Tailoring Nutrition Education Intervention Programs to Meet Needs and Interests of Older Adults

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Tailoring Nutrition Education Intervention Programs toMeet Needs and Interests of Older AdultsMary Meck Higgins PhD, RD, LD, CDE a & Mary Clarke Barkley PhD, RD, LD ba Department of Human Nutrition , Kansas State University , USAb Department 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 (2003) Tailoring NutritionEducation Intervention Programs to Meet Needs and Interests of Older Adults, Journal of Nutrition For the Elderly, 23:1,59-79, DOI: 10.1300/J052v23n01_05

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Tailoring Nutrition EducationIntervention Programs to Meet Needs

and Interests of Older Adults

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

ABSTRACT. Methods for determining appropriate content of olderadult nutrition education intervention programs and strategies for effec-tively delivering nutrition messages to older learners are presented. Edu-cators can determine the nutrition education needs and interests of theirolder learners by using results of food intake surveys and assessmentscreening tools, written surveys, interviews and group discussions. Find-ings of recent reports using these methods are summarized. Additionally,published experiences with and suggestions for tailoring education inter-vention programs for older adult audiences, including those of particularracial/ethnic groups, are reviewed. The need for research in this area ispresented. This article is one of a series of literature reviews of topics re-lated to nutrition education for older adults. [Article copies available for afee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mailaddress: <[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, Department of Human Nutrition, Kansas State University.

Mary Clarke Barkley is Professor Emeritus and Cooperative Extension Human Nutri-tion Specialist, Department of Human Nutrition, Kansas State University, Manhattan, KS.

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

Journal of Nutrition for the Elderly, Vol. 23(1) 2003http://www.haworthpress.com/store/product.asp?sku=J052

2003 by The Haworth Press, Inc. All rights reserved.10.1300/J052v23n01_05 59

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KEYWORDS. Nutrition education, older adults, ethnic groups, minor-ity groups, nutrition screening, focus groups, surveys, intervention, adultlearning

INTRODUCTION

Educators planning or conducting nutrition programs for older learn-ers should first probe for the educational needs and desires of their par-ticipants before deciding on the objectives and strategies of an interven-tion (Grommet, 1997). Defining, ranking and meeting the consumers’nutritional needs and interests; understanding and emphasizing nutri-tion behavior from the consumers’ point of view; and developing mes-sages for specific subgroups of an intended audience are importantaspects to consider when providing nutrition education to the public(Grommet, 1997; American Dietetic Association, 1996; Sutton et al.,1996).

Contento et al. (1995) noted two major problems with publishedstudies on nutrition education for older adults. One was the lack of cleargoals regarding knowledge or behavior, or both; the other concernedbehavioral outcomes expected. Some of their recommendations for nu-trition education programs were to: segment the older population on thebasis of their needs for nutrition education; emphasize cultural rele-vance and local adaptations of programs; and apply successful programelements identified in research studies to developing programs.

While appropriate content of a nutrition education message is criti-cal, it is also vital to use a process for delivering the message that is suit-able for the intended audience. Nutrition education programs are moreeffective when they are structured with consideration for the special anddiverse characteristics of older adults. However, the task of developingeducation programs is complicated by their heterogeneity.

It is well to remember that the term elderly refers to a very large agespan of 25 years or more. The diversity of older adults in calendar years,health status, physical and cognitive abilities, race, culture, ethnicity,social class, literacy levels, years of formal education, financial re-sources, social support, experiential living, emotional health, personalliving skills, lifestyle, rural versus urban living setting, etc., is extreme.Projections are that the older adult population will become even morediverse (U.S. Bureau of the Census, 1996). Therefore, to reach this agegroup with effective programming, programs need to be designed care-fully to fit the requirements of each identified audience.

60 JOURNAL OF NUTRITION FOR THE ELDERLY

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Older adults present unique challenges to nutrition educators who tryto accommodate their multiple variations. This article reviews reportspublished mostly since 1994 that discussed methods used for determin-ing either the nutrition needs or the nutrition education interests of olderadults, or both, as well as reports that discussed experiences with tailor-ing the delivery of educational programs to varying segments of theolder population, including particular racial/ethnic groups. It is one of aseries of literature reviews of topics related to nutrition education forolder adults. The purpose of this series is to review recent scientific lit-erature in order to assist nutrition educators, researchers and healthpractitioners in familiarizing themselves with more effective strategiespertaining to nutrition education for older adults.

