Concepts, Theories and Design Components for Nutrition Education Programs Aimed at Older Adults

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Concepts, Theories and Design Components forNutrition Education Programs Aimed at Older AdultsMary Meck Higgins PhD, LD, CDE a & Mary Clarke Barkley PhD, RD, LD aa Department of Human Nutrition , Kansas State University , Manhattan, Kansas, USAPublished online: 24 Sep 2008.

To cite this article: Mary Meck Higgins PhD, LD, CDE & Mary Clarke Barkley PhD, RD, LD (2003) Concepts, Theories and DesignComponents for Nutrition Education Programs Aimed at Older Adults, Journal of Nutrition For the Elderly, 23:2, 57-75, DOI:10.1300/J052v23n02_05

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Concepts, Theories and Design Componentsfor Nutrition Education Programs Aimed

at Older Adults

Mary Meck Higgins, PhD, LD, CDEMary Clarke Barkley, PhD, RD, LD

ABSTRACT. This article examines characteristics of older adult learn-ers and discusses adult education theory and empowerment concepts,along with nutrition education and behavioral change strategies for olderadult nutrition education programs. Design components for older adultnutrition education programs are presented. Educational and behavioralchange strategies should be selected based on characteristics of the in-tended audience, including their nutrition needs, wants and desires, andshould be based on appropriate theory. Multi-disciplinary research isneeded to develop behavioral and educational theoretical frameworks, aswell as designs, intervention strategies, and evaluation methods for edu-cational programs that lead to older adults adopting more healthful nutri-tion practices. This is one of a series of recent literature reviews onnutrition education for older adults. [Article copies available for a fee fromThe Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<[email protected]> Website: <http://www.HaworthPress.com>© 2003 by The Haworth Press, Inc. All rights reserved.]

Mary Meck Higgins is Assistant Professor and Cooperative Extension Human Nu-trition Specialist.

Mary Clarke Barkley is Professor Emeritus and Cooperative Extension Human NutritionSpecialist, Department of Human Nutrition, Kansas State University, Manhattan, Kansas.

Address correspondence to: Mary Meck Higgins, Assistant Professor, Department of Hu-man Nutrition, 202 Justin Hall, Manhattan, KS 66506 (E-mail: [email protected]).

Journal of Nutrition for the Elderly, Vol. 23(2) 2003http://www.haworthpress.com/store/product.asp?sku=J052

2003 by The Haworth Press, Inc. All rights reserved.10.1300/J052v23n02_05 57

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KEYWORDS. Nutrition education, older adults, ethnic groups, behaviorchange, empowerment, adult education, intervention program

INTRODUCTION

Nutrition education has been defined as “any set of learning experiences de-signed to facilitate the voluntary adoption of eating and other nutrition-related be-haviors conducive to health and well-being” (Contento et al., 1995). Nutritioneducation is found in treatment as well as prevention and wellness programs; im-plemented via one-on-one, small group or community-wide modalities; and sup-ported by private as well as public funds (Grommet, 1997). Opportunities fornutrition education for the public have been presented in a position paper by theAmerican Dietetic Association (1996) as a continuum that ranges from provisionof: (1) nutrition information to meet consumer interests; to (2) nutrition communi-cations that inform consumers of the role of foods in a healthful diet; to (3) nutri-tion promotion that translates science-based dietary guidanc e into consumer-oriented messages to facilitate appropriate eating behaviors; to (4) nutrition inter-vention to create planned behavior change to empower consumers to make health-ful food choices. Templeton (1991) asserted that extending a healthy life, ratherthan disrupting a lifestyle, should be the goal of nutrition education. Also, nutritionprofessionals must remember that food means much more to people than being amere vehicle for obtaining nutrients (Betts, 1988).

Sahyoun (2002) lamented that nutrition education programs to promotenewly-identified unique dietary needs of older adults have lagged behind discov-ery research, and argued that it is time to keep pace with recent findings and de-velop national and state-sponsored programs that will provide nutrition educationand information transference to older people in their communities. Similarly,McBean et al. (2001) called for effective public policies directed to older adults.For example, the authors encouraged nutrition educators to provide practical di-etary and lifestyle advice tailored to this rapidly expanding segment of older indi-viduals, in order to help them age successfully and ensure their quality of life.

