:mzsrs 4 MICHIGANng ES 1 O ATE UNIVERSITY 04 EAST LANSING, MICH 48824-1048 This is to certify that the dissertation entitled IMPROVING DIETETICS AND NUTRITIONAL SCIENCES STUDENTS' ATTITUDES TOWARDS WORKING WITH OLDER ADULTS: PEDAGOGICAL IMPLICATIONS presented by SEUNG-YEON LEE has been accepted towards fulfillment of the requirements for the Ph.D. degree in Human Nutrition fiajor Professor’s Signature Augst 26, 2005 Date MSU is an Affinnative Action/Equal Opportunity Institution PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE APR 2 3 2007 2/05 a/CITaC/oateomtnda-ms IMPROVING DIETETICS AND NUTRITIONAL SCIENCES STUDENTS’ ATTITUDES TOWARDS WORKING WITH OLDER ADULTS: PEDAGOGICAL IMPLICATIONS By SEUNG-YEON LEE A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Food Science and Human Nutrition 2005 ABSTRACT IMPROVING DIETETICS AND NUTRITIONAL SCIENCES STUDENTS’ ATTITUDES TOWARDS WORKING WITH OLDER ADULTS: PEDAGOGICAL IMPLICATIONS By SEUNG-YEON LEE The purposes of this study were: 1) to assess dietetics and nutritional sciences students’ knowledge about older adults, attitudes towards older adults and preference for working with this age group, 2) to explore students” attitudes towards working with older adults and factors influencing formation of those attitudes, and 3) to develop, implement and evaluate an intervention to improve nutrition students’ attitudes towards working with older adults. This study consisted of three parts to address each purpose. In the first part, on responses to psychometric instruments, students demonstrated low knowledge levels about older adults, neutral to slightly positive attitudes towards this age group and the lowest preference for working with older adults compared to infants, children, adolescents and adults. Students’ attitudes towards older adults were related positively to their preference for working with older adults. Limited information about students’ attitudes towards older adults obtained from a psychometric scale and the need for insight into how such attitudes were formed and could be altered led to the use of a qualitative approach for Part II of this study. In Part II triangulated qualitative research methods (focus groups and in-depth interviews) were used with 27 students. Students’ previous experiences influenced their attitudes as well as their beliefs about older adults and working with them. Students’ perceived satisfaction and confidence to work with older adults affected students’ preference for working with this age group. Students who preferred to work with older adults did report some barriers to working with them, but the students’ comfort level and desire to help seemed to overcome the barriers. Part III of this study, an intervention to improve students’ attitudes towards older adults, was developed based on findings from Part II and the literature reviewed. The intervention was implemented with nutrition students enrolled in a junior level community nutrition course, and mixed methods were used to evaluate the intervention. Students’ attitudes and their preference for working with older adults improved after the intervention. These findings related to positive changes in .students’ beliefs about and working with older adults, values for working with older adults, and their increased confidence as a pre-health professional. The intervention component—comprised of a structured series of interactions as a pre-health professional with an older adult Willing to change a dietary behavior—successfully improved nutrition students’ attitudes towards working with older adults and preference for working with them. In dietetics and nutritional sciences program curricula, this type of assignment with healthy older adults might help students have positive attitudes towards older adults and encourage students to work with older adults in the future, when they have a choice. Copyflghtby SEUNG-YEON LEE 2005 To my parents and my sisters whose endless love and encouragement have brought me to this point ACKNOWLEDGMENTS The completion of my Ph.D. program at Michigan State University was an unsurpassed life experience. Without the help and support from my family, friends, advisor and my committee members, I could not have accomplished it. They have offered endless love, encouragement and support throughout my graduate program. I would like to express my sincere and most heartfelt thanks to my academic advisor and mentor, Dr. Sharon Hoerr, Who has a very warm heart and cares about her students beyond academics. She has been understanding and encouraging and has helped me grow professionally, intellectually and personally. I could not complete this research without her help. I would also like to thank my guidance committee members. Dr. Barbara AmeS who was kind enough to join my guidance committee in the middle of my project, has given me very valuable comments and led me to think about the implication of pedagogy with my research. Dr. Wanda Chenoweth Showed her strong passion to help students by reviewing my material very thoroughly and helped me think through my research even after her retirement. Dr. Rachel Schiffman, one of the best researchers, whom I have ever met has been very supportive and positive, and has given me direction on my research when l was stumped. Dr. Lorraine Weatherspoon who has always been very friendly and approachable, helped me combine the three parts of my research and helped me find the implications for dietetics and nutritional sciences curriculum. vi “.4 a: .4- -\v I. \.1 use This research could not have been completed without the willingness of all participants: the dietetics and nutritional sciences students and also older adults who were clients of students in the intervention. i also appreciate the faculty who have helped me directly and indirectly to grow academically, and shared their broad views with students. I would like to express my special thanks to Dr Won 0 Song who has helped me get through my hardest time and persistently encouraged and supported me to complete my degree. Also thanks to Dr Bond who has encouraged me to complete good quality research. I would like to thank colleagues and friends, Crystal Jun Rivero, Michelle Henry, Anne Utech, Amy Elizabeth Bems, Jean Kerver, Marsh Scott, and Emily Meier, who offered their help for this research project in spite of their busy lives. I would also like to thank my friends and colleagues, Jia-Yau Doong, Saori Obayashi, Ock Kyoung Chun, Sue Gunnik, Christy Mincy, Debra Keast, Julie Plasencia, Lorraine McKelvey, and Jeannie Nichole who always listened to me and Showed me the support to get through my graduate program. i would especially like to thank, Joo-won Lee, Seong-joo Kim and Hee Kyong Bae, who have cared for me like Sisters through good times and bad. They have always been with me and their friendship will always be cherished. Finally, I would like to thank my dear family, my parents, Jeong-ja Kim and Sang-tae Lee, who have been my role models as well as supporters, and my sisters, Soo-hyoun Lee, Ji-Sun Lee, Ji-young Lee, Jeong-hyeon Lee and Min- seob Lee, who have always been my most Sincere friends throughout my life. vii TABLE OF CONTENTS LIST OF TABLES ........................................................................ xii LIST OF FIGURES ...................................................................... xv CHAPTER 1 INTRODUCTION ................................................... 1 Conceptual Definition .......................................... 15 CHAPTER 2 REVIEW OF RELATED LITERATURE ................... . 18 A. Increase in the population of older adults and demand for health professionals ..................................................... 19 B. Low preference to work with older adults by pre-health professionals .................................................................... 20 C. Pre-health professional students’ attitudes towards older adults .. 23 .1. Assessing attitudes towards older adults and their care ....... 24 2. Factors associated with attitudes towards older adults ........... 28 D. College students’ knowledge of older adults ............................ 29 E. Changing attitudes towards older adult .................................. 31 1. General theoretical background: attitude, intention and behavior ............................................................... 31 2. Curriculum development to change attitudes towards older adults ................................................................. 35 CHAPTER 3 METHODS ........................................................... 47 Part I: Nutrition students’ knowledge about older adults, attitudes towards his group and preference to work with them ........... 47 Part II: Dietetics and Nutritional Sciences students” attitudes towards working with older adults .................................... 57 Part III: Improving dietetics and nutritional science students’ attitudes towards older adults 63 viii CHAPTER 4 NUTRITION STUDENTS’ KNOWLEDGE ABOUT OLDER ADULTS, ATTITUDES TOWARDS OLDER ADULTS AND PREFERECE FOR WORKING WITH THEM ABSTRACT .............................................................................. 74 INTRODUCTION ....................................................................... 75 METHODS ................................................................................ 77 RESULTS .................................................................................. 85 DISCUSSIONS ............................................................................ 93 CHAPTER 5 DIETETICS AND NUTRITIONAL SCIENCES STUDENTS’ ATTITUDES TOWARDS WORKING WITH OLDER ADULTS ABSTRACT ............................................................................. 97 INTRODUCTION ....................................................................... 98 METHODS .............................................................................. 100 RESULTS ................................................................................ 105 DISCUSSIONS .......................................................................... 133 CHAPTER 6 IMPROVING DIETETICS AND NUTRITIONAL SCIENCES STUDENTS’ ATTITUDES TOWARDS OLDER ADULS ABSTRACT .............................................................................. 136 INTRODUCTION ...................................................................... 137 METHODS ............................................................................. 140 RESULTS ............................................................................... 149 DISCUSSIONS .......................................................................... 171 CHAPTER 7 SUMMARY AND CONCLUSIONS .............................. 178 APPENDICES Appendix 1 Alternative activity for extra credit in 2002 .................... 192 Appendix 2 Pre-test (original instrument) in 2002 .......................... 193 Appendix 3 Post-test instrument in 2002 ..................................... 206 Appendix 4 Traditional lecture outline in 2002 ............................... 215 Appendix 5 Item analysis results of knowledge about older adults (FAQ) ................................................................... 217 Appendix 6 Item analysis results of knowledge about f geriatric nutrition ............................................. 219 ix Appendix 7 Appendix 8 Appendix 9 Appendix 10 Appendix 11 Appendix 12 Appendix 13 Appendix 14 Appendix 15 Appendix 16 Appendix 17 Appendix 18 Appendix 19 Appendix 20 Appendix 21 Appendix 22 Appendix 23 Appendix 24 Appendix 25 F lyer for recmitment for participants for Part II ............... 221 RecnIitment focus group including brief survey .............. 222 Consent form for focus groups ................................... 224 Brief survey to assess students’ preference for working with older adults .................................... 225 Structured questions for focus groups and in-depth interviews .................................................. 227 Consent form for in-depth interviews ........................... 229 Dietary behavior change assignment .......................... 230 Recruitment of older adults (65 years old or over) .......... 235 Recruitment of young adults (20-30 years old) .............. 236 Pre-test instrument in 2004 ....................................... 237 Alternative activity for extra credit in 2004 ..................... 246 Consent form from students obtaining approval for using data ......................................................... 247 Post-test instrument in 2004 ..................................... 248 Table 5.9 Factors affecting students’ perceived satisfaction with working with a certain age group .......................... 255 Table 5.10 Factors affecting students’ perceived dissatisfaction with working with a certain age group ....... 256 Table 5.12 Factors affecting students’ perceived confidence in working with a certain age group ............................ . 257 Table 5.13 Factors affecting students’ lack of perceived confidence in working with a certain age group ............. 258 Table 5.14 Factors affecting students’ preference for working with a certain age group ................................ 259 Table 5.16 Factors affecting students’ job selection 260 Appendix 26 Appendix 27 Appendix 28 Appendix 29 REFERENCES . Table 6.8 Correlation coefficients of knowledge, attitudes, interest and preference for working with older adults in intervention and comparison groups at pre- and post-tests ............................................................................ 261 UCRISH Approval ................................................... 263 Approval of the use of reprints Facts on Aging Quiz ................................................ 265 Approval of the use of reprints Wall-Dyer Attitudes on Aging Inventory ........................ 268 .............................................................................. 270 xi Table 1.1 Table 2.1 Table 3.1 Table 3.2 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 LIST OF TABLES Study objectives, design, subjects, and data analysis .............. 13 Summary of 14 studies to change students’ attitudes towards older adults .......................................................... 37 Research questions and key interview questions ..................... 61 Research questions and questions in the assignment ............... 67 Demographics of subjects who completed both pre- and post- tests .................................................................... 84 Percentage of students responding the listed age group to the item, “When does old age begin?” .................................. 85 Percentage of degree 'of importance of social and environmental factors in job preference ..................................................... 86 Mean interest level to work with different age groups using Likert scale (post-test) ................................................... 87 Percentage of job preference to work with a certain age group using rank order ................................................................. 88 Student responses to knowledge and attitudes .......................... 89 Correlation coefficients between knowledge and attitudes at the pre-test ..................................................................... 91 Correlation coefficients between knowledge and attitudes at the post-test ................................................................... 92 Research questions and key interview questions .................... 102 Characteristics of participants .............................................. 105 Students’ beliefs and attitudes towards working with infants and frequency of response ....................................................... 108 Students’ beliefs and attitudes towards working with children and frequency of response ........................................................ 111 Students’ beliefs and attitudes towards working with adolescents and frequency of responses ...................................................... 113 xii Table 5.6 Students’ beliefs and attitudes towards working with adults and frequency of response ...................................................... 116 Table 5.7 Students’ beliefs and attitudes towards working with older adults and frequency of response ................................................. 119 Table 5.8 Factors affecting students” satisfaction and dissatisfaction 124 Table 5.9 Factors affecting students’ perceived satisfaction with working with a certain age group ............................................................ 255 Table 5.10 Factors affecting students’ perceived dissatisfaction with working with a certain age group ................................................... 256 Table 5.11 Factors affecting students” professional confidence .................. 126 Table 5.12 Factors affecting students” perceived confidence in working with a certain age group ..................................... . 257 Table 5.13 Factors affecting students’ lack of perceived confidence in working with a certain age group ..................................... 258 Table 5.14 Factors affecting students’ preference for working with a certain age group ......................................................... 259 Table 5.15 Factors affecting students’ preference for working with a certain age group .......................................................... 128 Table 5.16 Factors affecting students’ job selection ................................ 