The purposes of this article are: (1) To describe methods and findingsreported in recent studies regarding nutrition education needs and inter-ests of the older learner, in order to stimulate planners to assess the ap-propriateness of a program’s content and tailor it for their ownaudiences. (2) To describe reported methods for tailoring the delivery ofnutrition education intervention programs to older adults, includingparticular racial/ethnic groups, in order to suggest processes that couldbe adopted by program designers, educators or researchers. (3) To sug-gest future directions for research on nutrition education interventionsdesigned to reach specific segments of older adults.

METHODS FOR DETERMINING NUTRITION EDUCATIONNEEDS AND INTERESTS OF THE OLDER LEARNER

In the following two sub-sections, studies using methods for deter-mining older learners’ nutrition needs or interests, i.e., subject contentof the program, are reviewed. Methods fell into two main categorieswhen assessing nutritional needs: food intake surveys and nutrition as-sessment screening tools. When probing for nutrition information inter-ests, authors reported using written surveys, interviews and groupdiscussions. (See Figure 1.) By using the results of one or a combinationof these methods, educators can better understand the needs and wantsof their program’s participants, and then tailor their nutrition mes-sage(s) accordingly.

Along with a description of the methods used to discover nutritionneeds and educational interests, a summary of findings of each pub-lished report is included. These findings inform programmers as to whatto adjust for regarding an elderly audience’s nutritional needs. Based on

Nutrition Education for Older Adults 61

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common themes in these reports, educators should consider emphasiz-ing calories or certain nutrients, or particular food groups or meals, ac-cording to their participants’ lifestyles, demographics, and/or healthstatus. Additionally, literature reviewed in this article indicated thatolder adults desire nutrition information regarding behaviors that im-pact their overall health as well as disease-specific management; foodchoice strategies; food shopping, selection and preparation; and foodresource management. Once an audience is identified, it is important forthe educator to verify the members’ needs and interests before proceed-ing.

Tailoring Program Content to Nutrition Needs

Programmers can consider the nutritional status of their older audi-ences, based on reviewing health records, food intake surveys, and nu-tritional assessment screening tools. Educators can use publishedresults of food intake surveys and nutrition screenings, examples ofwhich are cited below, to identify common nutritional needs of olderadults. However, the focus should be on the needs of the specific indi-vidual or population to be taught. It is important to target each audiencewith appropriate nutrition messages based on their actual identifiedneeds. For instance, while many members of the older age group con-sume insufficient calories, have at least one major chronic disease, andhave low-quality diets (American Dietetic Association, 2000), otherssuffer morbidity and mortality health implications from overfeedingthat results in obesity and high cholesterol levels (Contento et al., 1995).

For certain sub-groups of the elderly, nutrition educators will need toemphasize increased intake of nutrients. Metabolic aspects of specific


FIGURE 1. Examples of Methods for Determining Nutrition Education Needsand Interests of Older Learners

1. Tailoring program content to nutrition needs, using results of:

a. Food intake surveys

b. Nutrition assessment screening tools

2. Tailoring program content to nutrition information interests, using results of:

a. Written surveys

b. Telephone or face-to-face interviews

c. Group discussions: informal groups, focus groups

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nutrients needed by older adults were briefly reviewed by Blumberg(1997). The third National Health and Nutrition Examination Survey(NHANES) reported data from 3,885 people 65 years of age and over,of whom 113 were judged to experience varying degrees of food insuf-ficiency (Sahyoun and Basiotis, 2000). There was a strong relationshipbetween poverty and food insufficiency. Those with inadequate foodwere in poor or fair health and had low average calorie intakes (nearly300 kilocalories less than food-sufficient older adults), low intakes ofseveral nutrients, low intakes of foods from the vegetable and meatgroups, low mean serum levels of certain nutrients, limited dietary vari-ety, and were at high risk of being underweight.

By obtaining 3-day food records and responses to questions aboutfood practices using face-to-face and telephone interviews, Prothro andRosenbloom (1999) concluded that those who were at highest nutri-tional risk were female, black, and older adults who consumed inade-quate amounts of food for breakfast and supper. The authors recom-mended that nutrition education efforts in federal congregate ElderlyNutrition Programs be directed to those most at risk of energy/nutrientinadequacies.

By knowing the usual food consumption of older adults, educatorscan tailor a nutrition program to emphasize the benefits of eating tar-geted nutrients or food groups. Data from USDA’s Continuing Surveyof Food Intakes by Individuals 1994-96 were used to compare the dietquality of “pre-elderly,” ages 45-65 years, with that of older adults liv-ing independently (Gaston et al., 1999). When median Healthy EatingIndex scores were compared, the pre-elderly group lagged behind olderadults in meeting recommendations for consumption of fruit, total fatand sodium, but they scored better than the older adults group in meet-ing recommendations for consumption of grains, vegetables, milk,meat, saturated fat, and dietary variety. After 85 years of age, olderadults had dramatically worse scores for dietary variety.

