Development and analysis of acceptance of a nutrition education package among a rural elderly population: an action research study

Tackling nutritional issues among older adults in Malaysia is a challenge because of both undernutrition and overnutrition, with half of these adults being illiterate [1]. Within a decade, the prevalence of overweight among Malaysian older people doubled from 15.6% in 1996 to 29.8% in 2006. Obesity increased more than three-fold from 3.1% in 1996 to 10.9% in 2006. However, the prevalence of overweight decreased with age from 35.63% (age 60-64 years) to 12.64% (80+ years). A similar trend has been noted for obesity [1]. As in other rapidly developing countries, the prevalence of chronic diseases among the Malaysian population is on the rise, with the highest prevalence among those age 50 years and older [2, 3].

Lifestyle and dietary changes should be advocated to curb the rise of such diseases. However, the nutritional knowledge of older adults [4] in rural areas is inadequate [5, 6]. A recent study among adults with diabetes at a government health clinic [7] indicated that older adults had lower nutritional knowledge scores than others. Illiteracy is widespread but often a hidden problem, and those with the lowest literacy rates also have the poorest health status. These facts must be considered when developing and evaluating suitable educational print materials for patients and their families [8]. Therefore, development of an appropriate nutrition education package could be effective in improving the quality of dietary intake and lifestyle of older adults in Malaysia. The Family Health Division of the Ministry of Health of Malaysia [9] has developed a series of educational materials, including some for older adults. However, a nutrition component is plainly lacking.

Thus, the aim of this study was to develop a nutrition education package about healthy ageing and reducing the risk of chronic diseases for implementation at health clinics in a rural area of Malaysia. This is an action research study with the aim of facilitating change in a particular community and program. Previously, authors reported the needs assessment findings from this study [10]. This manuscript will present the developmental aspects of the package and analysis of its acceptance among health professionals and older people. We hypothesised that an education package that was developed based on needs of the community would be well accepted by both health professionals and older adults. This study was approved by the Universiti Kebangsaan Malaysia Medical Research and Ethics Committee.

The study was designed and conducted in three stages, as shown in Table1. In each stage, specific data collection techniques were employed to elicit facts and gather data from various sources of information such as documents, guidelines, protocols and targeted respondents. As in other action research, involvement of the respondents in developing the product was essential. In this study, older adults were involved as partners [11] in developing and evaluating the nutrition education package, representing the underpinning philosophy held by the research team members.

A research-based nutrition education package on healthy ageing and reducing risk of metabolic syndrome was developed and well accepted among subjects in this study. To address the increasing prevalence of obesity and chronic diseases among Malaysian populations [1, 2, 19, 20], the package consisted of a flipchart, placemats and a booklet. The flipchart has been developed as a teaching tool for health professionals involved in the care of older adults, particularly those living in rural areas, with the aim of reducing the risk of chronic diseases. The design of the flipchart, equipped with nutrition educator notes, was useful for staff at health clinics where there were no nutritionists or dietitians. The flipchart was also equipped with illustrations that facilitated the understanding of specific concepts such as obesity, diabetes mellitus and hyperlipidaemia. In rural areas of Malaysia where the illiteracy rate is high, counselling sessions with health professionals are the most appropriate strategy for imparting nutrition education to older adults with health and nutritional problems [21]. Individuals with low literacy often have unsatisfactory health status compared with those with higher educational level. Use of photos and illustrations can increase the understanding of health messages. In this study, most subjects understood the nutrition guidelines or messages primarily because of the illustrations provided. Print materials including a booklet and placemats developed in this study can be valuable tools for patient education, but they are only supplements and can never be a substitute for verbal communication. When used effectively, print materials can enable patients to manage their health better and help healthcare professionals maximize limited teaching time. According to the Nova Scotia Cancer Patient Education Committee [8], print materials can convey basic repetitive information, freeing the health professional to concentrate on individualized follow-up instruction. They can also facilitate consistency in teaching.

Results of the study revealed that older adult subjects had difficulty understanding the food pyramid concept compared with the food plate, as reported in the needs assessment phase [10]. In contrast, health professionals preferred the food pyramid rather than the food plate, probably because they had been trained with the pyramid. Most of the older adult subjects were exposed to food pyramids during their visits to the health clinics. The food plate concept is being used to translate nutrient recommendations to food choices in the National Food Guide in other countries [22]. Consumers prefer the food plate with respect to its visual and contextual impact compared with the food pyramid, which is deemed to be less effective in conveying messages on portion size and a balanced diet [23].

The food plate concept introduced in this study provided detailed recommendations on portion size and number of servings from the major food groups, namely cereals and grains; meat and dairy products; and fruits and vegetables, with the intake of simple sugars, fats and oils minimised. In addition, a recommendation of six to eight glasses of water a day was included because of the importance of water and higher risk of dehydration among older adults [18]. This is in agreement with fluid recommendations in Malaysian Dietary Guidelines [12]. However, until recently this recommendation was not incorporated into the Malaysian food pyramid [12].

The Dietary Guidelines for Older People in this study were delivered as food-based recommendations as opposed to the Nutrition Guide for Elderly People developed by the Ministry of Health of Malaysia, which uses a nutrient-based approach [9]. Food-based guidelines are more effective in conveying nutrition and health messages to the population as well as promoting traditional and healthy food [24].

The Malaysian Dietary Guidelines [12] were developed for the Malaysian population aged 2-60 years old. This study successfully developed dietary guidelines specific to Malaysian older adults aged 60 years and over termed ‘10 Healthy Eating Guidelines for Elderly People’. The aim of these guidelines is to provide recommendations enabling older adults to engage in a healthy lifestyle leading to a good quality of life.

The acceptance analysis of the nutrition education package showed that the majority of older adults did not understand terms such as 'diabetes mellitus', 'hypertension' or 'fibre'. In addition, they suggested the use of simple and short sentences. Researchers modified the package according to the suggestions and tested for face and content validity. However, some medical and scientific terms were retained with the intention of educating the population, with explicit explanations provided in simple language. The suggestion by health staff to incorporate more photos and illustrations in the flipchart and booklet are in agreement with the finding by Goldberg and Owen [25] that photos and illustrations should facilitate understanding of health messages without the need for text. Use of colour in developing an education package is essential in attracting interest of the target group [26]. Furthermore, the font size used in this study was considered acceptable by subjects. Small font sizes are unsuitable for older adults because of the high prevalence of eyesight problems due to ageing [27].

The intervention package can be used by health professionals and non-governmental organisations (NGOs) as a guideline and tool in the care of older adults. It is being translated into other languages such as English and Mandarin to increase its outreach among other ethnic groups in Malaysia.

The nutritional education intervention package we developed was well accepted by both older adult subjects and health staff. However, modifications with respect to medical terminology and addition of more illustrations were needed to further improve the understanding and acceptability of the package. The intervention package has the potential to increase the nutrition and health knowledge of older adults and motivate them to adopt healthy eating and a healthy lifestyle, thus reducing morbidity risk and health care costs. However, health staff must be trained to use and implement the package to ensure its sustainability in improving health outcomes of older adults in the community.