Symposium.

Symposium. In the Public Domain The Cerontologist Vol. 31, No. 5, 584-592

This collection of five papers evaluates the participation of older adults in clinical trials, health promotion/disease prevention initiatives, and health programs designed to maintain or improve the functioning of chronically ill older adults. Understanding the willingness or unwillingness of older adults to participate in these programs is critical to the development and implementation of health programs and policies for this population. In this introductory paper we briefly review illustrative literature to provide both an overview of the participation of older adults in health programs as well as background information relevant to the symposium papers. Key Words: Elderly research participants, Health promotion, Disease prevention, Disability reduction

Participation of Older Adults in Health Programs and Research: A Critical Review of the Literature1 William B. Carter, PhD,2 Kurt Elward, MD, MPH,3 Judith Malmgren, PhC,4 Mona L. Martin, BSN, MPA,5 and Eric Larson, MD, MPH6

Participation rates determine the feasibility of conducting health programs and randomized clinical trials, and they influence the accuracy of survey results and population-based rates in epidemiological studies for all age groups. Despite the increasing proportion of persons 65 years of age or older in the U.S. population, surprisingly little is known about the participation of older adults in health programs. Understanding the willingness or unwillingness of older adults to participate in research, demonstration, and service programs is critical to the develop-

1 This research was supported in part by the CDC-funded Center for Health Promotion/Disease Prevention in Older Adults, School of Public Health and Community Medicine, University of Washington; the Northwest Health Services Research and Development Field Program, Seattle VA Medical Center; and by a National Research Service Award in Primary Care, Department of Medicine, University of Washington. Address correspondence to: William B. Carter, PhD, Department of Health Services (SC-37), University of Washington, Seattle, WA 98195. department of Health Services, University of Washington, and the Northwest Health Services Research and Development Field Program, Seattle VA Medical Center, Seattle, WA. department of Family and Internal Medicine, University of Virginia, Charlottesville, VA. 4 Center for Health Promotion/Disease Prevention in Older Adults, Department of Health Services, and the Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA. 5 Center for Health Promotion/Disease Prevention in Older Adults, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA. 'Department of Medicine, University of Washington, and University Medical Center, Seattle, WA.

ment and implementation of health programs and policies for this population. University of Washington investigators in the Center for Health Promotion and Disease Prevention in Older Adults, the Center for Health Studies at Croup Health Cooperative of Puget Sound, the Northwest Health Services Research and Development Field Program at the Seattle VA Medical Center, the Northwest Geriatric Education Center, and the Fred Hutchinson Cancer Research Center jointly organized a conference in November 1989. The papers presented in this symposium on participation of older adults in health programs are a product of that conference. In this introductory paper, we review briefly illustrative literature from surveys, research studies, clinical trials, health promotion/disease prevention initiatives, and health programs designed to maintain or improve the functioning of chronically ill older adults. To the extent data are available in each of these areas, we attempt to identify: whether participation rates for older adults differ from those of other age groups, factors that differentiate participants from nonparticipants, and strategies for improving participation.

Participation of Older Adults in Surveys

Because survey research attempts to estimate characteristics of large populations that generally cannot be enumerated, it is subject both to selection bias and to participation bias. The potential for selection 584

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bias is particularly critical in studies of persons aged 65 or older because this age group has greater heterogeneity in health status and disease burden than any other (Zimmer et al., 1985). The representativeness of population estimates derived from a survey sample may be jeopardized by any sampling method that systematically excludes certain segments of the population. For example, random digit dialing, a sampling method commonly used in survey research (Herzog, Rodgers, & Kulka, 1983), systematically excludes persons without telephones. Although older adults are more likely to have telephones than younger persons, this method is relatively inefficient and expensive for identifying older adults, because only about 25% of households are home to an older adult (Czaja, Snowden, & Casady, 1986; Sudman, Skrken, & Cowan, 1988). A recent study found that some commercial telemarketing lists may provide an efficient, low-cost method for identifying older adults, but potential sources of sampling bias need further exploration (Psaty et al., submitted). Other sampling methods, such as Medicare enrollment files, or telephone, voter, and driver license directories, are either difficult to access or represent only some subgroups of the older adult population (Leuthould & Scheele, 1971; Hartge et al., 1984). The representativeness of a survey may be further jeopardized by the unwillingness of persons in the sample to participate. Comparison of participants and nonparticipants in three national in-person interview surveys conducted by the Survey Research Center at the University of Michigan showed a small but consistent decline in participation rate with age (Herzog & Rodgers, 1988). The average participation rate was 74% for persons aged 18-34 years, 70% for 35-44 years, 67% for 45-54 years, 69% for 55-64 years, 69% for 65-74, 65% for 75-84, and 52% for those 85 or older. Older adults appear to be less willing to participate in telephone interviews than in-person interviews (Massey, Barker, & Hsiung, 1981). It is estimated that telephone surveys of persons over age 65 miss approximately 50% of the total eligible population, whereas in-person surveys miss only about 33% (Herzog, Rodgers, & Kulka, 1983). Furthermore, older participants in telephone surveys tend to be healthier and more educated than older participants in in-person surveys. Among all age groups, telephone survey participants are more likely to be white and report higher incomes than participants of inperson interviews. Although the quality of survey data did not vary by age, a greater number of missing values and "don't know" responses occurred in telephone versus in-person interviews among all age groups (Herzog, Rodgers, & Kulka, 1983). Recruiting Older Adults to Clinical Trials

