Barriers to nutritional well-being for rural elders: community experts' perceptions

Factors Influencing Food Choice for Independently Living Older People-A Systematic Literature Review

Unyielding, disproportionate growth in the 65 years and older age group has precipitated serious concern about the propensity of health and aged-care services to cope in the very near future. Preservation of health and independence for as long as possible into later life will be necessary to attenuate demand for such services. Maintenance of nutritional status is acknowledged as fundamental for achievement of this aim. Determinants of food choice within this age group need to be identified and better understood to facilitate the development of pertinent strategies for encouraging nutritional intakes supportive of optimal health. A systematic review of the literature consistent with PRISMA guidelines was performed to identify articles investigating influences on food choice among older people. Articles were limited to those published between 1996 and 2014 and to studies conducted within countries where the dominant cultural, political and economic situations were comparable to those in Australia. Twenty-four articles were identified and subjected to qualitative analysis. Several themes were revealed and grouped into three broad domains: (i) changes associated with ageing; (ii) psychosocial aspects; and (iii) personal resources. Food choice among older people is determined by a complex interaction between multiple factors. Findings suggest the need for further investigations involving larger, more demographically diverse samples of participants, with the inclusion of a direct observational component in the study design.

Complementary and Alternative Medicine Use Among Rural Older Adults

Little research has investigated Complementary and Alternative Medicine (CAM) use prevalence and its determinants among older adults. We examined ethnic and gender variation in CAM use among rural older adults who reside in two North Carolina counties. Home and folk remedies, and vitamin and mineral supplements, were used by most participants. Men and women did not differ. African and Native American elders used home and folk remedies more than European Americans; European and Native Americans used vitamin and mineral supplements more than African Americans. Health care providers should be aware that their patients use CAM and may need counseling to minimize CAM-drug interactions.

Access to Care Issues for Health Professionals in the Mountain Region of North Carolina

This article compares perspectives on access to health care issues in 12 rural counties in the mountain region of North Carolina from three sources: 1) meetings with 38 health providers; 2) a survey of 1059 households; and 3) relevant health and population statistics. The main provider concerns were: 1) transportation to care; 2) dental services; 3) lack of resources for small populations; 4) population-based issues; and 5) negative perceptions about local health care. These concerns were compared to results from the survey and health statistics and similarities and differences among the three sources of information were noted. Comparisons were not made to validate or discredit any of the three sources of information, but rather to provide a rounded picture of access to care problems in a rural area. Results are discussed in terms of their policy implications, such as the degree of congruence between health professionals' perceptions and other information, the need to provide better transportation to care, and the issues of providing care to the elderly and Hispanics.

Meaning and Management of Food Security Among Rural Elders

Food insecurity is the limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways. This study uses fixed response and textual data obtained through in-depth interviews with adults 70 years and older from a multiethnic population in rural North Carolina to examine the incidence of food insecurity and how older adults experience food insecurity and maintain food security. We interviewed 145 elders up to five times over the course of 1 year. Responses to standard food insecurity questions indicate that only 12% of older adults experience food insecurity. However, analysis of textual data reveals common themes concerning food insecurity that suggest that these questions may underestimate the number of rural elders who are food insecure and not tap the potential vulnerability of others who are dependent on precarious nutritional self-management strategies to meet their needs.

Differences in the Perceived Need for Assistive Services by Culturally Diverse Caregivers of-Persons With Dementia

Various explanations have been advanced to explain why older members of ethnic minority groups in the United States tend to use proportionally fewer assistive social and medical services than nonminorities. One possibility is that culturally based differences in attitudes toward need for particular services affect the likelihood of use. Data were analyzed from 2,947 Black, His panic, and White caregiving dyads participating in the Demonstration Grants to States program. Hierarchical logistic regression models were estimated separately for three discretionary ser vices (adult day care, in-home respite, and meal services) and one nondiscretionary service (home health care). Hypothesized outcomes were observed in all of the service models tested