Additionally, older adult nutrition education programs that use reliable andvalid evaluation methods are needed. Higgins and Clarke Barkley (2003a) foundonly 16 recently published U.S. research studies using nutrition education inter-ventions–but not nutrition counseling or mass media–with older adults that alsoincluded statistical analysis and program evaluation. Most of the programs thatsuccessfully changed behavior or had other significant impact addressed severalissues relating to promoting health. Twelve of the 16 studies demonstrated statisti-cally significant outcomes, with nine of these measuring verified behavioral orphysiologic impact. Improvements in various other outcomes included knowl-

58 JOURNAL OF NUTRITION FOR THE ELDERLY

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edge, attitudes, intentions and perceptions. Benefits of various forms of educationfor selected groups relative to their costs are unknown at this time, particularly forolder adults, both majority and minority groups, and no data for both costs andbenefits of nutrition education for older adults were found by Higgins and ClarkeBarkley (2003b). The authors cited data projecting that enormous yearly savingsin economic and human resources could be realized through research on the bene-fits of appropriate nutrition education and behavior change, and that another majorbenefit would be increased quality of life, resulting in longer, more productive andmore satisfying independence and health status.

This article discusses the older learner and the relevance of concepts and theo-ries about older adult education and behavior change, along with components use-ful in designing an older adult nutrition education program. The review ofliterature was limited to articles containing information about nutrition educationof older adults living independently in the U.S. Articles published primarily since1995 were examined, while those reviewed by Contento et al. (1995), as well asunpublished papers and dissertations, were excluded. Further, articles that focusedon intensive individual nutrition counseling by various health care providers wereexcluded, as were reports of mass media campaigns broadcasting health messagesto older adults and reports of nutrition screening techniques for senior adults.

This article is one of a series of reviews of recent literature on topics related tonutrition education for older adults. The purpose of this series is to assist nutritioneducators, researchers and health practitioners in familiarizing themselves withcurrent or recently published strategies pertaining to nutrition education for olderadults (Higgins and Clarke Barkley, 2003a, b, c). Specifically, the purposes of thisarticle are: (1) To characterize older adult learners; (2) To discuss briefly adult ed-ucation theory and empowerment concepts and older adult nutrition education andbehavioral change strategies; (3) To present components to consider when design-ing older adult nutrition education programs, and (4) To indicate where research isneeded.

CHARACTERISTICS OF OLDER ADULT LEARNERS

“Younger” older adults are people 65 to 74 years old, while the “oldest-old” are85 years of age and older (American Dietetic Association, 2000). The latter werethe fastest-growing group of the older population during the 1990s (U.S. CensusBureau, 2001a). The number of people ages 85 years and over increased 38% be-tween 1990 and 2000. In 2000, there were 50,454 centenarians (people age 100 orover), a 35% increase from the 37,306 people in this age category in 1990. Thethird fastest-growing sub-group among all ages in the population from 1990 to2000 was 90-to-94 year olds, which increased by 45% (U.S. Census Bureau,

Nutrition Education for Older Adults 59

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2001b). (The fastest-growing sub-group was 50-54 year olds, followed by 45-49year olds.) The number of people ages 65-to-74 years old grew less than 2% dur-ing the 1990s, but the low growth rate among younger older adults is expected toreverse as baby boomers reach age 65, starting in 2011 (U.S. Census Bureau,2001a). From 1990-2010, the older adult population will grow at a lower averageannual growth rate than during any similar period since 1910, but will realize sub-stantial growth and unparalleled increases in the absolute number of elderly per-sons during 2010-2030 (U.S. Bureau of the Census, 1996). Minority ethnicgroups, especially Hispanics, are making the most gains among the older popula-tion (Rogers, 2002; U.S. Bureau of the Census, 1996). Many senior adults livealone, especially among the oldest old. In addition, older adults are disproportion-ately female, especially among the oldest old; in 2000, 71% of those ages 85 andolder were women (Rogers, 2002). Many Black and Hispanic elderly, 19% and15%, respectively, experience food insecurity and hunger, in large part because oflimited financial and social support resources (Nord, 2002). The diversity of olderadults in calendar years, health status, physical and cognitive abilities, race, cul-ture, ethnicity, social class, literacy levels, years of formal education, financial re-sources, social support, experiential living, emotional health, personal livingskills, lifestyle, rural versus urban living setting, etc., is extreme (Higgins andClarke Barkley, 2003c).

