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Promoting nutritional well-being in seniors: feasibility study of a nutrition information series.

INTRODUCTION

Canadians are enjoying longer and better lives (1). By 2036, Canada's senior population will more than double, to one in every four Canadians (2). Seniors are more health conscious than ever before (3) and are active information seekers (4,5). An interest in health information and, specifically, nutrition is especially relevant, given that people are more likely to experience chronic diseases as they grow older (6,7).

Nutrition education programming is vital to address the link between healthy eating and healthy aging (8,9). At the same time, nutrition programming and policy-making are lacking for Canadian seniors, and this limits nutritional well-being among this population (10). For this group, limited research focuses on nutrition and physical activity health-promotion programming that provides clear, concise, and understandable information (11-15). Health promotion programming is essential for helping community-living seniors to maintain their independence (13), and is a particular priority for the province of Ontario (14).

Better Living Health and Community Services (Better Living) is a charitable organization that runs activities and workshops related to physical, mental, and social well-being to suppport healthy and independent living among seniors (16). Better Living, along with community partners, was responsible for developing and implementing nutrition information series (NIS) workshops on healthy eating, physical activity, and injury prevention targeted at adults aged 55 or older in priority neighbourhoods in Toronto (17). Programming within community centres offers a logical advantage, as the purpose is to "meet people where they are"--a mandate pioneered in community nutrition programming (18).

PURPOSE

This feasibility study was conducted to permit a brief description of the process of developing and implementing the 12-week NIS and to identify the practicality and plausibility (19) of the program process and content attributes.

METHODS

Workshop development

Within the context of food intake, Keller (10) stresses the importance of using health promotion framing to promote seniors' coping skills and informed decision-making, while emphasizing preventive behaviours (20,21). Workshop development was guided by this theoretical underpinning to enhance participants' control over their health and well-being. The objective of the NIS is to promote nutrition knowledge and therefore help seniors have healthy lives at home and in the community. Topics for the 12-week series were identified through a review of key evidence-based resources, from which the topics most relevant to community-dwelling seniors were selected. Informal discussions also took place with community program leaders. These were intended to provide key demographic and lifestyle information about clients served by the community programs (e.g., the presence of food insecurity, dietary restrictions/practices, literacy/language barriers). The topics and objectives for each session are listed in Table 1.

Presentation slides included simple language and were presented in a visually accessible format. An interactive activity was integrated into each session to facilitate discussion of the topic and provide a format that allowed seniors to ask questions about their nutritional well-being. Relevant handouts were either based on and credited to existing public sources such as public health websites, or developed specifically for this group. The handouts supplemented presentations, and, after each session, participants received a healthy snack that included foods/nutrients discussed in that session.

Selection criteria and data collection

The NIS was implemented in three neighbourhoods. The Thorncliffe Park community cohort was selected for evaluation of the series because of its members' regular attendance and its community partners' administrative support. Community members' ethnicities included Chinese, Persian, Filipino, and Tamil. Participants who were members of the Thorncliffe Park community were invited to attend the NIS, which took place in a community room, via promotional posters, telephone invitations, and monthly calendar event postings. Most participants spoke English. However, two to three interpreters were available at each session for specific languages.

Before commencing the NIS, Better Living obtained participants' informed consent to gather and publish participant data, as per its organizational guidelines. Participants were asked to register and complete a demographic survey of information, including their age, sex, and any diagnosed chronic condition. Additional information was gathered through questions related to their general interest in nutrition and health, and their impetus for attending the NIS.

A brief paper-based pretest nutrition assessment was developed and conducted to determine participants' perception of nutrition and healthy eating. This evaluation included questions on the perception of the importance of nutrition to health, confidence in knowing which foods support a healthy diet, personal eating habits, and overall health status. The Canadian Community Health Survey 2.2 was reviewed for questions pertaining to general health, eating habits, and perceived health (22), as perceived health is an indicator of overall health status (23). Areas were assessed using a five-point Likert scale. In addition, data were collected on general usefulness of the program sessions and overall program satisfaction.

Within two weeks of program completion, a follow-up telephone call was made to participants. The purpose was to evaluate participants' satisfaction with the program, as well as to assess whether any of the participants' responses to the four assessment questions had changed after attendance at the NIS.

