Improving Effectiveness of Nutrition Education Resources for Older Adults

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Improving Effectiveness of Nutrition EducationResources for Older AdultsMary Meck Higgins PhD, RD, LD, CDE a & Mary Clarke Barkley PhD, RD, LD ba Kansas State University , Manhattan, KS, USAb Dept. of Human Nutrition , Kansas State University , Manhattan, KS, USAPublished online: 05 Oct 2008.

To cite this article: Mary Meck Higgins PhD, RD, LD, CDE & Mary Clarke Barkley PhD, RD, LD (2004) Improving Effectiveness ofNutrition Education Resources for Older Adults, Journal of Nutrition For the Elderly, 23:3, 19-54, DOI: 10.1300/J052v23n03_03

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Improving Effectivenessof Nutrition Education Resources

for Older Adults

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

ABSTRACT. This article discusses published reports and studies fromthe past decade that focused primarily on using written or other tangiblenutrition educational resources with older adults, such as brief “hand-outs,” newsletters, brochures, booklets, curricular lessons, board games,audiotapes and videotapes. Studies of health professionals’ needs anddesires for such materials are also reviewed. Thirteen articles, of whichfour were theory-based, were found. They are summarized in tables thatinclude details regarding the educational resource(s) used; a descriptionof the subjects and controls, if any; the evaluation methods used; and re-sults obtained. Ten practical suggestions are offered to help educators se-lect or develop more effective printed, audiotape, videotape and othertangible nutrition education resources appropriate for older adults. Muchresearch remains to be done in this area. This article is one of a series ofliterature reviews of topics related to nutrition education for older adults.[Article copies available for a fee from The Haworth Document Delivery Ser-vice: 1-800-HAWORTH. E-mail address: <[email protected]>Website: <http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc.All rights reserved.]

Mary Meck Higgins is Assistant Professor and Cooperative Extension Human Nu-trition Specialist, and Mary Clarke Barkley is Professor Emeritus and Cooperative Ex-tension Human Nutrition Specialist, Dept. of Human Nutrition, Kansas State University,Manhattan, KS.

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

Journal of Nutrition for the Elderly, Vol. 23(3) 2004http://www.haworthpress.com/store/product.asp?sku=J052

2004 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J052v23n03_03 19

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KEYWORDS. Nutrition education, older adults, ethnic groups, educa-tional resources, print materials, newsletters, videotapes, audiotapes, ed-ucational strategies

INTRODUCTION

The rapidly expanding numbers of adults 60 years of age and older necessitatesincreasing amounts of health care resources to control health care costs and safe-guard quality of life. One potential solution is nutrition education. Unfortunately,the value of nutrition education for this older population group has not yet beenwell documented, for the quality and amount of nutrition education research isquite limited.

Nutrition education is far more difficult than administering a vaccination toprevent disease, and more complex than passing out tip sheets or giving a nutritionlecture. Both print materials and lectures can be effective science-based strategiesfor increasing awareness and knowledge about nutrition topics. However, theygenerally need to be combined with other techniques to bring about improvementsin outcomes such as nutrition behaviors, attitudes toward nutrition or nutritionalstatus. Research findings show that nutrition education programming that includesa complement of strategies, including print materials and other nutrition educationresources, for teaching older adults can improve knowledge, attitudes, food prac-tice behaviors, and physiologic factors (Higgins and Clarke Barkley, 2003a).

Written and visual nutrition education materials are some of the most popularresources for nutrition education for all ages. They include “handouts,” newslet-ters, brochures, curricular lessons, posters, displays, booklets, magazine articles,board games, videotapes, audiotapes, and many other educational materials. Theyhave the advantages of being available at the convenience of the learner and of be-ing easily matched with the learner’s interests and abilities/disabilities. They canalso be one of the least expensive educational methods. However, they are oftendifficult to evaluate, and their effectiveness is questionable.

This article focuses on published literature that describes or supports how toimprove effectiveness of tangible nutrition education resources for older adults. Itreviews research published in the past decade regarding effective use of nutritioneducation resources, particularly written materials such as newsletters and educa-tional brochures, and audiotapes and videotapes, with older adults. A computer-assisted literature search was conducted for reports that examined use of thesetypes of resources in nutrition education programs that targeted, or at least sepa-rately reported on, older adult participants, i.e., those age 55 years and preferablyolder, living independently in the U.S. To be considered for review, articles had toinclude information about the nutrition education component of the program.

20 JOURNAL OF NUTRITION FOR THE ELDERLY

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Studies that combined print materials and/or videotape with other educationalstrategies were included here. No attempt was made to find unpublished papers ordocuments such as dissertations, and articles reviewed by Contento et al. (1995)were excluded. Only thirteen articles published since 1993 were found that metthese criteria, and they are summarized in this article. This date was chosen be-cause of the review by Contento et al. (1995) that summarized research on nutri-tion education, including a chapter on older adults. Older literature is includedhere, in some instances, but only to provide an historical perspective of supportingor conflicting documentation of the concept under discussion; it is not summa-rized in detail. Search methods are reported more fully elsewhere (Higgins andClarke Barkley, 2003b).

The current literature is scattered and limited. Some of the articles we reviewedhad a different focus than to provide guidelines regarding improving effectivenessof nutrition resources, but nevertheless, portions of them were appropriate in pro-viding supporting information. We tried to cover the breadth of nutrition educa-tion materials for older adults, both written and audiovisual, in our search forpublications. No such similar review was found in the literature.

This article is one of a series of literature reviews on topics related to nutritioneducation for older adults. Published findings on older adult nutrition education is-sues such as difficulties in evaluating outcomes and impacts (Higgins and ClarkeBarkley, 2003a), cost-benefits of nutrition education for older adults (Higgins andClarke Barkley, 2003b), methods for determining nutrition education needs andinterests and experiences tailoring education intervention programs to differentpopulations of older learners (Higgins and Clarke Barkley, 2003c); and older adultlearning and behavioral change theories, nutrition education/behavioral strategies,and nutrition education program design components (Higgins and Clarke Barkley,2003d) are discussed in the review series. The purpose of this series is to assist nu-trition educators, researchers and health practitioners in familiarizing themselveswith recent methods and to discern published strategies and their evaluation. Italso suggests the need for a greater quantity and an improved quality in the pub-lished research. The purposes of this article are: (1) To summarize recent researchregarding educational resources for older adults that primarily involve print andaudiovisual materials; and (2) To discuss issues and present practical recommen-dations to educators for selecting or developing printed and audiovisual nutritioneducation materials appropriate for specific segments of older adult audiences.

NUTRITION EDUCATION RESOURCES REPORTEDIN OLDER ADULT NUTRITION PROGRAMS

In reviewing published studies and reports of educational resources, we exam-ined them in terms of being theory- or non-theory-based, since designing studies

Nutrition Education for Older Adults 21

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and developing educational resources according to one or more theoretical frame-works is recommended. (For more information about educational and behavioralchange theories as they relate to older adult nutrition education, see the recent re-view by Higgins and Clarke Barkley, 2003d). Nutrition educators are encouragedto articulate their education and behavior change perspectives and use behaviorchange theories to clearly identify the processes of change. They should selecttheir intervention and evaluation methods based on the chosen education and be-havior change theories they endorse. Then they should choose the educationalstrategies and program interventions that will promote change by incorporatingthose processes identified by the selected theory. Examples of theoretical frame-works include adult learning theory and the various models explaining behaviorchange, such as Social Learning theory, Health Belief model and Stages ofChange theory. For instance, adult learning theory promotes using the learner’sown experience and expertise and using approaches to education that address onlythose issues that have practical, relevant applications to the older learners’ life sit-uations. It encourages goal setting, active participation, and problem-solving bythe learner.

The importance of articulating a vision for education and the role of theory inenhancing the ability to achieve certain objectives were discussed by Andersonand Funnell (1999). The authors argued that the selection of appropriate theoriesshould be based on how well they: (1) fit one’s vision, (2) explain one’s experi-ence and observations, and (3) help one develop educational strategies and tech-niques, design studies, or guide intervention and evaluation choices. Chapman etal. (1995) also concluded that theoretical perspectives should be used as the back-bone of nutrition education efforts.

Figure 1 shows the specific type of information included in corresponding col-umns of subsequent tables about each of the thirteen study’s interventions, partici-pants and control groups, and outcomes.