The primary objective of a randomized controlled clinical trial is to evaluate the efficacy of an intervention (e.g., a new drug or treatment program, screening procedure, health-behavior modification program) under ideal circumstances. Trial subjects are Vol. 3 1 , No. 5,1991

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selected on the basis of strict entry criteria (e.g., diagnostic or functional status), as well as estimates of their ability to follow what are often arduous study protocols for extended periods of time. For the effort of following the treatment protocol, subjects have an equal chance of being assigned to a new treatment of unknown efficacy or to a control group that receives the status quo or nothing. As a result, subject recruitment and retention are among the most difficult tasks faced by investigators who conduct clinical trials, regardless of the age of the target population (Leader & Neuwirth, 1978; Agras & Marshall, 1979; Croke, 1979; Prout, 1979; Schoenberger, 1979; Collins et al., 1980; Agras & Bradford, 1982). Few large clinical trials have included older adults. In a recent pilot study to recruit older adults for a multicenter clinical treatment trial of systolic hypertension (SHEP), 20% of the eligible subjects screened refused to continue the enrollment process (Vogt et al., 1986). The most common reasons reported for nonparticipation were objections by the subject's physician or a family member (32%) and inconvenient clinic location or operations (19%). A large "other" category (40%) included inconvenience, lack of time, and medical problems of the participants or their families. Although participants were initially healthier and more likely to have had some college education than persons in a general population, the investigators concluded that it is no more difficult to draw inference from clinical trials involving persons 60 years and older than for any other age group. Some investigators have suggested that older adults may make poor participants (i.e., less willing than younger subjects to follow the study protocol) in clinical research (Cobb, King, & Chen, 1957; Maddox, 1970). In a more rigorous evaluation, however, Black and his colleagues (1987) found that compliance rates with the SHEP treatment protocol were high (80-90%) at 3 months and 1 year in all age categories, including those over age 80. In the second paper of this symposium (following this Introduction), Thornquist and Omenn examine the participation and compliance of high-risk older men and women recruited to a clinical trial examining the efficacy of beta-carotene and retinol in preventing lung cancer. Although the youngest and oldest age groups had slightly lower compliance rates, it was feasible to recruit and achieve good protocol compliance with smokers up to age 69 and with asbestos-exposed workers up to age 74. Participation in Health Promotion/Disease Prevention Initiatives

Until recently, major research on risk factors and the effectiveness of health promotion and disease prevention activities, such as the Multiple Risk Factor Intervention Trial (MRFIT) and the Lipid Research Centers Coronary Primary Prevention Trial, excluded persons over the age of 60 years. As a result, health promotion and disease prevention recommendations for older adults were relatively sparse. Even

participation rates are summarized in Table 1, and examples of variables that are related significantly to participation are summarized in Table 2.

smoking cessation was omitted from the list of preventive activities recommended for older adults in many medical textbooks and by the landmark policy document Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (1979). Nevertheless, recent findings show comparable increments in survival rates for persons with coronary heart disease who quit smoking after age 65 and those who quit at younger ages (Hermanson et al., 1988). These data suggest that older persons may live longer by following health promotion and disease prevention practices, and there is some evidence to suggest they might also live "better" (i.e., better functional status) (Healthy People, 1979). Below we examine the participation of older adults in primary prevention programs (e.g., influenza vaccination), secondary disease prevention programs (e.g., screening tests for blood pressure, and breast, cervical, and colon cancers), and in comprehensive health promotion programs. Examples of program