Study sample

A convenience sample was used because of the nature of this feasibility study. Fifty-five community members from the Thorncliffe Park community neighbourhood registered and participated in at least one NIS session. We felt that participants who attended fewer than five workshops should not be included in the post-program evaluation, as their responses would not represent the four evaluation areas adequately. However, reasons for nonattendance were documented. Fifty-one participants were reached by telephone to complete the post-program evaluation, while four could not be reached after four phone attempts. Twenty-four of the 55 participants attended five or more sessions. These 24 are the focus of the evaluation results.

Data analysis

We used SPSS (version 19, IBM, Armonk, NY, 2010) for data analysis. Paired sample r-tests were used to determine if any change occurred between pre- and post-test time points for the four evaluation questions.

RESULTS

All 24 participants were women. Thirteen (54%) who attended five or more sessions were aged 66 to 75 (Table 2). Overall, participants were active and living independently, shopping for food on their own, and eating regular meals. As is the case with Canada's aging population in general, the majority of participants were living with at least one chronic disease. Seventeen (71%) participants reported an interest in supporting their health and well-being by attending the NIS.

Participants found the sessions either useful (17%, n=4) or very useful (83%, n=20). Participants also reported being satisfied (13%, n=3) or very satisfied (88%, n=21). When participants' pretest and post-test responses to the four questions were compared, small improvements in mean scores were seen for all items, although only participants' perception of their eating habits improved significantly ([t.sub.24] = 2.1, P=0.046) (Table 3). In the pretest, two participants identified their eating habits as "poor" or "very poor." In the post-test, 11 participants rated their eating habits "good," and 13 participants reported their eating habits were "very good."

For the 31 participants who attended four or fewer sessions, frequent reasons included language barriers (19%, n=6), health conditions that limited participation (13%, n=4), and scheduling conflicts (9%, n=3). However, more than 50% of nonparticipants did not offer a reason for low attendance when they were asked about it during the post-test follow-up call.

DISCUSSION

The results suggest that the NIS has the potential to promote the health and well-being of community-living seniors. The development and implementation of the NIS offered insights into the practical issues involved in providing such a program. However, further examination is needed to determine the plausibility of the program in meeting its stated objective of promoting awareness of nutrition as an important aspect of healthy aging.

Program attributes that worked well

Participants' positive perspectives of program availability, accessibility, and acceptability may have resulted because the NIS covered topics relevant to seniors' nutritional well-being. Furthermore, participants noted that sessions were presented in a clear, understandable, and interactive format, which allowed them to ask questions freely and addressed concerns related to a variety of topics. In addition, the NIS provided social opportunities for seniors to connect with other community members, which is an important determinant of health among the aging population (24).

Program attributes that need improvement

While 51 participants attended at least one session, fewer than 50% attended four or more sessions, which was a major limitation of the program. Despite the availability of translation services, program comprehension was considered a barrier. This may be partly due to health literacy skills in the aging population (25), as well as to the application of health literacy principles in the series content development and implementation (26). The NIS was delivered within the community residence itself, and most participants lived in or near the residence; this limited difficulties with physical access to the program. However, limitations because of personal health are more difficult to address. Many participants did not offer a reason for limited attendance, and further community consultation may be needed for future program implementation; this could permit identification of needs that were not addressed (27,28). Limited participation and program impact have been addressed in the existing Canadian literature, with recommendations for better participant turnout and outcomes (29,30). These studies underscore the need for further development of the NIS programming.

In the current study, program plausibility was evaluated by determining whether participants' perception of health and nutrition changed as a result of attending the program. The perception of the importance of healthy eating decisions increased, which may suggest potential changes in food choices and dietary behaviour. However, while the small increase may be attributed to the promotion of awareness of key and relevant nutritional messages (10), knowledge change in this target population must be explored further. This is an area that requires additional research with rigorous evaluation methods, which will permit an examination of whether a perception that nutrition is important is a determinant of healthy eating (30-32). Furthermore, a better understanding of individual and collective factors that affect food choice is needed to support healthy eating in community-dwelling seniors. The NIS is one element of this equation; a broader examination of familial, social, and economic factors is required (33), and should be a cornerstone of program evaluation (34).