Use of Telephone-Administered Survey for Identifying Nutritional Risk Indicators Among Community-Living Older Adults in Rural Areas

The ability of Elderly Nutrition Programs, especially in rural areas, to address increasing needs for disparate program services is linked to determining which older people are most likely to be at nutritional risk and what constitutes the potential risk. The purpose of this study is to characterize nutritional risk factors in a probability sample of rural elders (n = 152) through telephone interviews using a 67-question modified version of the Nutrition Screening Initiative's Level I and II screens. Participants reported high levels of unintentional weight loss, medication use, multiple health conditions, and depression. This study demonstrates that comprehensive information on general health, eating habits, living environment, and functional status can be collected from rural elders by telephone. Because much of the reported nutritional risk in this sample occurs in residents living in areas not receiving nutrition services, expanded nutritional risk data can be used to anticipate need for programs and services in areas not presently served.

Nutrition initiatives in the context of population aging: where does the United States stand?

In 2011, the earliest segment of the baby boom generation turned 65 years of age. This event marks the beginning of a new phase of growth of the older adult population in the United States and is in line with what is referred to worldwide as "population aging." By 2030, older adults will comprise 20% of the U.S. population. With the impending increase in the older adult population, the United States is unprepared to handle the accompanying social and economic impact of growing rates of age-related diseases such as diabetes, hypertension, and cardiovascular disease. These diseases have nutritional determinants and, as such, they signify the need for effective preventive nutrition initiatives to address population aging in the United States. Comparatively, the European Union (EU) is projected to reach an older adult population of 24% by 2030. In this special article we evaluate nutrition initiatives for older adults in the United States and also examine nutrition initiatives in the European Union in search of an ideal model. However, we found that available data for EU initiatives targeted at population aging were limited. We conclude by offering the proposal of a physician-based model that establishes the primary care physician as the initiator of nutrition screening, education, referrals, and follow-up for the older adult population in the United States as a long-term goal. Apropos of the immediate future, we consider barriers that underscore the establishment of a physician-based model and suggest objectives that are attainable. Although the data are limited for the European Union, this model may serve to guide management of chronic diseases with a nutritional component in economies similar to the United States worldwide.

Healthy eating perceptions of older adults living in Canadian rural and northern communities

Aging produces physiologic changes that can affect the nutritional health of the older adult. It is estimated that 80% of community-dwelling older adults have inadequate intakes of four or more nutrients. Socioeconomic factors, such as income and geographic location, can also play an important role in nutritional status; however, limited research is available that specifically explores this. The purpose of this qualitative study was to examine the healthy eating perceptions of older adults residing in rural and northern communities in one Canadian province. Five focus groups were conducted in three rural and two northern Manitoba communities. Thirty-nine older adults participated in audio-recorded focus groups. Five themes emerged from the discussions. All respondents stated that healthy eating was important, but knowledge deficits were observed regarding label reading, understanding and visualizing portion sizes, and vitamin D recommendations and sources. Food programs were not commonly attended by participants due to availably and resistance. Regularly delivered nutrition education programs would assist in providing current nutrition information to older adults and their families in rural settings.

Food security in older adults: community service provider perceptions of their roles

Food insecurity in older adults is influenced by financial constraints, functional disability, and isolation. Twenty-eight social- and community-service providers participated in four focus groups to report (a) perceptions and experiences with food insecurity in their older clients, (b) beliefs about their potential role(s) in promoting food security, and (c) opinions about constraints that influenced these roles. A constant comparison analysis identified key themes. The formal caregivers reported six roles for improving food security: (a) monitoring, (b) coordination, and (c) promoting services, (d) education, (e) advocacy, and (f) providing a social environment. The final theme summarizes these roles as "the need for personalization of service". Social and community service providers are involved in roles that can promote the health of older adults by addressing their food insecurity. Social service providers need to be acknowledged and supported in this health promotion role.

Health and dietary patterns of the elderly in Botswana

OBJECTIVE

To describe associations among socioeconomic conditions and dietary patterns of Botswana elderly.