260 Table 5.16 Factors affecting studentS’ job selection ................................ 130 Table 6.1 Research questions and questions in the assignment .............. 143 Table 6.2 Demographics of subjects who completed both pre- and post-test ..................................................................................... 149 Table 6.3 Frequency of students responding with an age group to the item, ”When does old age begin?” ............................................... 151 Table 6.4 Students” average scores for knowledge about older adults and attitudes toward older adults 153 Table 6.5 Students’ interest in working with different age groups using Likert scale .............................................................................. 154 xiii Table 6.6A Frequencies of students’ preference to work with a certain age group by rank order ...................................................... 155 Table 6.68 Frequencies of students’ preference to work with older adults by rank order 156 Table 6.7 Changes in preference to work with a certain age group between pre- and post-tests ................................................. 157 Table 6.8 Correlation matrix for changes between groups from pre- to post-tests for knowledge, attitudes, interest and preference to work with older adults ..................................... 261 Table 6.9 Changes in students” beliefs about older adults after the intervention ..................................................................................... 158 Table 6.10 Reasons for increasing students’ value on working with older adults after intervention .............................................................. 160 Table 6.11 Reasons for increasing students’ confidence in working with older adults after intervention ..................................................... 164 xiv LIST OF FIGURES Figure 2.1 Theory of Planned Behavior .............................................. 34 Figure 2.2 Conceptual model for this study (Modified Theory of Planned behavior) ................................... 36 Figure 3.1 Development of instrument for knowledge about geriatric nutn'tion ....................................................................................... 54 Figure 3.2 Study design for Part III ....................................................... 63 Figure 4.1 Distribution of attitudes towards older adults at pre- and post-tests ......................................................... 90 Figure 7.1 Summary of findings ......................................................... 190 XV CHAPTER 1 INTRODUCTION The aging population‘ continues to increase in the US. and is projected to reach from 12% in 2003 to 20% by 2030 (US Bureau of the Census, 2001 ). Because this population’s use of and need for health services is increasing, an increase in the number of health and allied health professionals to serve them is urgently needed (Health Resources and Services Administration [HRSA] 1995). Nutrition services such as nutrition education, counseling and medical nutrition therapy are essential components for disease management and prevention, as well as, for health maintenance and for health promotion in the aging population (Hutchinson, 1985). Most previous research on the need for geriatrics in the education of health professionals has focused on health professions other than dietetics. For example, studies have shown there is an insufficient supply of geriatricians (Reuben, Bradley, Zwanziger, Vivell, Fink,Hirsch, & Beck, 1991) and nurses with gerontological training (Kovner, Mezey, & Harrington, 2002), as well as low interest of those health professionals to seek geriatrics or gerontological expertise (Kovner et al., 2002). A study with medical students demonstrated low knowledge about older adults, negative or neutral attitudes towards the aged and low interest in working with older adults (Fitzgerald, Wray, Halter, Williams, & Supiano, 2003). 1 Older adults Where the aging population included all those 65-75 years old (young old), 76—85 years old (old-old) and 86 years or older (oldest-old) (Riley 8- Riley, 1986). Although a link between quality of health services and attitudes of health professionals or pre-health professionals has not been established, it is intuitive that those with poor attitudes towards a specific age group would be likely to deliver poorer quality of health care compared to those with positive attitudes towards the same group. Indeed, this assumption has been made by educators in the health professions over the last 35 years (Hatton, 1977; Knowles & Server, 1985) as is clear by the number of studies that have attempted to improve attitudes of pre-health professionals via didactic interactions. Because many educators have assumed that knowledge of a topic influences or precedes attitude formation, several studies on students’ attitudes towards this age group have examined knowledge of the aging. Some studies have demonstrated that greater knowledge about older adults was associated with more positive attitudes towards this age group (Duerson, Thomas, Chang & Stevens, 1992; Kaempfer, Wellman, & Himburg, 2002; O‘Hanlon, Camp & Osofsky, 1993; Perrotta, Perkins, Schimpfhauser & Calkins, 1981; Reed, Beall & Baumhover, 1992; Tarbox, Connors & Faillace, 1987). Only a few studies have examined dietitians” or dietetics students’ knowledge about older adults, attitudes towards older adults and preference for working with this population (Kaempfer et al., 2002; Noel & Ames, 1989; Rasor- Greenhalgh, Stombaugh, & Garrison, 1993). Most recently, Kaempfer et al. (2002) assessed mostly senior dietetics students from five states and reported they had low knowledge of the aging process, neutral attitudes towards older adults and low preference for working with this group. The researchers probed for the students” previous experience with older adults, but did not investigate what influenced students’ attitudes, nor did the researchers attempt to change students’ attitudes. Because lack of knowledge about older adults and negative attitudes towards this group has been assumed to affect the low interest in working with them, investigators have studied these relationships. Some researchers have found positive relationships between knowledge of older adults and attitudes, but others have not (Dail 8. Johnson, 1985; Edwards & Aldous, 1996; Harris & Dollinger, 2001; Menz, Stewart, & Dates, 2003; Smith, Marcy, Mast, & Ham, 1984; Wilson & Hafferty, 1980). Likewise, findings have been contradictory on the associations between attitudes towards older adults and interest in working with this age group (Carmel, Cwikel, & Galinsky, 1992; Fitzgerald et al., 2003; O’Hanlon et al., 1993). Such differences might be due, in part, to the use of different instruments to measure knowledge and attitudes or to different samples of pre-health professionals in different settings. Thus the relationship among these key variables to Changing attitudes towards older adults and interest in working with this age group remains unclear. Because educators of health professionals have assumed that attitudes towards older adults influence pre-health professionals’ behaviors, the quality of care they deliver and their interest in working with older adults, research has focused on methods to improve attitudes towards older adults in students in the health professions. Such interventions have focused on curriculum development, experiential activities, clinical practice, and mentoring programs. Researchers have reported that direct contact with older adults has resulted in predominately positive attitude shifts towards older adults by students (Aday and Campbell, 1995; Anguillo, Whitboume, & Powers, 1996; Davis-Bennan & Robinson, 1989; Hamon & Koch, 1993; Murphy-Russell, Die, & Walker, 1986; O’Hanon & Brookover, 2002). Only one study, however, was found in which an intervention was designed for nutrition students to improve their attitudes towards older adults (Rasor—Greenhalgh et al., 1993). Twenty-seven dietetics students were asked to volunteer to conduct anthropometric measures and nutrition counseling for older adults. After the short and direct interaction with healthy older adults, students showed improved attitudes towards older adults. Despite the poor knowledge of, attitudes towards, and interest in older adults by dietetics students shown in one study (Kaempfer et al., 2002), the need is high for their nutrition services. Medical nutrition therapy for seniors is a growing area. Since Congress passed the Medicare Medical Nutrition Therapy Bill (H.R.561 Medicare, Medicaid, and SCHlP Benefits improvement and Projection Act of 2000; Kaempfer et al., 2002), Registered Dietitians have had increased opportunities for financial reimbursement in work with older adults. Because dietitians are largely unaware of these employment opportunities in long-term care facilities, the American Dietetics Association (ADA) chose “innovations and outcomes in long-term care” as one of five topics to highlight in their 2004 Strategic Plan. This area also was also a special focus in 2004 at the House of Delegates dialogue sessions at the ADA Food & Nutrition Conference & Expo (American Dietetics Association, 2004). ln dietetics programs, geriatric nutrition is generally less emphasized than maternal and child nutrition, with most aging content covered in life cycle and community nutrition courses (Rhee, Wellman, Castellanos, & Himburg, 2004). Dietetics faculty have identified the most common barriers to increasing aging content as “curriculum already full” and “lack of faculty expertise” (Rhee et al., 2004). These are additional factors that must be addressed in curricular interventions. The overall goal of this study was to develop an intervention to improve dietetics and nutritional science students” attitudes towards working with older adults that could feasibly be introduced into an already crowded dietetics curriculum. Thus, findings from this intervention may contribute to improving course content and activities in geriatrics and gerontology for nutritional sciences and dietetics programs and encourage students to consider positions in geriatric nutrition This study was designed in three parts to assess dietetics and nutritional sciences students’ knowledge about older adults, attitudes towards older adults and preference for working with older adults, to understand how these three variables related to each other and to develop and implement an intervention to improve students’ attitudes towards working with older adults. The expected outcomes were that an experiential activity with older adults would result in improved student attitudes toward older adults and that the activity could be easily incorporated into the curriculum without a lot of extra work by dietetics faculty. In the first part of the study (Part I), dietetics and nutritional sciences students’ knowledge of older adults, attitudes towards this group, and preference for working with them were assessed and changes in these variables examined before and after a 90-minute lecture on senior meal programs given, presented as part of a course in the dietetics curriculum. In addition, the relationships among these variables were of interest as was the need to test instruments to measure key variables. Some previous research and behavioral theory had demonstrated that knowledge of older adults could influence attitudes towards this group and interest in working with them. it was necessary to establish validity and reliability of the psychometric instruments assessing key constructs with nutrition students and to establish baseline values for any intervention within the course. Part ll of the study was designed to explore the factors affecting the attitudes of dietetics and nutritional sciences students towards working with older adults. Qualitative methods were used in its component to answer questions. For example, were there students who preferred to work with older adults, and, if so, what kinds of things might have contributed to this interest? Additionally, for students with low preference for working with older adults, what did they see as barriers and how might these be changed? This part of the study was designed to gain insights regarding the type of intervention that might improve students’ attitudes within an exciting curriculum structure. Finally, in Part III of the study, an intervention was developed, implemented and evaluated to improve nutrition students’ attitudes towards older adults. Findings from Part II had demonstrated that some students with negative attitudes towards working with older adults had low self-efficacy in working with them, likely due to the age difference and limited contact. Literature reviewed suggested that curriculum changes to enhance contact time between older adults and students within positive contexts in the health professions might improve the attitudes of pre-health professionals towards older adults. The research objectives, research questions and hypotheses for each part are described below. Table 1.1 also shows the study objectives, design, variables, subjects and data analysis for each part. In addition, study objectives are repeated at the beginning of the methods section. Part I: Nutrition students’ knowledge about older adults, attitudes towards this group and preference for working with them W 1. To assess students” knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults, and preference for working with them. 2. To investigate the relationships among students' knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults, and preference for working with them. 3. To examine Changes in students’ knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults, and preference for working with them after a lecture on senior nutrition and senior meal programs in a course on community nutrition. 4. To test the validity and reliability with this student population using the Facts on Aging Quiz, the knowledge about geriatric nutrition Questionnaire developed for this study and the Dyer-Wall’s Aging Inventory. Research guestions and hypotheses 1. What is the students” level of knowledge about older adults? H1: Students” mean knowledge score of aging will be low, less than 75% correct responses. 2. What is the students’ level of knowledge about geriatric nutrition? H2: Students’ mean knowledge about geriatric nutrition will be low, less than 75% of correct responses. 3. What are students' attitudes towards older adults? H3: Students’ mean attitude scores towards older adults will be negative, less than 2.75 for a possible range of 1.00-5.00. 4. What is the students’ preference for working with a certain age group (i.e., infants, children, adolescents, adults and older adults)? H4: Preference for working with older adults will be lower than that for other age groups. 5. What are the relationships among knowledge of older adults, knowledge about geriatric nutrition, attitudes towards older adults and preference for working with this group? H5A: There will be a positive relationship between knowledge about older adults and attitudes towards them. H53: There will be a positive relationship between knowledge about older adults and preference for working with them. H50: There will be a positive relationship between students’ attitudes towards older adults and preference for working with them. 6. Are there any changes in students’ knowledge about older adults, attitudes towards this group and preference for working with them following a traditional 90—minute lecture? HeA: There will be an increase in students’ knowledge about older adults. H63: There will be no change in students” attitudes towards older adults. Hsc: There will be no change in students’ preference for working with older adults. Part II: Dietetics and Nutrition Sciences students’ attitudes towards working with older adults _S_tudv Objectives 1. To explore dietetics and nutritional sciences students’ attitudes towards working with older adults compared to working With other age groups. 2. To explore the differences in attitudes towards working with older adults between students who preferred to work with older adults and those who did not. 3. To explore influential factors on attitudes towards working with older adults. Research Questions 1. What are students’ attitudes towards working with each of the following age groups: infants, children, adolescents, adults and older adults? 2. What are the differences between students who prefer to work with older adults and those who do not? 3. How does perceived job satisfaction and professional confidence influence students’ attitudes towards various age groups of clients? 4. Which factors affect students’ preference for working with a certain age group over other age groups? 5. How important is the age group of clients in students’ job selection? Part III: Improving dietetics and nutritional sciences students’ attitudes towards working with older adults Study objective 1. To design and implement an intervention and evaluate its effect on students’ attitudes towards older adults. Research guestions Quantitative component: from results of pre- & post-tests 1. To what extent does the intervention improve attitudes towards older adults? H1: The improvement of attitudes towards older adults in the intervention group will be significantly greater than that of comparison group. 