Significant improvement in the defined areas may have been limited because of the high positive response in all four areas in the preassessment. This finding is consistent with existing data on seniors' self-perceived health (35), and indicates the need to use a validated nutrition screening tool, such as Keller's Seniors in the Community Risk Evaluation for Eating and Nutrition (SCREEN), which can be applied in community programs (36).

Study limitations

The study sample size was small and consisted of seniors who were interested in their health and available to attend community programming regularly. Possible selection bias and participant bias may have occurred (37). The analysis was also limited to a one-time evaluation with no follow-up. While the initial prenutrition survey was completed with paper and pencil, the post-nutrition evaluation was completed by telephone follow-up, and this potentially provided an opportunity for interviewer bias. Further revision and evaluation of the NIS, including the potential for a stronger methodological design, are needed to determine the practicality and likely plausibility of a similar community nutrition program. Additional consideration must be given to the promotion of nutritional well-being in the context of greater continuity of care for seniors (38).

RELEVANCE TO PRACTICE

Seniors make a significant contribution to society because of their wealth of experience, their knowledge, and their ability to communicate a sense of continuity (9). Program practicality and plausibility must be considered for the development of programs that improve seniors' knowledge of and motivation to make healthy eating choices (39).

Acknowledgements

Better Living acknowledges funding support from the Ministry of Health and Long-Term Care (Health Promotion and Sport) and New Horizons in the facilitation of its health and wellness programming. Better Living also acknowledges support from its community partners, the Thorncliffe Neighbourhood Office and the Working Women Community Centre.

We thank Sri Halim and Magdolna Antal for their support in coordinating the nutrition information series. We also thank Graeme Zahrabelny and Jessica Riddell for their support with data collection.

References

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(3.) Macias W, McMillan S. The return of the house call: the role of internet-based interactivity in bringing health information home to older adults. Health Commun. 2008;23:34-44.

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ELIZABETH MANAFO, MHSc, RD, School of Nutrition, Ryerson University, Toronto, ON; KATRINA JOSE, BSW, NWS, PTS, OAS, DENA SILVERBERG, BA (Hons), Better Living Health and Community Services, Toronto, ON
Table 1
Nutrition information series sessions and learning objectives

Session                     Learning objectives

1. Introduction to          * Why nutrition is important
nutrition and healthy       for our health
aging                       * How nutrition can help
                            healthy aging
                            * How to make nutrition a
                            priority in our lives

2. Introduction to          * What is Canada's Food Guide
Canada's Food Guide         to Healthy Eating?
to Healthy Eating           * What are the four food
                            groups?
                            * How do I use the food
                            guide?

3. Eating more              * Why are vegetables and fruit
vegetables and              important for me?
fruit                       * How many servings of vegetables
                            and fruit do I need?
                            * How do I get more servings of
                            vegetables and fruit every day?

4. Eating more              * Why are grains important
grains                      for me?
                            * How many servings of
                            grains do I need?
                            * How do I get more servings
                            of grains every day?

5. Including milk           * Why are milk and alternatives
and alternatives            important for me?
                            * How many servings of milk and
                            alternatives do I need?
                            * How do I include servings of
                            milk and alternatives every day?

6. Including meats          * Why are meat and alternatives
and alternatives            important for me?
                            * How many servings of meat and
                            alternatives do I need?
                            * How do I include servings of
                            meat and alternatives every day?

7. Eating healthfully       * What is fat?
with less fat
                            * How much fat do I need?

                            * How do I eat healthfully with
                            less "bad" fat and more "good"
                            fat?

8. Eating healthfully       * What is sodium?
with less salt
                            * How much sodium do I need?

                            * How do I eat healthfully
                            with less sodium?

9. Eating healthfully       * What is sugar?
with less sugar
                            * Why is too much sugar harmful?

                            * How do I eat healthfully
                            with less sugar?

10. Eating healthfully      * What is fibre?
with more fibre             * Why do we need fibre in
                            our diet?
                            * How do I eat healthfully
                            with more fibre?

11. Shopping for            * Why is it important to read
healthy foods               a food label when shopping?
                            * How do you read a food label?
                            * Tips to shop for healthy food

12. Top five tips for       * Reminder: Why is nutrition
healthy eating as we age    important as we age?
                            * What are the top five
                            nutrition tips as we get
                            older?
                            * What questions do I have
                            about healthy eating?