In 1999, people ages 55 to 70 years were globally healthier and less disabled bychronic conditions such as cardiovascular disease, hypertension, and chronic ob-structive pulmonary disease than were similarly aged people born approximately17 years earlier (American Dietetic Association, 2000). Many changes experi-enced by elders result from chronic diseases rather than “old age.” Normal age-re-lated changes occur, but are varied among individuals with regard to rates ofdecline for different bodily systems and to chronological age at which physicallosses become noticeable. Age-related sensory changes have recently been dis-cussed, and the importance of their impact on food choices and the nutritionalwell-being of older adults has been challenged (Mattes, 2002). When chronic dis-ease is layered on top of normal-aging changes, the result is that humans differmore from one another in old age than at any other period in their lives (Ahroni,1996; American Dietetic Association, 2000). The vast majority of Americans overthe age of 65 years, 95.5%, live independently; and even among those ages 85years and over, only 18% lived in nursing homes in 2000 (U.S. Census Bureau,2001a). Many rely on home and community-based services. About 20% arehomebound (Buchowski and Sun, 1996). Before age 69 years, only 9% of the el-derly need assistance with everyday activities, while after age 85 years, about 50%of non-institutionalized elders need assistance with their Activities of Daily Liv-ing (ADLs) (U.S. Bureau of the Census, 1996).


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The capacity of humans to learn and integrate new information remains intactthroughout the life cycle (American Association of Diabetes Educators positionstatement, 1999). Walker (1999) noted that there are two categories of adult edu-cation. Older adults are heavy users of informal/non-credit education, as opposedto formal/for-credit education. Informal education often deals with skill and hu-man resource development and health education for the prevention or treatment ofa condition such as diabetes. Self-management of diet for health or disease fallsinto this category. Contrary to popular belief, most elderly people continue to en-gage in learning throughout their lifetimes. For instance, Ralston and Cohen(1999) described elderly Blacks as being interested and motivated to learn, withmany substantially involved in self-directed learning projects.

Templeton (1991) characterized older adults in general as being a group who isreceptive to nutrition education and who already realizes the importance of goodnutrition. Compared with young adults today, most elderly grew up valuinghealthy eating habits. Evidence of great interest in health by the elderly is reflectedin sales of dietary supplements and fortified foods. Older adults may have good in-tentions, but may find it very difficult to initiate and maintain healthful changes.Because many older adults are healthy and living independently, programs em-phasizing dietary guidelines and a modified food guide pyramid are generally ap-propriate. Older adults’ primary health goals are to maintain their health status andprevent disease and disability.

ADULT EDUCATION THEORY AND EMPOWERMENT CONCEPTS

Adult education is similar to that for children and youth in many respects.However, there are a number of considerations particularly suitable for adultlearners. For example, adult education theory posits that the teaching and learningapproach best suited to adults uses the learner’s own experience and expertise, isproblem based, and is relevant to challenges they face (Anderson and Funnell,1999). Ahroni (1996) reviewed differences between teaching adults and children.Older learners especially are self-directed, can serve as resources for one another,and have internal motivations for learning. If their education is organized aroundlife situations rather than by topical subject, their readiness to learn can be en-hanced. Practical application of information is of more importance to older adultsthan are facts. A teacher should act as a facilitator, not as a “knows-it-all.” Thewisdom of older adults can be utilized in the teaching/learning interaction; theyhave much to teach as well as to learn. An important positive social role for the el-derly is to embody and transmit traditions and to be involved in guiding the nextgeneration. Similarly, adult learner principles used in diabetes education, as de-scribed by Walker (1999), include: self-directed learning enhances autonomy;


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adults must feel a need to know; problem-oriented learning is more acceptable toadults than just learning information about a subject; incorporating life experi-ences enhances motivation; and active participation is essential for behaviorchange.

Health professionals must change from a prescriptive to a collaborative style ofinteraction in order to elicit behavior change more effectively (Lorenz et al.,1996). A truly collaborative approach is one where patients and health care profes-sionals relate as equals, and where health professionals abandon trying to be re-sponsible for patients and instead become responsible to them (Glasgow andAnderson, 1999; Anderson and Funnell, 2000 and 1999). Collaborative goal set-ting and on-going self-management support are key elements of success inchronic illness education. Empowerment approaches use the terms “self-care” and“self-management” to describe the cluster of daily behaviors that patients performto manage their diabetes. These terms have generally displaced older concepts of“compliance and adherence” in diabetes organizations, in order to avoid pejora-tively implying that problems are the result of patients’ behavior. The nature of thedesired behavior changes is dynamic; there is no static standard against which tocompare patient behavior. “Autonomy motivation” refers to the psychologicalprocess that drives patient behavior change, and the term “autonomy support” re-fers to actions by health care professionals that enhance patient autonomy motiva-tion. Another discussion of issues underlying these concepts, and proposal forusing the terms “adherence” or “collaborative management,” have been presentedby Wishner and Lutfey (2000).