In determining nutrition education needs of the elderly in Illinois,Chapman et al. (1996) used a modified Behavioral Risk Factor Surveil-lance Survey. It included 55 questions from the master instrument plusten additional questions to clarify issues related to hypertension- andhypercholesterolemia-related behavior; obesity; and fruit, vegetableand dairy intake. This telephone survey suggested that older men andwomen should be targeted for nutrition education programs, especiallyregarding fruit, vegetable and dairy foods; and women needed educa-tion to reduce cardiovascular risk.


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Using data from the 1987-88 Nationwide Food Consumption Sur-vey, Gerrior et al. (1995) noted that living alone affected dietary qualityfor adults of all ages. Their sample of single women, ages 75 years andolder, had diets lower in protein and sodium, while older single men’sdiets were lower in protein, folate, phosphorus, calcium and zinc thanthose living with others. Thus, lifestyle characteristics of an audiencemay influence nutrition education needs.

Another method for determining possible programming needs of anelderly audience is to use results of surveys conducted with nutrition as-sessment screening tools, such as the DETERMINE Your NutritionalHealth Checklist, and Level I and Level II Screens (NSI, 1991). Nutri-tion screening strategies have their drawbacks, however, as discussedby Rush (1997).

Weddle et al. (1997) used a modified Checklist and Level I instru-ment to identify levels of malnutrition risk and to determine the array ofnutrition-related services needed by congregate nutrition site and homedelivered meal recipients. Nutrition education was identified as one ofthe needs this group had, particularly for chronic disease diet-relatedproblems and basic healthy eating. The authors stated that educationwas subsequently provided, in the form of group counseling sessions.

Nutrition educators should segment the older adult audience basedon DETERMINE risk factors for malnutrition, or on specific demo-graphic characteristics, and develop programs that feature sessions thatattend to a particular group’s identified needs, according to recommen-dations by McClelland, Bearon, Velazquez et al. (2002). Dutram et al.(2002) also noted that interventions could be designed to specifically tar-get problem areas identified by participant responses to DETERMINEfactors. The latter group showed that of more than 4000 primarilynon-Hispanic Caucasian older adults who completed the DETERMINEchecklist, nutrition risk factors varied according to gender, age, andcongregate vs. home-delivered meal delivery method. Many of theirpopulation sample consumed low amounts of grains, fruits, vegetables,dairy products and meats, and they were at high risk of being under-weight. Using the DETERMINE Checklist and Block Brief Food Fre-quency Screeners, Lokken et al. (2002) reported a Mississippi telephonesurvey completed by 212 low-income adults, age 55 years and over, ofwhich approximately half were African-American and the other halfCaucasian. Seventy-four percent were classified as being at high nutri-tional risk, 57% of whom were African-Americans. Independent of nu-trition risk categories, participants self reported low intakes of fruits andvegetables, and high fat intakes.


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The Nutritional Risk Index, a 16-item screening questionnaire, wasused to conduct personal interviews with rural older adults (Quandt andChao, 2000). Women were at greater risk of developing nutrition-related health problems than were men. The authors reported on a ran-dom sample of 638 White adults aged 55 years and older who were liv-ing in two rural Kentucky counties.

Tailoring Program Content to Nutrition Information Interests

Consulting individuals or groups of the intended audience regardingtheir nutrition education interests is another avenue for guiding pro-gramming. Probing for food practices with nutrition site managers,home health care providers and health professionals also can help deter-mine interests of an intended audience. Educators may need to empha-size certain food behaviors with one audience more than with others.Below are some recently published studies where elderly subjects werequestioned about their nutrition practices and interests by written sur-veys, telephone or face-to-face interviews, informal group discussions,or focus groups.

A mailed questionnaire was used to examine the association betweenhealth beliefs and five self-reported nutrition- and health-behaviorchanges in older adults in a study by Ferrini et al. (1994). The authorsconcluded that increasing age did not diminish the relationship betweenhealth beliefs and health change behaviors: Those with positive healthbeliefs were more likely to report positive changes in health behavior.Their older, well-educated Caucasian subjects, however, reported moreconfusion about which foods to eat in order to decrease risk of heart dis-ease and about staying healthy than younger respondents did. Theyurged health educators to direct more of their research and program-ming efforts to older adults.

