Determining Knowledge and Behaviour Change

Transcription

1 Determining Knowledge nd Behviour Chnge After Nutrition Screening Among Older Adults KATHERINE M. SOUTHGATE, BASc, University of Guelph, Guelph, ON; HEATHER H. KELLER, PhD, RD, FDC, Deprtment of Fmily Reltions nd Applied Nutrition, Mcdonld Institute, University of Guelph, Guelph, ON; HOLLY D. REIMER, RD, MSc, University of Guelph, Guelph, ON ABSTRACT Two eduction interventions involving personlized messges fter nutrition screening in older dults were compred to determine chnges in nutrition knowledge nd risk behviour. Of 150 older dults rndomly selected from locl seniors centre, 61 completed bseline screening nd demogrphic nd nutrition knowledge questionnire nd were rndomized to one of two groups. Group A received personlized letters plus n eductionl booklet, nd Group B received personlized letters only. All mterils were sent through the mil. Forty-four prticipnts completed post-test questionnires to determine chnge in knowledge nd risk behviour. Both groups hd reduced nutrition risk scores nd incresed knowledge scores t post-test. After the intervention, significnt difference ws observed in knowledge chnge by tretment group. Group A prticipnts experienced greter gins in knowledge, with men gin of 5.43 points, thn did those in Group B, who hd men gin of 1.36 points (p=0.018). Screening nd eduction with print mterils hve the potentil to chnge risk behviour nd nutrition knowledge in older dults. A specilly designed booklet on older dults nutrition risk fctors plus personlized letter provide n effective eduction strtegy for older dults fter screening. (Cn J Diet Prc Res. 2010;71: ) (DOI: / ) Résumé Deux interventions en mtière d éduction utilisnt des messges personnlisés remis près un dépistge du risque nutritionnel chez les dultes plus âgés ont été comprées fin de déterminer le chngement sur le pln des connissnces en nutrition et des comportements à risque. Des 150 dultes plus âgés choisis létoirement dns un centre de jour pour personnes âgées, 61 se sont prêtés u dépistge du début d étude en remplissnt un questionnire qui comprenit des questions démogrphiques et reltives à leurs connissnces en nutrition. Ces 61 personnes ont ensuite été réprties létoirement en deux groupes. Chque prticipnt du groupe A reçu une lettre personnlisée et une brochure didctique, et ceux du groupe B ont reçu seulement une lettre personnlisée. Tout le mtériel été envoyé pr l poste. Qurnte-qutre prticipnts ont rempli le questionnire postétude visnt à déterminer le chngement sur le pln de leurs connissnces et des comportements à risque. Les deux groupes présentient des scores de risque nutritionnel réduits et des scores de connissnces plus élevés près l étude. Après l intervention, une différence significtive été observée entre les deux groupes de tritement sur le pln des connissnces. Les prticipnts du groupe A ont cquis plus de connissnces, vec un gin moyen de 5,43 points, que ceux du groupe B, qui ont obtenu un gin moyen de 1,36 point (p = 0,018). Le dépistge et l éduction à l ide de documents imprimés ont le potentiel de chnger les comportements à risque et d ccroître les connissnces en nutrition des dultes plus âgés. Une brochure tritnt spécifiquement des fcteurs de risque nutritionnel des dultes plus âgés jumelée à une lettre personnlisée constitue une strtégie d éduction efficce pour les dultes plus âgés près un dépistge. (Rev cn prt rech diétét. 2010;71: ) (DOI: / ) Introduction Older dults re growing popultion in North Americ (1,2). Fixed incomes, diminished mobility, filing helth, nd lck of nutrition knowledge plce these individuls t risk for mlnutrition (3). An estimted 10% to 60% of the older dult popultion in Cnd is t risk nutritionlly (4). A blnced diet plys centrl role in sustining qulity of life nd promoting longevity, mintining utonomy, nd preventing or decresing the effects of chronic disese (4,5). A need therefore exists for incresed nutrition nd helth promotion progrms nd interventions for this segment of the popultion (4,6-8). Appropritely designed 128 Revue cndienne de l prtique et de l recherche en diététique Vol 71 n o 3, utomne 2010