While behavior change is the ultimate goal of health education, the instructor isnot responsible for the change (Lorenz et al., 1996; Walker, 1999). The role of theinstructor should be to support individuals in expanding their capabilities tochange behaviors. Health professionals can provide expertise related to self-man-agement, help persons acquire knowledge necessary to make informed decisionsabout self-management, teach self-care techniques, help identify barriers as wellas social and emotional supports, offer suggestions for behavior change and cop-ing strategies, problem solve, and create opportunities for individuals to reflect onchoices they make and goals they hope to achieve.

Patients with a chronic disease such as diabetes are similar in many ways toadults living independently who are trying to eat healthfully. Thus, we suggest thatnutrition educators transfer to their work with senior adults many of the conceptsproposed by diabetes educators, such as Anderson and Funnell (2000) and Glas-gow and Anderson (1999). Independently living individuals–not educators orhealth professionals–are fully responsible for the self-management of their condi-tion, because of three characteristics (Anderson and Funnell, 2000 and 1999).First, that person, not the health professional, makes the most important choicesaffecting his or her health and well-being. Second, the individual is in control of all


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daily self-management decisions. Third, the consequences of the choices madeabout their care accrue mostly to themselves. We believe that families and care-givers also need to support older adults in understanding and accepting these re-sponsibilities. These concepts seem particularly appropriate for adoption bynutrition educators who work with older adults with an internal locus of control.(A belief that outcomes are within the individual’s capacity to control indicates in-ternal locus of control, while belief that powerful “others,” fate, or chance controloutcomes indicates external locus of control.)

OLDER ADULT NUTRITION EDUCATIONAND BEHAVIORAL CHANGE STRATEGIES

Effective nutrition education programs include many elements, including com-munication and educational strategies for enhancing awareness and motivation,behavioral change strategies, environmental interventions, and community activa-tion and organization (Contento et al., 1995). From their studies with adults,Brownell and Cohen (1995) summarized components of effective interventionsthat increase the number of changes toward recommended dietary behaviors. Theauthors presented an overview of a sample comprehensive approach to dietarychange using both educational and behavioral strategies, with consideration ofpsychological, cultural and environmental factors. These strategies included nutri-tion education regarding awareness, knowledge and motivation about what tochange and why; self-awareness and monitoring of current behavior patterns; en-vironmental changes to support dietary changes and to control undesired stimuli;barriers identification using cognitive factors and relapse prevention plans; socialsupport systems; and possibly public policy changes. According to literature re-viewed by Higgins and Clarke Barkley (2003c), researchers should investigateboth program content and process methodology when determining how to tailornutrition education interventions appropriately for older adults.

Clinical outcomes are emphasized as the basis for judging program effective-ness in recommendations by the American Diabetes Association (2000). Since thegoal is behavior change in diabetes education, it is appropriate to teach only thatwhich will facilitate behavior change, using effective teaching strategies to do so(Peyrot, 1999). We believe that the same generalization is pertinent for nutritioneducation for older adults, while realizing that knowledge gain may enhancechange in nutrition practices.

The following sub-sections will examine more closely various educational andbehavioral strategies, and the need for validation of behavior change theory toolder adult populations.


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Nutrition Educational Strategies

Currently, we know much more about what a healthy diet is than about how toget messages about it effectively across to consumers (Sutton et al., 1996). The au-thors proposed understanding and emphasizing nutrition behavior from the con-sumer’s point of view; focusing messages in lively and entertaining ways (such asdescribed by Peterson, 2002, for instance) that are also personal and meaningful toprecise audience segments; delivering messages through multiple and reinforcingmedia; and continually refining consumer messages. Despite our incomplete un-derstanding of communication methods, however, it may be easier to convey nu-trition messages than other types of health information (Brown, 1999).

Education is a process that encompasses a wide range of different interventionmodalities. Nutrition education strategies should vary depending upon the in-tended audience (Hanson and Benedict, 2002; Contento et al., 1995). Learningstyles differ among older adults. Examples of educational strategies include didac-tic education to increase knowledge and change beliefs/attitudes, demonstra-tion/feedback to improve skills, goal setting to improve intentions, problemsolving to reduce barriers, and support/counseling to increase self-efficacy(Peyrot, 1999). (Self-efficacy is one’s belief that he or she has the capability to doa behavior with his or her skills.) Lecture, discussion, simulation and project/ac-tivity intervention strategies have been described by Grommet (1997), who main-tained that all four methods are effective in meeting cognitive objectives, whilelectures alone will not meet affective/attitude objectives. Simulation and proj-ect/activity methods are excellent for meeting objectives in the psychomotor do-main.