Concern for health strongly influenced nutrition behavior among 98older adults in eleven states, who were selected to respond to a mailedquestionnaire because they had a diagnosis of heart disease, hypercho-lesterolemia, hypertension, breast cancer or colorectal cancer (Nitzke etal., 1999). Data regarding race and ethnicity of subjects were not gath-ered. Subjects’ concern for health was the primary factor influencingtheir diets, followed by personal skills and preferences. Very few indi-cated that lack of time or expectations of family members were primaryinfluences on the food they consumed.


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In face-to-face interviews with food-stamp-eligible older adults withchronic disease, 70% wanted more nutrition information to be providedby their doctor’s office (Shawver and Cox, 2000). Nineteen percent oftheir fifty-seven subjects, mostly female Caucasians with a median ageof 70 years, responded that they never followed the nutrition advicethey were given. The researchers suspected that the dietary advice pro-vided by many primary-care physicians was not tailored to patients’specific needs and resources, which could be a major factor in lack ofadherence to that advice. Furthermore, results indicated that this groupof low-income older adults would respond positively to being toldabout community nutrition education programs to help them with theirneeds. For example, programs should be free and easily accessible, andoffer practical advice from well-trained staff on how to make recom-mended dietary changes.

In-depth interviews with sixteen Caucasian older adults revealed thatthe main strategies they used to simplify making food choices included:eliminating certain foods from their diet, limiting amounts of certainfoods, substituting one food for another, and establishing routines foreating certain meals (Falk et al., 1996). Older adults with more healthproblems used a combination of these strategies, rather than relying onjust one or two of them. Nutrition educators who know which foodchoice strategies are most comfortable for their audiences can facilitatechange by incorporating special diet modifications into those strategies.They can also teach clients how to expand their repertoire of strategiesin order to cope with new health issues. The authors found that olderadults’ food choices were most often affected by their ideals, such aswhat constitutes a good meal and what healthy eating should be; and bysocial frameworks, such as seeking food activities as a means for com-panionship. Other factors affecting their food choices were taste,whether they ate alone or with someone, food cost, ease of preparation,and physical well-being.

Informal group discussions were conducted during the developmentof a nutrition education curriculum to learn more about the nutrition in-terests and learning preferences of the intended audience by ClarkeBarkley et al. (2003). This group of mostly Caucasian older adults de-sired information about food preparation and selection, healthy eating,and modifying diet for chronic diseases.

Current food purchasing and preparation practices, the importance offood to health, and preferred topics and methods for receiving nutritioninformation were probed in focus groups by Stewart et al. (1998).


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Among the 35 white and African-American low-income older adultsparticipating in a congregate meal program, health conditions were theprimary influence on their food choices. Many were confused abouthow to choose and prepare foods that complied with dietary restrictionsrelated to their health condition, and believed that they did not receiveenough diet information from their doctor.

Twenty-four well-educated non-Hispanic white women, ages 65-89years old, participating in focus groups were strongly influenced bytheir physicians on the type of diet they followed and the foods theychose (Eddy et al., 1999). Family and friends, and educational programsand written materials, had less influence.

Similarly, Pierce et al. (2002) led focus groups with 35 primarilyCaucasian, 75 to 90 year old, low-income widows. In addition, theyconducted 12 in-depth interviews. The widows’ most common sourcesof stress related to nutrition were: limited finances to buy food; dietsneeding to be reduced in calories, fat, salt or sugar, or increased in fiber;lack of transportation to the grocery store; difficulty shopping and pre-paring foods; and depression. They received instrumental support, suchas help with shopping, more often than informational support, includingeducation. The authors concluded that it is important for nutrition edu-cators to understand issues from the perspective of the client, and thendevelop goals and objectives that are practical and realistic for their au-diences to implement.

We believe that it is more appropriate to plan nutrition education ef-forts to meet the identified needs and interests of older adults than tosegregate them just by virtue of their “senior citizen” age. We have re-viewed an array of techniques from which nutrition educators canchoose in order to learn what to teach their older adult audiences. Theimportant thing to remember is that, for older adults, one size does notfit all. Programmers should exercise good judgment to develop or selecteducation intervention programs tailored to meet the needs and interestsof the recipients.

Educational efforts directed towards older adults do influence theirfood practices (Higgins and Clarke Barkley, 2003a). Also, Lee et al.(1997) reported on food attitudes and practices, based on personal inter-views and 24-hour food intake recalls. They observed an association be-tween diet knowledge and quality of diets in southern rural elderly.Higher diet knowledge scores were associated with higher educationand income levels, and their diets were generally superior in quality.