2 nd implemented helth promotion progrms help older dults cquire nutrition knowledge nd trnslte this into dietry behviour chnges (9). Screening tools re becoming commonplce in prctice. Currently, screening indices re used lrgely to identify those t risk, nd to ssist them in receiving needed services (10). However, they my lso be used s mens of strting the nutrition eduction process for older dults (11) becuse they cn increse risk behviour wreness. Personlized nutrition messges tht tke into ccount current behviours requiring modifiction hve been found effective t promoting dietry behviourl chnges (9,12-15). Becuse of their nture, nutrition screening tools my be used s bsis for this personlized feedbck. PURPOSE The first im ws to demonstrte how nutrition screening nd personlized nutrition eduction messges bsed on risk identifiction cn chnge knowledge nd risk behviour scores. Another im ws to evlute whether dding more detiled but less personlized eductionl resource provided ny dditionl benefit. METHODS Study design After completing bseline questionnires to determine nutrition risk nd knowledge, study prticipnts were rndomly ssigned to one of two groups. Group A received full intervention, including personlized letters nd the Food for Aging Well: A Guide to Helthy Eting for Older Adults booklet (vilble t Group B received personlized letters only. Study prticipnts nd procedures Ethics pprovl for this study ws obtined through the University of Guelph Reserch Ethics Bord. Informtion letters explining the study were miled to 150 non-institutionlized members of locl recretion centre for seniors (people ged 50 or older). Potentil prticipnts were rndomly chosen from the membership list (n=3000); members who ssisted with questionnire development were excluded. The first miling included the Seniors in the Community: Risk Evlution for Eting nd Nutrition, Version II (SCREEN II), nd Diet Knowledge Questionnire (DKQ). Return of completed bseline questionnires implied consent to prticipte in the study, with up to three milings being used to collect bseline dt. Approximtely two to four weeks fter the return of these questionnires, personlized recommendtion letters bsed on risk results were sent to prticipnts. Fifty percent of prticipnts were rndomly chosen to receive the dditionl eduction booklet. A post-test miling occurred pproximtely one month fter the eductionl intervention. The post-test questionnire ws identicl to the one t bseline, except tht the demogrphic questions were excluded nd questions bout whether prticipnts hd red the miled interventions were included. Two repet milings were used to elicit full prticiption. Chi-squre nd independent t-tests were performed to determine significnt differences between the bseline nd post-test smple. those rndomized t bseline to Group A nd Group B. Group A nd Group B respondents gender, ge, mritl sttus, eduction, bseline SCREEN II scores, nd bseline DKQ knowledge scores. Test instruments The SCREEN II instrument is vlid nd relible nutrition risk screening tool for older dults, designed for both self- nd interviewer dministrtion (16). This instrument contins 17 questions with item scores rnging from 0 to 4, nd totl score rnging from 0 to 64. A higher totl score denotes lower risk for mlnutrition. The DKQ ws developed for this study. Demogrphic questions, including ge, sex, eduction level, mritl sttus, nd living sitution were included. Knowledge questions were developed to reflect the content of the nutrition risk screening questionnire nd the Food for Aging Well booklet. A five-point Likert scle (definitely true to definitely flse) ws used to determine knowledge. The reserch tem developed these questions, which five seniors reviewed to ensure clrity of wording. To determine relibility of this new knowledge questionnire, pretest group of seniors (n=25) from the sme recretion centre completed two dministrtions one week prt. Relibility of knowledge items ws determined through kpp, intrclss correltion (ICC), nd Cronbch s coefficient lph. In generl, the relibility sttistics were dequte for most items (kpp from to 0.840; ICC from to 0.808), nd those with low relibility (i.e., >0.5) tht were retined were deemed to differentite knowledge. The Cronbch s coefficient lph for the finl 12-point Likert scle ws dequte (mximum score=60; lph 0.42); however, response intervls for these knowledge questions were not necessrily considered equl by respondents. Nutrition eduction tools The dietitins on the reserch tem creted mster personlized letter consisting of ll possible sttements in reltion to specific