In order to help clients learn how to make informed choices and to develop per-sonal solutions to nutrition problems, nutrition educators should focus on the pro-cesses people use to make decisions about their foods (AbuSabha et al., 1999).While the authors described results obtained with adult women, but not olderadults, our experience suggests that this method favors characteristics of olderadult learners by giving them opportunities for building rapport, increasing posi-tive affect, sharing pertinent life experiences and developing self-efficacy. Incor-poration of these opportunities was also a quality of a successful wellnesseducation program for senior adults, as described by Collins (2001).

Methods for determining appropriate content of and strategies for older adultnutrition education intervention programs were presented recently by Higgins andClarke Barkley (2003c). Educators can determine the nutrition education needsand interests of their older learners by using results of food intake surveys and as-sessment screening tools, written surveys, interviews and group discussions.Based on common themes in these reports, educators should consider emphasiz-ing calories or certain nutrients, or particular food groups or meals, according to


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their participants’ lifestyles, demographics, and/or health statuses. Older adultsdesired nutrition information regarding behaviors that affect their overall health aswell as disease-specific management; food choice strategies; food shopping, se-lection and preparation; and food resource management. Once an audience isidentified, however, it is important for the educator to verify the members’ needsand interests before proceeding. Strategies for effectively delivering nutritionmessages to older learners, including those of particular racial/ethnic groups, alsowere reviewed by these authors. A summary of 18 common themes, such as plan-ning time for discussion and opportunities for participatory interactive involve-ment and accommodation of differing physical abilities, was presented toencourage educators to enhance their own set of strategies for use in meeting theneeds and interests of their older adult audiences.

Nutrition Behavioral Change Strategies

More research to prove that education works to change behavior is not needed.It does work, according to Peyrot (1999), who discussed determinants affectingbehavior changes. However, the author argued that a better understanding of theprocess is needed. Relatively little information about what types of education pro-duce what particular benefits for which groups through what types of processeshas been generated. The author proposed many ideas for research regarding de-signs, issues needing further study, and appropriate methodology.

In discussing practical information about various health behavior change strat-egies used with adults in the Diabetes Control and Complications Trial, Lorenz etal. (1996) also concluded that ordinary people could adopt and maintain substan-tial behavioral changes. The authors described a process that facilitated change. Itincluded planning and negotiating, while focusing on individualized specific se-rial changes in behaviors, with frequent reinforcement, reminders and problemsolving. To bring about behavior changes, such as improved dietary habits, inter-active forms of learning must coincide with client needs and teach meaningful nu-trition that helps empower clients (AbuSabha et al., 1999). The authors facilitatedgroup discussions as interactive forms of nutrition educational interventions.

Goal setting is one of the most important elements of a behavioral self-manage-ment program, but it can be the most difficult part (Diabetes Care and Educationdietetic practice group, 1997). There are short-and long-term goals, as well as be-havioral and outcome goals. Goals that are realistic and achievable from the cli-ents’ perspective are best set through a process of discussion and negotiation. Eacheducational session should include a review and discussion of goals. Use of agoal-setting process was found to be an effective strategy for promoting dietarybehavior change among adults, according to Cullen et al. (2001). The authors rec-ommended a four-step process including: recognizing a need for change, estab-


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lishing a goal, adopting a goal-directed activity and self-monitoring it, andself-rewarding the goal attainment.

Effective nutrition education intervention must focus not only on behavior, butalso be based on stated theoretical frameworks of behavioral change at the indi-vidual, interpersonal or community levels (Grommet, 1997). Nutrition behavioralchange strategies have been developed based on numerous theoretical frame-works, such as Social Learning theory, Health Belief model, theory of PlannedBehavior, Transtheoretical or Stages of Change model, Knowledge-Attitude-Be-havior model, Social Cognitive or Social Learning theory, theory of Reasoned Ac-tion, and Social Marketing model (American Dietetic Association, 1996;Chapman et al., 1995; Contento et al., 1995; Walker, 1999). Another perspectivefor understanding health attitudes and behaviors over a person’s lifespan is thelife-course framework (Edstrom and Devine, 2001). Chapman et al. (1995) con-cluded that theoretical perspectives should be used as the backbone of nutritioneducation efforts. However, only seven of the 16 older adult nutrition interventionstudies reviewed by Higgins and Clarke Barkley (2003a) stated which theoreticalframework(s) was used to predict behavior change. We suspect that in many casesnone was used; the program simply was based on the researchers’ experience andbeliefs about older adults. Similarly, Bowen and Beresford (2002) noted that fewauthors of the 80 studies that they reviewed regarding dietary interventions men-tioned a theoretical basis or model of intervention.