DESIGN

Secondary analysis from a cross-sectional nationwide survey.

PARTICIPANTS

Subjects (N = 1086, 60-99 years old) were selected after multistage sampling.

MAIN OUTCOME MEASURES

Dietary patterns were dependent variables; health and socioeconomic variables were independent variables.

ANALYSIS

Factor analysis with varimax rotation; least squares regression.

RESULTS

The most widely consumed food items were tea (91%), sorghum (82%), and maize-meal (63%). Five dietary patterns emerged: beer; meat/fruit; vegetable/bread; seasonal produce; and milk/tea/candy patterns. Elderly women, those attending church, and those living with grandchildren were less associated with the Beer Pattern. The Vegetable and Bread Pattern was more common among grandparents living with children and those living in towns (urban). Widowed elders were less likely to consume meat/fruit (P < .005). Half had a large family size (6 to 10 children), with about 30% supporting 1 to 5 children.

CONCLUSIONS AND IMPLICATIONS

Dietary patterns suggested both food to be emphasized in nutrition education programs and those who may benefit most. Nutrition education efforts in Botswana should focus on improving food diversity, with particular targeting of widowed elderly and those in rural areas, and on increasing vegetable, fruit, meat, and milk intake.

Problems with preparing food reported by frail older women living alone at home

Although nutritional risk is a critical health concern for older persons, there are few data about day-to-day problems with nutrition-related tasks. Such data were reported by 18 frail women during a longitudinal descriptive phenomenological study of the home care experience. Six problems were understood as elements of the life-world of older women, including having trouble figuring out what to fix, having trouble getting the food cooked right, and struggling with moving and standing while cooking. The results suggest topics for research and underscore the need for partnership between frail older women and helpers relative to food preparation.

Identifying diabetes knowledge network nodes as sites for a diabetes prevention program

This paper reports on the methods used and results of a study that identified specific places within a community that have the potential to be sites for a diabetes prevention program. These sites, termed diabetes knowledge network nodes (DKNNs), are based on the concept of socio-spatial knowledge networks (SSKNs), the web of social relationships within which people obtain knowledge about type 2 diabetes. The target population for the study was working poor African Americans, Latinos, and European Americans of both sexes in a small rural southern town who had not been diagnosed with diabetes. Information was collected from a sample of 121 respondents on the places they visited in carrying out their daily activities. Data on number of visits to specific sites, degree of familiarity with these sites, and ratings of sites as places to receive diabetes information were used to develop three categories of DKNNs for six subgroups based on ethnicity and sex. Primary potential sites of importance to one or more subgroups included churches, grocery stores, drugstores, the local library, a beauty salon, laundromats, a community service agency, and a branch of the County Health Department. Secondary potential sites included gas stations, restaurants, banks, and post offices. Latent potential sites included three medical facilities. Most of the DKNNs were located either in the downtown area or in one of two shopping areas along the most used highway that passed through the town. The procedures used in this study can be generalized to other communities and prevention programs for other chronic diseases.

Why are elderly individuals at risk of nutritional deficiency?

The older population is the single largest demographic group at disproportionate risk of inadequate diet and malnutrition. Ageing is associated with a decline in a number of physiological functions that can impact nutritional status, including reduced lean body mass and a resultant decrease in basal metabolic rate, decreased gastric secretion of digestive juices and changes in the oral cavity, sensory function deficits, changes in fluid and electrolyte regulation and chronic illness. Medication, hospitalization and other social determinants also can contribute to nutritional inadequacy. The nutritional status of older people is an important determinant of quality of life, morbidity and mortality. This review critically examines the factors that contribute to the development of poor nutritional status in older people and considers the consequences of malnutrition.