Table 1 summarizes both the theory-based and non-theory-based studies rely-ing primarily on written materials. It also summarizes those studies that provideinformation on how to improve the effectiveness of audiotapes and videotapes inteaching nutrition to older adults. These studies are discussed in the next three sec-tions. Table 1 and the following tables allow the reader to compare similarities anddifferences in the design of the studies we found.

Theory-Based Studies Using Primarily Written Materialsto Teach Nutrition to Older Adults

Taylor-Davis et al. (2000) used the nutrition communication model and adultlearning theory principles to design five nutrition newsletters specifically for se-nior adults. Components of these models were manifested in the newsletters. The


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isof

varia

nce,

regr

essi

onan

dS

chef

fé’s

test

.

The

grea

ter

thei

rpe

rcei

ved

nutr

ition

know

ledg

e,th

em

ore

posi

tive

was

the

attit

ude

tow

ard

the

new

slet

ter’s

appe

aran

ce(p

<.0

02).

Tho

sew

ithco

llege

orgr

adua

tede

gree

sw

ere

less

inte

rest

edin

the

new

slet

ter’s

cont

ent(

p<

.05)

.The

high

erth

elif

esa

tisfa

ctio

n,th

em

ore

likel

yth

ete

nden

cyto

read

the

cont

ent

(p<

.052

).T

hegr

eate

rth

e“e

xter

nal”

locu

sof

cont

rols

core

s,pa

rtic

ular

ly“p

ower

fulo

ther

s,”

the

mor

ein

tere

stth

eyha

din

new

slet

ter

cont

ent&

inre

ceiv

ing

futu

reis

sues

(p<

.05)

.

Inte

rest

infu

ture

new

slet

ters

was

high

estf

orw

omen

(p<

.001

)&

thos

ew

holik

edto

read

(p<

.001

),ha

dgr

eate

rin

tere

stin

nutr

ition

(p<

.002

),ha

dgr

eate

rnut

ritio

nkn

owle

dge

(p<

.03)

orw

ere

ona

spec

iald

iet(

p<

.05)

.P

eopl

ew

/gre

ates

tbel

iefi

n“c

hanc

e”lo

cus

ofco

ntro

lwer

ele

asti

nter

este

din

futu

rene

wsl

ette

rs(p

<.0

2).

Lancasteretal.,1997

LocusofControl:Internalvs.External

Nonestated

27

Dow

nloa

ded

by [

Uni

vers

ity o

f N

orth

Tex

as]

at 0

9:02

04

Dec

embe

r 20

14

TA

BLE

1(c

ontin

ued)

AB

CD

EF

GH

No

educ

atio

nal

reso

urce

stud

ied.

Aut

hors

cond

ucte

dfo

cus

grou

psto

expl

ore

opin

ions

ofpe

rson

sw

ithlo

wlit

erac

ysk

ills

abou

tnu

triti

oned

ucat

ion

reso

urce

sth

eyde

sire

.

50fo

cus

grou

ppa

rtic

ipan

ts

Age

s21

to72

year

s;av

erag

eag

e,37

year

s

72%

fem

ale

Gro

upcl

assi

fied

them

selv

esas

48%

blac

k,24

%La

tino,

12%

Asi

an,1

0%w

hite

&6%

othe

r

3rd

to6t

hgr

ade

read

ing

leve

ls;s

tudy

cond

ucte

din

Bos

ton,

Mas

sach

uset

ts

Par

ticip

ants

wer

ere

crui

ted

from

clie

nts

ofad

ultb

asic

educ

atio

npr

ogra

ms.

No

cont

rol

grou

pV

erifi

catio

nm

etho

ds,l

engt

hof

follo

w-u

pan

dst

atis

tical

anal

yses

:non

e.T

his

was

aqu

alita

tive

stud

y.

Foc

usgr

oup

mem

bers

rece

ived

mos

toft

heir

heal

thin

form

atio

nth

roug

hfa

mily

,fr

iend

san

dne

ighb

ors,

and

inth

ehe

alth

care

setti

ngth

roug

hw

ritte

nfo

rmat

s.

Mos

tdid

notw

antt

olis

ten

toau

diot

apes

.Som

esa

idth

atth

eyw

ould

wat

cha

vide

oin

thei

rph

ysic

ian’

sof

fice

orat

hom

e.

The

mos

tpop

ular

form

atfo

rre

ceiv

ing

nutr

ition

info

rmat

ion

was

inte

ract

ive

disc

ussi

ongr

oups

with

food

dem

onst

ratio

ns,w

ithin

tere

stin

gto

pics

,cou

pons

orfo

odas

the

ince

ntiv

eto

atte

nd.

Macarioetal.,1998

Nonestated

Focusgroupmemberswereculturallydiverse

28

Dow

nloa

ded

by [

Uni

vers

ity o

f N

orth

Tex

as]

at 0

9:02

04

Dec

embe

r 20

14

AB

CD

EF

GH

Prin

ted

info

rmat

ion,

pack

aged

toge

ther

,fo

cuse

don

low

erin

gdi

etar

yfa

tand

chol

este

rol,

eatin

gfe

wer

calo

ries,

choo

sing

heal

thy

food

s,an

dre

duci

nghe

artd

isea

seris

kfa

ctor

s.D

iet

anal

ysis

and

feed

back

abou

tfo

odre

cord

sw

asgi

ven

aton

em

onth

.

The

self-

pace

dpr

ogra

mw

asco

mpl

eted

bysu

bjec

tsin

20m

inut

esto

6w

eeks

.

Num

ber

ofin

itial

inte

rven

tion

part

icip

ants

notg

iven

;18

(64%

)co

mpl

eted

60-9

0ye

ars

old

72%

fem

ale

Eth

nici

ty&

race

notg

iven

;st

udy

inC

olor

ado

Par

ticip

ants

and

cont

rols

wer

ere

crui

ted

from

user

sof

9di

ffere

ntco

ngre

gate

mea

lsi

tes.

Num

ber

ofin

itial

cont

rol

part

icip

ants

not

give

n;11

(64%

)co

mpl

eted

60-9

0ye

ars

old

82%

fem

ale

Eth

nici

ty&

race

notg

iven

Com

plet

edda

taco

llect

ion.

Did

notr

ecei

vepr

inte

dpr

ogra

mun

tilth

een

dof

the

stud

y,bu

tdi

dre

ceiv

edi

etan

alys

isan

dfe

edba

ckab

out

food

reco

rds

aton

em

onth

.

Foc

used

onaf

fect

ive,

cogn

itive

&be

havi

orch

ange

.

Pre

-&

post

-tes

tkn

owle

dge

quiz

zes,

attit

ude

surv

eys,

&tw

o-da

yfo

odre

cord

sw

ere

com

plet

edon

em

onth

,&ag

ain

thre

em

onth

s,af

ter

pack

etw

asdi

strib

uted

.

Sta

tistic

alan

alys

esin

clud

edC

hi-s

quar

e,t-

test

san

dan

alys

isof

varia

nce.

No

stat

istic

alsi

gnifi

canc

ebe

twee

ndi

etar

ybe

havi

ors

ofin

terv

entio

nan

dco

ntro

lgr

oups

.

Nin

ese

lf-re

port

edth

eydi

dno

tle

arn

new

info

rmat

ion.

Abo

utha

lfse

lf-re

port

edch

ange

sin

diet

ary

habi

ts,b

utth

isw

asno

tcor

robo

rate

dby

food

reco

rdch

ange

s.

Fou

rtee

nra

ted

the

prog

ram

asei

ther

good

orex

celle

ntin

bein

gun

ders

tand

able

,whi

le3

thou

ghti

twas

not

unde

rsta

ndab

le.F

our

othe

rsth

ough

titw

asim

prac

tical

orto

olo

ng.

Mayeda&Anderson,1993

HealthBeliefModel;StagesofChangeTheory

Nonestated

29

Dow

nloa

ded

by [

Uni

vers

ity o

f N

orth

Tex

as]

at 0

9:02

04

Dec

embe

r 20

14

TA

BLE

1(c

ontin

ued)

AB

CD

EF

GH

Fiv

enu

triti

onne

wsl

ette

rs,

mai

led

biw

eekl

y,fo

cusi

ngon

fat&

fiber

.New

slet

ters

incl

uded

self-

asse

ssm

ents

,qu

estio

ns&

answ

ers

sect

ion,

&pr

oble

m-

cent

ered

,se

lf-pa

ced

lear

ning

topr

omot

ekn

owle

dge,

attit

ude

&be

havi

orch

ange

.