2. What iS the relationship between Changes in knowledge about older adults and attitudes towards this group? H2: There will be a positive relationship between changes in knowledge about older adults and attitudes towards older adults. 10 3. How do Changes in attitudes towards older adults affect interest in and preference for working with this group? H3: if attitudes towards older adults improve after completing an experiential assignment, there will be an increase in interest in and preference for working with this group. Qualitative component: a content analysis of students” assignment reports (See questions described in the intervention.) 4. In what ways are students’ attitudes towards older adults and working with this group influenced by completing the experiential assignment? 4A. How are students’ beliefs about older adults influenced by interacting with them? 48. How are students’ beliefs about older adults influenced by participating in a structured small group discussion? 4C. How are students’ values about working with older adults influenced by interacting with this group? 4D. How are students’ values about working with older adults influenced by participating in a structured small group discussion? 5. If there is Change in students’ perceived self-efficacy in working with older adults, how do changes in students’ self-efficacy in working with older adults relate to Changes in attitudes (beliefs and value) towards working with this group? 6. If there is change in students’ perceived satisfaction in working with older adults, how do Changes in students” satisfaction in WOIking with older 11 adults relate to Changes in their attitudes (beliefs and value) towards working with older adults? 12 — -~— —.-. o 5.6.0.200 . .00... 02.0.. c an"... 90.6.: 090.0. 30:03.00: 600.2. 5.00.. 5.3 00.000 50.295 u:.&< MESS .545 05 new $030 0.5 6.. 0000.060 9.050.626 .6233: 030:3 5000 030.265. 05 NBC 9.9.. :0 £00". 05 9.0: 20.6.3000 .5me as 5.; 3.39.2 Em 3.2.9, 05 .8. oh . 60:33: b.5EEoo :0 02:00 0 c. 050.605 .00.: 6.50 can EELS: 6.50 :0 0.800. 0 6:0 E05 5.3 3:05 com. 9.2.63 6. 00:20.05 0:0 6.300 .020 59.00 5.3 9.2.03 00.030. 00022.0 602:5: 2.6.56 .3000 6.. oocoLopoLn. - 0900.205. .mzaum 60.0 .0 080.305 0:05 b.5030 c. «00:20 05.296 0% . com 50:00 0 5.3 9.263 c. .092... - EOE 5.3 9.5.63 Lo“. 00:06.05 3.300 60.0 0:0 .m..:om 60.0 02026. 000320 0.0.030. 0003.5. - £035.: 050:3 .3000 030.305. c0352: 030:3 .3300 L020 .3000 3.00.265. .3503» 5000 030.265. - 0:080 8.55.6.0. 05 209.002.. 0... . .300 60.0 5000 0000.265. - .Eoc. 5.3 95:03 .0. 00:20.05 0:0 0030...; o .3500 60.0 02026. 000250 603:5: 00.6.50 coats: EcaEEoo >o>5m . oEmtom .0090 080.265. £500 620 02.0.8000 o m c. 02.0.5 $5005 0.003000 0:92.". o 5000 0000.305. 6.5020 3030 0... . .ted .9022... 858.25.. «Sautg 0 2.980 8.5830 «.0205 San new 30033 65.00.. 6.02.0030 >035 F ._. 030... 13 .03"... .33 0.8.. 8 o. 00. 0.330 0.500 0030.. 5.3 60.0 0..3 00263 002.03 0.00030 .0. 00006.0... - .0390 000000060. 0.500 .020 5.3 fimué. 00263 0. .0065. - 8.0 0.00.. 00N. 0.500 0.500 60.0 5.3 60.0 00.030. 0033.4 - 002.03 0.00030 0.500 .020 0.00000 50.000 . ”030.0 00..00>.0.0. . .3000 0000.305. - 0.500 60.0 02.0.0000 . Sovuc. 00.300 00.00..0> . 00.030. 003....0 0. 0000000 00..0000 2.0 . 00.....30 3.030.060 02.0000. 0.6000060 00..00>.0.0. 3.0000. 0....N 3000300.. .0002. 0 0. 00.6.00 0.00030 .._00 000 030230 a 0.500 .020 00.030. 0003....0 .0.00030 02.2.0.0 00000.00 502.050 00..00>.0.0. . 0. 0000000 00 60.6 00..00>.0.0. 03.0.6000 o 000 02.0.0.0 0.003000 0000.0 o 00 0.03.06 000 .00E0.0E. 00.000 0.... =_ .60 .v.u=. 0.500 60.0 5.3 0.63 0. 00.6.0.0 .00 0.0 003 0.00030 0. 030.0 o 03036.0. ..00 0.0 003 0000. 000 0.500 60.0 5.3 .0 W0. 0.500 0.0000. 0.. 000 0.63 0. 00.6.0.0 003 0.00030 0003.00 .020 5.3 0.63 030.0 0000 0. n. v u: 0.500 60.0 5.3 002.03 00.030. 0.00000 0.0.000 . 0. 00.6.0.0 003 0030.0 0300. .300. 0003.00 0. 6000.005 00. 0.0.0.6 0.0.0 300036.. 000.2. 0.00030 H. 030.0 . 03056.0. 0030.0 000 60.0 5.3 002.03 00.000.00E00 Chuc. 0.00030 0.0000. 000 0030.0 0. 00.00E00 0.500 .020 3.3 9.263 .0. 02.2.0.0 00000.00 002.05: 0300". ”000.00. 00.030. 0003....0 0.00030 00000.00 02.0.6000 . 000 02.0.0.0 00.0000. 0>..0.._03O . 502.050 000 02.0.0.0 06.06 0.0.. = .60 0.03.5. 333.20... 8.3003 0 20.83 8338.30 .3308. . .. 0.3a. 14 Conceptual Definitions Behavioral intention: an indication of perceived likelihood of performing the behavior (Montano, Kasprzyk, & Taplin, 1996) MM! determined by individuals’ beliefs about outcomes or attributes of performing the behavior (behavioral beliefs), weighed by the value of those outcomes or attributes. This is sometimes expressed in psychometrics as Beliefs x Value of belief = Attitude score. Attitudes are the degree to which individuals have a favorable or unfavorable evaluation of the behavior. (Montano et al., 1 996) Subiective nonn: determined by individuals” normative beliefs (belief about whether each referent approves or disapproves of the behavior) and individuals’ motivations to comply (motivation to do what each referent thinks). (Montano et aL,1996) Perceived behaviorgl control (Self-efficacy or configence): determined by an individual’s control beliefs (perceived likelihood of occurrence of each facilitating or constraining condition) and perceived power (perceived effect of each condition in making behavioral performance difficult or easy). it is an individual’s perception that he/she will be able to perform a certain behavior successfully. (Montano et al., 1996). Job satisfaction: a feeling defined as the fulfillment or gratification of desire from work as a health professional. Beliefs about workiniwith older adults: an individual’s beliefs about outcomes or attributes of working with older adults 15 Attitudes towards older adults: an individual’s favorable or unfavorable evaluation of older adults. Attitudes towards working with older adults: an individual’s favorable or unfavorable evaluation of working with older adults. Interest in working with older adults: measured using a Likert Scale which allows for the possibility of having the same level of interest in working with several age groups. Preference for working with older adults: measured using rank order. People are required to rank or prioritize each age group based on the interest in working with older adult group over another. Knowledge about older adults: An individuals’ knowledge about characteristics of older adults rather than the biological process of aging. Knowledge about older adults was measured using Facts on Aging Quiz, Part I (Palmore, 1998) Overview of Subsequent chapters In this chapter, the significance and rationale for this study are described, as well as the study objectives and research questions for each part. Chapter two explores previous related literature and the theoretical background related to the study objectives. Chapter three summarizes the overall methods for Parts I, II and Ill. Chapters four, five and six present Parts I, II and Ill, concisely as separate manuscripts ready to submit for publication. Each of these topics includes sections on the introduction, method, results and discussion. Finally, 16 chapter seven summarizes major findings and overall evaluation of this dissertation research as well as recommendations for further study. 17 CHAPTER 2 REVIEW OF RELATED LITERATURE The topics covered in this review of literature are those relating to the significance, rationale and methods for this study. The literature reviewed has been limited to the last 5-10 years to reflect that the demand for additional health professionals, including dietitians, is increasing and important. Within the last 35 years, research on poor attitudes towards and low preference for working with older adults of students in the health professions has been conducted. This range reflects the length of time that interest in this topic has been addressed in the health professions, as well as the limited research in this area in dietetics. The behavioral theory about attitude formation and the relationships among knowledge, attitudes, experience and behavior is from the original sources in the 1970’s, but little of the research on pedagogy in the health professions has been theory-driven. Although there has been support in the health professions that improving students’ attitudes towards older adults will improve the quality of health services to seniors, this link has not been established via research methods. Finally, the latter part of this chapter reviews previous studies on efforts to change students’ attitudes towards older adults by changes in pedagogy. Most of the studies reviewed are those from health professions other than dietetics, reflecting how little research in dietetics pedagogy has addressed this topic. 18 A. Increase in the population of older adults and demand for health professionals Advances in public health, food availability and medical technology have prolonged life expectancy; consequently, the aging population (2 65 years of age) has grown to over 12.4% of the US population in 2000. By 2030, 20% of the population is expected to be over 65 years of age, and 12.5% of this group, 85 years old or more (US Bureau of the Census, 2001). This increase in number of older adults puts increased demands on health professionals, because older adults use and need more health care services than any other age group (Committee on Nutrition Services for Medicare Beneficiaries, Institute of Medicine, 2000; US. Department of Health and Human Services (US. DHHS), 2003). Approximately 80% of older adults (over 65 years) have at least one chronic condition, and 50% have at least two (US. DHHS, 1999). Four out of ten leading causes of death in older adults are diet-related chronic diseases, such as heart diseases, cancer, stroke and diabetes mellitus (U.S. DHHS, 2003). The rapid growth in the aging population, particularly in the oldest segment (over 85 years), who use more health care services, demands health professionals, including dietitians, who are experienced, sensitive, and knowledgeable about the health and well-being of the elderly and who are also interested in working with older adults (Ward, Duquin, & Streetman, 1998). Employment changes projected from 2002 to 2012 show increased needs for all health professionals including dietitians and nutritionists (18%), social workers 19 (27%), occupational therapists (35%), physical therapist (35%), physicians and surgeons (19%), dental assistants (42%), medical assistants (59%), nursing psychiatric, and home health aides (31%), and occupational therapies assistant and aides (40%) (Committee on Nutrition Services for Medicare Beneficiaries, IOM, 2000; US. DHHS, 2003). Such changes are projected from the increase in the number and percentage of older adults in the US. The increased demand for dietitians by 2012 will be driven not only by needs in well care and primary care, but also by needs for meals and nutrition counseling in hospitals, nursing care facilities and home healthcare agencies (Kaempfer et al., 2002; US. Bureau of Labor Statistics, 2004). In addition, since the passage of the Medicare medical nutrition therapy bill by Congress, Registered Dietitians have increased opportunities for financial reimbursement for nutrition counseling with older adults (H.R.561 Medicare, Medicaid, and SCHIP Benefits Improvement and Projection Act of 2000). The American Dietetics Association (ADA) has recognized this need and begun to take steps to address it in their strategic planning and national meeting (American Dietetics Association, 2004). ADA’s position on nutrition and aging recognized the need to establish standards of practice to ensure that older adults receive adequate and appropriate nutrition care (Position of ADA, 2000). B. Low preference for working with older adults by pro-health professionals Although the increase in the percentage of the population over 65 years of age necessitates additional qualified health professionals in geriatrics, previous 20 research has shown that most health professionals generally give low priority to work with geriatric populations (Futrell & Jones, 1977; MacNeiI, 1991; Robb, 1979; Tollett & Adamson, 1982; Williams, Lusk, & Kline, 1986). Because little previous research has focused on dietetics students’ preference for working with seniors, most of the literature reviewed in this section about pre-health professionals will focus on that from other health professions. For example, medical students, nursing students, social work students and physical therapy students have been found to have little interest and low preference for working with an aging population, and such a tendency has been prevalent over the last 30 years (Aday & Campbell, 1995; Carmel, Cwikel, & Galinsky,1992; David- Bennan, & Robinson, 1989; Fitzgerald et al., 2003; Gomez, Young, & Gomez, 1991; Greenhill, 1983; Hart, Freel, & Crowell, 1976; Kayser, & Minnigerode, 1975; Mount, 1993; Robb, 1979). Aday & Campbell (1995) compared nursing students’ preferences for providing nursing care to clients aged 56-74 years and those 75 or older with six other age groups: infants to 1-year-olds, preschoolers (2-4 years), school-age children (5-13 years), adolescents (13-19 years), young adults (20-39 years), and middle-aged adults (40-55 years). Only six students out of 45 ranked those 75 years and older as one of their first three choices. MacNeiI (1991) assessed therapeutic recreational students’ work preference for working with three age groups (i.e., youth = birth to 20 years; adults = 21 - 54 years; and seniors 2 55 years) with five different disability categories, i.e., sensory impairment, chemical dependency, psychiatric impairment, physical impairment, and chronic health condition. Regardless of 21 the nature of the disability of the hypothetical client, the students preferred to work with younger clients, rather than with older adults. Fitzgerald et al. (2003) surveyed 171 medical students, asking with which age group they expected to prefer to work with as physicians and found that only 2% of students reported patients aged 65 years and older, compared to 16% reporting 19- to 24-year-old patients, and 46% reporting 25- to 64-year-olds. These studies as a group are notable as well for the inconsistencies in the age groupings selected for comparison of work preferences. One study was identified that assessed dietetics students’ preference for working with older adults (Kaempfer et al., 2002). Nearly 300 students in dietetics programs from five different states with the largest populations of older adults participated in the survey. Students’ preference for working with various age groups was assessed using a 10-point scale (the higher the score, the less preferred). Students showed the least preference for working with older adults compared to other age groups and their preference declined as the client groups’ age increased (65 -74 year-old, 6.0123; 75 - 84 year-old, 7302.3, 85 year-old or over, 8612.3, Scores range from 1-10, with low scores indicating the highest preference). Low preferences for working with older adults appear to be common among students in the health professions. Such findings have raised concerns about not being able to meet the needs of a growing population of seniors, as well as the adequacy of education in gerontology and geriatrics (Health Resources & Services Administration, 1995). Students’ attitudes towards older 22 adults have been studied as a major contributor to their low preference for working with older adults, and this topic will be addressed in the next section. C. Pro-health professional students’ attitudes towards older adults Over the past 35 years, research to assess the attitudes towards older adults of students in the health professions has been conducted because students’ low preference for working with older adults has been assumed to be due to students’ negative attitudes and stereotypes of older adults. The assumption has been that if negative attitudes continue after becoming health professionals, such attitudes will harm the quality of the care provided to the aging population (Beland & Maheux, 1990; Knowles et al., 1985; Hatton, 1977). Several studies have examined links between negative attitudes towards older adults and low preference for working with this age group. Shmotkin, Eyal and Lomranz (1992) found that major factors for lower motivation to treat older adults as compared to other age groups were attitudes toward psychotherapy for older adults and post professional experience in this field. Kaempfer et al. (2002) reported a weak but significant positive relationship between attitudes towards older adults and work preference for this group. Carmel and colleagues, however, found that no correlation between attitudes towards older adults and preference for working with this age (Carmel et al., 1992). Negative attitudes of students in the health professions towards older adults have been reported for many years (Benson, 1982; Campbell, 1971; Carmel et al., 1992; Davis-Bergman & Robinson, 1989; Eddy, 1986; Greenhill, 23 1983; Gunter, 1971; Hatton, 1997; lngham & Fielding 1985; Kosberg & Harris, 1978; Mills, 1972; Penner, Ludenia & Mead, 1983; Spence & Feigenbaum, 1968). However, some research has shown slightly positive (Davis-Bergman, & Robinson, 1989; Schwalb 8 Sedlacek, 1990) or neutral attitudes (Bralthwaite, 1986; Kaempfer et al., 2002). There have been few studies designed to assess dietetics students’ attitudes towards older adults (Kaempfer et al., 2002; Rasor-Greenhalgh et al., 1993). Kaemfer et al. (2002) assessed dietetics students’ (n=299) attitudes towards older adults using the Oberleder Attitude Scale, and the results indicated that students’ attitudes towards older adults were neutral. More than half of the students reported that older adults were set in their ways, glad to retire at age 65, did not adjust to new conditions easily and must expect to depend on others as they grow older. Rasor-Greenhalgh et al. (1993) measured 27 dietetics students’ attitudes using the Kogan Scale. Before an intervention designed to improve attitudes towards older adults, the average score was 144 (SD =15.9) indicating that negative attitudes towards older adults. 