Participation in Immunization and Screening Programs The first entry in Table 1 summarizes three influenza vaccination intervention studies targeting older adults. Although initial vaccination rates were low, these studies show that low-cost mailed interventions can improve participation rates in vaccination programs by 15-30 percentage points in a single application in clinical settings. With repeated annual mailings, vaccination rates continue to improve, reaching 80% in one setting after 5 years (Carter et al., submitted). The next four entries in Table 1 are examples of multiple-risk-factor screening programs for heart disease, conducted in community and clinical set-

Table 1. Participation Rates in Health Promotion/Disease Prevention Programs, by Study Source Primary prevention Larson et al., 1979; Carter etal., 1986,1991 Wilhelmsenetal.,1976 Walker etal., 1987

Program/study question/condition

Age of participants

% Participating

Interventions to improve influenza vaccination rates in clinical settings Community primary prevention trial (6-year follow-up) British Regional Heart Study (7-year clinic follow-up)

65+ years

34-37% (control groups) 53-64% (intervention groups)

Men 45-55 years at enrollment

75%

Men 40-59 years at enrollment

74%

Roseto community screening for CHD risk factors HMO screening for risk factors of

Over age 21

53%

Men, 35-57 years

49%

Over 40 years

8-60%

Over 45 years

68% (control group) 80-93% (intervention groups) 75%

Qrroonmo

OLrecning Bruhn,1969 Greenlick etal., 1979

Meal I Uijt-doC

Blalock etal., 1987 Thompson etal., 1986 Weintraub etal., 1987 Fink etal., 1972 Zapka etal., 1989 Taplin etal., 1989 Todd etal., 1984 Health promotion programs Bruce etal., 1976

Haber, 1986

Morey etal., 1989

Windsor & Morris, 1984

Review of colon cancer screening programs HMO colon cancer screening intervention trial Physician screening program for cervical cancer HIP mammography study Six-community study of mammography Mammography risk factor intervention trial Hypothetical adult development program

Over 65 years 40-64 years Over 60 years 50-79 years 60-80 years

65% 50% (have had a mammogram) 31% (mammogram in last year) 66% (50-59 years) 73% (60-79 years) 13% expressed a willingness to participate

Active participants and dropouts in CAPRI cardiopulmonary rehabilitation programs (supervised exercise program) Health promotion to reduce blood pressure among African Americans (yoga and aerobics classes met weekly or three times/week for 10 weeks)

Mean age for men = 53.5 years ( ± 8.8) Mean age for women = 52.1 years ( ± 8.6) Over 60 years

42% of males active at 20-22 months 38% of females active at 20-22 months 52% of target population participated 74%-83% class attendance 65%-86% compliance with homework

Active participants and dropouts of a supervised exercise program among VA outpatients Hypothetical health promotion program (e.g., exercise, smoking cessation, weight loss) in a community medical center

Over 64 years

71% of participants active at 4 months

20-49 years 50-69 years

84%/83% younger men/women and 42%/69% older men/women expressed a willingness to participate

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tings for middle-aged adults. Activities in each of these programs are similar, yet participation rates range from 49% to 75%. Even in programs that achieve relatively high participation rates, generalizability is limited by a higher rate of morbidity and mortality among nonparticipants (see Wilhelmsen et al. and Walker et al. entries in Table 2). Finally, age was positively related to participation in three of these studies (see Bruhn, Creenlick et al., and Walker et al. entries in Table 2), even though the range of age among study participants was limited. Participation rates in programs that focus on a single screening activity also vary widely both within and among prevention activities. This variability appears to be related both to the nature of the activity and to whether the program targeted is a known clinical population or a general community population. For example, in Table 1, participation rates in single screening activities tend to be higher in clinical settings than in community settings. In addition, the large variation in participation rates for colon cancer screening compared with other screening activities may reflect barriers associated with collecting fecal samples (see Blalock et al. in Tables 1 and 2). It is encouraging, however, that a relatively simple intervention like a reminder postcard (Thompson et al., 1986) can significantly improve participation rates by 12-25 percentage points. A substantial proportion of women at high risk for breast and cervical cancers are not screened (Brown & Hulka, 1988; Zapka et al., 1989; Weintraub, Viola, & Freedman, 1987). Factors related to participating in mammography screening programs in community settings are similar to those found in clinical settings (e.g., a family history of breast cancer, having a regular physician, encouragement from friend or doctor, and practices self-breast exams; see Table 2). Participation in Health Promotion Programs Although many investigators have studied health promotion programs, surprisingly few have examined participation and adherence rates for older adults (Elward & Larson, submitted). Examples of studies that have included older adults in health promotion programs are listed in the last entries of Table 1. Of the studies examined, only one (Haber, 1986) reported an overall participation rate (i.e., percentage of the total target population who participated). Two additional studies reported program attendance (Bruce et al., 1976; Morey et al., 1989), and one study reported willingness to participate (Windsor & Morris, 1984). Older adults with chronic diseases are willing to participate and benefit from exercise programs (Morey et al., 1989); however, unlike younger populations, their primary reason for dropping out of exercise programs is illness or perceptions of diminished physiological reserve (Bruce et al., 1976; Krista et al., 1986; Morey et al., 1989). Morey et al. (1989) found that participants and a sample of nonparticipants in an outpatient exercise program were similar in age, and in both impatient and outpatient utilization, but nonparticipants had a Vol. 31, No. 5,1991