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REPORTED EXPERIENCESWITH TAILORING EDUCATION INTERVENTION PROGRAMS

TO OLDER LEARNERS

The previous section reviewed research in order to help educators de-termine appropriate content for older adults’ educational programs.This section will highlight reports describing processes that have beenused in programming for the elderly. It reports published experienceswith, and suggestions for, tailoring educational intervention programsto older learners. Examples were taken from nutrition education litera-ture, as well as from the research of diabetes educators. Following thissection are examples of reports, mostly reviews of literature, that sug-gested strategies for tailoring the delivery of educational programs tovarying races and ethnicities. A summary of common themes is pre-sented in Figure 2. We hope that these examples, and the ideas that theymay generate, will encourage educators to enhance their own set ofstrategies for use in meeting the needs and interests of their senior adultaudiences.

How to adjust nutrition education delivery for the older adult learnerwas discussed in previous literature reviews (Fanelli, 1988; Magnus,1993). The authors recommended factors for consideration, and sug-gested guidelines for implementing strategies. For example, program-mers were urged to create self-paced programs and learning environ-ments that offset elders’ physical disabilities, to provide an open dia-logue of information perceived to be relevant, and to select action-oriented participative education methods.

Based on a review of studies published prior to 1995, Contento et al.(1995) suggested several successful elements contributing to the effec-tiveness of nutrition education for older adults. An effective startingpoint is using personalized approaches, such as self-assessment of nu-tritional status or behaviors and comparing them with recommenda-tions. A behavioral approach is key. Following individual self-assessment,behavioral self-management techniques should be used. These involvethe participant in more than just attending a class, for instance. Exam-ples of these techniques include goal setting, problem solving, enhance-ment of self-efficacy, and social support. Active participation isessential, such as participants entering their own dietary intake data intothe computer, being a peer educator, solving mutual problems, prepar-ing and tasting food, keeping food diaries, modifying recipes and hold-ing small group discussions. Of primary importance is attention to


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FIGURE 2. Examples of Strategies to Consider When Tailoring Education In-tervention Programs to Meet the Nutrition Needs and Interests of Older Adults

• Segment older adults into compatible groups with similar needs and interests, ratherthan by age, sex, ethnicity, or race alone.

• Know the specific audience, such as their perceptions, beliefs, preferred learningstyles, expectations, priorities, and short- and long-term goals.

• Keep program content practical and relevant to activities of the participants.

• Incorporate life experiences of the audience into program content and processes, rec-ognizing that they are influenced by situations such as housing conditions, racism, em-ployment status, family and social network support, community violence, and acculturat-ion.

• Define clear goals for expected outcomes regarding changes, such as in knowledge,attitude and beliefs, self-efficacy, intentions to change or actual change in behaviors,physiological factors, or sense of well-being and quality of life.

• Plan for an open exchange of communication, with empathy and mutual respect.

• Include components that allow for individualized attention to participants, such asself-assessment activities or individual consults.

• Accommodate physical abilities, such as visual, auditory and ambulatory needs of theaudience, in the details of the learning environment and the selection and use of multipleeducational resources.

• Structure the program to increase retention by presenting multiple lessons on a singletopic, using familiar terminology, and simplifying concepts.

• Plan time for the group to discuss issues regarding nutrition practices.

• Create opportunities to practice ways to overcome barriers to change.

• Plan for motivators to encourage behavior change, such as practical gifts and prizes.

• Plan multiple opportunities for participatory, experiential, interactive involvement that isalso self-directed and self-paced, such as by preparing or tasting foods, or modifyingrecipes.

• Reinforce skills learned and encourage success.

• Build formal and informal social support, including positive interaction between groupmembers.

• Capitalize on the strength of religious, social, and kinship ties that already existwithin some audiences to support individuals in desired behaviors.

• Consider preparing peers to teach others.

• Search out appropriate peer opinion leaders, creative funding and a coalition of educ-ators to implement programs.

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reinforcements and motivators. These include interest in maintaininghealth, opportunities for social interaction and social support, enhancedself-efficacy, desire for ease of food preparation and tasting foods. Anempowerment philosophy that enhances personal choice, personal con-trol, and social support should be used. Subgroups of older adults, seg-mented by gender, cultural background, disabilities and chronic diseases,for example, need to be identified and served. It is also necessary to besensitive to age-related physical changes such as sight and hearing.

Walker (1999) reviewed conceptual and research literature on gen-eral adult education and adult learning. The author reported that adultlearner principles used in diabetes education are: self-directed learningenhances autonomy; adults must feel a need to know; problem-orientedlearning is more acceptable to adults than just learning informationabout a subject; incorporating life experiences enhances motivation;and active participation is essential for behavior change. We believethat these are likely to be useful for the majority of elderly as well, sincemost have one or more chronic diseases.