1. Assessing attitudes towards older adults and their care The inconsistent findings on attitudes towards older adults might be explained by the differences in the types of instruments used and by the attributes examined. Attitudes towards older adults have been assessed using two major types of instruments, either close-ended or open-ended. Close-ended instruments have been the most commonly used to assess attitudes towards older adults. Both the Kogan's Old People Scale (Kogan, 24 1961) and the Aging Semantic Differential Scale (Rosencranz & McNevin, 1969) have been used over the last forty years. The Kogans’ attitudes scale is a 34- item instrument with a 6-point Likert-scale format, ranging from strongly agree to strongly disagree. Scored from 34 (positive) to 204 (negative), the instrument includes 17 positively rated and 17 negatively rated statements. The Semantic Differential Scale is a multi—dimensional measure of global attitudes towards older adults and is composed of 32 polar-adjective pairs scored on a 7-point scale with scores ranging from 32 (positive) to 224 (negative). Originally, this scale was designed to assess attitudes about older persons’ level of competence, autonomy, and acceptability. Examples of the adjective item pairs are independent/dependent, generous/selfish, tolerant/intolerant, weak/strong, unproductive/productive, sad/happy and exciting/dull. Most research on attitudes towards older adults has been focused on whether attitudes are positive or negative in a global sense (Hickey, & Kalish, 1968; Hummert, 1990; Kite, Deaux, & Miele, 1991; Kogan, 1979a; Kogan, 1979b). Distinguished from the these two instruments (the Kogan’s Old People Scale and the Semantic Differential Scale) which assess general attitudes towards older adults are scales designed to also measure the attitudes towards caring for older adults or working professionally with them. For example, the UCLA Geriatric Attitudes Scale is a 14 item-questionnaire (Reuben, Lee, Davis, Eslami, Osterweil, & Melchiore, 1998). The Maxwell-Sullivan Attitudes Scale is a 27-item questionnaire that includes subscales on general attitudes, as well as those on cost-effectiveness, time and energy, therapeutic potential, and 25 adequate educational preparation towards medical care of older adults. This instrument is focused more on the individual's attitudes towards the provision of care to older adults (Maxwell & Sullivan, 1980). The Elderly Patient Care Inventory (EPCI) is also used to measure attitudes towards caring for elderly persons. EPCI is composed of 12 statements about both positive and negative aspects of caring for the elderly with a 4-point scale from strongly disagree to strongly agree (e.g., “It is hard to teach older clients new info about their care; old people complain more than any other age group; I think older clients are more grateful than children for the care they receive”) (Aday & Campbell, 1995). The Wall-Oyer’s Aging Inventory is also composed of two domains of personal attitudes and professional attitudes towards working with older adults. The 22 items with a 5-point scale from strongly agree to strongly disagree were developed based on the intuitive and reasoned notions of Wall and Oyer in the Department of Speech and Hearing Science at Ohio Sate University. The subscales of this instrument focus evenly on the global attitudes towards older adults as well as those towards working with older adults (Noel, 1988). Sentence completion procedures (an open-ended instrument) have been used because they provide spontaneous responses from participants, without biases introduced by the instmment and researcher (Bomstein, 1986; Carmel et al., 1992; Golde & Kogan, 1959; Kogan, 1979b; Doka, 1986; Shenk & Lee, 1995). Pre-health professionals’ descriptions of older adults using open-ended questions were “smart, experienced, fun, transition, faced with major changes, just people, chronological age, physical and mental decline” (Shenk & Lee, 1995). 26 Carmel et al. (1992) also used open-ended questions to assess attitudes towards older adults compared to those towards young people. The students were asked to answer, “What is pleasant and what is unpleasant for you about young people and old people?” Positive attitudes towards old people were “warmth, appreciation of help and wisdom from life experience"; negative attitudes were “dependence, physically unattractive, and slow reaction time”. The most common negative attitudes of pre-health professionals thus appeared to be those related to physical and cognitive attributes. When an open-ended instrument was used, Doka (1986) reported that negative stereotypical views tend to be prevalent. In contrast, Murphy-Russell et al. (1986) found that attitudes of undergraduate students in psychology toward older adults using close-ended item rating scales were slightly positive. This conclusion has been supported in several other studies with students in nursing and social work using rating scales to assess attitudes towards older adults (Knox, Gekoski, & Johnson, 1986; Reed et al. 1992). However, one meta- analysis by Kite & Johnson (1988) showed that attitudes towards older adults assessed using scales were primarily negative attitudes. Using bipolar adjective scales, college students' attitudes towards older adults tended to be negative (Gellis, Sherman, & Lawrence, 2003; Hummert, Garstka, Shaner, & Strahm, 1994; Schwalb, & Sedlacek, 1990). Without a set of standardized instruments to assess attitudes, it becomes difficult to compare findings across professions or over the years. 27 Added to this problem of interpretation of different open- versus closed- ended instruments, subtle distinctions of the construct domains might also result in inconsistencies. The scales described previously include at least three major domains of a person’s attributes - such as cognitive, personal-expressive, and physical attributes. Because people have negative stereotypes about older adults’ physical and intellectual attributes, it is likely that the instruments with the most physical and cognitive items, could lead to more findings of negative attitudes towards older adults (Slotterback 8. Saamio, 1996). Hence, if students have lack of knowledge about older adults, for example, they might underestimate older adults’ physical and mental status and so they might have negative attitudes towards this age group. The instruments previously described and used were designed to measure attitudes towards older adults and/or their care but not the reasons for such attitudes. Until researchers know more about why young adults hold certain attitudes, it is difficult to elucidate the reasons and to design effective interventions to change them. Thus, qualitative research methods might be the most appropriate method to understand their attitudes and factors affecting them. 2. Factors associated with attitudes towards older adults Factors such as knowledge about older adults, previous interaction with older adults, especially grandparents, and age and gender of respondents have been shown to be associated with people’s attitudes towards older adults, although such associations have not been consistent (Chumbler, 8 Robbins, 1996; Meyer, Hassanein, & Bahr, 1980; Penner et al., 1983). Kaempfer et al. 28 (2002) reported that younger students in dietetics (~18 years) were more likely to have negative attitudes towards older adults compared to only students those who were older (~22 years). In the health professions, students’ knowledge about older adults has often been measured and correlated to students’ attitudes towards this group. This common practice is likely due to the belief that lack of knowledge is a major contributor to poor attitudes. Several studies have reported a positive relationship between knowledge about and attitudes towards older adults (Dail & Johnson, 1985; Edward & Aldous, 1996; Menz et al., 2003; Sachs et al., 1984; Wilson & Hafferty, 1980) but others have not (Harris & Dollinger, 2001). The following section briefly reviews students’ knowledge about older adults in the health professions. D. College students’ knowledge about older adults Research on pre-health professionals’ knowledge about older adults has focused not so much on increasing students’ knowledge as it has on measuring students’ knowledge and the items most frequently misperceived by students. This research practice is based on the belief of some that perceptions of older people are strongly influenced by general knowledge about older adults, and that a lack of knowledge will manifest as negative attitudes and stereotypes of older people (Edwards & Aldous, 1996; Menz et al., 2003; Shahidi & Devlen, 1993). The knowledge of health care professions and students majoring in health and allied health about older adults and aging has been assessed mostly using 29 the Facts on Aging Quiz (FAQ). The FAQ is a 25-item instrument created by Palmore with a true-false format and designed to assess one’s knowledge about older adults and the aging process. The score range is zero to 25. The FAQ items are factual/empirical statements reflecting physical, mental and social factors about aging, as well as frequently believed stereotypes about older adults. The FAQ has been used with a wide range of age and occupational groups, including health professionals and students. This instrument has been reported to be a reliable and valid measurement tool of knowledge about the elderly and the aging process (Palmore, 1998). Harris, Changas, and Palmore (1996) revised the FAQ true-false format by changing it to a multiple-choice format in order to reduce the effects of guessing. Most studies have shown that medical, nursing, social work and dietetics’ students lack knowledge about older adults as do college students in general (O’Hanlon et al., 1993). Fitzgerald et al. (2003) assessed incoming medical students’ (n = 171) knowledge about older aduts using the Facts on Aging Quiz with the true-false format and found that knowledge about older adults was low (mean score = 37% and SD = 13.8%). Carmel et al. (1992) measured first year medical students (n = 50), third year nursing students (n=32) and the third year social work students (n=20), respectively, using the FAQ, and the mean scores were only 55—61%. Gellis et al. (2003) reported that the mean score of first year graduate social work students’ knowledge of aging using the multiple-choice format was 49%. A recent study to measure predominantly senior dietetics students’ (n= 299) knowledge about older adults showed similar low knowledge 30 level, with mean scores 40% and SD = 13% (Kaempfer et al., 2002). Researchers found that more than half of the dietetic students thought that older adults were set in their ways, did not adjust to new conditions easily and depended on others as they grow older. Thus, the scores of this small group tended to be as poor as those of students in other health professions. None of the groups assessed — students in dietetics, nursing, medicine or general college students — have done well on the FAQ. Most of the students consistently missed the quiz item, “Most older adults are set in their ways or unable to change.” This finding is not too surprising from a group of students in the health professionals who want to help and see change. If this belief is a factor in negative attitudes towards older adults, then it would be important to address both didactically and experientially. E. Changing attitudes towards older adults Educators in the health professions have attempted to improve the attitudes of pre-health professionals towards older adults, mostly through curriculum development. This section provides some theoretical background for attitude change and then reviews some of the curricula used to attempt attitude changes. 1. General theoretical background: attitude, Intention and behavlor There is no one theory that can directly explain how knowledge about older adults might affect attitudes towards older adults and students’ preference for working with this age group. The Theory of Reasoned Action and the Theory 31 of Planned Behavior (T PB), which propose causal relationships among attitudes, intentions, and behaviors, might be the best of the theoretical frameworks, however, to explain the relationships to preference. This choice of behavioral theory is valid if preference for working with older adults can be considered as a precursor to “intention to perform a behavior“. Few of the previous studies reported in this literature review have alluded to a theoretical background for the research. In order to inform pedagogy in a meaningful way, research in nutrition education requires a theoretical basis. The Theory of Planned Behavior extends the Theory of Reasoned Action by addition of behavioral control. This is the environmental condition intervening actual behavior in spite of positive attitudes and motivated intention to behavior. Perceived behavioral control is conceptualized as a function of controlled beliefs and perceived power. The control belief is a belief about the presence or absence of resources and opportunities, and the perceived power is the control factor to facilitate or inhibit performance of the behavior (i.e., skill, recourses, benefits, and barriers). Beliefs, value and knowledge can be targeted to change attitudes. The major constructs in TPB are attitudes, subjective norms, perceived behavioral control (self-efficacy), intention and behavior. An attitude is a “psychological tendency expressed by evaluating a particular entity with some degree of favor or disfavor" (Eagly 8 Chariken, 1993). An attitude is a function of a person's beliefs about an object or person and the evaluative responses attached, wherein the belief, multiplied by its value to the individual, equals the attitude (Belief X Value = Attitudes) (Fishbein 8 Ajzen, 1975). Subjective norms 32 are normative beliefs that important referent individuals or groups think the individual should or should not perform the outcome behavior, weighted by the motivation of the individual to comply with the referent’s desire (Montano et al., 1996). Based on the previous research on preference for working with older adults, subjective norms have not appeared as a factor affecting attitudes towards or preference for working with older adults. In TPB attitudes, subjective norms and self-efficacy all influence behavioral intent. The perceived behavioral control is very similar to the concept of Bandura’s self-efficacy, which is defined as “an individual’s judgment of how well he can perform a behavior under various inhibiting conditions” (Bandura, 1991 ). The concept of intention refers to one’s likelihood of performing various acts. Behavior is the observable action that has occurred in response to particular stimuli. It is presumed that the behavior will be consistent with expressed intention, but of course this is not always true. In the Theory of Planned Behavior (Figure 2.1), human behavior is determined by a person’s behavioral intention, and the behavioral intention is influenced by attitudes, subjective norms, and self-efficacy, towards the same behavior (Montano et al., 1996). When an attitude towards a behavior is defined as the beliefs about outcomes or attributes of performing the behavior 33 .o_>mcom """"""""""" E82 958.33 corset: .82 i=5 383a: .2555. 3328 8:55 so has: .3 2:2". .9200 .o_>mcom uczcoucn. " seam ._ .928 2anO 2 c2328.). wm=0m c>=mctoz .2233 2952 $62.53. 82$ moEooSO .mLo_>m_._cm Co mcozmagm /\ $2.0m .m.o_>mcom 34 (behavioral beliefs), weighed by evaluations of those outcomes or attributes, an individual’s belief is sometimes considered as the knowledge (or lack of knowledge) one possesses in respect to a given object. Beliefs form an information base, factual or not. Attitudes are conceived as one’s affective evaluation (i.e., good, bad, desirable, undesirable) of an object (Fishbein 8 Ajzen, 1975). A person who holds strong beliefs that positively value outcomes about performing a behavior will have a positive attitude towards that behavior. In contrast, a person who holds strong beliefs that negatively valued outcomes about performing a behavior will have a negative attitude towards that behavior. Therefore, interventions that can attach positive value to various beliefs have the potential to positively affect attitudes. A conceptual map for this study based on the TPB is shown Figure 2.2. 2. Curriculum development to change attitudes towards older adults Several studies have investigated the influence of aging courses on students’ knowledge about older adults, as well as on attitudes towards this age group. Fourteen such studies since 1976 have been summarized in Table 2.1, highlighting the types of interventions, the types of students, the instruments and the findings. Most researchers (n=9 studies in the table) reported improved attitudes after medical students and general college undergraduates completed aging courses, whereas other researchers did not find a positive influence on medical students’ attitudes towards older adults. These studies reported significantly increased knowledge of aging using the FAQ. 35 3328 2.25: so E85. 