Changes
~ fruits & vegetables
~ water
~ salt and/or sugar
3) Learning Aids & Activities
~ samples & recipes
~ test tubes & label reading
~ grocery store tour
4) Other Behavior Changes
~ physical activity
~ stress management
~ blood pressure control
~ unintended benefits
Strauss & Corbin, 2015; Glaser & Strauss, 1967; Lincoln & Guba, 1985
Grounded Theory, open & axil coding, constant comparison analysis

17. Qualitative Results Differences
Peer Influences
Advice & Ideas Well, the different
opinions of different people gave me more
ideas of a, you know, what you should do
and how you should go about doing it. (So
that was helpful for you.) Um huh. (SCT-
31Sp)
Successes Well it was pretty enlightening
to see how others were operating, which
was already shittier than mine. I think
we've all improved… when you realize
that even though someone else had bad
habits that you have, then you're more
conscious of it and you're curtailing it.
And so now when I'm offered that third
glass of wine, I'm not going to say that I
say no to the second…But if I'm offered
the third, except maybe twice a year, I
have said no. (would you say it was the peer
influence?) Yes (SCT-05Su)
Health Relationships
Bucket List …made you sit down & think
about things... expanden your thirst for getting
more information & identify those things
within yourself that you need to
reevaluate…that’s a major issue, that was
really emphasized in the class. Looking at
things that you do every day. (AE-57F)
Noticing the Connections …if I’m not healthy,
I wouldn’t enjoy doing, on going those places.
Wouldn’t be able to walk around if I don’t
keep my walk up…when you, go on a trip and
do the touring, especially when you’re walkin
around, you get in a lot of walking miles…we
took the girls, I’m a Girl Scout leader… Disney
World…we walked around all day long, it
seemed like… I had over 10,000 miles on those
days we were down there. So I thought, you
know, if I had been keep doin this before, I
wouldn’t be able to keep this up today! (AE-
20Sp+)

18. Qualitative Results Similarities
Enjoyment
I loved takin that class, I mean
I, you know, had so much fun
and I always get something
out of it. (AE-39F)
I think the most interesting
thing to me was taking time to
read on the different things in
the grocery store before I
purchase. (So reading the
labels)… Yeah. That was just
too interesting I really enjoyed
that. I had no idea things, so
many fascinating things were
(laughter) right there before me
and I was just buying, taking
home, having a great time, and
hum, a, but after coming here
it bothered me, the difference,
you know...Oh yea. And I been
trying to keep it up. (SCT-
84Su)
Consumption Changes
Fruits, Vegetables & Water
Well to at least think about
your servings of food
everyday. Are you getting 4
servings of fruits &
vegetables … daily which I
had never given a lot of
thought to before…less of
the complex carbs…sugary
drinks, more water. (SCT-
03Sp)
I've been drinkin water as
much as I can...every once
in a while, if I go out to eat,
I will, sometimes I will get
a soda, a diet soda, I'm
tryin to, I'm tryin to wean
myself away...probably the
most important thing felt
like was about drinkin the
water (AE-02F+)
Accountability
Food & Physical
Activity
First of all a, my eating
habits…eliminating fat
& some salt, including
fruits & vegetables, cut
down on meat and a
also a lot of starches.
The other thing was
not just the eating was
exercising & relaxation
a lectures that we had I
found very beneficial,
also…particularly the
little thing that you
gave us that …we put
on when you walk.
(AE-51Sp)

19. Qualitative Results Similarities
Learning Aids & Label Reading
Samples & Recipes Well, well I've
always observed that what you can see
with your eyes and what you hear goes
together and if you can observe
something, it sticks with you a lot better
than what you hear sometimes. Yes
and the nice treats that you had for us
and showing us how things could go.
(SCT-71Su)
Test-tube & Label reading I didn't
know so, when, when that lady showed
us in the little containers that the salt
that was in different items I had no idea
there was that much salt. Have mercy,
tried to cut back on salt, and some of the
sugar. I like sweets. (AE-65F)
Other Behavior Changes
Blood Pressure Control I think the fact
that my blood pressure has finally
gotten down to normal and it's still
normal. (…being an RN you already knew
about your blood pressure [laughter] so that
was just kind of a reminder again) Yeah,
oh yeah. Because until I retired my
blood pressure was nowhere near
normal so then when I retired, it was
still sort of borderline and then when I
took this class, then it came down to
normal and … it's still normal. (Do you
take any medications?) It was high, even
with the medications. And we couldn't
get it down and my doctor was so
exasperated, so she's very pleased now.
(AE-42F)

20. Discussion
Quantitative
≈ Self-selected and Fast gait
only significant differences
between groups
≈ Intervention is effective in
reducing BMI, systolic &
diastolic BP
≈ EATS & IPAQ results
affected by missing data
& outliers
Qualitative
≈ Perspective differences
theme 1 peer influences &
2 health relationships reflect
the respective theoretical
approaches
≈ Food samples effective in
encouraging increase in
healthy food choices
≈ Qualitative results were
overwhelmingly positive;
a larger sample size or
modification to the delivery
protocol might yield more
significant qualitative results

21. Results in Relation to Previous
Research and Supporting Theories
≈ Hypertension gait decline
Rosano et al., 2011
≈ Gait speed can increase
Hardy et al., 2007;
Plummer-D'Amato et al., 2012; Wang et al., 2015
≈ Positive aging stereotypes and gait speed increase a AE
Hausdorff, Levy, & Wei, 1999;
Wolff, Warner, Ziegelmann, & Wurm, 2014
≈ Effective lifestyle interventions; LU, PREMIER, AA Senior Center
I. M. Hajjar, Dickson, Blackledge, Herman, & Watkins, 2007
Appel et al., 2003
Fernandez, Scales, Pineiro, Schoenthaler, & Ogedegbe, 2008
≈ Social Cognitive Theory a Peer Influence perception theme
≈ Appreciative Education a Health Relationship perception theme

22. Recommendations
for Future Study
≈ Design AE intervention
from bottom up linking
personal goals &
functional ability
≈ Measure long-term
intervention effects
≈ Include food prep in
intervention
≈ Long-term case studies
of older adults
Limitations
≈ Internal validity
≈ External validity
≈ Instruments
≈ Use of Community
Health Advisors
≈ Attendance at
multiple courses
≈ Medications