Conceptualizing and Assessing Nutrition Needs

This study aimed to understand how local Older American Acts Nutrition Program (OAANP) providers perceive and assess client need for the OAANP. Qualitative in-depth interviews were done with a sample of 36 local OAANP providers in upstate New York. Providers' perceptions of needs for the OAANP were determined by comprehensive understanding of the extent to which an elderly person has problems eating properly to maintain good nutritional and health status. Need was determined by various aging and environmental factors including food insecurity of the elderly, rather than by a single characteristic of problems of elders. Efforts to better understand and meet the needs of elders will enable nutrition programs to respond to heterogeneous needs in ever increasing older population.

Aging and eating in the rural, southern United States: beliefs about salt and its effect on health

This paper draws upon qualitative research conducted among older adults in the rural, southern United States in which they articulated their beliefs and experiences with nutrition and foods, and lay models of the connection of diet with chronic disease. Salt emerged as a focus of contention. The goals of the paper are to (1) present the culturally constructed meaning of salt, (2) contrast the cultural meaning with biomedical views, and (3) discuss how these findings can be applied to health education and better doctor-patient communication. Data were collected in two rural communities characterized by high rates of poverty and a high proportion of minority residents. A total of 116 African American, Native American and white adults aged 60 years and older participated in 55 in-depth interviews or seven focus groups. A systematic analysis of text showed that salt was a highly contested component of food. While valued for its role in traditional foods and cuisine, it also held negative connotations because of biomedical links to chronic diseases prevalent in the population. We suggest that attempts to control salt intake are made difficult by the changes in taste perceptions that accompany aging. Respondents' articulation of salt's role in health and disease shows cross-over among different chronic diseases and a lay interpretation of blood as the medium through which salt affects disease. These older adults' narratives demonstrate their attempts to reconcile the important role of traditional foods in their identity as Southerners with their attempts to meet medical recommendations for healthy eating.

Social isolation, support, and capital and nutritional risk in an older sample: ethnic and gender differences

This study examines the relationships that exist between social isolation, support, and capital and nutritional risk in older black and white women and men. The paper reports on 1000 community-dwelling older adults aged 65 and older enrolled in the University of Alabama at Birmingham (UAB) Study of Aging, a longitudinal observational study of mobility among older black and white participants in the USA. Black women were at greatest nutritional risk; and black women and men were the groups most likely to be socially isolated and to possess the least amounts of social support and social capital. For all ethnic-gender groups, greater restriction in independent life-space (an indicator of social isolation) was associated with increased nutritional risk. For black women and white men, not having adequate transportation (also an indicator of social isolation) was associated with increased nutritional risk. Additionally, for black and white women and white men, lower income was associated with increased nutritional risk. For white women only, the perception of a low level of social support was associated with increased nutritional risk. For black men, not being married (an indicator of social support) and not attending religious services regularly, restricting activities for fear of being attacked, and perceived discrimination (indicators of social capital) were associated with increased nutritional risk. Black females had the greatest risk of poor nutritional health, however more indicators of social isolation, support, and capital were associated with nutritional risk for black men. Additionally, the indicators of social support and capital adversely affecting nutritional risk for black men differed from those associated with nutritional risk in other ethnic-gender groups. This research has implications for nutritional policies directed towards older adults.

Meanings of targeting from program workers

Program workers have a critical role in targeting in nutrition programs, but little has been studied about the concept and the operation of targeting from their perspectives. This paper introduces and compares meanings of targeting from the perspectives of program workers in food assistance programs in the United States. There exist some variations in perceptions of targeting and actual operational procedures adopted by program workers at the local and federal levels. Regardless, program workers' perspectives on targeting suggest a new framework of targeting, which consists of key components (program access, service, and evaluation) and issues in need of careful attention in targeting nutrition programs. The success of targeting depends on how well these components and related issues can be translated into targeting policy, rules, and procedures. With increased devolution to the state and local levels in the United States, it is even more critical for federal policy makers and administrators to understand how frontline program workers perceive and implement targeting. The new framework based on the perspectives of program workers may contribute to developing a conceptual definition as well as practical guidance for targeting that can be used to formulate better ways of targeting in nutrition programs.

Access to transportation and health care utilization in a rural region

CONTEXT

Access to transportation to transverse the large distances between residences and health services in rural settings is a necessity. However, little research has examined directly access to transportation in analyses of rural health care utilization.