SCREEN II responses. Personlized letters were then developed by deleting those suggestions tht did not pply to individul prticipnts. Letters lso included positive reinforcement for helthy nutrition behviours currently performed. Tble 1 includes smple messges. The dditionl eduction booklet ws previously developed resource designed to ccompny SCREEN II. It provided more generic informtion to support risk behviour chnge. Qulittive evlution of this booklet ws completed with helth professionls nd older dults (17). Sttisticl nlysis All dt were mnged nd nlyzed using the Sttisticl Pckge for the Socil Sciences SPSS version 14.0 (SPSS Inc., Chicgo, IL, 2005). Knowledge items were summed for nlysis (with reverse coding, s necessry). A totl score of 53 ws used to identify Cndin Journl of Dietetic Prctice nd Reserch Vol 71 No 3, Fll

3 Tble 1 Smple personlized nutrition feedbck SCREEN II question stem nd risk-item response Do you think your weight is... less thn it should be? Do you think your weight is... more thn it should be? Do you think your weight is... just right? Exmple of personlized feedbck Hve full mel t the time of dy your ppetite is best. Keep nutritious high-clorie sncks where you cn see them nd rech them esily (e.g., nuts, grnol brs, or muffins). Try hving five or six smll mels (or big sncks) ech dy. Hve snck before bed ech night. Et wht you like nd hve lots of these foods round. Et smller portions. Try using smller plte or choose foods tht come in single-serving pckges. Broil, rost, brbecue, bke, boil, stem, or microwve foods insted of frying them. At mels, try filling hlf your plte with vegetbles or fruit. Et slowly. Chew well nd put your fork down between bites. Exercise by doing fun ctivity tht you enjoy. Wlking, swimming, nd biking re good wys to exercise. Strt slowly nd build up the time you spend. Aim for 30 to 60 minutes of physicl ctivity most dys. You reported tht you feel your weight is just right. Tht s gret! Mintining helthy body weight helps reduce your risk of helth problems including hert disese nd dibetes. SCREEN stnds for Seniors in the Community Risk: Evlution for Eting nd Nutrition, nutrition screening tool for older dults with mximum score of 64 (16). Personlized feedbck ws provided ccording to prticipnts item scores on this screening tool. prticipnts who were t risk ccording to SCREEN II (16). Pired t-tests were conducted to test within-group chnges. A chnge score ws clculted for SCREEN II nd the knowledge scle, nd independent t-tests determined between group chnges. Sttisticl significnce ws determined t the p=0.05 level. RESULTS Subjects Sixty-one prticipnts (41% of the rndomly selected smple) returned the bseline questionnires; 44 (72% of the bseline; 29% of the rndomly selected smple) completed post-test questionnires. As Tbles 2 nd 3 show, no significnt differences were noted mong subgroups for demogrphics or bseline scores, lthough lck of significnce my hve resulted from smll group sizes. Approximtely 50% of the prticipnts who completed post-test questionnires were femle nd over ge 75, lthough few did not stte their gender (bseline, n=5). Less thn hlf hd completed post-secondry eduction. Seventytwo percent were mrried or living in common-lw reltionship (Tble 2). Bseline results Thirty-eight prticipnts (62.3% of the 61 t bseline) were considered to be t nutritionl risk (70% of those in Group A nd 54.8% of those in Group B). The cut-off vlue ws 2 for ech question, nd the proportion of individuls t risk for ech SCREEN II item is shown in Tble 4. The proportion of bseline prticipnts with correct knowledge for individul knowledge items is shown in Tble 5. Cronbch s coefficient lph for these bseline scores ws Common personlized messges were similr for prticipnts in both groups. The mjority of prticipnts in both groups received personlized messges pertining to incresing dily fruit nd vegetble consumption (Group A, 53.3%; Group B, 58.1%) nd dily met nd lterntives consumption (Group A, 70.0%; Group B, 64.5%). Post-test results All respondents (n=44) to the post-test indicted they hd reviewed the eduction pckge provided. As nticipted, SCREEN II (t=-2.119, 95% CI [-2.859, ], p=0.040) nd knowledge scores (t=3.951, 95% CI [1.638, 5.060], p=0.000) chnged fter the intervention. This chnge indicted decresed risk nd incresed knowledge overll. SCREEN II bseline nd post-test men scores were