Numerous specific strategies to both develop and deliver a group nu-trition education program for older adults that was behaviorally focusedand sensitive to participants’ needs and interests were suggested byClarke Barkley et al. (2003), based on their experiences piloting amulti-state program primarily with Caucasian elders. For example, theyproposed conducting a series of lessons on a topic, such as increasingfruits and vegetables consumption. It would allow participants opportu-nity to repeat new food behaviors, and to discuss ways to overcome anybarriers they encounter. They reported that their audience wanted dis-cussions of nutrition topics, simple printed materials, and food demon-strations and recipes. After attending group classes, participants espe-cially liked tasting different foods and receiving recipes. The authorssuggested that educators should know their audience, and in turn beknown and respected by the older learners, so that nutrition lessonscould be culturally sensitive and environmentally comfortable.

Similarly, focus group members favored receiving nutrition informa-tion in “a discussion group with food demonstrations,” according to areport by Macario et al. (1998). Their focus groups were comprised oflow-literacy adult participants who ranged in age from 21 to 72 yearsold, with an average age of just 37 years. All had reading skills rangingonly from the third to the sixth grade. Of the 50 participants, most wereblack or Latino.

Pilot testing with 35 white and African-American low-income olderadults participating in a congregate meal program revealed that focus


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group questions needed to be simplified, learning settings needed to beadapted for those who were hearing impaired or physically disabled,and older individuals often needed to be prompted in order to elicit re-sponses (Stewart et al., 1998). Participants preferred to receive nutritioninformation in group discussions and through media such as “how-to”written materials. The authors recommended that educators conductcooking classes with older adults to teach them cooking skills and todemonstrate easy and inexpensive recipes for foods that conform to di-etary restrictions. The authors’ model of pilot testing questions, as wellas the implementation of their conclusions, would seem to apply notonly to programmers and researchers wanting to adopt the focus groupmethod for determining older adults’ interests, but also to educatorslooking for specific strategies in order to conduct successful programs.

Studies reporting ways to improve print and other educational re-sources for use with older learners were reviewed by Higgins and ClarkeBarkley (submitted). Ways to make both the learning environment andeducational materials appropriate for the physical and learning needs ofrural southern older audiences at congregate nutrition sites were sug-gested by McClelland, Bearon, Fraser et al. (2001). The latter group out-lined how elements of the behavior change models they used wereincorporated into their educational activities. Innovative ways to moti-vate elders and improve their ability to change nutrition practices werealso described. For instance, they suggested that group sessions shouldlast 30 to 40 minutes each, and focus on relevant and familiar informa-tional topics. Of note was their observation that the same activity wasrated at different levels of enjoyment by groups at different sites, pointingout once again that older adults vary in their specific needs and interests,and programs should be tailored to the individuals in the group.

Dutram et al. (2002) used a variety of interactive adult educationtechniques, including group and individual lessons and written educa-tional materials and videos, and either face-to-face or telephone con-tact, to address nutrition education needs in their study with ElderlyNutrition Program (congregate nutrition site) participants, most ofwhom were non-Hispanic Caucasians. These authors also worked witha coalition of nutrition educators, including gerontological nutritionists,dietetic technicians, Cooperative Extension Service paraprofessionalnutrition aides, and university nutrition students. They noted that col-laboration among several community partners was essential to fund theprogram and to ensure a range of staff skill levels to carry out the variedassessment, education, counseling, social support and evaluation func-tions of the program. Higgins and Clarke Barkley (2003b) also ad-


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dressed the need for such teams of experts to collaborate on providingeffective elderly nutrition education.

Older adults enrolled in a self-help nutrition education program maybenefit from a 15-minute individual counseling session, even if the pro-gram does not require direct counseling, according to suggestions byMayeda and Anderson (1993). These Colorado authors used the indi-vidual sessions to improve the understanding of their subjects, whowere aged 60-90 years, in areas for potential improvement in dietarypractices, and for computer-assisted feedback. Their suggestion of in-corporating an individual counseling session into a self-help programmight also be a way to tailor educational messages to individuals whoparticipate in group classes.

Tailoring education for older adults with diabetes has been the sub-ject of a number of publications. For instance, Templeton (1991) de-scribed the need to personalize strategies for nutrition education forolder adults with diabetes. Based in part on published literature, the au-thor’s comments likely apply also to older people without diabetes. Sheasserted that before selecting a certain nutrition education tool, the edu-cator should assess the seniors’ learning style, expectations, experi-ences, goals, life priorities and degree of involvement, i.e., the educatorshould be well acquainted with the audience. She also reviewed ways toimprove the educational setting for older adults, including the physicalenvironment and teaching techniques, such as the format of the sessiontopics. Published guidelines to assess the suitability of written materialsfor older adults, such as formatting and readability, also were described.