significantly higher number of chronic diseases and prescribed medications than participants. In fact, the frequency of chronic heart and lung diseases was twice as high among program nonparticipants. Comparing program participants to a sample of nonparticipants, however, Buchner and Pearson (1989) found that ratings of general health were not related to participation in a health promotion educational program. In fact, participants were more likely to have lower mental and social health ratings and higher depression ratings than nonparticipants. Other factors that were positively related to participation included seat belt use, having a smoke alarm, exercise, and nonsmoking status. Obesity and alcohol abstinence were positively related to participation for men, but were negatively related to participation for women. Studies that have examined the intention to participate in community health promotion programs ha^e found that older adults are more reluctant to participate than are younger age groups (Todd, Davis, & Cafferty, 1984; Windsor & Morris, 1984). Older adults may have different values and beliefs about health promotion activities than younger age groups (Biddie & Bailey, 1985; Mobily, 1982; Mobily et al., 1986; 1987; Myers & Gonda, 1986; Shephard et al., 1987), beyond that, we know very little about which program characteristics may be particularly attractive to older adults. This may in part explain variation in participation among programs that differ in content and format. For example, participants of community health promotion programs exhibit a wide range of preferences in selecting both the content of health promotion programs they are willing to attend (e.g., blood pressure, serum cholesterol, nutrition, weight loss, smoking, and exercise programs) and the format in which they prefer to have information presented (e.g., groups or classes, self-help materials, community screening) (Lefebvre et al., 1987). Lefebvre and colleagues found that two-thirds of the participants in the activities offered by a community health promotion program were women. The gender disparity was greatest among those who attended exercise and weight loss activities. Blood pressure programs attracted the highest percentage of persons aged 60 or over (40% of all participants) whereas only 8% of participants in smoking cessation programs were 60 or above. Recruitment strategies and the level of program supervision also appear to play an important role in achieving and maintaining participation in health promotion programs. For example, Haber (1986) achieved a 52% participation rate in a 10-week yoga and exercise program for older African-American residents of a federally subsidized residential facility. This rate was impressive because the maximum rate achieved by other programs in this setting was only 9%. Features of the recruitment procedure included initially gaining the support of administrative staff and influential residents, lengthening the recruitment period (10 weeks), selecting recruiters with characteristics similar to the target population, scheduling activities to minimize personal schedule 587

O

00 00

Taplinetal., 1989

Fink etal., 1972

HMO mammography intervention study

NIH survey of cervical cancer screening of women 35-74 years HIP mammography study

Kleinman & Kopstein, 1981

Blalock et al., 1987

HMO colon cancer screening intervention trial Review of colon cancer screening programs

Roseto community risk factor screening for health disease HMO risk factor screening for heart disease (men, 35-57 years)

British Regional Heart Study (long-term follow-up of men 40-59 years) Community primary prevention trial (long-term follow-up of men 45-55 years)

Health promotion activity

Thompson etal.,1986

Greenlick etal.,1979

Screening Bruhn, 1969

Wihelmsen etal.,1976

Primary prevention Walker et al.,1987

Source

Age( + )

Age (-); education ( + ); married ( + ); Jewish religion ( + )

Age (-); income (-); metropolitan residence ( + )

>75 years (-); education (mixed); marital status (mixed)

Age ( + )