nd 53.32, respectively, while men knowledge scores were nd (A lower vlue indictes gin in knowledge.) When nlyzed by intervention received, the men chnge in nutrition risk behviour s reported on SCREEN II ws not found to be significntly different (Group A, 1.95; Group B, 1.05). Chnge in knowledge ws found to be significntly ssocited with the type of intervention received (t=-2.513, 95% CI [-4.065, ], p=0.018) (Tble 3). Specificlly, Group A prticipnts, who received the full intervention, experienced greter increse in knowledge (men gin of 5.43 points) thn did Group B prticipnts (men gin 1.36), with n verge difference of 4.07 (Tble 3). DISCUSSION This study shows tht reltively simple print resources in the 130 Revue cndienne de l prtique et de l recherche en diététique Vol 71 n o 3, utomne 2010

4 Tble 2 Demogrphic vribles by subgroups Rndomized Rndomized Group A Group B Bseline to Group A to Group B Post-test respondents respondents (n=61) (n=30) (n=31) (n=44) (n=22) (n=22) Vrible % % % % % % Gender Mle Femle Age < > Mritl sttus Mrried (nd not seprted) or living common lw Seprted, divorced, or widowed Eduction Completed community or technicl college or higher Completed some community or technicl college or higher form of personlized letter with recommendtions nd nutrition eduction booklet re effective t chnging nutrition knowledge nd risk scores fter screening. Previous work focusing on knowledge fter eduction hs hd limited success (18,19), which my be relted to older dults perceived lck of relevnce of these eductionl messges (20). In this study, personlized messges provided suggestions on chnging behviours for the better, while the Food for Aging Well booklet provided more generic nutrition informtion. In concert, these two forms of intervention work to promote risk behviour chnge nd knowledge. Further work is required to understnd how older dults use risk wreness nd subsequent eduction to chnge their knowledge, ttitudes, nd risk behviour. However, this study hs demonstrted tht simple pper resources in the form of personlized letters fter screening nd senior-friendly eduction pmphlets re beneficil for strting the process of risk reduction nd knowledge chnge. Prior work supports the use of personlized eduction resources in dietry behviourl chnge (9,12,13-15,21), especilly when motivtionl stge of chnge is determined. Possibly not ll prticipnts were redy to mke behviour chnges in this study, nd thus risk ssessment nd generlized eduction re good pproch for those who might begin to consider chnge. Further, behviour chnge is often not immedite, nd resistnce in the short-term is common (22). The short follow-up period chosen becuse of concerns bout memory nd for- Tble 3 Outcome vribles by subgroups Rndomized Rndomized Group A Group B Bseline to Group A to Group B Post-test respondents respondents (n=61) (n=30) (n=31) (n=44) (n=22) (n=22) Vrible men men men men men men Bseline SCREEN score Follow-up SCREEN score N/A N/A N/A Bseline knowledge score Follow-up knowledge score N/A N/A N/A Chnge in knowledge score N/A N/A N/A N/A b -1.36* N/A = not pplicble SCREEN stnds for Seniors in the Community Risk Evlution for Eting nd Nutrition ; the mximum score is 64 (16). b Men chnge in knowledge scores is negtive when compring follow-up to bseline scores becuse lower vlue indictes increses in knowledge or correct nswers. * Sttisticlly significnt difference in men chnge score for knowledge questionnire (p<0.05). Cndin Journl of Dietetic Prctice nd Reserch Vol 71 No 3, Fll

5 Tble 4 Proportion of prticipnts t risk for individul SCREEN II item scores t bseline, nd post-test chnge in item scores for the two intervention groups Bseline Men Screen II score (n=61) Group A Group B SCREEN II item % 2 b (n=22) (n=22) >5-lb weight chnge Unintentionl weight chnge Think weight is more or less thn it should be Often/lwys skip mels Limit foods Fir/poor ppetite fruits nd vegetbles dy met nd lterntives dy milk products dy to 4 cups of fluid dy Sometimes/often swllowing difficulty Sometimes/often chewing difficulty Sometimes/often use mel replcements Sometimes/never et with others Sometimes/usully cooking is chore or disstisfied with others cooking Often/lwys difficulty with groceries SCREEN stnds for Seniors in the Community Risk: Evlution for Eting nd Nutrition. Ech item hs mximum score of 4 nd the totl screening tool hs mximum score of 