PURPOSE

This analysis addresses the association of transportation and health care utilization in a rural region.

METHODS

Using survey data from a sample of 1,059 households located in 12 western North Carolina counties, this analysis tests the relationship of different transportation measures to health care utilization while adjusting for the effects of personal characteristics, health characteristics, and distance.

FINDINGS

Those who had a driver's license had 2.29 times more health care visits for chronic care and 1.92 times more visits for regular checkup care than those who did not. Respondents who had family or friends who could provide transportation had 1.58 times more visits for chronic care than those who did not. While not significant in the multivariate analysis, the small number who used public transportation had 4 more chronic care visits per year than those who did not. Age and lower health status were also associated with increased health care visits. The transportation variables that were significantly associated with health care visits suggest that the underlying conceptual frameworks, the Health Behavior Model and Hagerstrand's time geography, are useful for understanding transportation behavior.

CONCLUSIONS

Further research must address the transportation behavior related to health care and the factors that influence this behavior. This information will inform policy alternatives to address geographic barriers to health care in rural communities.

Food consumption patterns of rural older African American, Native American, and white adults in North Carolina

This paper describes the major food sources of selected nutrients for an ethnically diverse sample of older adults in rural North Carolina. A representative sample of 130 elders (> 70 years) completed semi-quantitative food frequency questionnaires. Percentages of foods most frequently consumed as the lead source of seven nutrients were calculated overall, by gender and ethnic group. Foods eaten at least one time per week were identified, and percentages of participants consuming that frequency were calculated. Major food sources included: salad oil/cooking oil for calories, total fat and saturated fat; miscellaneous vegetables for dietary fiber and folate; and orange/grapefruit juice for vitamin C. Heterogeneity in food sources was greatest for zinc and least for vitamin C. Variation across gender and ethnic groups was observed only in the degree to which specific food sources contributed to nutrient intake. These data provide greater insight into the dietary patterns of rural elders than examining nutrient intakes.

Faith and health self-management of rural older adults

This analysis uses in-depth interview data collected from 145 African American, European American and Native American men and women aged 70 and older who reside in two rural North Carolina counties to understand the role of religious faith and prayer in the health self-management of these older adults. The analysis addresses three specific questions: how do these older adults use religion to help them manage their health; are there ethnic and gender differences in the use of religion; and are differences in health status related to differences in the use of religion? The integral role of religion in the lives of these older rural adults is an overarching theme present in the interview texts. Six major themes link religion and health self-management: (1) prayer and faith in health self-management, (2) reading the Bible, (3) church services, (4) mental and spiritual health, (5) stories of physical healing, and (6) ambivalence. Faith and religious activities provide an anchor in the lives of these older adults. There is little variation in the use of religion for health self-management by gender, ethnicity or health status. These results suggest that the strength of religion in rural culture may limit the effectiveness of general religiosity scales to discern the relationship of religion to health and health behavior in rural populations.

Staying healthy: the salience and meaning of health maintenance behaviors among rural older adults in North Carolina

Beliefs about what constitutes health promoting behaviors vary by culture and class, and knowing how an older adult interprets a specific health behavior can improve health education and medical compliance. Ethnomedical approaches have investigated how people define disease and the therapies used to return to a state of health. However, little research has addressed how individuals define health, or the behaviors they use to maintain health. We analyze the behaviors elders state are needed to stay healthy, and their meanings for these behaviors. Narratives collected through in-depth interviews with 145 male and female rural North Carolina residents aged 70 and older, including African Americans, Native Americans and European Americans are analyzed using systematic text analysis. The participants' narratives include seven salient health maintenance domains: (1) Eating Right, (2) Drinking Water, (3) "Taking" Exercise, (4) Staying Busy, (5) Being with People, (6) Trusting in God and Participating in Church, and (7) Taking Care of Yourself. Several of these domains are multi-dimensional in the meanings the elders ascribe to them. There is also overlap in the content of some of the domains; they are not discrete in the minds of the elders and a specific health behavior can reflect more than one domain. Four themes cross-cut the domains: "balance and moderation", "the holistic view of health", "social integration", and "personal responsibility". Elders in these rural communities hold a definition of health that overlaps with, but is not synonymous with a biomedical model. These elders' concept of health seamlessly integrates physical, mental, spiritual, and social aspects of health, reflecting how health is embedded in the everyday experience of these elders. Staying healthy is maintaining the ability to function in a community. These results indicate that providers cannot assume that older patients will share their interpretation of general health promotion advice.