Age ( + ); nonwhite race (-)

Age ( + ); male ( + ); socioeconomic ( + )

Age( + ); married ( + ); less skilled workers (-)

Demographic factors

Dependents ( + )

(+)

Larger families ( + ); years in community

Social support

Clinical risk status intervention ( + )

MD( + )

Family/friends, MD recommend

Previous biopsy ( + )

Symptoms & prior Hx (+ for intention, not compliance)

Cholesterol >240( + ); at or < ideal body weight (-); DBP >90 (-) Symptoms ( + )

Chronic disease (-); alcohol problem (-); mortality total & all causes (-)

Mortality (-)

Health status

Family history

Previous test (+)

Prior Hx/ behavior

Positive attitudes toward screening ( + ); Concern about cancer

Severity, susceptibility (+ intention, not compliance); efficacy of Tx ( + ); barriers (-); Follow MD advice

Taking care of health ( + )

Health beliefs

Table 2. Variables Related Significantly to Participation in Health Promotion/Disease Prevention Programs, by Study

MD visit in last year

Smokers (compliance, not intention); dental visits & seat belt use ( + ); medical visits (mixed)

Smoker ( + ); medical visit last 2 years ( + )

Other health behaviors

z

Vol.3

00

». 5.1991 Age (-); married ( + ); education ( + ); female ( + )

Health education and risk factor screening for health disease

Pirieetal., 1986

Age {NS); gender (NS); diabetes mellitus (NS)

Feasibility and effectiveness of a 4-month exercise program for older VA outpatients Exercise program for university employees and retirees

Moreyet al.,1989

(NS)

Number of chronic medical conditions and medications (-) Baseline treadmill (NS; VO2max. (NS); body mass

Baseline body mass index (-)

Randomized trial of exercise program for older women: Activity level at 2 years and factors that predict compliance

Kristaet al., 1986

Shepard etal., 1987

Number of months of illness before program (-)

Age (NS); weight (NS)

Cardiopulmonary rehabilitation program for cardiac patients: Comparison of active participants and dropouts

Bruce etal., 1976

General health (NS); lower mental & social health ( + )

NS

Health status

Age ( + ); education ( + ); income ( + ); female ( + )

Heard about program from family/friend ( + )

MD( + )

Friends ( + );

Family/friends, MD recommend

Health education: HMO senior health promotion program Social participation (-)

NS

Social support

Buchner & Pearson, 1989

Health promotion

Age ( + ); education ( + ); income ( + ); never married (-); Jewish religion ( + ); Regular MD( + )

Demographic factors

Community mammography study

Health promotion activity

Zapka et al.,1989

Source

Months in program ( + ); inability to increase heart rate at baseline exercise (-) Baseline blocks walked/day ( + ); completed training period ( + )

Personal or family history ( + )

Prior Hx/ behavior

(NS)

Interest in training and tension relief (-);TypeA(-); self-efficacy

NS

Satisfaction ( + ); benefit ( + ); most women get ( + ); need symptom to be screened (-)

Health beliefs

Table 2. Variables Related Significantly to Participation in Health Promotion/Disease Prevention Programs, by Study (continued)

Alcohol use (NS)

Smoking (-); number of blocks walked at baseline ( + )

Seat belt use( + ); Smoke alarm ( + ); exercise & nonsmoking ( + men); obesity, alcohol abstinence (+ men,-women)

Medical checkup (-); dental checkup ( + ); seat belt use ( + )

Other health behaviors

conflicts, and using demonstrations and films to dispel negative perceptions about exercise. In addition, participants in classes that met three times per week were more adherent with daily homework assignments than those who participated in classes that met weekly. This finding supports previous suggestions that older adults may benefit from more frequent professional supervision in implementing new behaviors (Haber, 1986). Aside from the Haber research (1986), few studies have examined actual participation rates in health promotion programs in an older adult population. The findings of a comprehensive survey of persons who did not participate in a large HMO health promotion program for well older adults are reported in the third paper of this symposium by Wagner and colleagues. Participants had significantly higher incomes, more education, and higher levels of community involvement. Interestingly, although participants perceived themselves to be healthier than did the nonparticipants, no differences emerged between groups in terms of hospitalization rates, falls, disability scores, and number and potency of medications taken for major chronic diseases. Finally, in addition to knowing about well older adults, we need to know the extent to which comprehensive health promotion programs are useful for older adults with chronic disease, psychological distress, or functional disabilities. Because these individuals are likely to be higher users of medical care services, effective health promotion programs may have the greatest detectable impact on this group by altering utilization patterns. In the fourth paper in this symposium, Durham and colleagues examine the participation of higher users of medical care in a Health Care Financing Administrationsponsored trial to determine whether Medicare reimbursement for preventive services delivered to seniors results in better health and fewer doctor and hospital visits. They found that although participation rates were slightly lower for persons 85 years and older and for those with chronic diseases, most older adults were willing to make additional visits for health promotion. Participation of Chronically III Older Adults in Health Programs