1/3

rece

ived

8-10

min

ute

follo

w-u

pte

leph

one

inte

rvie

ws

10-1

4da

ysaf

ter

each

new

slet

ter.

45%

ofth

ose

cont

acte

dw

ere

recr

uite

dfo

rst

udy.

The

num

ber

ofin

itial

inte

rven

tion

part

icip

ants

not

give

n;25

4(8

0%)

com

plet

ed.

60-7

4ye

ars;

mea

n,69

year

s

43%

fem

ale

100%

whi

te

Hal

fwer

eed

ucat

edth

roug

hat

leas

thig

hsc

hool

;stu

dyco

nduc

ted

inP

enns

ylva

nia.

Par

ticip

ants

and

cont

rols

wer

ere

crui

ted

from

Med

icar

ere

cipi

ents

ofa

rura

lter

tiary

care

hosp

ital.

Num

ber

ofin

itial

cont

rols

notg

iven

;13

2(8

0%)

com

plet

ed.

Tra

itssi

mila

rto

trea

tmen

tgro

ups.

Com

plet

edda

taco

llect

ion

butd

idno

tre

ceiv

epr

inte

dne

wsl

ette

rs.

Cha

nges

inkn

owle

dge,

attit

udes

,and

beha

vior

rega

rdin

gdi

etar

yfa

tsan

dfib

er.

Pos

t-te

stda

taw

asco

llect

ed2

wee

ksaf

ter

last

of5

biw

eekl

yne

wsl

ette

rs.

Sta

tistic

alan

alys

esin

clud

edan

alys

isof

cova

rianc

e,D

unca

n’s

post

hoc

test

,ana

lysi

sof

varia

nce

and

effe

ctsi

ze.

New

slet

ter

alon

evs

.con

trol

s:im

prov

edac

tual

and

perc

eive

dkn

owle

dge,

inte

rest

innu

triti

on,a

ndbe

havi

oral

inte

ntio

nsto

avoi

ddi

etar

yfa

ts(p

<.0

5).

‘New

slet

ter

plus

tele

phon

ein

terv

iew

s’vs

.new

slet

ter

alon

e:im

prov

edac

tual

and

perc

eive

dkn

owle

dge

(p<

.05)

.

Effe

cts

wer

ela

rger

for

the

‘new

slet

ter

plus

tele

phon

ein

terv

iew

s’gr

oup

vs.n

ewsl

ette

ral

one.

The

grea

test

effe

cts

wer

ese

enin

know

ledg

e,m

oder

ate

effe

cts

wer

ese

enfo

rin

tere

stin

nutr

ition

,and

smal

leffe

cts

occu

rred

indi

etar

yst

age

ofbe

havi

orch

ange

for

diet

ary

fiber

.

Gre

ater

chan

ges

inkn

owle

dge

occu

rred

than

for

chan

ges

inat

titud

esor

beha

vior

alin

tent

ions

.

30

Taylor-Davisetal.,2000

NutritionCommunicationModel;AdultLearningTheory;

Suitableforolderadults

Dow

nloa

ded

by [

Uni

vers

ity o

f N

orth

Tex

as]

at 0

9:02

04

Dec

embe

r 20

14

AB

CD

EF

GH

12nu

triti

onau

diot

aped

vign

ette

san

dvi

deot

apes

,gro

upco

unse

ling,

and

food

pict

ures

and

prin

ted

mat

eria

lsat

5th

to8t

hgr

ade

read

ing

leve

l;or

food

pict

ures

and

prin

tmat

eria

lson

ly.

One

year

prog

ram

tom

otiv

ate

and

teac

hab

out

redu

cing

diet

ary

fat,

chol

este

rola

ndso

dium

for

hear

the

alth

.

339

tota

l;%

part

icip

ants

who

com

plet

edno

tpr

esen

ted

200

(59%

)w

ere

55-7

0ye

ars

old;

139

(41%

)w

ere

40-5

4ye

ars

old

74%

fem

ale

99%

Afr

ican

-Am

eric

an

237

(70%

)of

entir

egr

oup

educ

ated

atle

astt

hrou

ghhi

ghsc

hool

and

beyo

nd;

stud

yco

nduc

ted

inW

ashi

ngto

n,D

.C.

Asu

bset

of98

pers

ons,

ages

notp

rese

nted

,abo

utha

lfof

who

mha

dlit

erac

ysc

ores

less

than

(vs.

abov

e)th

e8t

hgr

ade,

was

used

toco

mpa

repr

int

mat

eria

lsw

ithau

diot

apes

.

Par

ticip

ants

recr

uite

dat

supe

rmar

kets

.

No

cont

rol

grou

p20

ques

tion

liter

acy

scre

enin

gto

ol.

Fol

low

-up

inte

rvie

w4

mon

ths

post

star

tof

inte

rven

tion.

Sta

tistic

alan

alys

esin

clud

edan

alys

esof

cova

rianc

ean

dlo

gist

icre

gres

sion

.

No

rela

tions

hip

betw

een

prev

ious

CV

Dnu

triti

onco

unse

ling

and

reco

gniti

onof

com

mon

nutr

ition

and

CV

Dte

rms.

48%

scor

edat

orbe

low

8th

grad

ere

adin

gle

vel.

Low

liter

acy

scor

esw

ere

nota

ssoc

iate

dw

ithag

ebu

twer

eas

soci

ated

with

less

educ

atio

n(p

<.0

001)

,les

she

alth

ydi

ets,

(p<

.01)

,and

mor

ehe

artd

isea

se(p

<.0

2),d

iabe

tes

(p<

.05)

orde

pres

sion

(p<

.000

1).

Per

sons

with

liter

acy

scor

esle

ssth

an8t

hgr

ade

wer

e2x

mor

elik

ely

tous

eau

diot

apes

inst

ead

ofpr

intm

ater

ials

than

bette

rre

ader

sw

ere.

Am

ong

the

low

leve

lrea

ders

,slig

htly

mor

eth

anha

lfus

edau

diot

apes

mor

eth

anpr

int

mat

eria

ls,a

ndab

outo

ne-f

ourt

hus

edbo

thty

pes

ofm

ater

ials

equa

lly.A

mon

gth

ebe

tter

read

ers,

abou

tone

four

thus

edth

eau

diot

apes

mor

eth

anth

eyus

edth

epr

inte

dm

ater

ials

,and

slig

htly

less

than

half

used

the

two

type

seq

ually

.

31

TenHaveetal.,1997

Nonestated

Culturallyappropriate,&lowliteracy

Dow

nloa

ded

by [

Uni

vers

ity o

f N

orth

Tex

as]

at 0

9:02

04

Dec

embe

r 20

14

TA

BLE

1(c

ontin

ued)

AB

CD

EF

GH

Fou

rfa

ctsh

eets

with

nutr

ition

&he

alth

tips.

One

30-6

0m

inut

ehe

alth

coun

selin

gse

ssio

nw

ithnu

rse;

and

a6-

mon

th(3

x/w

k)ex

erci

sepr

ogra

m

Prim

ary

focu

sw

ason

exer

cise

asa

met

hod

topr

even

tdi

sabi

lity.

Tel

epho

neca

llsat

2,4

&16

wee

ksto

revi

ewpr

ogre

ss,

mot

ivat

e,an

did

entif

ypr

oble

ms.

53pa

rtic

ipan

ts;4

5(8

5%)

com

plet

ed,

with

90%

atte

ndan

ceat

exer

cise

clas

ses

Ave

rage

age:

71ye

ars

70%

fem

ale

99%

whi

te

21%

educ

ated

atle

astt

hrou

ghgr

adua

tion

from

colle

ge;9

8%se

lf-re

port

edgo

odor

bette

rhe

alth

;stu

dyco

nduc

ted

inS

eattl

e,W

ashi

ngto

n

Par

ticip

ants

and

cont

rols

wer

ere

crui

ted

from

user

sof

asu

burb

anse

nior

cent

er.

47co

ntro

ls;4

5(9

6%)

com

plet

ed

Ave

rage

age:

73ye

ars

77%

fem

ale

99%

whi

te

36%

educ

ated

atle

ast

thro

ugh

grad

uatio

nfr

omco

llege

Com

plet

edda

taco

llect

ion

only

,unt

ilth

een

dof

the

stud

y.

Que

stio

nnai

res

invo

lvin

ghe

alth

asse

ssm

ents

and

func

tioni

ngab

ilitie

s;an

dph

one

inte

rvie

ws

ofse

lf-re

port

ednu

triti

onbe

havi

ors.