85.32. >36 £5 .8 .282 533800 «.N 2:2". 3.22 .85 5E 8:82, how $259391 .\ - 3.22 820 5;) 8:82, 5 8:63:09 >omoEc£cm 8.3%. EEO £3, c_V_L_o>> $.33. .6 _O . Lab; Dc_vtw>> \ H385 ¢:_m> 3532 33:34. / $.25 520 Scam Ezcm .m._o_>m;cm 36 0.88:5 0:880 8.9: 2:. ~ 5:0 050.4 :0 200“. 0:... . 00g :0_.:0>:0.5 0:0 65:00 .000:0.:00x0 3:90 000 052.0 803.8 803.8 c. .850. 3.80 5.3. .880 .2, 8.88:... .000: 00:20:50 0:005:00 02 00000. :00.0 5.? 5:00:25 .00"... 00:00:50 050::2 :33 a. ___..:00:0 05:00 :00.0 2 00.50 00.200 3.08. 000250 05 0:0 05:00 :00_0 5.3 .035 2:0020 5:3 a .00E0Fr 00>0:0E. 5:005:05 Cozumcmurtwm 0000050 :0 0550200 0:0 00:0:0 000 5.3 0003 5 3.5000030 :0 00.9.0 :0: 000:0:0:0:0 5:00:25 ”0:90 0:00“. .058 :80 5.; 8.8.9:. 5:02. .5000 200::0.0000m .mpuc. 020020 0:03 .5000 :00» -35 08 .308. 0.88.0 ._00:0w 60:00 000250 5 000250 :0: 05500:: 0:0 .0:0.00:00.0 0505: :00>-0:_5 5.qu 3005 5.05.00 000:0:0 :c005:0.0 oz 000:0.:000 0:5: .05. :000 00:300.. 00:30 2:00:50 .00.00E 00:305.... 0 .0530 ..0E:0O 00:< 00500.0 ANN": .6550 55005005 00:02.2 00025.0. 0:0 .Nuu: 60.50325. 05.000 5:005:90 05 0:0 0.00m >000_w 00:05 .0:o..00:000 .8 :2. 22088.2 05 8:08. 803...... 0.58 8.0.8.0 :. 0.88.0 :835: .000: 80.0800 flag 5.20225 0:0 .0:.:00 .2500 00.0 0530.225 00.500: 5:": :00500 .5050 0:0 500350 ._05:00. 000.0 50:00:00 5:005:90 .0: .3 .02 0:0:0 =0E0 .0E0: 5 2:00:00 20:00:0:00:: 5000 05 5 0000.305. 050.5: 5 05:00 050 0:0 89" : 52:05:09.0. 0000205 0:0 0005.50 :050050: :0: :00.::.0> “0.00.90 00::00 0500 :0 >00.0...0>00 8.685. 8858.0 .80 «.00.: 0 P0...“. 8.8.8.. 8:80 c. 0.8030 0.08888: .000: 0.3.05 5500.02.00 52:05. 0:00 E0500 .000:0.:00x0 083.8 .82.". .885. >820 .850 0 228.. .0000 00:205. 5:005:90 0:0 050< :0 05500200 E0:00:0 000.0200m 635 2:00:00 050::2 =000E0O w >00< 0505“. 005000.). :0.E0>:25 200.3:w 3.000 :00.0 00:01.0: 0003.00 .200030 00:0..0 on 00.030 3. :0 DEE—cam _..N 0.00... 37 0.80 0.800 0.0 0.808. 0.5 n 0003.50 00>0:0::. 5:005:05 <>Oz<.2 .005000 0. .0300 E0:: 00:0..0 000.>0:0 0:0..00 005009.500 mmov. 208000000 5.00... 6:000 :00.0 5.3 :0.:00:0.:. £0"... 0.88.0 88.0.0 :0..0E :0 30.:0> 5.3 5.8: o8 0:9: c. .0 :8 .000: 80.80 0 50:28.0 .:0_0::00:0.:000m .<>Oz00 5:00 .38. 0503.50 05.000 :0.:00_:0:.:.00 w om< :00.0 0530.335 5 .m. 0.:0030 0.0:00:0:00:: :0>9.00:m 0 5.51.0 0003.50 5 000:0:0 49305.: .c00.:.:0.0 .00.: 0:0 :0.00:00.0 :000 00::00 30.0:050 30.0:0055 .000: $502. .5 003020 0:03:00 .0050 w00x 60:00:35. 00:00:02. 5 0.:0030 0.0:00:0:00:: 3 .05 ...000:m.50::s. :050050: .0050?— .:.00 33:05. 500m. .3500 .05E.:0 5 mm .6550 0:0 0003.50 0:0 050< :0 :05000:00 :00.0 5.3 :0500:0.5 0500 :0 30.9.0500 5 mm": .0003 88:05. 38058.0 0.8.2.5 .00< .0000. 0:022... 8:80 8:88.... 0.8.5.0 000.00 208.230 0 085. 0:0:0 .0.:0::...00x0 05 5 0003.50 .038 :00.0 0530.235 0 =50 8:00:35 .5500 :0..0.:::.0 :0 ".928 0:0 00": 60.30205. .80: 0:800 0 8.9m. .38. .85... 00>0:0E. 5:005:06 G<0 w 09.. .:050E._0::.. 0550; 0.:0030 .0509: 00305:... .0500 0:0 0.00m 050< .:000 0005300 :0 mm Pu: ..05:00 0000.305. 30.084. dw< .N.:0 .m.:0.5. .508 00>0:0E. 5:005:05 :0 0000.305. .04.". 050505. 00500 0.:0030 0.0:00:0:00:: :005__0n_ 0 05.0... 05050 0050005. :05:0>:0.:. 0.00.05 .0380. 9.0 0.00» 38 ___ 5.829% 38523 698388 965 6:50 8:023 .25: coEEo 3.3m 8m": .6950 9 323.56 835% 25.53.. cc 8338 .620 93,2225 new m F": 626029;; 68: 32:95 >=cmoEcQw wmuBEm no 35322 9.6225 88:00 3.53% .869: EQEQE 3.3%.: w com__>> 3E0: arts: 5 «325m 5 «mucosa moocmtoaxo bofibam. 2.85ch .0: =5 gmccozmmao 038.". E w x $9.38. 83: .EoEo>2aE_ ozgmoa 20 3.632 395:4. EN x NV 0@300 Sans 3:036 @5832 :8:sz w 2_n__>> 9.65m «9:305. 53522:. $8.35 6.2.8. ta 2%.. 39 Only one study was conducted to improve dietetics students’ (n=27) attitudes towards older adults through a brief interaction with older adults, such as anthropometric assessment and counseling of older adults (Rasor- Greenhalgh et al. 1993). Researchers examined the students’ attitude changes using the Kogan Scale and found significantly improved attitudes (t= 3.05, p<0.01). However, the sample size was too small to have a clear conclusion, and there was no comparison group. Three major ways to change adults” attitudes towards older adults have been proposed by Glass and Knott (1982) and Triandis (1971): 1) through increased information or knowledge about the aging process; 2) through group discussion with peers about attitudes and feelings about older adults; and 3) through direct experience with older adults. Researchers have used one or more of these methods to improve students’ attitudes. For example, Puentes, & Cayer (2001) designed a two-week intervention program which was composed of two parts: 1) a 15 hr aging theory class, teaching and learning activities (lecture, discussion, handout, audio/visual aids, student presentations, and gaming techniques), and evaluation (class participation, quizzes, a test and an article review); and 2) a 42-hour series of seminars, run by invited community experts and older adults to enable students to interact with older adults. Researchers found a significant increase in students' knowledge of aging and improved attitudes towards aging after participating in this intervention. Some researchers have expressed concerns that the interaction with ill older adults results in a negative shift of medical students’ attitudes towards older 40 adults (Murden, Meir, Bloom & Tideiksaar, 1986). Wittig & Grant-Thompson (1998) investigated five contact conditions that have been shown to be associated with increased positive attitudes towards groups: 1) voluntary contact supported by authority figures; 2) equal-status contact; 3) cooperative and interdependent contact; 4) contact providing the potential for forming friendships across groups; and 5) stereotype-disconfirming contact. Attitudes towards older adults may be improved by ensuring that contact conditions are favorable. Pedagogy in geriatrics and gerontology education has focused on improving students’ attitudes towards older adults by including direct interactions with older adults in a variety of settings, including clinical settings, community learning service, interviewing, and volunteering. Aday and Campbell (1995) reported the effectiveness for attitude change using a curriculum with nursing students that emphasized the rewards of caring for older adults who had diverse physical and mental capabilities through direct contact. This was done in both a clinical as well as in the home setting. Knapp & Stubblefield (2000) examined the effect of an intergenerational service learning course to improve students’ attitudes towards aging in a psychology of aging course. intergenerational programs include planned, constant interactions between younger and older adults mutually beneficial to both (Newman, Ward, Smith, McCrea, & Willson, 1997). Several researchers have recognized the worth of including intergenerational programs in the curriculum, in order to increase knowledge of aging and eliminate stereotypes about aging and older adults (Angiullo et al., 1996; Chapman & Neal, 1990; 41 Larkin & Newman, 1997). Service learning is an educational method in which students engage in organized service planned to meet needs of the community. The academic curriculum includes service learning to provide opportunities for students to serve the community and then to reflect on the service experience via personal journals and classroom discussion (Westacott & Hegeman, 1996). Knapp & Stubblefield (2000) found that the intergenerational service learning activity in a senior level gerontology course had a positive influence on college students’ knowledge and attitudes towards older adults. Shoemake & Rowland (1993) evaluated gerontology laboratory experience for positive influences on students’ attitudes towards working with older adults. Half of the subjects were undergraduates (n= 27), and the rest were master's degree students (n=31) or specialist and doctorate level students (n=2) in various majors including nursing, home economics, therapeutic recreation, dietetics/food and nutrition, adult education, social work, and psychology. Students enrolled in various courses in professional fields impacting the elderly participated in this study through observation, one-on-one contact, group activities and field experiences in senior service centers. After the laboratory experiences, half of the students expressed a high level of enthusiasm for working professionally with the elderly. This study did not distinguish the impact of different types of interaction with older adults or the settings for the interactions. lnteieri, Kelly, Brown, and Castilla (1993) developed a gerontology training program which combined lecture on normative and non-nonnative aging and psychological development, experiences with sensory changes associated with 42 aging and training to improve interpersonal skills in clinical interviews with elderly patients; This gerontology training program focused on social skills to systematically teach interpersonal effectiveness with patients. After participating in this training program, the third-year medical students showed a significant increase in knowledge and significantly improved attitudes towards older adults. Several investigators have used experiential activities and active learning techniques to improve students’ attitudes towards older adults. Hamon and Koch (1993) examined an experiential learning tool that required college students to develop a relationship with an older adult as a mentor. The objectives of this older adult-student mentorship, which involved three contacts during one semester, were to provide opportunities for students to meet older adults and to explore the similarities and differences of experiences among themselves, as well as to integrate textbook information with real-life situations and people. About 80% of the students reported that this activity positively affected their attitudes. O’Hanlon & Brookover (2002) evaluated a class activity which required students to interview an older adult with structured interview questions, including the older adults’ life history and his or her perspective on growing older. After students spent approximately one to three hours in the interviews, most students demonstrated favorable attitude changes towards older adults. Later, a content analysis was performed on the students' reports including their own beliefs about older adults and self-reflections of the interview project. The results confirmed that the interview activity was an influential and valuable experience. 43 Bachelder (1989) developed an intervention to improve occupational therapy students’ attitudes towards the elderly using a simulation activity to transmit information about age-related sensory changes and impairment, including hearing, vision, taste and smell, kinesthesia, and touch. Even though there was a moderately positive modification of students’ attitudes towards older adults, it was not a significant improvement. Thus, this type of simulation activity might not be a good choice to improve students’ attitudes, because older adults were specifically viewed as disabled. One study to improve dietetics students’ (n=27) attitudes towards older adults was identified (Rasor-Greenhalgh et al., 1993). Dietetic students were assigned to conduct a project to evaluate body composition, exercise patterns and eating habits of elderly subjects. Ten students were assigned to counsel older adults, and the remaining 17 students conducted anthropometric assessments on the older adults. The change in attitudes was assessed using the Kogan Scale in pre- and post-tests. After completing the project, both groups of students showed significantly improved attitudes towards older adults. However, this study had a small number of subjects and did not have control group. Most recently, Rhee et al. (2004) examined the course content on aging in dietetics programs in the US. using an lntemet search and a follow-up questionnaire of dietetic program directors. Only 20% of undergraduate programs reported having an entire course on aging for students in dietetics. Life cycle and community nutrition courses provided the most content on aging. Most 44 programs emphasized maternal and child nutrition more than nutrition for older adults at both the undergraduate and graduate levels. Faculty in dietetics programs reported that the most common barriers to including more coursework on aging were "the curriculum is already full” and “lack of faculty expertise”. The researchers, thus, suggested that field experience and course assignments might help enhance dietetics students’ knowledge about older adults and challenge negative stereotypes without greatly expanding the courses required by students. To summarize the recent research on changing the attitudes of students in pro-health professions towards older adults, most investigators have found that course work involving interaction with older adults and some type of experiential activity with seniors was effective for positive attitude changes. However, the separate impact of lectures (providing information only) and interaction with older adults has not been examined. Although small group discussions, increased knowledge, and self-reflections have also been proposed as important ways to change attitudes, little research was located in which these methods were used. This literature review has demonstrated that there is an increased need for dietitians to work with seniors. Only one study has been conducted to examine the impact of nutritional assessment on healthy older adults in improving dietetics students’ attitudes towards older adults (Rasor-Greenhalgh et al., 1993). Thus, additional research is needed to understand nutrition students’ attitudes towards older adults related to knowledge about older adults and interest in or preference for working with older adults. Theoretically grounded and effective intervention to improve dietetic students’ attitudes towards older adults in established courses 45 might potentially inform dietetics pedagogy to meet emerging demographic trends for the next several decades. 46 CHAPTER 3 METHODS Part i: Nutrition students’ knowledge about older adults, attitudes towards this age group and preference for working with them Study objectives 1. To assess students’ knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults, and preference for working with them. 2. To investigate the relationships among students' knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults, and preference for working with them. 3. To examine changes in students' knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults, and preference for working with them after a lecture on senior nutrition and senior meal programs in a course on Community Nutrition. 4. To test the validity and reliability with this student population using the Facts on Aging Quiz, the knowledge about geriatric nutrition Questionnaire developed for this study, and the Oyer-Wall’s Aging Inventory. Research Design This was a cross sectional study with nutrition students to establish baseline values for knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults, and preference for working with them. In 47 addition, changes in these variables following a 90-minute lecture on senior nutrition and senior meal programs were also determined. Pre- and post-tests were conducted in a predominately junior level college course on community nutrition. This course was required of all majors in dietetics and nutritional sciences. Participants and Recruitment Potential subjects were students enrolled in a junior level course on community nutrition in Fall 2002 (n=121) at a large, landgrant university in the north central United States. Subjects were primarily majors in dietetics, nutritional sciences or other health related majors. In the class, the instructor of the course made a short verbal announcement to recruit students to complete both the pre-and post-test instruments about knowledge and attitudes towards older adults of pre-health professionals. As an incentive, students received 1 point extra credit (out of 200 total for the course) on each occasion they completed instruments. Students were offered an alternative option, which was an in-class activity of about the same length for the 1point extra credit if they chose not to complete the instmments (See Appendix 1 for Alternative Activity). Procedures After approval by the University Institutional Review Board, students were recruited and the researcher administered a pre-test (12-page, instrument) at the beginning of class, during the first week of October (See Appendix 2 for the original pre-test instrument). For the pre-test, all students in the class on the day of the survey completed the instrument (n = 99) in about 30 minutes. 