Nutrition education interventions that define their theory base are less vulnera-ble to practitioners’ assumptions of how participants make behavioral changes(Grommet, 1997). When practitioners explicitly assume that participants in thenutrition program will change behavior according to specific determinants ofchange, per one of the tested models of behavior change, such as predisposing fac-tors, enabling factors and reinforcing factors, they can design interventions tochange participants’ behavior by more clearly identifying the processes of change.For example, Clarke Barkley et al. (2003) described three theoretical frameworksused in the design of their older adult nutrition education program and the corre-sponding components that were incorporated into the program because of thesetheories. In another example, in a descriptive study using the Health Belief model,Hanson and Benedict (2002) found only a weak relationship between perceivedthreat of food-borne illness and safe food-handling behaviors among older adults,while cues to action (such as educational materials describing safe food handling)were more useful but only among certain segments of their participants. The au-thors suggested that to change this population’s practices, it may be more benefi-cial to describe safe behaviors than to focus on the threat of illness, and that moreneeds to be learned about the needs and interests of specific sub-groups in order topromote behavior changes. However, most authors do not relate their theoreticalconstructs in the intervention models that they use to the program intervention ac-


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tivities they choose. Full descriptions of the model and intervention activitiesshould be included in future published articles (Bowen and Beresford, 2002).

Behavior change theory enhances the practitioner’s ability to achieve certainobjectives (Anderson and Funnell, 1999). The authors argued that selection ofappropriate theory(ies) should be based on how well it fits with the educator’svision; on whether it helps explain, organize and expand the educator’s experi-ence and observations into a coherent pattern; and whether it helps the educatorappropriately choose or develop educational strategies and techniques, designeducational studies, and/or guide their intervention and evaluation choices. Edu-cators should explicitly articulate their vision, i.e., perceptions, values, attitudes,and fundamental beliefs about the nature of human behavior, as well as their the-oretical perspectives or framework(s) regarding behavior change. For example,one vision of education may be that it works best as a collaborative nondirectiveeffort among autonomous responsible adults. Another vision may be that educa-tion is a way of persuading people to do what educators believe is in the group’sbest interest.

Brownell and Cohen (1995) recommended using elements of several behaviorchange models–the health belief model, health locus of control, self-efficacymodel, stages of change theory, a behavioral intention model, and social supportsmodel–all of which emphasize how to make behavior changes, along with tradi-tional nutrition education, which focuses more on what changes should be made.Similarly, in a review of predictive factors of self-efficacy and locus of control fornutrition- and health-related behavior change, AbuSabha and Achterberg (1997)concluded that three theories and models for food and diet-related behaviorchange, Social Learning theory, theory of Reasoned Action, and Health Beliefmodel, should be integrated and expanded to help explain human behavior.

Need for Validation of Educational and Behavior Change Theoriesfor Older Adult Populations

Education research and theory have existed for at least fifty years, but little re-search has been done with older adults. Comparisons of effectiveness of strategiesbased on different theories tailored to the age and ethnicity of subjects were notfound using the literature search protocol described by Higgins and ClarkeBarkley (2003b). Research is needed to validate educational approaches and be-havior change theories that are applicable for use with older adult populations.

Haber (1996) has argued that readiness stages of change are not yet acceptedfor widespread practice with older clients, and questioned if age makes a differ-ence in the response of individuals in each stage. The author discussed the benefitsof health educators identifying and offering a repertoire of strategies–includingeducation, social support, behavior and psychological management techniques,


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and referral to community resources–that are appropriate to enhance readiness forbehavior change in most older people, and allowing clients to choose what theyfind useful. The psychosocial factors, internal locus of control and social support,are not always contributors to behavior change among older adults. For example, astrong internal locus of control and strongly functioning social support networkwere not indicators for the success of participants in a diet change program, whichhad a small sample of primarily white male participants, average age 65-66 years,enrolled in a four-year diet intervention trial (Murphy et al., 2001). Rather, the au-thors attributed behavior change to the large amounts of instruction, personal at-tention, group meetings and other contacts provided by the dietary interventionprotocol, and concluded that intensity of the program may mediate effects of locusof control or social support.

The personal behavioral change approach, which assumes that individuals arewilling to change and that self-directed behavioral changes are both possible anddesirable, is commonly used in Western countries, where self-change and the fo-cus on personal behavior are consistent with prevailing beliefs (Brownell and Co-hen, 1995). The authors note, however, that in cultures where this is not the case,institutional changes created at the policy level may be more fruitful. Similarly,Oomen et al. (1999) commented that existing theories and models, such as theTranstheoretical and Health Belief models, are rooted in male, Anglo-Saxon cul-ture that emphasize self-orientation rather than the collectivist orientation typicalof older female Hispanic populations that emphasize cooperation rather than com-petition and family rather than self. Peyrot (1999) also noted that some current the-oretical models of behavior change have yet to be rigorously tested.