Pre

-tes

t,at

2m

onth

spo

stst

arto

fpr

ogra

m,a

ndat

the

end

ofth

epr

ogra

m(6

mon

ths)

.

Sta

tistic

alan

alys

esin

clud

edt-

test

s,ch

i-squ

are,

regr

essi

onan

dan

alys

isof

cova

rianc

e.

92%

repo

rted

read

ing

the

nutr

ition

tipsh

eets

and

83%

repo

rted

that

they

wer

eus

eful

.

90%

self-

repo

rted

nutr

ition

beha

vior

chan

ge.N

oob

ject

ive

evid

ence

mea

sure

dre

gard

ing

nutr

ition

.

Sco

res

onph

ysic

al,m

enta

l,so

cial

and

emot

iona

lhea

lthfu

nctio

nal

abili

ties

and

gene

ralh

ealth

perc

eptio

nsw

ere

sign

ifica

ntly

impr

oved

inth

ein

terv

entio

ngr

oup

vs.d

eclin

ing

amon

gth

eco

ntro

lsaf

ter

6m

onth

sof

the

exer

cise

prog

ram

(p<

.02)

.

32

Wallaceetal.,1998

Nonestated

Nonestated

Dow

nloa

ded

by [

Uni

vers

ity o

f N

orth

Tex

as]

at 0

9:02

04

Dec

embe

r 20

14

authors explained the learning characteristics or targeted goals for each section ofthe 8-page newsletters. For example, features such as self-assessments were in-cluded in the newsletters to promote involvement and enhance memory throughactive engagement; and a questions and answers section used a senior-friendlyproblem-centered approach to learning. Newsletters were selected as the desiredmode of intervention because of their accessibility and acceptance by older adultsin promoting self-paced learning (Lancaster et al., 1997). Knowledge, attitude andbehavior change responses were reported. Most subjects said they enjoyed read-ing and about half of the participants were educated through at least high school.Newsletters were sent biweekly to the homes of two-thirds of the group; the otherone-third were designated as control subjects who did not receive newsletters.One-half of the newsletter group also received brief (i.e., 8 to 10 minutes) fol-low-up telephone interviews two weeks after distribution of each newsletter.Compared to the control group, older adults completing the study improved actualand perceived nutrition knowledge, were more interested in nutrition, and indi-cated behavioral intentions to improve their dietary fiber intake and dietary fats.Overall, effects were larger for the ‘newsletter plus telephone interviews’ groupthan for those who received only the newsletter. The greatest effects were seen inknowledge change. Moderate effects were seen for improved interest in nutrition,and small effects occurred in stage of dietary behavior change relative to fiber in-take. Thus, the authors’ use of two theories helped them design nutrition newslet-ters that led to changes in cognition and to some extent in attitudes, but that onlyslightly affected behavioral measures.

In an earlier study, this group had evaluated a nationwide sample of olderadults’ acceptance of their nutrition newsletter (Lancaster et al., 1997). Subjectscompleted two surveys and read one issue of a newsletter. Half were educated be-yond high school, which is greater than the general senior population. Subject se-lection methodology gave the project a bias for subjects with higher than averagelevels of interest for reading about nutrition in English, and who owned a hometelephone. Approximately three people refused the researchers’ offer for everyone person who accepted it, although some of those who refused did not meetstudy criteria. Unfortunately, the authors did not collect data necessary to deter-mine what percentage of eligible persons agreed to participate. Their intended au-dience approved the use of a newsletter as a medium for nutrition education.Printed nutrition education tools have the advantage of allowing older adult read-ers to control the rate and amount of information they receive. The authors notedthat their data supported other reports that “most” older adults get their health andnutrition information from print materials. As perceived nutrition knowledge in-creased, so did having a positive attitude toward the newsletter’s appearance, butthose with college or graduate degrees were less interested in the newsletter’s con-tent. People who reported higher life satisfaction were more likely to be interestedin the content of the newsletter than were those whose life satisfaction was lower.


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People who believed in “powerful others” were more interested in the content thanthose who believed in a “chance” locus of control or an “internal” one. (A beliefthat outcomes are within the individual’s capacity to control indicates internal lo-cus of control, while belief that powerful “others,” fate, or chance control out-comes indicates external locus of control.) Those who were more interested in orwho had the greatest knowledge about nutrition, those who liked to read, women,and those who followed a special diet were most likely to be interested in receiv-ing future issues of the newsletters. People with the greatest belief in a “chance”locus of control were the least interested in receiving future newsletters. The au-thors showed that using the strategy of gaining prior approval and then sending awell-designed, printed educational message into the homes of older adults hadbroad appeal to their study participants, and virtually everyone was interested, to agreater or lesser degree, in receiving more of them. Their theoretical framework,i.e., that audience characteristics will affect the acceptance of a message, was sup-ported by their results. Unfortunately, it was outside the scope of this early studyby Lancaster et al. (1997) to report on outcomes that may have been elicited byreading the newsletter, such as changes in knowledge, attitudes, or intentions tochange, perceived change, or actual change in nutrition practices.

Yet another study by this group of researchers described characteristics ofprinted media that influence how people receive, comprehend and react to bro-chure messages (Clark et al., 1999). These authors focused on information reten-tion as the specific outcome measured among women of varying age groups afterreading nutrition education brochures. Two theoretical models were used to guidebrochure alterations: the nutrition communication model and dual-coding theory.The latter theory suggests that memory is coded either by reading words, which isverbal coding, or by seeing pictures or meaningful graphics, which is image cod-ing, or both. Based on these theories, the authors hypothesized that information re-tention would improve with concrete vs. abstract brochures, and that alteringnutrition inputs (or messages) would influence attentiveness, interaction and sub-sequent comprehension. Among their 209 intervention subjects, 69 (33%) wereage 60 or older. Remaining subjects were ages 20 to 50 years. The women wereasked to read several items, including two of the USDA Dietary Guidelines forAmericans brochures. The older subjects recalled significantly less, by about25%, of the information after reading the nutrition information brochure than didyounger women. At best, the older women were able to immediately recall almost40% of the original concepts in the nutrition education brochures. Overall, boththe younger and older groups were able to write down only about 40% of the con-cepts they remembered from the brochures 30 days after reading one of them, re-gardless of format type or amount of learning observed immediately after readingthe printed material. Knowledge gains were lost by 30 days for older subjects. Theauthors’ theoretical framework was supported by the short-term results of theirstudy, but there was no statistically significant effect of a single educational ses-sion by one month later. The authors suggested that people need focused (i.e., ad-


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dressing only one or two primary beliefs at once), frequent, and multipleexposures to unfamiliar information in order to change their attitudes andmisperceptions about nutrition facts, improve long-term retention of accurate in-formation, and improve nutrition knowledge. This would seem to apply particu-larly to older adults.

Mayeda and Anderson (1993) described a print-materials nutrition educationprogram. Their theoretical framework was based on the Health Belief and Stagesof Change models, which influenced them to develop print materials that includedsections to create reader awareness, interest, practice and reinforcement. Dietanalysis feedback and goal setting, along with refrigerator magnets to help triggerbehavior change, were other components of the printed materials. Designed forsenior adults and to be self-paced, it focused on affective, cognitive, and behav-ioral objectives with regard to lowering fat and cholesterol intake, reducing calo-ries, making healthier food choices, and reducing risk factors for heart disease.Length/number of pages of the print materials was not mentioned. Age and otherdemographic information about the participants were not presented in the methodssection, but age of subjects was given in the abstract. During the 14-week study,the overall dropout rate was high–34%. Numbers of participants versus controlsinitially were not presented. Eighteen seniors completed the intervention, with thelength of time to complete the packet of materials ranging from 20 minutes to sixweeks, and averaging less than two weeks. Eleven older adults served as controls;they received the printed program after study data collection ceased. However,both intervention and control subjects received food record analysis/feedback in-formation at one month. No treatment differences between groups were found.Very little of the data collected were presented in tabular format. More thanone-third of the participants stated they did not learn new nutrition information,but objective measures of knowledge were not discussed. Nor did the authorspresent their nutrition attitude data. About half of all subjects self-reportedchanges in dietary habits, but this was not corroborated by changes in food re-cords. With the bias occurring because of their high dropout rate, it was likely nosurprise that two-thirds of the subjects who completed the program preferred tolearn with print material. An additional 20% preferred print material plus fol-low-up. The authors did not measure their subjects’ stage of change, nor measureother aspects that would support or refute the theoretical basis of their study. Gen-eralizing the results of this study to other groups must be done with caution.