48 The Campus Scoring Office scored the students’ scantrons, and the results of item analysis were evaluated. Items with an Index of Discrimination $19 or an Index of Difficulty <20 or >80 were omitted or edited (Scoring Office at Michigan State University). Based on results of the pre-test, the instrument was shortened and items clarified as described in the next section. Two months following the pre-test and the lecture, a shortened instrument of eight pages was administered again to students for 1-point extra credit (Appendix 3 for the revised post-test Instrument). All 99 students in attendance that day chose to complete the post-test instrument that took approximately 15 minutes. Eighty-nine students completed both the pre-and post-tests. ngtgre on senior nut_r1t_ion and senior meal programs This lecture covered several topics including: 1)the human ecological model for senior nutritional status; 2) screening for nutrition risk in seniors; and 3) government nutrition programs of Home Delivery Meals and Congregate Meals. (See Appendix 4 for the lecture outline). Variables Two sets of insthments were used in the pre- and post-assessments of the students to measure key variables. These are described in the following paragraphs. Demographics (pre-test only). Students reported their age, gender, academic major, school year, ethnicity/race and courses taken related to aging. In addition, they were asked about their career plans following graduation. 49 Definition of older adults (pre- and post-tests). Students selected the age that they perceived to be the beginning age of ‘old’ adulthood as 55, 60, 65, 70, 75 years old, and other. Interest in working with different age groups (post-test). Interest in working with different age groups, i.e., infants, children, adolescents, adults, and older adults, was measured using a Likert Scale, with response options from 1 = not at all interested to 5 = very interested. This permitted some students the possibility of having the same level of interest in working with each of the five age groups. Preference for working with these age groups (pre- and post-tests). Preference for working with the same five age groups, was ranked from 1 = most preferred to 5 = least prefened in pre- and post-tests. Preference for working with older adults differs from interest in working with older adults, because for the latter, students were required to rank or prioritize each age group based on their interest. Interaction and experience with older adults (pre-test only). Students’ experience with older adults was probed in detail to examine how past experience might relate to their attitudes towards older adults and work preferences. Students listed the older adults with whom they had interacted most, whether they lived with the older adults, the length of interaction period, how close they were to the older adult, the older adults’ physical and mental health status, how often they contacted the older adult face to face or by mail, phone or e-mail, and the purpose of the interaction. Next, students rated the 50 overall quality of experience with older adults using a Likert scale (1= very positive to 5 = very negative). For the post-test, this section of the instrument was deleted, because the findings could not be quantified in a meaningful way to relate to attitude, and because this part took approximately 10 minutes to complete. An alternative approach to obtain this information was performed in Part II, where students’ experiences and interactions with older adults in relation to their attitudes were explored using qualitative methods. Knowledge about older adults (pre and post-tests). Knowledge about older adults was assessed using the Facts on Aging Quiz which has been widely used to assess knowledge on aging (Palmore, 1998). This quiz was answered originally as true or false and consisted of three parts (Part I, II and III) with a total of 75 questions. In 1996, The Facts on Aging Quiz was reformatted to use a multiple-choice format, reducing the effect of guessing. By 1997, over 150 studies had used Palmore’s Facts on Aging Quiz with students in a variety of majors and with various health professionals. Each item had high level of face validity, and people with training in gerontology scored higher on it than those without. Studies on the reliability of the multiple-choice format were not located, but Harris et al. (1996) reported that ”the multiple fonnat-choice format reduces the chances of guessing the correct answers and also can be used to identify more specific common misconceptions, misunderstandings, and factual errors than would be possible with the true-false format” (Harris, Changas, & Palmore, 1996). 51 Part I of the Facts on Aging Quiz was used in this pretest, because it was easiest of the three parts for nutrition students with only an introductory nutrition course as a prerequisite for the this course. Part II required more specific and in- depth knowledge to answer the items and part III focus on mental health (Palmore, 1998). Not many students were assumed to have taken courses related to aging, so the Facts on Aging Quiz Part I with the most general items was selected. For this study, students’ knowledge about older adults was assessed using Part I of the Facts on Aging Quiz, composed of 25 items, for the pretest. To test reliability of this instrument, Kuder—Richardson reliability was used which is measures the test reliability of inter-item consistency. A higher value indicates a strong relationship between items on the test and a value >0.60 is necessary to be considered acceptance. The Kuder—Richardson Reliability score for 25 items on the pretest was 0.45. Item analysis of the pretest resulted in the elimination of 12 items with unacceptable indices of discrimination and/or difficulty (See Appendix 5). Some items were edited in order to keep at least 13 items for the post-test in 2002. For the post-test of 13 items, the Kuder-Richardson Reliability was 0.41 and two items still demonstrated poor discrimination. Knowledge about geriatric nutrition (pre-and post-tests). A measure of students’ knowledge about geriatric nutrition was developed for Part I of this study because an extensive literature search uncovered no instrument appropriate for dietetics and nutritional sciences students. A review of 14 syllabi 52 from geriatric nutrition classes (Georgia State University, Madonna University, North Dakota State University, Purdue University, University of Cincinnati, University of Georgia, University of Wyoming, Brooklyn College, Oklahoma Sate University, Pennsylvania State University, University of Washington, Winthrop University, Texas Tech University, and Washington State University) led to the selection of topics within two areas of general nutritional knowledge for older adults and clinical nutrition for older adults (Figure 3.1). Nine topics focused on area of general nutrition related to older adults: 1) aging and changes in body function - such as digestion, absorption, and metabolism; 2) aging and Dietary Reference Intakes; 3) change of body composition and physical activity with aging and energy intake; 4) micronutrients and fiber with aging; 5) fluid consumption in older adults; 6) risk factors for nutritional status in older adults; 7) nutritional status of elderly in the United States; 8) nutritional assessments; and 9) nutrition services for older adults. There were eight topics on clinical nutrition knowledge for older adults covering cardiovascular diseases; hypertension; dementia/cognitive functions; diabetes; osteoporosis and dairy consumption; obesity; malnutrition/protein-calorie malnutrition; and food-drug interaction. For each topic, items were adopted from two sources (Academy of Family Physicians, American Dietetic Association & National Council on Aging, INC., 1997; Stanek, Powell, & Betts, 1991) or were generated for a specific topic area. All items had a multiple-choice response format of four choices to minimize the chances of guessing correctly. Not all this information was provided in the course on community nutrition in which subjects were recruited. 53 Figure 3.1 Development of instrument for knowledge about geriatric nutrition 14 syllabi of geriatric nutrition [_ General Geriatric Nutrition 1.Aging and changes in body function - digestion, absorption, and metabolism” 2. Aging and Dietary Reference Intakes 3.Change of body composition and physical activity with aging and energy intake" 4. Micronutrients and fiber with aging" 5.Fluid consumption in older adults* 6. Risk factors for nutritional status in older adults 7.Nutritional status of elderly in the United State” 8. Nutritional assessments“ 9. Nutrition services for older adults” ‘7, Clinical Nutrition 1 . Cardiovascular diseases 2. Hypertension 3. Dementia/cognitive functions‘ 4. Diabetes‘ 5.0steoporosis and dairy consumption* 6. Obesity 7. Malnutrition/protein-calorie malnutrition" 8. Drug interactions' . 2 questionnaires (see text) . Comments from committee 13 items in General Geriatric Nutrition 9 items in Clinical Nutrition Pro-test Reduced according to Item analvsis results I 8 Items In General 5 items in Clinical Geriatric Nutrition" 1 Nutrition“ Post-test Kuder Richardson Reliability = 0.62 .* One item from the topic included in the post-test questionnaire ** Two items from the topic included in the post-test questionnaire 54 Following review of these items for content validity by three faculty members in human nutrition and one in nursing, 22 geriatric knowledge items (13 general items and nine clinical items) were selected and answered by 99 students in the pre-test. (The Kuder Richardson Reliability was 0.45). Only 13 items had acceptable indices of difficulty and discrimination as shown in Appendix 6. To increase the reliability score and to reduce respondent burden, the 22 items were reduced to 13 based on the results of the item analysis and additional review by content experts. Ninety-nine students answered 13 knowledge items (seven general items and six clinical items) in the post-test. Post-test item analysis results showed adequate indices of discrimination and difficulty (See Appendix 6). The Kuder Richardson Reliability was 0.62, and also considered adequate (Mitchell & JoIIey, 2001). Attitudes towards older adults (pre-and post-tests). Because the Wall- Oyer Aging Inventory can assess attitudes towards older adults from both personal and general perspectives, it was selected to measure the students’ attitudes towards working with older adults. The original items of the instrument were developed based on the intuitive and reasoned notions of Wall and Oyer in the department of Speech and Hearing Science at Ohio Sate University. Five senior professors in speech and hearing, communication and change, aging and family relations checked the content validity. Test-retest reliability using the Pearson correlation was r = 0.62 (p<0.05) for the personal dimension and r = 0.72 (p<0.05) for the general dimension of the inventory (Noel, 1988). In this 55 study, the score range between 1.00 and 2.74 was considered negative; 2.75 to 3.24, neutral; and the score range between 3.25 and 5.00, positive. For this study, the internal reliability assessed by Cronbach’s alpha was 0.80 in both pre- and post-tests. The possible range of scores was between 1.00 (negative attitudes) and 5.00 (positive attitudes). Despite good reliability, one limitation of this instmment is that there is no functional cut off-point established to indicate positive or negative attitudes. Data Analysis Descriptive statistical analyses (mean, standard deviation, and frequency) were performed to describe the subjects and response to each variable on the pre-and post-tests including knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults and interests in and preference for working with each age group. To examine the relation of interest in and preference for working with older adults with knowledge about older adults and geriatric nutrition and attitudes towards older adults, the Pearson correlation coefficient was calculated. To examine changes in knowledge about older adults, knowledge about geriatric nutrition and attitudes towards older adults after the 90—minute lecture and taking a course on community nutrition, the Student’s t-test was used. To examine change in preference for working with older adults, the Wilcoxon test (Nonparametric two related sample test) was performed. 56 Part II: Dietetics and Nutrition Sciences students’ attitudes towards working with older adults Study objectives 1. To explore dietetics and nutritional sciences students’ attitudes towards working with older adults compared to working with other age groups 2. To explore the differences in attitudes towards working with older adults between students who preferred to work with older adults and those who did not 3. To explore influential factors on attitudes towards working with older adults Research Desigp Qualitative research methods were used to explore attitudes towards working with older adults compared to other age groups. Upper level nutrition students were grouped according to whether they preferred working with older adults or not. Additionally, the students’ demographic information was collected. Participants Participants were 27 students majoring in dietetics or nutritional sciences at a land—grant university in a north central United States. The students were recnrited via e-mail, flyers and visits to nutrition classes (Appendix 7). Fifty-eight students who were willing to participate in this study completed an initial survey (Appendix 8) indicating their preference for working with certain age groups, i.e., infants, children, adolescents, adults and older adults. Fifteen students ranked older adults as the first or second choice of age group to work with; this was the student group who preferred to work with older adults. Twelve 12 students 57 ranked older adults as their third choice and 31 students ranked them as their fourth or fifth choice; the later was the student group who did not prefer to work with older adults. Thirty-two students out of the 58 students who responded to the initial recnritment agreed to participate in this study, because of availability of their time to participate in focus groups or in-depth interviews. Participants in this study were 13 students who preferred to work with older adults and 14 students who did not prefer to work with this age group. Five students who ranked older adults as their third choice of a group to work with participated in the pilot focus group. All participants received a coupon ($1.25) to a campus snack shop as an incenfive. Procedures After approval by the University Institutional Review Board, two moderators (interviewers) were trained according to interview guidelines (Greenbaum, 2000). One moderator was a non-Hispanic, white masters’ degree student in human nutrition and dietetics. The other moderator was a dietetics senior who was a non-Hispanic, white American. One pilot focus group (n = 5) was conducted. After a debriefing session with these students, the focus group moderator and the researcher reworded several questions. Four focus groups and 10 in-depth interviews were conducted separately following recommended procedures, half with students who preferred to work with older adults and half with those students who did not. There were two reasons to use two different qualitative data collection such as focus groups and in-depth interviews. First, 10 students were not available to attend one of the 58 focus groups scheduled. Also, using two different methods is known as triangulation for qualitative methods and considered to enhance the strength of finding, when two different data collection techniques results in the same pattern of results from the two techniques. Participants can respond differently in group discussions and individual interviews, so using both methods can help detect different patterns of responses. Focus groups were conducted in a conference room at the university and took approximately one hour. After a brief introduction, the focus group moderator reviewed the consent form (Appendix 9) with the participants and explained their right to withdraw from the research at any time. Additionally, the moderator explained the confidentiality of participation and described the research in general. Before starting the actual discussion, participants signed a consent form. Participants completed a short survey (Appendix 10) on their demographics, the courses they had taken related to aging, and their attitudes towards working with each age group, i.e., infants, children, adolescents, adults and older adults. Next, the moderator explained the procedures and led the discussion according to stnrctured questions. The researcher took field notes to help distinguish voices when multiple participants spoke at the same time. The interview questions (Appendix 11) were followed by inquiries and probes for more information. The moderator managed the discussion time to allow each participant to have an equal chance to participate. Two audiotape recorders were used for each focus group to ensure that the discussion was recorded. For the in-depth interviews, nearly identical 59 procedures were followed, with the exception that the interviews took only 20—30 minutes (Informed consent from: Appendix 12). lnstnrments 1. Demographics and attitudes towards working with certain age groups The one-page demographic questionnaire included gender, race/ethnicity, age, major, classes taken related to aging, and future job plans or preferred profession. Students described their beliefs about working with different age groups in the questionnaire in order to prevent influencing each other during the group discussions. 