Session                     Activity

1. Introduction to          * Making a simple food record
nutrition and healthy
aging

2. Introduction to          * Organizing food record
Canada's Food Guide         results by food group
to Healthy Eating

3. Eating more              * Photo cards of various
vegetables and              vegetables and fruit: How
fruit                       would you use this vegetable
                            or fruit in preparing your
                            meals?

4. Eating more              * Photo cards of various
grains                      grain products: How would
                            you use this grain in
                            preparing your meals?

5. Including milk           * Photo cards of various
and alternatives            milk products: How would
                            you use this milk or
                            alternative product in
                            preparing your meals?

6. Including meats          * Photo cards of various
and alternatives            meat and alternative
                            products: How would you
                            use this meat or alternative
                            product in preparing your
                            meals?

7. Eating healthfully       * True-or-false fat challenge
with less fat

                            * Food label reading

8. Eating healthfully       * True-or-false sodium
with less salt              challenge

                            * Food label reading

9. Eating healthfully       * True-or-false sugar
with less sugar             challenge

                            * Food label reading

10. Eating healthfully      * Fibre challenge: Which
with more fibre             food has more fibre, and why?

11. Shopping for            * Food label reading to
healthy foods               find which products have
                            more or less of specific
                            nutrients or ingredients

12. Top five tips for       * Healthy eating quiz
healthy eating as we age

Table 2
Demographic and lifestyle characteristics of the
Thorncliffe Park community cohort who attended five or
more sessions (n=24)

Variable                                Percentage    Number

Sex
Female                                  100           24

Age (years)
55-65                                   17            4
66-75                                   54            13
>75                                     29            7

Daily meal frequency
<1                                      0             0
2-3                                     79            19
>3                                      21            5

Food shopping
I do my own                             83            20
Someone assists me                      13            3
Someone else shops for me               4             1

Incidence of chronic disease (a)
Heart disease                           13            3
Diabetes                                38            9
High blood pressure                     42            10
High cholesterol                        21            5
Osteoporosis                            4             1
Arthritis                               4             1

Program expectations
Better overall health and well-being    71            17
Feeling more energetic                  17            4
Weight control                          4             1
Better self-esteem                      4             1

(a) All that apply

Table 3
Mean scores of perceived changes in nutrition and
healthy eating among participants (n=24), following
the nutrition information series (NIS)

Perceived change               Pre- or     Mean     SD    [T.sub.
                               post-NIS   scores          (DF=23)]

Perception of nutrition's      Pre-NIS     4.29    0.46     1.3
importance to health (a)

Statement: "I consider         Post-NIS    4.71    1.4
nutrition to be important
to my health."

Confidence in knowledge        Pre-NIS     4.30    0.82     0.32
of which foods support
a healthy diet (a)

Statement: "I feel confident   Post-NIS    4.39    0.97
that I know which foods to
eat to be healthy."

Personal eating habits (b)     Pre-NIS     4.08    0.51     2.1

Statement: "I consider         Post-NIS    4.54    0.97
my eating habits to be ..."

Overall health status (b)      Pre-NIS     4.04    0.93     0.16

Statement: "In general,        Post-NIS    4.08    0.75
I rate my own health to
be ..."

Perceived change                P value

Perception of nutrition's        0.187
importance to health (a)

Statement: "I consider
nutrition to be important
to my health."

Confidence in knowledge          0.753
of which foods support
a healthy diet (a)

Statement: "I feel confident
that I know which foods to
eat to be healthy."

Personal eating habits (b)     0.046 (c)

Statement: "I consider
my eating habits to be ..."

Overall health status (b)        0.873

Statement: "In general,
I rate my own health to
be ..."

SD = standard deviation

(a) Ranged from "strongly disagree" to "strongly agree" on a
five-point Likert scale

(b) Ranged from "very poor" to "very good"
on a five-point Likert scale

(c) Statistically significant (P<0.05)
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Title Annotation:Perspectives in practice/Perspectives pour la pratique
Author:Manafo, Elizabeth; Jose, Katrina; Silverberg, Dena
Publication:Canadian Journal of Dietetic Practice and Research
Article Type:Report
Geographic Code:1CANA
Date:Jan 1, 2013
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