Non-Theory-Based Studies Using Primarily Written Materialsto Teach Nutrition to Older Adults

A summary of the studies reviewed in this section is included in Table 1.Wallace et al. (1998) focused on providing health promotion interventions, pri-

marily an exercise program for 60-minutes three times a week for six months, at asenior center. The authors also indicated that the study participants “received nu-


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trition counseling.” Unfortunately, these authors did not take into account thecomplexity of providing effective nutrition education. In actuality, all subjects inthe intervention group received a 30- to 60-minute visit with a registered nurse,during which time she reviewed risk factors for disability and developed an indi-vidualized health promotion plan, following a review of baseline data, that fo-cused on current exercise habits, alcohol and tobacco use, dietary habits, andhome safety issues. During this same visit, the nurse also introduced the super-vised exercise program. All participants received nutrition tip sheets. The authorsdescribed these only by stating that they emphasized “four areas”: fiber and carbo-hydrates; fats and cholesterol; calcium and sodium; and calories and water. Phoneinterviews revealed that 92% of subjects had read the nutritional tip sheets, 83%reported that they were useful, and 90% reported meeting some or all of their nu-tritional goals. The authors used self-reported nutrition behavior change withoutcorroborating objective measures, which has been shown to be an unreliable wayto determine dietary composition for an elderly population (Arnold et al., 1996;Mayeda and Anderson, 1993). Most of the study outcomes measured showed thatthe exercise program had significant impact. We believe that referring to such lim-ited nutrition education exposure as “nutrition counseling” should be avoided, andthat caution should be used in linking the reading of tip sheets with causing nutri-tional goals to be met.

Lach et al. (1994) described a three-state nutrition education campaign that in-cluded printed nutrition information materials distributed in community settingsto senior adults by older adult volunteers. One to two months after completing theself-assessment nutrition questionnaires and reading the two booklets with topicalnutrition information, menus and recipes, 58% of responding participants self-re-ported changing their dietary practices. However, only 35%, or 350 people, of thefollow-up sample who were sent questionnaires responded. Self-reported dietarybehavior changes included buying different foods, preparing foods new ways,adding new foods to their diet, and substituting foods. These results must beviewed with caution, since the dropout rates were high and because changes wereself-reported and not corroborated by other measures. In addition, statistical anal-yses of results were not reported. Changes in knowledge, attitudes, beliefs, self-ef-ficacy or verifiable nutrition practices were not measured.

TenHave et al. (1997) adapted nutrition education delivery techniques to ac-commodate the low reading abilities and cultural needs of 339 urban AfricanAmericans in their study, who were recruited primarily through finger-prick cho-lesterol screenings at grocery stores. Two hundred (59%) of the sample were olderadults, ages 55-70 years. The remaining subjects were 40-54 years old. A liter-acy-screening instrument using 20 common cardiovascular disease (CVD) or nu-trition terms was developed and tested. They found no relationship between asubject’s own or a family member’s exposure to CVD nutrition counseling and


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recognition of written words commonly found in CVD health and nutrition infor-mation. One-half of their subjects had literacy assessment scores at or below 8thgrade reading levels. As might be expected, low literacy scores were associatedwith less education. They were also linked with less healthy diets but not with age.The proportion of respondents reporting a history of heart disease or diabetes, orhaving a higher depression score, was inversely related to literacy scores, inde-pendent of age and gender. Unfortunately, then, subjects with the worst diets andmost health problems, such as heart disease, diabetes and depression, were thesame ones who had the lowest literacy levels, and their previous nutrition educa-tional experience did not affect their recognition of written, commonly used healthand nutrition terms. Among a subset of 98 subjects, half of whom had literacyscores less than the 8th grade, the low-level readers relied on easy-to-read pictureand print materials less often than those who were better readers, 19% versus 28%.It was beyond the scope of these authors’ study to address the question of whetheror not participants could or did choose to use the printed materials to be remindedof the advice they received orally. Two other questions that they did not addresswere: Would increasing the subjects’ ability to recognize and comprehend com-mon terms have helped participants get more out of future educational endeavors?Did participants change nutrition knowledge, attitudes or practices in any way?

Studies Using Audiotapes and Videotapes to Teach Nutrition to Older Adults

A summary of the studies reviewed in this section that provide information onhow to improve effectiveness of using audiotapes and videotapes to teach olderadults about nutrition is included in Table 1.

Audio and video information sources, such as radio or television, often supple-ment or substitute for advice received during personal encounters with health per-sonnel. TenHave et al. (1997), working with urban African Americans as describedin the previous section, developed culturally appropriate nutrition educational ma-terials, including topics on reducing dietary fat, cholesterol and sodium. Twelveaudiotapes and a motivational videotape, group counseling sessions, and printedmaterials including pictures that were geared to a 5th to 8th grade reading levelwere used with some subjects. Playback equipment for the audiotapes was pro-vided to participants. A within-person analysis of a subset of 98 people who weregiven both types of materials and who completed a four month follow up inter-view after receiving them, showed that persons whose functional literacy was at orbelow the eighth grade were twice as likely to have used the audiotapes as com-pared to the easy-to-read printed information. Even among those who read better,only 28% used the printed materials more often than the audiotapes, and 44% ofthem used both types of media equally.


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Elshaw et al. (1994) used videotapes with group classes of low-income Mexi-can-American men and women with type 2 diabetes and low literacy levels. Basedon their experiences not on quantitative measurement, the researchers stated thattheir culturally specific videotapes were very effective in promoting small groupdiscussions. They suggested that the videotapes were a positive factor in the trendstowards dietary improvements reported. However, the effect of using videotapeswas not measured, nor could the magnitude of their effect be imputed, since theyhad no comparison group who did not use videotapes. The authors recommendedproviding more than education about diabetes complications and the diabetic dietin order to produce major changes in eating behavior over time. They suggestedintensive long-term follow-up and emphasis on improving self-efficacy to em-power participants to improve their own health. Only 58 of the 78 (74%) interven-tion subjects completed the study, and 46 of the 74 (62%) controls completed thestudy. Common reasons for leaving were lack of transportation, interest or familysupport.

Based on their experiences, health professionals and literacy experts recom-mended that nutrition and health videos be shown only when accompanied by anexpert who could answer questions that may arise (Macario et al., 1998). Otherideas for increasing impact that the experts suggested during interviews included:playing the videos in a quiet room rather than an office/clinic waiting room; hav-ing them available for home use, along with playback equipment; and having ac-cess to voice-activated videos. Most of the low-literate focus group participants inthis study did not desire to listen to audiotapes; more said they would watch avideo at the physician’s office or at home.

Studies Using Non-Traditional Educational Resources for Older Adults

Table 2 summarizes the two studies we found that introduced innovative edu-cational resources to reach older adults with nutrition education messages innon-traditional ways. This table provides information about each study in a man-ner shown in Figure 1.

Innovative nutrition education resources that incorporate print materials are of-ten appropriate alternatives to standard text. One creative approach that was re-ported recently used a board game with large game pieces and large, easy-to-readprint. Peterson (2002) assessed the newly-developed nutrition education tool withCaucasian and African American senior adults. No data were provided on percentfemale subjects. Concepts that were addressed included three nutritional recom-mendations based on the Food Guide Pyramid: to what group does a food belong,how many servings from each group are recommended for daily consumption,and what portion constitutes a serving size. The game was similar to Monopoly,with words and food pictures depicting serving sizes. Older adults were chal-


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TA

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39

Langetal.,2000

Nonestated

Surveyadaptedforlow-literacy

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TA

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40

Peterson,2002

Nonestated

Largegamepieces&easy-to-readprintappropriateforolderadults

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lenged to use game pieces to replicate the Food Guide Pyramid. Knowledge im-proved significantly for the 36 game players and for the 33 controls who listenedto similar information presented in a lecture with slides format. In addition, the au-thor stated that the game offered a fun way for older adults to learn about nutrition.The game pieces were easy to manipulate and participants interacted with eachother conversationally and with laughter during the 90 minutes of game play.They also interacted as they focused on competing against each other to win thegame.