OLDER ADULT NUTRITION EDUCATION PROGRAMDESIGN COMPONENTS

How does one develop a program to promote changes in nutrition practicesamong older adults? Steps to consider in designing a nutrition education programfor older adults are presented in Table 1, and were compiled from suggestions andfindings described in the literature. An educator getting ready to initiate an olderadult nutrition education intervention program ideally should gather a multi-disciplinary team (Higgins and Clarke Barkley, 2003b). Next, the team should ar-ticulate their vision and theoretical perspective(s) or framework(s) regarding educa-tion and behavior change (Anderson and Funnell, 1999; Bowen and Beresford,2002; Chapman et al., 1995; Grommet, 1997).

Grommet (1997) described the next design component steps common to nutri-tion education interventions. Educators must define the audience’s needs, includ-ing those based on their input, then rank their needs, and include an assessment of


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TABLE 1. Steps to Consider in Designing a Nutrition Education Program forOlder Adults

An educator works with a team of people with expertise in research, program evaluation,information management, older adult nutrition, adult education, chronic disease, researchmethodology, behavior change techniques, cultural understanding of the target audience(s),and/or gerontology to initiate an older adult nutrition education intervention program. Theteam:

• describes their perceptions, values, attitudes, and fundamental beliefs about the natureof human behavior, especially regarding older adult behavior and health care educatorsand caregivers behaviors; i.e., their “vision.”

• articulates their theoretical perspective(s) regarding education and behavior change.• with input from the planned audience and others who know the audience, defines the

audience’s needs and desires; the focus should be on the particular audience to betaught.

• segments the older learners that the program will be aimed at according to the identifiedneeds and wants of the audience, rather than segregating the audience strictly by agecategories, ethnicity, sex, etc.

• ranks the audience’s needs, interests and desires.• assesses the audience’s knowledge and attitudes.• formulates cognitive, affective and psychomotor program objectives, based on audi-

ence’s identified problems and issues.• selects the desired program evaluation method, such as formative/process evaluation

and summative/impact/outcomes evaluation.• decides which specific, measurable change(s) are desired as the program’s out-

come(s). When feasible, long follow-up of the program is recommended, along with in-corporation of a standard outcome measure for comparison across programs.

• decides upon what level the change(s) is desired and can be measured. Measuringchange at multiple levels and including short-term outcomes as well as longer-term im-pacts from a variety of domains, such as performance/cognitive/behavioral, psycho-social, and physiologic, are recommended, e.g., knowledge, attitudes, beliefs, intentionsto change behavior, self-efficacy and other cognitive constructs, self-perceived/reportednutrition and health behavior, perceived quality of life and well-being, measures of cop-ing skills, verified behaviors, and physiologic health.

• selects or develops and validates older-adult-friendly, fun and educational evaluationinstruments that will measure desired outcomes for effectiveness with distinct popula-tions.

• selects experimental designs as appropriate, e.g., experimental, quasi-experimental,and descriptive designs. When appropriate, the incorporation of control or comparisongroups and randomizing participants is desirable.

• designs intervention methods to meet program objectives for the target population andpromotes behavior change support from the audience’s environment of family, friendsand community; and chooses behavioral intervention strategies based upon the behav-ior change theory(ies) selected, with regard to special needs and characteristics ofolder adults.

• recruits older adult participants, which is often easier to do from an already-establishedgroup rather than by forming a totally new group.

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both their knowledge and attitudes. Then educators should formulate nutrition ed-ucation program objectives based on problems and issues identified. In order to fa-cilitate behavior change, cognitive, affective and psychomotor objectives, allshould be considered for inclusion. The educator needs to decide upon the pro-gram evaluation method, such as formative/process evaluation and summative/impact/outcomes evaluation, and should include the desired outcome of behaviorchanges. After this, Grommet recommended designing intervention methods tomeet program objectives. We believe that this step also includes planning for sup-port for older adults to change through environmental and social support networkssuch as their family, friends and community policies. The program designer mustchoose strategies based upon the change theory(ies) selected previously and alsotailored to meet characteristics of the intended older adult population, as discussedby Higgins and Clarke Barkley (2003c).