Adult day care programs may be viewed as an extension of the types of health promotion programs described above that are designed to improve or maintain the functioning of chronically ill older adults. In this country, adult day care programs have had problems recruiting and maintaining sufficient numbers of patients to meet their target case loads. The inconvenience of arranging for transportation, difficulty in planning for and implementing, and preference for privacy and personal choice of companions are cited as factors possibly responsible for patient resistance to these programs (Kane & Kane, 1987). Further research is needed to characterize those who do and do not agree to participate in adult day 590

care programs in order to understand the feasibility of these programs and their place in the continuum of long-term care. In the fifth paper in this symposium, Hedrick and colleagues explore factors related to participation in a congressionally mandated study of the effectiveness of adult day care programs in the VA Medical Care system. Encouragingly, few differences were found between participants and nonparticipants. Participants were more likely to be enrolled in a nursing home at the time of referral to adult day care than nonparticipants. Participants were also more likely to have a caregiver who was having some difficulty with instrumental activities of daily living (e.g., housework, money management) and they were perceived by their caregiver as having more behavioral problems than were nonparticipants. Summary

It appears to be no less feasible to include adults up to age 74 in surveys, clinical research, and health promotion/disease prevention programs than any other age group. Although recruitment periods may need to be extended, participation rates for this age group are either comparable or only modestly lower than other age groups. Furthermore, these older adults are good study participants. They comply with study protocols, and the quality of their responses to telephone and in-person surveys is comparable (Herzog, Rodgers, & Kulka, 1983) or only modestly lower than other age groups (Colsher & Wallace, 1989). This is particularly noteworthy for future clinical trials and health promotion/disease prevention research, areas that have excluded persons 60 years of age or older until recently. As people progress through their later years, however, it will become increasingly difficult to obtain adequate participation, compliance, and highquality responses to surveys. Participation rates in telephone surveys are consistently lower for persons 85 years of age and older. The underrepresentation of all groups of older adults in telephone surveys is not easily understood and needs further study. Perhaps the best current strategy is to offer an in-person interview option for persons with hearing impairment or for those who object to telephone interviews. Even though the participation rate is lower for persons 85 years or older, it is feasible to include this age group in studies. Generally, participation rates exceed 50% for persons 85 years or older. Because most nonparticipants 85 years of age or older decline because of episodes of ill health (Herzog & Rodgers, 1988), it is important for studies to have flexible data collection procedures (e.g., making provisions for multiple recruitment contacts, a flexible follow-up schedule, and provisions for proxy respondents) (Herzog, Rodgers, & Kulka, 1983; Zimmer et al., 1985). Reducing disability, the national objective for health promotion, requires that effective programs reach older adults at risk of acquiring disabling conditions. Older adults are generally as willing as other The Gerontologist