A study targeting heart-healthy nutrition education messages to African-Amer-icans was reported by Lang et al. (2000). The authors measured a point-of-pur-chase educational campaign where words and color-coded supermarket shelf-labels identified foods as “Best Choice” with a green shelf label, “AcceptableChoice” with a yellow shelf label, or did not identify the food with any label if itdid not meet recommended dietary criteria. Coding criteria were based on promot-ing heart health and took into account the total fat, saturated fat, cholesterol, so-dium and fiber content of the foods. One-third of the 361 subjects were age 60years or older and 67% were African-American. Forty-five percent of the subjectswere ages 36-59 years. Subjects responded to a request to complete a survey withten low-literacy questions as they exited the supermarket. Age, education, andgender made no difference in awareness or usage of the intervention. Afri-can-Americans were more likely to report being aware of the program than werewhites, but there was no difference between groups in usage. Nevertheless, overallutilization of the shelf labels was 56%. This study showed that older adults, in-cluding those from minority ethnic groups, responded similarly to younger shop-pers to this point-of-purchase intervention and may be reached when innovativestrategies for printed nutrition education materials are used. However, the resultsof this study also point to the crucial need for nutrition educators to first take stepsto create awareness of such a program among their intended audience, so that par-ticipants may benefit from it.

HEALTH PROFESSIONALS’ NEEDS AND DESIRESFOR NUTRITION EDUCATION RESOURCES FOR OLDER ADULTS

Determining health practitioner opinions about their needs and desires for nu-trition education materials for older adults is another approach to improving effec-tiveness of nutrition education resources. Asking questions of health professionalsregarding both content and format of desired nutrition information materials canassist in the development of useful, practical materials. Only three studies were lo-cated that used surveys or interviews of health professionals. These studies aresummarized in Table 3.


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TA

BLE

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Primary care providers (two-thirds of whom were private-practice physicianspracticing in rural areas) were surveyed by Kenner et al. (1999) to determine whattopics and formats they needed for nutrition educational materials. These physi-cians expressed a need for patient materials regarding healthful eating for olderadults, i.e., 74% of respondents indicated a high to very high need for (low-cost)educational materials that addressed this topic. Delivery medium preference was83% for one-page, printed handouts. Printed materials were preferred over post-ers, videos and interactive computer programs, despite the fact that 81% believedthat patients’ low reading levels were often or sometimes a barrier to their use.Ninety-two percent of the 303 respondents cited limited time with patients as themain barrier to using nutrition and wellness education materials. Many (79%) re-ported that they often or sometimes were unable to obtain nutrition materials be-cause of cost or because they lacked knowledge of sources. Sixty-three percentalso believed that nutrition and wellness education materials were often or some-times not culturally relevant. Overall, respondents seemed to view educationalmaterials as a supplement to, rather than a substitute for, education provided byhealth professionals.

Many older adults do not read well in their old age, some because of lack ofskill and some because of physical decline. For instance, Taylor-Davis et al.(2000) reported that approximately 20% of her subjects had difficulty reading be-cause of poor eyesight. During interviews, 35 health professionals and literacy ex-perts thought that low-literacy audiences of all ages would be able to use printmaterials such as diagrams, displays, posters, pamphlets and flip charts, as long asthey incorporated simple words, short sentences, concrete concepts and graphic il-lustrations (Macario et al., 1998). A culturally-appropriate “photonovel,” that is, astory formatted like a comic book but containing photographs and speech directlydrawn from the target population, was also suggested as an effective format forlow-literate adults of any age that could be developed for participatory nutritioneducation interventions. Additionally, they suggested using food models, cookingdemonstrations, role playing, discussions, home visits, supermarket tours, massmedia, games, videos and interactive computer programs, and capitalizing on theinfluence of family and friends in providing nutrition education. The authors con-cluded that community-based nutrition interventions that build on patients’ socialnetworks, are culturally appropriate and are presented in an interactive formatwould be of interest to populations with low literacy. This study did not focus spe-cifically on professionals’ opinions of resources needed for older adults.

A questionnaire about methods of communicating with elderly who are hear-ing impaired, visually impaired, or communication disordered was mailed to 500registered dietitians who were members of a national gerontological nutritionpractice group (Wright et al., 1997). Responses were received from 288,two-thirds of whom worked with older adults either in a nursing home(s) or a se-


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nior meals program, and 44% of whom worked with older adults more than 20hours per week. While three-fourths of the dietitians who completed the surveyhad had no formal or other training in working with special populations, they didhave practical experience, since almost all had worked with people with hearingimpairments (95%), vision impairments (84%), and communication disorders(76%). Large-print materials were the most widely used source of materials, alongwith reliance on a caregiver, while audiotapes and other specialty resources werenot widely used. The authors concluded that more resources need to be developedfor use with special populations of older adults, and they pointed out that educa-tors should make special efforts to communicate with older adults with hearingand vision impairments and communication disorders. We would add that dieti-tians and other health educators should consider seeking formal training on this as-pect of their work, either while they are in college or as continuing professionaleducation, rather than relying solely on experiential knowledge.

DISCUSSION

Only thirteen reports of nutrition education studies focusing on primarily printor audio/videotape resources for older adults were found in literature published inthe past decade, and these lacked a standardized approach. Ten studied a specificeducational resource and three gathered opinions about print and other educa-tional materials in general. Six of the ten resource-based studies looked at tradi-tional print materials, including newsletters, curricular lessons, brochures and factsheets; one used a board game; one used grocery store labels; one used print mate-rials plus audiotapes, and the tenth one used videotapes plus group discussions.

Four of the print materials studied included components in the resource thatwere related to one or more specific elements of educational or behavior changetheory. (For example, a section called “tips to try” was added to one of the print re-sources based on an adult learning theory tenet that says best-practice educatorspromote active participation, reinforce with repetition, and increase interaction byan older learner.) With such a small sample, such different goals, and varyingmethodologies, no conclusion can be made at this time based on this group ofstudies as to whether theory-based resources are more effective than the materialsdescribed that were not based on an identified theory.

Other inconsistencies between studies were seen as well. For instance, some ofthe researchers tried to establish the type of audience who would use their educa-tional resource most effectively, while others focused on achieving an educationalgoal without seeming to give much attention to the resources they used in trying toachieve their results. Some of the researchers examined the impact of older adultsusing multiples of the same type of educational resources, e.g., four topic-diver-


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gent fact sheets, five different newsletters focusing on two nutrients, an unspeci-fied number of lessons centered around one health condition, an unspecified num-ber of various food product labels at a store, eight videotapes centered on onehealth condition, or twelve audiotapes focusing on one health condition. Someevaluated use of the resources over time, e.g., six, eight, ten or sixteen weeks toone year. Some of the researchers evaluated impact concurrent to or immediatelyafter intervention ended, while others waited two to fourteen weeks after the closeof the program. In some cases, effects of other aspects of the educational programwere not examined independent of the printed or other type of resource used. Sta-tistical analyses were not reported for some results. Some researchers did not em-ploy control or comparison groups.

Overall, the main conclusions that we draw from this eclectic group of studiesare that print and other tangible nutrition education resources remain popular withthe public, with health care practitioners, and with educators. Older adults may beable to increase their perceived and actual knowledge, at least for a short time, byreading one or several print materials, or by watching/listening to videotapes oraudiotapes. Print, audio or video materials can also increase older adults’ interestin nutrition, and increase their perception of improving at least some of their nutri-tion practices. Some able readers may prefer to use audiovisual rather than printresources, or may prefer using a combination of printed materials and audiovisu-als. These educational resources can be used to promote further discussion of nu-trition topics.

However, findings from these studies cannot be generalized to all older audi-ences. Most importantly, data from these individual studies–or even collec-tively–are not conclusive. Much research is needed regarding all aspects ofnutrition education resources for older adults. It is an area rich in opportunities forinvestigation. Published proposals and speculations based on experiential knowl-edge remain to be proven as effective interventions. Most of the resources reportedin this article have not undergone extensive testing to verify their effectiveness withthe sample audience, nor with a variety of other population groups. Research dataare particularly lacking regarding tailoring educational resources effectively forspecific populations-such as those of certain age cohorts, of racial or ethnicgroups, in certain living conditions, with certain social supports, with certainphysical or cognitive abilities, etc. On the other hand, we also need to know whichmethods can appropriately be generalized to wider audiences.

Print and other teaching tools might be particularly effective for those who can-not or do not wish to attend group classes or for those who have special needs,such as chronic diseases. Print materials generally can be read at the olderlearner’s own pace, and re-read at a later date if a personal copy is available. Forthese reasons, and more, these types of nutrition resources may be particularly ap-propriate and effective for teaching older adults. Printed materials and tapes may


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be less expensive to administer and evaluate than other educational methods, butthis needs to be tested. One new method to test for reaching certain older adults iscomputer web-based reading and audiovisual nutrition education materials.