2. Focus group and in-depth interview questions Standard focus group and in-depth interview questions are generally composed of five types of questions, such as the opening, an introduction, transitions, the key and ending questions (Krueger & Casey, 2000). The key questions for this study were developed to explore students’ attitudes towards working with older adults compared to other age groups, i.e., infants, children, adolescents, and adults. Questions about contributing factors to their attitudes were developed based on the Theory of Planned Behavior and the findings from Part I of this dissertation. The key interview questions are in Table 3.1. 60 Table 3.1 Research questions and key interview questions Research Questions 1. What are the attitudes towards each age group including infants, children, adolescents, adults or older adufis? Key Interview Questions Please complete the following sentences. > Working with infants would be _. > Working with children would be _. > Working with adolescents would be > Working with adults would be _. > Working with older adults would be c What factors affected these responses? 0 What experiences do you have with each age group? 2. How does perceived job satisfaction and professional confidence influence students’ attitudes towards various age groups of clients? 0 What would make you feel confident to work with your preferred age group? a What would make you feel not confident to work with your preferred age group? 0 Which group is most fulfilling to work with? o What would make you satisfied with working with your preferred age group? . What would make you dissatisfied to work with your preferred age group? 3A. What factors affect students’ preference for working with a certain age group over other age groups? . With what age do you prefer to work? 0 What things made you prefer to work with this age group? a What kind of experience do you have with your preferred age group? . How often do you interact with your preferred age group? 3B. How important is the age group of clients in students' job selection? 0 What things will you consider when you are looking for a job and job selection? 0 What things are the most important factors when you will consider a job? 0 How important is the age group of your clients for your job selection? Data analysis Descriptive statistical analyses were performed on the quantitative data from the demographic survey. Content analysis of the qualitative data followed prescribed steps (Strauss, 1987). First, the audio taped data from each focus group and each in-depth interview were transcribed verbatim by an undergraduate assistant, and then the researcher reviewed all the transcripts for accuracy. Secondly, the researcher and one masters’ student independently coded the transcripts. Each transcript was coded using the open coding method 61 (Strauss, 1987) where the researcher underlined key words, phrases or sentences related to the research questions. After open coding all the transcripts, similar concepts or ideas were categorized into one group (axial coding) (Strauss, 1987) and overarching themes were identified. Then the researcher compared material (contents) within categories and across categories. When necessary, categories were reorganized appropriately. For example, one category might be split into two categories or multiple categories merged into one category. Finally, the researcher checked and discussed the coding, categories and themes with those done by the other independent coder to reach coding consensus and to find common themes. The average inter-rater reliability of the open coding by the two independent coders for the focus group was 0.74 and for in-depth interview was 0.85. Part III: Improving Dietetics and Nutritional Science Students’ Attitudes towards Older Adults Study objective 1. To design and implement an intervention and evaluate its effect on students’ attitudes towards older adults Research Design This study used a pre- and post-test design with an intervention (Figure 3.2). All nutrition students in a junior level community nutrition class were randomly assigned to work with either an older adult (intervention group) or with a young adult (comparison group) to conduct an assigned project on dietary 62 636.5 5.2622... 65 c. $.36 .626 5.3 9.2.63 .8 69.6.6.6... u 0.5.“. 6:65 266.6688 65 c. $.36 .626 5.3 9.3.9... 8.. 66:26.65 u 0.5.. 9.6.6 c8526.... 65 c. 8.366 .626 5.3 653.6; c. 56.6.... n .>>. 955 56:62.88 65 c. 3.366 .626 5.; 95.95 c. «66.6.5 u 0.5. 9.65 5.56262. 65 c. 8.366 .626 62632 6663...... u C< use... coatSES 65 c. 3.366 .626 536 6666.255. u 05. .52.. 8.56:2... 65 c. 6.33 .620 53.. 88.383. n .5. Bee c8c858 65 a. 6.8m 62° «22.5. 8252 u 02 «CE F02f..— ~O>>_ PU>>_ N05. .64"... .62 .5"... :5. N0...... comtmano F0.3. comtmanO E.< ~_>>n. A: ..................... .v. F_>>n. _..6.c_ voom .5. c .E . . 60 co 5.86:6”. Avoow .660. .vm 52 co 6:0 Avoow .569 an" 5 26:66:86 666866 .6 new 80 co umwwmmhunr. .6.66E66 .o mc.cc.m6m 6332.30 80.. u 5 36" “6633.. . . .3: n 5 team «68.6... ~=eE=o.em< .maceteaxm 5 tan. 3.. 5.86 .536 u.» 2:6... 63 behavior change. Changes in knowledge about older adults, attitudes towards older adults, and preference and interest in working with older adults were assessed before and after the intervention using psychometric scales. In addition, changes in attitudes towards older adults and working with older adults were explored through content analysis of students’ reports from the experiential assignment Part A (individual reflections on this assignment) and in Part B (the group reflections on this assignment). Intervention The intervention was composed of two components: 1) the experiential assignment, Part A, which included direct interaction with a client to complete a dietary change assignment (half of the students were assigned to an older adult 265 yr and half assigned to work with a young adult (20—30 yr) and 2) theexperiential assignment, Part B, was a small group discussion about the assignment by students (n=4 - 5 in each group), who had all worked with a client from the same age group (Appendix 13 for the dietary behavior change assignment). Part A of this assignment was neariy identical to one of two final project options used in this course for the previous three years. However, the course instructor had never previously assigned the students’ client age groups, and few students had worked with clients over 55 years of age. Part A. The purpose of the experiential assignment Part A was to give students an Opportunity to interact with an older adult or a young adult to help a client change a dietary behavior as a pre-health professional. The objectives of this experiential assignment were: 1) to build students’ skills in identifying clients’ 64 self perceived needs, wants, health goals and motivation for change; 2) to change students’ attitudes about the importance of Ieaming about the clients’ needs and wants with professional counseling; and 3) to experience the importance of setting one small goal at a time (through a behavioral change objective) in order to increase the client's self-efficacy for dietary change, as well as their own self-efficacy as pre-health professionals. Each student found one client from her/his assigned age group by him/herself or through the aid of a researcher (SYL). Criteria to be a client for this assignment were: 1) not a family member or close friend, e.g., grandparents, sister, brother, boyfriend, or girlfriend; 2) not an institutionalized person, because of limited dietary choices or preplanned meals; and 3) someone willing to change a dietary behavior. These criteria did not eliminate people in assisted living or in campus resident halls. Diversity in clientele was desirable in terms of age, health, and socioeconomic status. To be prepared to assist students in the intervention group to find clients, the researcher recruited 77 older adults from congregate meal sites, senior centers, the university’s retiree association and retirement living facilities (See Appendix 14). In addition, eight young adults from the university, who were willing to change a dietary behavior were recmited to help students in the comparison group (See Appendix 15). Twenty-five students in the intervention group needed a contact from the list of older adults and two students in the comparison group requested a contact for a young adult. In the first meeting with their client, students conducted a dietary assessment (24-hour dietary recall), interviewed the client about lifestyle and 65 dietary patterns, identified the client’s perceived needs, wants, health goals and beliefs, and discussed willingness and interest to change a dietary behavior. The second meeting was conducted after the student completed a nutrient analysis of the client’s diet from the 24-hour dietary recall. At this meeting, and together with the client, the student developed three specific and measurable behavioral objectives for dietary change. The client then chose only one of the three objectives on which to work over the next three days and kept dietary records for each day for subsequent analysis by the student. At the third and final meeting, the student provided feedback on the client’s progress and discussed the client’s perceptions of success and barriers to change. In this assignment, students described their relationship with the client in addition to stating the number and length of interactions with the client. Part B. The Instructor assigned students to a group of four to five others with whom to complete Part B of this assignment. Each group who worked with a client from the same age group held a small group discussion. The purpose of this part was to provide students the opportunity to compare and contrast their individual experiences and share findings with their peers. The discussion questions were designed to help students recognize heterogeneity of age and health status within each age group. The duration of group discussions was approximately 30 minutes and concluded with a short report written by the entire group for which they shared the grade. Students described their reflections on the assignment following key questions stated in Table 3.2. 66 Table 3.2 Research questions and questions in the assignment Research Question 4. In what ways are students’ attitudes towards older adults and working with older adults influenced by completing the experiential assignment? 4A. How are students’ beliefs about older adults and working with older adults influenced by interacting with older adults? 4B. How are students' beliefs about older adults and working with older adults influenced by participating in the small group discussion? 4C. How are students' values on working with older adults influenced by interacting with older adults? 4D. How are their values on working with older adults influenced by participating in the small group discussion? 5. How do changes in students’ perceived self-efficacy in working with older adults relate to changes in their attitudes (values and beliefs) towards working with older adults? 6. How do changes in students' perceived satisfaction with working with older adults relate to changes in their attitudes (values and beliefs) towards working with older adults? Participants Key questions in the experiential assimment report 0 How have your perception and beliefs about your client age group changed after completing the assignment Part A and if so, how and why? Have any of your perceptions and beliefs about your client age group and working with your client group changed after your group discussion? If, so, how and why? Have any values in working with your client age group changed after completing the assignment Part A and if so, how and why? Have any of your values on working with your client age group changed after completing the assignment Part B group discussion, and, if so, how and why? a What was the hardest part and why? 0 What kind of information, skills and previous experiences helped you with this assignment? What changes were there in your confidence in ability to work with your client as fire-health professional? What was the most satisfactory part and why? What changes were there in your perceived satisfaction in working with a client as a pre-health professional? Potential participants were students enrolled in a junior level course on community nutrition, Fall 2004 (n=129). The students were primarily majoring in dietetics, nutritional sciences or double majors (in dietetics and nutritional sciences) at a land-grant university in the north central United States. After the researcher briefly described the purpose of this study, students were invited to participate in each assessment (pre- and post-tests). As an incentive, students received 1 point extra credit (out of 200 total points for the course) for completing each assessment. Procedures After approval by the University Institutional Review Board, the researcher invited students in the course to complete an 11-page, multiple choice, 15-20 minute, self-administered in-class assessment (See Appendix 16) early in the fall semester. Students were offered an alternative in-class activity for extra credit if they chose to not to participate in the assessment (See Appendix 17 for Alternative Activity). Prior to the intervention, students Ieamed how to write behavioral objectives from class lectures and activities on nutrition education and behavior change. This assignment provided the opportunity for students to experience and apply such didactic knowledge, as well as to develop their self-confidence to do so. The instructor assigned students to their respective group and distributed the assignment. Students submitted the completed dietary behavior change assignment for a grade. Students were asked to give the researcher permission to review and use their assignment, without grade penalty; all students agreed to permit the researcher to review their reports (the consent form in Appendix 18). During the last two weeks of class, the students were recruited to participate in the post-test, a 6-page, multiple choice, 10 minute, self- administered in-class assessment (See Appendix 19). An in-class extra credit 68 activity was offered again for those who might choose not to complete the assessment (See Appendix 17 for Alternative Activity). Variables The pre- and post assessments of students used two sets of instruments to measure key variables. These are described in the following paragraphs. Demographics (pre-test only). Students reported their age, gender, academic major, school year, ethnicity/race, and list of courses taken related to aging. In addition, they were asked about their career plans following graduation. Definition of older adults (pre- and post-tests). Students selected what they perceived to be the beginning age of ‘old’ adulthood from 55, 60, 65, 70, 75 years old, and other. Interest in working with different age groups (pre- and post-tests). Interest in working with different age groups, i.e., infants, children, adolescents, adults, and older adults, was measured using a Likert Scale, with response options from 1 = not at all interested to 5 = very interested. This allowed some students the possibility of having the same level of interest in working with each of the five age groups. Preference for working with these age groups (pre- and post-tests). Preference for working with the same five age groups, was ranked from 1 = most prefened to 5 = least preferred in pre- and post-tests. Preference for working with older adults differs from interest in working with older adults, because for the latter, students were required to rank or prioritize each age group based on their interest. 