64 (16); score <_2 for n individul item on the SCREEN II indictes risk relted to tht item. A negtive score indictes n improvement in reported nutrition-relted behviour, while positive score indictes lowering of the item score, or more risk. b Individul item cut-off vlue Tble 5 Proportion of prticipnts by intervention, with correct nd incorrect knowledge for individul knowledge questions t bseline nd follow-up Group A: Group A: Group B: Group B: pre-intervention post-intervention pre-intervention post-intervention % with correct % with correct % with correct % with correct Diet Knowledge Questionnire items score (n=30) score (n=22) score (n=31) score (n=22) A portion of nuts contins s much protein s met Egg yolks re high in sturted ft (reverse coded) Coffee is dehydrting (reverse coded) Older dults tend to lose muscle when they diet Light exercise cn increse your ppetite Weight loss is norml prt of ging (reverse coded) Mediction cn ffect the tste of food Skim milk powder is good source of clcium The colour of fruit or vegetble tells you how nutritious it is Cnned vegetbles re not s helthy s fresh vegetbles (reverse coded) Eting 1 to 2 eggs dy is helthy when low-ft cooking method is used It is importnt for someone of my ge to et t lest 3 servings of diry products dy The Diet Knowledge Questionnire ws creted for this study to ssess knowledge relted to eductionl nd screening mterils used in this study. 132 Revue cndienne de l prtique et de l recherche en diététique Vol 71 n o 3, utomne 2010

6 getting the nutrition messges provided my hve led to n underestimtion of the potentil risk-behviour chnge tht cn result from similr process in prctice. In future studies, multiple post-intervention mesures should be considered in n ssessment of potentil risk-behviour chnge. Study limittions In ddition to the limittions noted bove, the smll, bised smple (e.g., primrily mrried prticipnts) should lso be noted. Prticipnts responded to miled questionnire, nd therefore they re unlikely to be typicl of clients in generl clinicl prctice. The low response rte my be result of conducting the study during the summer months, when mny communityliving older dults my be vctioning. The reltively high level of risk for this smple suggests tht they my hve hd helth nd other physicl limittions, s well s n interest in the screening process. The internl relibility of the knowledge questionnire, noted previously, suggests tht further work is required on this instrument. RELEVANCE TO PRACTICE Older dults cn improve their nutrition knowledge when eductionl products re designed for their use. Screening rises wreness of behviours nd my be useful for strting the process of chnge when community resources re limited. In prctice, screening is used to trget individuls who need further tretment. Prior work hs shown tht ccess to dietitin services is limited nd witing lists re brrier to services (4). This study demonstrtes tht while older dults re witing for limited resources in the community, personlized messges nd nutrition informtion help them chnge their knowledge nd risk behviour fter screening. This study lso demonstrtes tht cpitlizing on the wreness of risk behviours tht result from screening is importnt. Immedite provision of eductionl mteril tht reinforces identified risks will permit dietitins to tke dvntge of this techble moment. Prctitioners re encourged to pir simple eduction tools such s the Food for Helthy Aging booklet with their screening progrms, long with personlized written behviour modifiction messges. Acknowledgements The uthors wish to thnk members of Evergreen Seniors Centre who prticipted in this study, the mngement of the centre for help with smple identifiction, nd the dvisory group tht ws essentil to tool development nd plnning. Funding ws received from the Betty Hvens Awrd for Knowledge Trnsltion in Aging (CIHR Institute of Aging). References 1. Sttistics Cnd, Helth Sttistics Division. Projected popultion by ge group nd sex ccording to medium scenrio for 2006, 2011, 2016, 2021, 2026 nd 2031, t July 1; 2005 [cited 2007 Aug 7]. Avilble from: www40.sttcn.c/l01/cst01/demo23.htm 2. US Census Bureu. Ntionl popultion projection III. Popultion pyrmids: totl resident popultion of the United Sttes by sex, middle series; 2000 [cited 2008 Aug 4]. Avilble from: 3. Weiss EH, Dvis HC. 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