Using tangible nutrition education resources to supplement interpersonal com-munication and other educational strategies, such as demonstrations, discussiongroups, telephone follow-up, individual counseling, and internet message boardsor chat rooms, seems a likely way to enhance their effectiveness longer-term. Un-der what conditions also needs to be tested.

SUGGESTIONS FOR SELECTING OR DEVELOPING PRINTED,VIDEOTAPE AND OTHER NUTRITION EDUCATION MATERIALS

The following are ten suggestions for selecting or developing nutrition educa-tion resources for older adults. Each is drawn primarily from the findings or expe-riential advice in the diverse published studies and reports reviewed in the precedingsections. Each suggestion is supported with selected citations. However, our sug-gestion may not have been the primary focus or main conclusions of the studycited. While all of these suggestions will not be applicable to all older audiences,we hope that they will encourage research that elucidates the conditions and popu-lations for whom they are most (and least) suited. New research is needed beforeconclusive guidelines can be provided. For the present, we offer the following tensuggestions as examples to be considered by educators as they devise and evaluatethe effectiveness of the nutrition education resources that they use with their olderlearners.

1. Provide older adults with practical, “to the point,” “how to” information.

Newsletters address older adults’ interest in learning practical, “how to” infor-mation. They like specific information, and want it to be provided with organiza-tional cues, such as by being grouped under bold headings (Lancaster et al., 1997).The most popular features reported by these authors were quizzes that reinforcednutrition knowledge and dietary self-assessments. Besides articles, the newslettersincluded easy-to-prepare recipes with few ingredients that were sized for one ortwo servings, nutrition label information, a glossary of terms, tips for changingfood practices, and questions and answers. Older adults wanted pictures in thenewsletter and information about meal planning, low-fat foods, sodium, exerciseand diabetes.

Similarly, in their review of the nutritional interests of older adults, Higgins andClarke Barkley (2003c) reported numerous studies indicating that the elderly de-


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sired relevant and practical information, such as simple printed materials includ-ing recipes.

2. Present only one or two messages at a time when challenging clients’current beliefs.

In cases where most of the public’s primary beliefs are at odds with current nu-trition teaching, Clark et al. (1999) found that effective nutrition education mes-sages must be designed to change only one or two primary beliefs at a time.Mayeda and Anderson (1993) developed print materials that used multiple com-ponents to present the single concept of heart-healthy eating in order to help createthe readers’ awareness, interest, practice and reinforcement. Lancaster et al.(1997) focused their newsletter’s eight-page first issue solely on dietary fat.

3. Plan for multiple contacts.

Older adults who are contacted over time are more likely to be influenced bythe intervention. For example, Taylor-Davis et al. (2000) mailed multiple newslet-ters, or sent newsletters followed by telephone calls to seniors. Intervention effectswere larger for those who also received telephone interviews, compared to thosewho received newsletters only.

Clark et al. (1999) emphasized the need to include more frequent exposure insmaller information chunks, especially for older adult learners.

4. Develop low-literacy nutrition education resources suitable for older adults.

Low-literate adults received most of their health information in the healthcaresetting through written formats (Macario et al., 1998). Literacy research applica-tions in nutrition education were reviewed by Macario et al. (1998) and Nitzke andVoichick (1992). We believe that their recommendations would also be applicableto many older adult populations as well. Printed materials for nutrition educationthat are written at a reading level lower than the 8th grade, and even lower than the5th grade, are recommended, even for those who have completed higher levels ofeducation (TenHave et al., 1997). Able readers prefer and are not offended by sim-ple-to-read materials.

Peterson (2002) described teaching nutrition concepts to older adults using aboard game similar to Monopoly. Groups of older adults who played the gamehad increases in nutrition knowledge after 90 minutes of playing time, along withhaving fun and interacting with their peers. The need for players to read was mini-mal, but the game was also appropriate for highly literate elders.


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Low-literacy, color coded grocery store shelf-labeling systems were developedby Lang et al. (2000) to assist shoppers in choosing heart-healthy foods. Abouthalf of the older adults, including those from minority groups, who were aware ofthe program used the point of purchase information, responding similarly to youn-ger shoppers.

5. For print materials, use colors with high contrast, and take other stepsto tailor readability to older eyes.

Findings regarding preferred colors are contradictory. Mayeda and Anderson(1993) reported that some older adults found certain colors, like red, hard to read.Lancaster et al. (1997) described characteristics of attractive designs to increasethe attention of older readers. Their findings for suitable newsletter colors, chosenafter several pilot studies with older adults, revealed the popularity of the colorblue, which was not surprising to the authors, since, with maturity, colors ofshorter wavelength increase in popularity, with blue being the most popular coloruniversally.

The findings of both of these reports conflict with other recommendations to“choose reds” and “avoid blues” (Templeton, 1991; Fanelli, 1988; Magnus,1993). More research seems warranted.

Readability, comprehensibility and clarity of print materials of all kinds shouldbe considered (Clark et al., 1999). Guidelines for preparing print materials to im-prove readability were described previously by Magnus (1993), Templeton(1991), and Fanelli (1988).

6. Use printed materials with concrete words, graphics and illustrationsto improve immediate recall of concepts.

The ability to immediately recall text and graphics may differ between concretevs. abstract concepts. The way text and graphics were presented in a brochuremade a difference in Caucasian women’s ability to remember the content of thenutrition message immediately after reading it (Clark et al., 1999). Printed materi-als with more concrete words, graphics and illustrations were easier for thewomen to remember immediately afterwards than when the original brochurewith concepts presented using abstract words and graphics was read. For example,the brochure with concrete words included the phrase “seeds, stems and leaves ofplants,” instead of the more abstract word, “fiber.” Abstract text had low imagery.Photographs of objects, such as food, were used as concrete graphics and illustra-tions, while abstract graphics depicted hexagon shapes. However, there was noadvantage to the concrete text and graphics in information retention among read-ers 30 days later, as compared to the printed information with abstract text and im-


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ages. To our knowledge, similar studies have not been published that tested theseresults with different racial or ethnic populations.

7. Develop short, simple materials in multiple languages.

Kenner et al. (1999) noted that current patient education materials are often toolengthy and complex. Some health care practitioners desired two separate sets ofmaterials for use with patients who had either high or low reading levels, whileothers preferred one set for both reading level groups to use. Nearly half of theirrespondents indicated a need for nutrition education materials in Spanish. Nutri-tion educators should develop scientifically-based and tested nutrition educationhandouts appropriate for the characteristics of their audience, then publicize theiravailability and distribute them at no or low cost, whenever possible. County co-operative extension service family and consumer science education faculty wouldbe one channel for providing primary care practitioners with educational materialsregarding healthful eating for older adults. We believe that other professionals, in-cluding dietitians, public health nutritionists and university faculty, could alsohelp provide appropriate low-cost print nutrition information to primary care prac-titioners.

8. Adapt written and aural messages for those with vision, hearing,and communication disorders.

Wright et al. (1997) pointed out that educators should make special efforts tocommunicate with older adults with hearing and vision impairments and commu-nication disorders. They stated that more suitable resources, such as large printmaterials, are appropriate for impaired individuals. They noted that audiotapes arenot widely used, but their study was not designed to indicate the reason(s).

Low-literate focus group participants reported by Macario et al. (1998) saidthat they would not want to listen to audiotapes, at least not at their physician’s of-fice. However, they were speculating about what the audiotapes might be like,rather than responding to actual samples of taped nutrition messages. They alsostated that videotapes would be more to their liking.

Alternatively, a high percentage of the public preferred audio nutrition educa-tion messages to printed materials (TenHave et al., 1997). Many did not havegood reading skills, while others were better readers who simply did not prefer touse printed nutrition materials. About one fourth of this latter group used the au-diotapes more than they used the printed materials, and slightly less than half usedthe two types equally. This is similar to the large segment of Americans, many ofwhom are excellent readers, who choose to listen to mass media for their newsrather than read newspapers.


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We believe that people with low literacy skills who may never have been goodreaders may respond differently to audiotapes than would those who have recentlybecome poor readers. This is an area that requires research.

Educational audiotapes and videotapes designed with a soundtrack that can beunderstood without viewing the visual portion would be useful to a wide circle ofusers, including low vision learners, people who know spoken but not writtenEnglish, people with dyslexia, commuters, and people who learn better throughaural rather than visual presentation, according to results of focus groups reportedby Williams (1999).