Developing socio-spatial knowledge networks: a qualitative methodology for chronic disease prevention

Chronic disease is a significant and costly social problem. The burden is even more pronounced in communities with high rates of a particular chronic disease. Assessment of health belief systems and the local geographies of health beliefs can assist community health planners to create cost-effective strategic intervention programs where populations are at high risk for chronic diseases. In this paper, we elaborate the concept of socio-spatial knowledge networks (SSKNs) and demonstrate that SSKNs can be useful in informing the design of health care prevention strategies. In our project, we demonstrate how to identify key socio-spatial information for intervention strategies which will prevent or delay the onset of a particular chronic disease, Type 2 diabetes. Our qualitative framework allows us to determine which sites might be best characterized as socio-spatial knowledge network nodes for sharing diabetes information and which sites might be less suited to such exchange. Our strategy explores cross-cultural similarities, differences, and overlap in a multi-ethnic rural North Carolina context through simple techniques such as mapping social networks and sites in which people share their knowledge and beliefs about diabetes. This geographical analysis allows us to examine exactly where health knowledge coincides with other social support, and where such resources may be improved in a particular community. Knowing precisely what people in a community understand about a chronic disease and its treatment or prevention and knowing where people go to share that information helps to (1) identify strategic locations within a community for future interventions and, (2) evaluate the effectiveness of existing interventions. The geographical approach presented here is one that can serve other communities and health practitioners who hope to improve chronic disease management in diverse local environments.

The feasibility of using a telephone-administered survey for determining nutritional service needs of noninstitutionalized older adults in rural areas: time and costs

PURPOSE

This study examined response, participation, time, and costs for a telephone-administered survey to obtain comprehensive information on general health, eating habits, living environment, and functional status from a sample of older persons in a rural North Carolina county.

DESIGN AND METHODS

A probability sample of persons aged 60 years and older from the most recent electoral rolls were mailed a personalized letter, which was followed by telephone contact to recruit them into a contemporaneous survey that used a modified version of the Nutrition Screening Initiative's Level I and II screens. Time requirements and costs associated with the completion of surveys were calculated.

RESULTS

Seventy-six percent of the persons contacted by telephone (residents of 96% of county precincts) completed the survey. Because minority elders were more likely to lack a working telephone, they were underrepresented in the sample. With 555 calling attempts (58% of surveys completed on first attempt), we estimated a cost of $10.65 per completed survey.

IMPLICATIONS

Telephone-administered surveying of older adults may be considered as an appropriate component of an overall community-based service strategy. The estimation of the constituents of nutritional risk, by geographic area, economic status, or ethnicity, may aid in providing estimates of service needs and procuring and allocating resources. Additional methods of data collection are necessary in order to target older persons without telephone service.

On their own: nutritional self-management strategies of rural widowers

In-depth interviews conducted with 12 rural widowers participating in a population-based study of nutritional strategies of rural adults 70 years and older were analyzed to (a) identify factors that place widowers at risk for nutritional problems and (b) understand how rural residence is related to this risk. The nutritional strategies that successfully accomplished three groups of food-related tasks (food acquisition, food use, and maintaining food security) focused on one of three resource domains: self-care, informal support, and formal support. Resources that facilitated these nutritional strategies are identified, as are those conditions that led to nutritional strategies inadequate to ensure food acquisition, food use, and food security. These findings can be used to help identify rural elderly widowers who are at nutritional risk.