age groups to participate in health promotion and disease prevention programs. When participation rates in clinical settings are low (influenza vaccination, breast and colon cancer screening), effective low-cost interventions are available. Achieving high participation rates in community settings is more challenging. Persons with lower levels of income and education as well as smokers consistently participate less frequently in health promotion programs. Health status, social support, obesity, drinking habits, and recent medical care may or may not be related to participation, depending on the program. These characteristics may have different patterns of association with participation for men and women (e.g., see Buchner & Pearson in Table 2). Finally, different health promotion programs appear to attract different groups of older adults. Identifying specific program characteristics that attract different subgroups of older adults and designing programs that are attractive to the disadvantaged are two significant challenges for future research. References Agras, W. S., & Bradford, R. H. (1982). Recruitment: An introduction. Circulation, 4(Suppl.), 2-5. Agras, W. S., & Marshall, C. (1979). Recruitment for the coronary primary prevention trial. Clinical Pharmacological Therapy, 25, 688-690. Biddle, S. J. H., & Bailey, C. I. A. (1985). Motives for participation and attitudes toward physical activity of adult participants in fitness programs. Perceptual and Motor Skills, 67, 831-834. Black, D. M., Brand, R. J., Creenlick, M., Hughes, C , & Smith, J. (1987). Compliance to treatment for hypertension in the elderly: The Systolic Hypertension in the Elderly Program. Journal of Gerontology, 42, 552557. Blalock, S. J., DeVellis, B. M., & Sandier, R. S. (1987). Participation in fecal occult blood screening: A critical review. Preventive Medicine, 76, 9-18. Brown, ]. T., & Hulka, B. S. (1988). Screening mammography in the elderly: A case-control study. Journal of General Internal Medicine, 3, 126-131. Bruce, E. H., Frederick, R., Bruce, R. A., & Fisher, L. D. (1976). Comparison of active participants and dropouts in CAPRI cardiopulmonary rehabilitation programs. American Journal of Cardiology, 37, 53-60. Bruhn, J. G. (1969). Sociological factors related to participation in a screening clinic for health disease. Social Science and Medicine, 3, 85-93. Buchner, D. M., & Pearson, D. C. (1989). Factors associated with participation in a community senior health promotion program: A pilot study. American Journal of Public Health, 79(6), 775-777. Carter, W. B., Beach, L. R., & Inui, T. S. (1986). The flu shot study: Using multiattribute utility theory to design a vaccination intervention. Organizational Behavior and Human Decision Processes, 38, 378-391. Carter, W. B., Inui, T. S., Hickam, D. H., Silverman, D., Stevens, D., & Lee, D. (1991). Effectiveness and cost of a patient-centered organizational program to improve influenza vaccination rates in a VA multi-center randomized trial. Manuscript submitted for publication. Cobb, M. D., King, S., & Chen, E. (1957). Differences between respondents and non-respondents in a morbidity survey involving clinical examination. Journal of Chronic Disease, 6, 95. Collins,). F., Bringham, S. F., Weiss, D. C , Williford, W. D., & Kuhn, R. M. (1980). Some adaptive strategies for inadequate sample acquisition in Veterans Administration Cooperative Trials. Controlled Clinical Trials, 7, 227-248. Colsher, P. L, & Wallace, R. B. (1989). Data quality and age: Health and psychobehavioral correlates of item nonresponse and inconsistent responses. Journal of Gerontology, 44(2), 45-52. Croke, C. (1979). Recruitment for the national cooperative gallstone study. Clinical Pharmacological Therapy, 25, 691-694. Czaja, R. F., Snowden, C. B., & Casady, R. J. (1986). Reporting bias and sampling errors in a survey of a rare population using multiplicity counting rules. Journal of the American Statistical Association, 81, 411419. Elward, K., & Larson, E. (1991). Participation in health promotion programs by elderly persons. Manuscript submitted for publication. Fink, R., Shapiro, S., & Roester, R. (1972). Impact of efforts to increase participation in repetitive screenings for early breast cancer detection. American Journal of Public Health, 62, 328-336. Creenlick, M. R., Bailey, J. W., Wild, J., & Crover,). (1979). Characteristics of men most likely to respond to an invitation to be screened. American Journal of Public Health, 69(10), 1011-1015.

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APHASIA: MY LIFE IN THE MISTS By Rosemary Collett A stroke or accident victi m may be unable to speak, read or write. Behavior may be erratic and over-emotionalism occurs. It's all a part of aphasia. For many aphasics, life is now one-step-at-a-time. This remarkably sensitive audiocassette was written by a writer who is taking those steps. —"very informative, particularly for stroke victims and their families." Kim Leatherwood, speech therapist at Thorns Rehabilitation Hospital, Asheville, NC. ISBN 1-878159-17-8 PARKINSONS: HOW TO COPE AND LIVE WITH IT By Jace Leach The author's courage, humor and a positive outlook have allowed him to define and cope with the limitations brought on by his i 11 ness.—"Along with a good layman's explanation of the disorder are descriptions ofsuch commonproblems as swallowing, walking ...as well as his suggestions for coping with each." United Parkinson Foundation ISBN 1-878159-14-3 Each tapeis$9.95 plus $2.00 shipping CA residents add 7.75% tax Mastercard/Visa To Order or to receive free catalog listing our other patient/family audiocassettes, videos and books, please write or Call Toll Free 800-726-3465. Duvall Media, Inc., P.O. Box 15892-G, Newport Beach, CA 92659, (714) 631-3445.

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