The American Association of Diabetes Educators (AADE) main-tained that assessment and individually planned educational programsare essential for desired health outcomes (AADE, 2000). Older adults“may have specific medical, pharmaceutical, visual, psychosocial, cul-tural, religious, nutritional, financial and transportation issues thatshould be considered when planning treatment and educational pro-grams.” The authors asserted that “you can teach an old dog newtricks.” Allowances need to be made, however, for slower acquisition ofskills and knowledge; vision and hearing deficits; and the impact offamily and friends on elderly behavior. They noted the importance ofindividualizing the education based on needs, and facilitating and sup-porting active participation by the older learner.

Black and Scogin (1998) proposed suggestions on memory trainingfor management of diet and medication by older people with diabetes.They recommended using association mnemonics, familiar terminol-ogy, and charts with check-off spaces, as well as avoiding excessive de-


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tails. Association mnemonics involve forming a link between to-be-remembered information and information already stored in long-termmemory. The authors did not specify racial or ethnic characteristics oftheir audiences, and based their suggestions on literature reports. Theirrecommendations seem applicable for tailoring programs to groups ofolder adults experiencing other common chronic health difficulties,such as osteoporosis, hypertension, respiratory disease, heart disease,cancer or general frailty.

On the basis of published literature about diabetes education pro-grams, Jack Jr. et al. (1999) concluded that “more culturally sensitiveand age-appropriate interventions are needed in which multiple envi-ronmental factors and levels of influence are recognized.” We believethat their comments are also relevant for nutrition educators who wishto tailor programs to suit the needs and interests of older adults. The au-thors called for using intervention models based on psychological prin-ciples, and also proposed a new public health model. They emphasizedlooking beyond factors that shape an individual’s psychological func-tions, to understanding that variations in individuals’ responses are alsoinfluenced by conditions under which they live and work. The conceptof environmental context deals with the cumulative effect of life experi-ences with situations such as housing conditions, racism, employmentstatus, family and social network support, community violence and ac-culturation.

REPORTED EXPERIENCESWITH TAILORING EDUCATION INTERVENTION PROGRAMS

TO THE RACE AND ETHNICITY OF OLDER LEARNERS

Educators need to consider clients’ perceptions of the factors thatcontribute to their illnesses, and the barriers such beliefs may present toimplementing recommended remedies (Bernard et al., 1997). Racialand ethnic grouping does not predict one’s degree of acculturation. Theauthors reviewed literature regarding the primary health problems ofAfrican-American, Hispanic-American, Asian/Pacific Islander-Ameri-can and Native-American elders. They maintained that while healthdata for these groups are often accumulated according to race, ethniccharacteristics need to be measured accurately and their influence on anindividual’s or group’s eating practices determined.

In order to increase their effectiveness, preparation of nutrition edu-cation programs for minority elders in particular should be individual-


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ized (Buchowski and Sun, 1996). Based on a review of publishedreports on nutrition issues for minority elders, the authors argued thatculturally and ethnically sensitive adaptations have yet to be validatedin specific population groups, nor have best practices for delivering nu-trition information to these groups been discovered.

While not focusing specifically on older adults, James (1997) recom-mended ten specific program considerations for African-Americans,based on a review of relevant literature. Examples of concerns that webelieve may be similar for African-Americans and older adult popula-tions include: social and economic problems that present formidablechallenges to daily existence; maintenance of traditional foods in thediet; lack of or inaccurate information to guide consistently healthfulfood choices; lack of innovative or specific-population-designed educa-tional tools and programs; the need for program relevance; the need forrespect and empathy for clients; and the need for educators to be ethicalas they strive to effect behavior changes.

Practitioners working with older Black populations should take intoaccount their diversity and its influence on a particular audience’s nu-tritional practices (Ralston and Cohen, 1999). In addition, the authorsrecommend understanding reasons for certain food practices; rein-forcing cultural traditions associated with positive dietary behaviors;working to assist leaders in the group to influence service organiza-tions to be more sensitive to the needs of older Blacks; involving for-mal and informal supports, such as home health aides and family mem-bers, in encouraging positive nutritional practices; and using cultur-ally-appropriate educational techniques and evaluation strategies. Theauthors’ suggestions, based on a review of research and practice litera-ture, are likely relevant for many other elderly groups as well.