Planning evaluation measures is integral to fulfilling objectives. We proposethat before designing the intervention methods, planners must take additionalsteps in the design process. The program planner must decide on specific changesto measure as the program outcomes; and if feasible, measure them again long af-ter the program is completed; and determine to what level change is desired andcan be measured, as discussed by Higgins and Clarke Barkley (2003a). Incorpo-rating one or more measures that can be compared across programs is desirable.Measuring change at multiple levels is recommended, e.g., knowledge vs. attitudevs. impacts or outcomes. The expected effect size diminishes as level of changeincreases. For instance, differences in pre-and post-dietary recalls could be accept-able evidence of changed milk product consumption behavior, while a measurefor impact, on the other hand, such as increased bone density, would be expected


TABLE 1 (continued)

• implements the program, including providing training and close supervision for instruc-tors to assure that all program elements are incorporated. Preference should be givento instructors who are known and respected by the target audience.

• evaluates the program, including providing training and close supervision for personscollecting the data.

• publishes program results with thorough descriptions of protocols for the program de-sign, including the theoretical framework(s) used; the numbers, age ranges, and race ofthe participants; intervention methods; and evaluation. Use of at least a few standardkey words, such as “older adults” and “nutrition education,” is recommended in order tofacilitate finding pertinent as well as related research.

• reflects on results, long-term effectiveness, cost-effectiveness, and practicality.• possibly modifies the original vision and theoretical perspective(s) and begins anew.

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to show a smaller change. However, duration of follow-up after an interventionmay not be long enough to warrant measuring an outcome such as bone density,and costs may be prohibitive. An additional step for the educator is to select or de-velop validated evaluation instruments appropriate for older adults that ideally arealso fun and educational. Next, consideration must be made regarding the designof the program, with inclusion of control groups and randomization of partici-pants, if feasible. One way to accomplish this would be to put a group(s) on a wait-ing list, then offer them the opportunity to participate after an initial round ofprogram outcomes data have been collected.

The next step, recruiting older adult participants, is often easier to do from analready-established group rather than by forming a totally new group (ClarkeBarkley et al., 2003). We further believe that additional essential components in-clude the obvious, actual implementation and evaluation. Training and supervi-sion needs to be provided to those charged with both the educational phase (ClarkeBarkley et al., 2003; Quinn and McNabb, 2001; McClelland et al., 2002) and withthe collection of evaluation data (Higgins and Clarke Barkley, 2003a). This is fol-lowed by publishing program results, including sufficient descriptions of the the-ory, design, intervention methods, participant characteristics, and evaluation, andusing the key words “older adults” and “nutrition education,” as recommended byHiggins and Clarke Barkley (2003b). Finally, after reflecting on results, long-termeffectiveness, cost-effectiveness and practicality, the team’s original vision andtheoretical perspectives may need to be modified before they begin the cycleagain.

SUMMARY

Many older adults live alone, and most are females. As a group, they arehealthy, independent-living lifelong learners who are receptive to nutrition educa-tion. Few nutrition education programs have been developed and/or evaluated thatmeet the specific educational, motivational, sociological and behavioral changeneeds and desires of older adults.

To meet these needs, multi-disciplinary research is needed that would provideinformation on motivators, learning styles and decision-making styles that willhelp target programs and educational techniques to specific older adult audiencesegments. Nutrition education strategies that only increase knowledge usually arenot effective in changing practices, and should be coupled with behavior changestrategies operating at individual and community levels. The most successful edu-cational interventions appear to be ones that emphasize learner and communityparticipation with instructors who are facilitators and collaborators. The role of


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nutrition educators should be to support older adults in health-promoting self-careactivities, rather than prescribing nutrition practices that require compliance or ad-herence. This review has emphasized that educational and behavioral changestrategies should be selected according to the characteristics of the intended audi-ence and should rely on appropriate theory(ies).

At this time, there are no effective comprehensive nutrition education modelsto be recommended and therefore, audience-based research for the widely diverseolder adult populations is needed. Educators teamed with appropriate colleaguesshould conduct research to establish behavioral and empowerment theories andapproaches that are effective and applicable to older adult behavior change. So-cial, cultural and environmental factors must be considered when designing nutri-tion education programs. Likewise, program evaluation of both the process andmeasurable outcomes must be included as part of nutrition education interven-tions, and costs and benefits should be documented. Lastly, results need to be re-ported so that educators and older adults can all benefit from improved nutritioneducation that promotes health and well-being in our expanding older population.The time has come to apply nutrition research findings and develop national,state-sponsored and local nutrition education programs for older adults.

Received: November 2002Revised: February 2003Accepted: March 2003

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Documents

Concepts, Theories and Design Components for Nutrition Education Programs Aimed at Older Adults