9. Use an interactive format.

Taylor-Davis et al. (2000) provided written educational resources with interac-tive elements, such as quizzes and self-assessments, and a question and answerssection to the newsletters. These features were the most popular aspect of thenewsletter. Some older adults received the newsletter along with brief personaltelephone communication, and this group improved more than those receivingnewsletters alone.

Interactive computer programs were suggested by Macario et al. (1998).Another way to achieve interaction is by conducting a group discussion of print

materials, or a short (e.g., 15 or 20 minutes) individual counseling session, even ifthe program does not require direct counseling. According to suggestions byMayeda and Anderson (1993), such a counseling intervention may benefit olderadults enrolled in a self-help nutrition education program. They believed that indi-vidual sessions would have improved the understanding of their subjects, whowere aged 60-90 years, of the printed computer-assisted feedback they receivedregarding their dietary status and in areas for potential improvement in dietarypractices.

10. Match educational materials to the intended audience with regardto interests and needs, reading preferences, and cultural appropriateness.

For example, understanding the preferences for visual vs. aural, or for wordsvs. images, of a specific audience can help clarify conflicting results reported inthe articles summarized above.

Tailoring educational materials to the cultural experiences of an audience hasbeen emphasized repeatedly in the literature, such as by Elshaw et al. (1994),Kenner et al. (1999), Macario et al. (1998), and TenHave et al. (1997).

Pre-test print materials with the target audience to determine its appropriate-ness and comprehensibility (Clark et al., 1999).


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For a discussion of published literature on how to tailor nutrition education pro-grams to older learners, see also Higgins and Clarke Barkley (2003c).

SUMMARY

Evidence suggests that, if properly done, nutrition education for older adults isan excellent long-term intervention to improve health, prevent chronic disease,lower long-term health care costs and enhance quality of life. Print and other edu-cational resources remain as some of the most widely-used and popular methodsof nutrition education. They are primarily effective at increasing awareness andknowledge. They should be science-based and used as one part of a multiple-strat-egy approach to reaching older adults with nutrition education messages that im-prove their nutrition practices. Only thirteen reports of nutrition education studiesfocusing primarily on print or audio/videotape resources for older adults, of whichfour were theory-based, were found in literature published in the past decade. Newresources, preferably based on education and behavior change theory, must be de-veloped and evaluated. More carefully designed and reported studies testing suchmaterials, and descriptions of any other program interventions used with them,should be published. Research should be directed toward proving–and improv-ing–effectiveness (i.e., increasing outcomes and impacts) for print, video/audio,and other nutrition educational resources for use with specific segments of olderadult learners. It is an area rich in opportunities for investigation and with thepromise of great benefit.

Received: July 2002Revised: July 2003Accepted: August 2003

REFERENCES

Anderson, R.M. & Funnell, M.M. (1999). Theory is the cart, Vision is the horse: Reflec-tions on research in diabetes patient education. The Diabetes Educator, 25 (suppl.),43-51.

Arnold, M.S., Funnell, M.M., Herman, W.H., Brown, M.B., Merritt, J.H., Fogler, J.M. &Halter, J.B. (1996). Discrepancies between perceived dietary changes and 4-day foodrecords in older adults with diabetes. Journal of the American Dietetic Association, 96,705-707.

Chapman, K.M., Ham, J.O., Liesen, P. & Winter, L. (1995). Applying behavioral modelsto dietary education of elderly diabetic patients. Journal of Nutrition Education, 27,75-79.


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14

Clark, K.L., AbuSabha, R., VonEye, A. & Achterberg, C. (1999). Text and graphics: Ma-nipulating nutrition brochures to maximize recall. Health Education Research, 14 (4),555-564.

Contento, I., Balch, G.I., Bronner, Y.L., Lytle, L.A., Maloney, S.K., Olson, C.M. &Swadener, S.S. (1995). The effectiveness of nutrition education and implications fornutrition education policy, programs, and research: A review of research. Journal ofNutrition Education, 27, 280-281, 339-346, 374-375.

Elshaw, E.B., Young, E.A., Saunders, M.J., McGurn, W.C. & Lopez, L.C. (1994). Uti-lizing a 24-hour dietary recall and culturally specific diabetes education in MexicanAmericans with diabetes. The Diabetes Educator, 20, 228-235.

Fanelli, M.T. (1988). Effective nutrition education for older adults. Topics in Clinical Nu-trition, 3 (4), 65-71.

Higgins, M. Meck & Clarke Barkley, M. (2003a). Evaluating outcomes and impact of nu-trition education programs designed for older adults. Journal of Nutrition for the El-derly, 22 (4), 69-81.

Higgins, M. Meck & Clarke Barkley, M. (2003b). Important nutrition education issues andrecommendations related to a review of the literature on older adults. Journal of Nutri-tion for the Elderly, 22 (3), 65-78.

Higgins, M. Meck & Clarke Barkley, M. (2003c). Tailoring nutrition education interven-tion programs to meet needs and interests of older adults. Journal of Nutrition for theElderly, 23 (1), in press.

Higgins, M. Meck & Clarke Barkley, M. (2003d). Concepts, theories and design compo-nents for nutrition education programs aimed at older adults. Journal of Nutrition forthe Elderly, 23 (2), in press.

Kenner, M.M., Taylor, M.L., Dunn, C., Gruchow, H.W. & Kolasa, K. (1999). Primary careproviders need a variety of nutrition and wellness patient education materials. Journalof the American Dietetic Association, 99, 462-466.

Lach, H.W., Dwyer, J.T. & Mann, M. (1994). P.E.P.: A partnership to assess and modifynutrition behavior in older adults. Journal of Nutrition for the Elderly, 13 (3), 57-67.

Lancaster, K.J., Smiciklas-Wright, H., Ahern, F., Achterberg, C. & Taylor-Davis, S.(1997). Evaluation of a nutrition newsletter by older adults. Journal of Nutrition Educa-tion, 29, 145-151.

Lang, J.E., Mercer, N., Tran, D. & Mosca, L. (2000). Use of a supermarket shelf-labelingprogram to educate a predominately minority community about foods that promoteheart health. Journal of the American Dietetic Association, 100, 804-809.

Macario, E., Emmons, K.M., Sorensen, G., Hunt, M.K. & Rudd, R.E. (1998). Factors in-fluencing nutrition education for patients with low literacy skills. Journal of the Ameri-can Dietetic Association, 98, 559-564.

Magnus, M.H. (1993). What’s your IQ on nutrition education for older adults? Journal ofNutrition for the Elderly, 12 (3), 59-70.

Mayeda, C. & Anderson, J. (1993). Evaluating the effectiveness of the “Self-CARE for aHealthy Heart” program with older adults. Journal of Nutrition for the Elderly, 13 (2),11-22.

Nitzke, S. & Voichick, J. (1992). Overview of reading and literacy research and applica-tions in nutrition education. Journal of Nutrition Education, 24, 261-266.


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by [

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Peterson, A. (2002). A new efficacious nutrition tool for seniors (50+years). Journal of Nu-trition for the Elderly, 21 (3), 55-63.

Taylor-Davis, S., Smiciklas-Wright, H., Warland, R., Achterberg, C., Jensen, G.L., Sayer,A. & Shannon, B. (2000). Responses of older adults to theory-based nutrition newslet-ters. Journal of the American Dietetic Association, 100, 656-664.

Templeton, C. (1991). Nutrition education: The older adult with diabetes. The DiabetesEducator, 17, 355-358.

TenHave, T.R., VanHorn, B., Kumanyika, S., Askov, E., Matthews, Y. & Adams-Camp-bell, L.L. (1997). Literacy assessment in a cardiovascular nutrition education setting.Patient Education and Counseling, 31, 139-150.

Wallace, J.I., Buchner, D.M., Grothaus, L., Leveille, S., Tyll, L., LaCroix, A.Z. & Wagner,E.H. (1998). Implementation and effectiveness of a community-based health promo-tion program for older adults. Journal of Gerontology: Medical Sciences, 53A (4),M301-M306.

Williams, A.S. (1999). Accessible diabetes education materials in low-vision format. TheDiabetes Educator, 25, 695-715.

Wright, K.J., Smiciklas-Wright, H., Blood, I. & Wright, C. (1997). Dietitians can andshould communicate with older adults with hearing and vision impairments and com-munication disorders. Journal of the American Dietetic Association, 97, 174-176.


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Documents

Improving Effectiveness of Nutrition Education Resources for Older Adults