Hahn and Gordon (1998) described a successful diabetes nutritioneducation program for an African-American community. They impliedworking with women over the age of 55 years. Focus group participantsrequested holding sessions in community settings, offering experientiallearning rather than lectures, and focusing on food preparation demon-strations and tasting foods. Many of their suggestions would seem to ap-ply to older adults of any cultural background.

Working with Native American men and women, Griffin et al.(1999) found focus groups to be instrumental in articulating successfulfeatures to tailor programs to their culture. One hundred fifty adults(mean age, 59 years) participated in a diabetes education program thatincluded support for dietary change. The program design was culturallyappropriate and personalized for each community. They used multiple


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educational strategies, such as mentors, informal environments, story-telling with culturally specific themes, demonstrations, videos, smallgroup discussions and incentive gifts. The authors provided details onhow components of the behavior change theories they used were incor-porated into the program. Participant satisfaction was very high at 96%.The authors were unsuccessful in studying potential participants whochose not to participate. Results on effectiveness were not published inthis report, but there was a difference of six pounds body weight be-tween the intervention group (four pound weight loss) and the compari-son group (two pound weight gain) at one year, and trends toward im-proved diabetes control (private communication from authors, 2000).

Elders from ethnic minority groups may have stronger social supportsystems than do older whites (Oomen et al., 1999). Older Hispanicadults, particularly women, often rely on relationships, especially kin-ship ties, for transportation, mealtime companionship and dietary infor-mation. Nutrition professionals working to change dietary habits ofHispanic women with diabetes need to consider the strong cultural roleof family for this audience. Based on a review of literature, the authorsrecommended culturally sensitive methods for increasing health behav-ior change among female Hispanics, including: use of language and ex-pressions familiar to Hispanic culture, identification of barriers tobehavior change, inclusion of a variety of accessible support systems,assessment of use of folk medicine, identification of perceptions of thewomen about their health conditions, and open communication be-tween health professionals and a woman’s family.

FUTURE DIRECTIONS FOR RESEARCH

In advancing knowledge concerning how to appropriately tailor nu-trition education interventions for older adults, researchers should in-vestigate determining both program content and process methodology.Older adults are an extremely diverse group regarding their ethnic/cul-tural heritages, socio-economic status, educational levels, physical abil-ities, chronic diseases, etc. This means that appropriate content ofeducational programs must be determined to suit the audiences’ partic-ular needs and interests. In addition, best practices regarding delivery ofthe program messages need to be investigated.

The research focus should be the person or group. Therefore, pro-grams and evaluation instruments should be designed or revalidated foreffectiveness with distinct populations. Data are lacking. Many of the


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reports we reviewed in this article on the process of tailoring programsfor older adults, especially those about ethnic population subgroups,were not backed up by research data. Rather, we noted that they wereproposals, e.g., speculations based on the authors’ experiential knowl-edge of their audience(s) and their insights into complex issues. Theirpublished suggestions, however, are yet to be proven as effective inter-vention strategies, or refined to define for which specific populationsthey are useful.

Similarly, in many instances throughout this article, we stated thatpublished findings may be applicable to nutrition educators and pro-grammers, but these, too, must be verified. We would generalize tomany nutrition education programs for older adults what Rush (1997)concluded regarding a nutrition screening tool, “The interventions sug-gested are non-specific, and there is no evidence for their efficacy . . .New research is needed.” We emphasize that new, rather than more, re-search is necessary because many, or even most, aspects of this fieldhave not yet been studied.

For members of underserved ethnic or minority populations,Buchowski and Sun (1996), Griffin et al. (1999) and Ralston and Cohen(1999) noted that research is needed to identify appropriate approachesand communication and intervention strategies, as well as the content ofthese interventions, and the patterns of adoption and diffusion of inno-vation that are effective in these groups. We believe this generalizationis apt to be true for all older adults, whether or not the older person alsobelongs to a certain ethnic or minority group.

Educators and programmers not only need more guidance as to thebest ways to reach and teach older learners, but they also need more re-search to guide them in evaluating older adult nutrition education pro-grams (Higgins and Clarke Barkley, 2003a). Finally, research findingsand reports should adequately describe specific interventions so thatothers can replicate findings or adapt and refine existing learning andevaluation instruments. Nutrition professionals await more specific in-terventions that have been shown to be appropriate, reliable and validfor meeting the needs and interests of the wide spectrum of older adultlearners that they wish to reach.

Received: April 2001Revised: June 2002Accepted: July 2002


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Documents

Tailoring Nutrition Education Intervention Programs to Meet Needs and Interests of Older Adults