69 Interaction and experience with older adults (pre-test only). Students were asked to rate the overall quality of their previous experience(s) with lolder adults using a Likert scale (1 = very positive to 5 = very negative). Interaction with grandparents and work or volunteer experiences with older adults were explored by five additional items, which probed for length, frequency and quality of such interactions. Knowledge about older adults (pre and post-tests). Knowledge about older adults was assessed using the Facts on Aging Quiz, which has been widely used to assess knowledge on aging (Palmore, 1998). Thirteen items, which remained after item analysis, were administered and had a low Kuder Richardson Reliability = 0.35. Attitudes towards older adults (pre-and post-tests). Because the Wall- Oyer Aging Inventory can assess attitudes towards older adults from both personal and general perspectives, it was used to measure the students’ attitudes towards working with older adults. Internal reliability Cronbach’s alpha was 0.75 and 0.82 in both pre- and post-tests, respectively. Despite good reliability, one limitation of this instrument is that no cut-point has been standardized as indicating positive or negative attitudes. In this study, the score range between 1.00 and 2.74 was considered as negative; 2.75 to 3.25, neutral; and the score range between 3.25 and 5.00, positive. Data Analysis From the pre-and post-tests, descriptive statistics (mean, standard deviation, and frequency) were used to describe the participants, as well as the 70 variables for knowledge about older adults, attitudes towards older adults, interest in and preference for working with a certain age group. Differences were calculated in scores for knowledge about older adults, attitudes towards older adults, and interest in working with a certain age group at pre- and post-tests. These scores were compared between intervention and comparison groups. Because there was a correlation between attitudes towards older adults and interest in working with older adults, General Linear Model (GLM) Multivariate analysis was used to test whether there were significant differences in knowledge about older adults, attitudes towards older adults, and interest in working with older adults as a unit between intervention and comparison groups. The value of knowledge about older adults, attitudes toward older adults and interest in working with older adults at pre-test were entered as covariates. GLM Univariate Analysis was then performed to test for a significant change in each variable. The score of knowledge about older adults in the comparison group was significantly higher than that of the intervention group at pre-test, so the value at pre-test was entered as a covariate for GLM Univariate Analysis. The difference in the frequency of students’ preference for working with older adults was calculated, and the difference between intervention and comparison groups was tested using independent t-test. The Pearson’s correlation among the scores of knowledge, attitudes, interest, and preference was calculated, as well as the correlation among changes in those variables after intervention. Students’ reports for the selected nine questions from the assignment Parts A and B were analyzed using content analysis and logical analysis (Patton, 71 1987). How students' beliefs about older adults and about working with older adults changed, and how such changes related to changes in attitudes, self- efficacy, and perceived satisfaction in working with older adults were investigated. Two independent coders used the codes and categories developed in previous qualitative research of this study to explore students’ attitudes towards working with older adults. New codes were added as new themes were identified. Inter-rater reliability of the coding by two independent coders was 0.88 for the individual reflection and 0.86 for group reflection analysis. A cross-classification matrix was generated to explore the emergent pattern of linkages among changes in beliefs about older adults and working with older adults and in self- efficacy and satisfaction to work with older adults (logical analysis) (Patton, 1987). 72 CHAPTER 4 Nutrition students’ knowledge about older adults, attitudes towards this age group and preference for working with them ABSTRACT The purposes of this study were to evaluate students’ knowledge about older adults and geriatric nutrition, attitudes towards older adults, as well as, their preference for working with older adults and to examine changes in these variables after one lecture on senior nutrition and meal programs. Eighty-nine students in a junior level college course on community nutrition completed questionnaires. Most students majored in dietetics and nutritional sciences. The Facts on Aging Quiz Part I and the Wall-Oyster Aging Inventory were used to assess knowledge about older adults and attitudes towards older adults, respectively. A geriatric nutrition knowledge questionnaire was developed for this study. Interest in working with older adults was assessed by one item with a Likert response format and preference for working with older adults was also measured using rank order. The average correct response rate for knowledge about older adults was less than 50% (6.4 i 2.3 for 13 items) and geriatric nutrition, 57% (7.4 d: 2.6 for 13). The mean of attitude scores was neutral. There were significant relationships between interest in working with older adults and attitudes toward aging (r = 0.50, p<0.01), between knowledge about older adults and geriatric nutrition (r = 0.38, p<0.01) and knowledge about older adults and 73 attitudes toward aging (r = 0.215, p<0.05). After the one lecture on senior nutrition and meal programs, there were no significant changes in knowledge about older adults but there was a slight decrease in attitudes and interest in working with older adults. Educators need to find ways to improve knowledge about older adults and attitudes towards older adults as well as to increase interest in working with older adults to help meet the growing demand for health care with this age group. INTRODUCTION The population 65 years and older continues to increase and is expected to reach 20% of the US population by 2030. Older adults have unique physiological needs as a result of both the normal aging process and frequent chronic conditions. Older adults frequently have three or more chronic conditions, take multiple medications, respond differently to treatments and medications and use more health care services than any other age group (Kirby, Machlin, & Thorpe, 2004). In spite of such needs, there is a shortage of health and allied health professionals qualified to work in geriatrics and gerontology (Kovner et al., 2002; Reuben et al, 1991). This shortage is a major concern for health care in the US (Kovner et al., 2002). Further compounding this shortage of health care professionals in geriatrics is the fact that students majoring in health and allied health professions demonstrate low interest in and preference for working with older adults (Aday & Campbell, 1995; Carmel et al., 1992; David-Berman, & Robinson, 1989; 74 Fitzgerald et al., 2003; Gomez, Young, & Gomez, 1991; Greenhill, 1983; Hart et al., 1976; Kayser, & Minnigerode, 1975; Mount, 1993; Robb, 1979). Previous research has shown that a major contributing factor to low interest in working with older adults is the negative attitudes about older adults and aging held by pre-health professionals. Students in the health professions also demonstrate a lack of knowledge about older adults and the process of aging (Dail & Johnson, 1985; Edward & Aldous, 1996; Menz et al., 2003; Sachs et al., 1984; Wilson & Hafferty, 1980). Nutrition is essential for successful aging, as well as, for health maintenance and diet-related disease control for older adults. Most older adults (87%) have at least one or more diet-related chronic diseases such as diabetes, hypertension and dyslipidemia, which could be improved with adequate nutrition interventions (Institute of Medicine, 2000). Nutrition interventions for older adults such as medical nutrition therapy (MNT) and nutrition education have demonstrated positive outcomes when followed in chronic disease management for diabetes, cardiovascular disease, renal disease, and osteoporosis (Institute of Medicine, 2000; Jonnalagadda, 2004; Sahyoun, Pratt & Anderson, 2004). Dietitians and nutritionists have increased opportunities to work with this age group, especially since the expansion of MNT benefits (Special Report on Medicare HR1, 2003). Despite the importance of nutrition in preventing diet- related chronic diseases and delaying progress of disease, only a few studies have assessed nutrition students’ interest in and preferences for working with older adults and their attitudes toward older adults (Kaempfer et al., 2002; Rasor- 75 Greenhalgh et al., 1993). Thus, the purposes of this study were: 1) to assess dietetics and nutritional sciences students’ knowledge about older adults, attitudes towards older adults and interest in and preference for working with older adults; 2) to examine the effect of a 90-minute lecture to nutrition students on their knowledge about older adults, attitudes towards older adults and preference for working with older adults; and 3) to test the validity and reliability of instruments for measuring knowledge about older adults and attitudes towards older adults. Anticipated outcomes were that knowledge about older adults would relate to the attitudes towards older adults and interest in and preference for working with this age group. The lecture on nutrition and aging and senior meal programs was not expected to change attitudes but possibly to improve knowledge about older adults and about geriatric nutrition to some extent. METHODS Research Design This was a study with nutrition students to establish baseline values for knowledge about older adults, knowledge about geriatric nutrition, attitudes toward older adults, and interest in and preference for working with older adults. In addition, it was determined whether there were changes in these variables following the regular 90-minute lecture on senior nutrition and senior meal programs. Pre- and post-tests were conducted in a predominately junior level college course on community nutrition. This course was required of all majors in dietetics and nutritional sciences. 76 Participants and recmitment Potential subjects were students enrolled in a course on community nutrition in Fall 2002 (n=121) at a land-grant university in the north central United States. These were primarily majors in dietetics, nutritional sciences or other health related areas. The instructor made a short, verbal in-class announcement to recruit students to complete both the pre-and post-test instruments about knowledge and attitudes towards older adults of pre-health professionals. As an incentive, students received 1 point extra credit (out of 200 total for the course) on each occasion they completed instruments. Students were offered an alternative option, which was an in-class activity of about the same length for the 1-point extra credit if they chose not to complete the instruments (See Appendix 1 for Alternative Activity). Procedures After approval by the University Institutional Review Board, students were recruited and the researcher administered a pre-test (12-page instrument) at the beginning of class, during the first week of October (See Appendix 2 for the original Pre-test lnstmment). For the pre-test, all students in the class on the day of the survey completed the instrument (n = 99) in about 30 minutes. The Campus Scoring Office scored the students’ scantrons, and the results of item analysis were evaluated. Items with an Index of Discrimination $19 or an Index of Difficulty <20 or >80 were omitted or edited (Scoring Office at Michigan State University). Based on results of the pre-test, the instrument was 77 shortened and items clarified as described in the next section. Two months following the pre-test and the lecture, a shortened instnrment of eight pages was administered again to students for 1-point extra credit (See Appendix 3 for the revised post-test Instrument). All 99 students in attendance that day chose to complete the post-test instrument that took approximately 15 minutes. Eighty- nine students completed both the pre-and post-tests. Lecture on senior nutrition and senior meal prpgrams This lecture covered several topics including: 1) the human ecological model for senior nutritional status; 2) screening for nutrition risk in seniors; and 3) government nutrition programs of Home Delivery Meals and Congregate Meals. (Appendix 4 for lecture outline). Variables Two sets of instruments were used for he pre- and post assessments of students to measure key variables as follows. Demographics (pre-test only). Students reported their age, gender, academic major, school year, ethnicity/race and courses taken related to aging. In addition, they were asked about their career plans following graduation. Definition of older adults (pre- and post-tests). Students selected the age that they perceived to be the beginning age of ‘old’ adulthood as 55, 60, 65, 70, 75 years old, and other. Interest in working with different age groups (post-test). Interest in working with different age groups, i.e., infants, children, adolescents, adults, and older adults, was measured using a Likert Scale, with response options from 1 = 78 not at all interested to 5 = very interested. This permitted some students the possibility of having the same level of interest in working with each of the five age groups. Preference for working with these age groups (pre- and post-tests). Preference for working with the same five age groups, was ranked from 1 = most preferred to 5 = least preferred in pre- and post-tests. Preference for working with older adults differs from interest in working with older adults, because for the latter, students were required to rank or prioritize each age group based on their interest. Interaction and experience with older adults (pre-test only). Students’ experience with older adults was probed in detail to examine how past experience might relate to their attitudes towards older adults and work preferences. Students listed the older adults with whom they had interacted most, whether they lived with the older adults, the length of interaction period, how close they were to the older adult, the older adults’ physical and mental health status, how often they contacted the older adult face to face or by mail, phone or e—mail, and the purpose of the interaction. Next, students rated the overall quality of experience with older adults using a Likert scale (1= very positive to 5 = very negative). For the post-test, this section of the instrument was deleted, because the findings could not be quantified in a meaningful way to relate to attitudes, and because this part took approximately 10 minutes to complete. 79 Knowledge about older adults (pre and post-tests). Knowledge about older adults was assessed using the Facts on Aging Quiz which has been widely used to assess knowledge on aging (Palmore, 1998). This quiz was answered originally as tme or false and consisted of three parts (Part I, II and III) with a total of 75 questions. In 1996, The Facts on Aging Quiz was reformatted to use a multiple-choice format reducing the effect of guessing. By 1997, over 150 studies had used Palmore’s Facts on Aging Quiz with students in a variety of majors and with various health professionals. Part I of the Facts on Aging Quiz was used in this pretest, because it was easier for the nutrition students compared to the other two parts (Palmore, 1998). Each item had a high level of face validity, and people with training in gerontology generally score higher on it than do those without training. Studies on the reliability of the multiple-choice format were not located, but Harris et al. (1996) reported that ”the multiple fonnat-choice format reduces the chances of guessing the correct answers and also can be used to identify more specific common misconceptions, misunderstandings, and factual errors than would be possible with the true-false fonnat”(Harris et al., 1996). For this study, students’ knowledge about older adults was assessed using Part I of the Facts on Aging Quiz, composed of 25 items, for the pretest. The Kuder-Richardson Reliability score for 25 items on the pretest was 0.45. Item analysis of the pretest resulted in the elimination of 12 items with unacceptable indices of discrimination and/or difficulty (See Appendix 5). Some items were edited in order to keep at least 13 items for the post-test. For the 80 post-test of 13 items, the Kuder-Richardson Reliability was 0.41 and two items still demonstrated poor discrimination. Knowledge about geriatric nutrition (pre-and post-tests). A measure of students’ knowledge about geriatric nutrition was developed for this study because an extensive literature search uncovered no instrument appropriate for dietetics and nutritional sciences students. A review of 14 syllabi from geriatric nutrition classes (Georgia State University, Madonna University, North Dakota State University, Purdue University, University of Cincinnati, University of Georgia, University of Wyoming, Brooklyn College, Oklahoma Sate University, Pennsylvania State University, University of Washington, Winthrop University, Texas Tech University, and Washington State University) led to the selection of topics within two areas of general nutritional knowledge for seniors and clinical nutrition for seniors. There were nine topics for the general nutrition for seniors: aging and changes in body function - such as digestion, absorption, and metabolism; aging and Dietary Reference Intakes; change of body composition and physical activity with aging and energy intake; micronutrients and fiber with aging; fluid consumption in older adults; risk factors for nutritional status in older adults; nutritional status of elderly in the United States; nutritional assessments; and nutrition services for older adults. There were eight topics on clinical nutrition knowledge for seniors covering cardiovascular diseases; hypertension; dementia/cognitive functions; diabetes; osteoporosis and dairy consumption; obesity; malnutrition/protein-calorie malnutrition; and food-drug interaction. For each topic, items were adopted from two sources (Academy of Family Physicians, 81 American Dietetic Association & National Council on Aging, INC., 1997; Stanek, Powell, 8 Betts, 1991) or were generated for a specific topic area. All items had a multiple-choice response format of four choices to minimize the chances of guessing correctly. Following review of these items for content validity by three faculty members in human nutrition and one in nursing, 22 geriatric knowledge items (13 general items and nine clinical items) were selected and answered by 99 students in the pre-test. (The Kuder Richardson Reliability was low 0.45). Only 13 items had acceptable indices of difficulty and discrimination as shown in Appendix 6. To increase the reliability score and to reduce respondent burden, the 22 items were reduced to 13 based on the results of the item analysis and additional review by content experts. Ninety-nine students answered 13 knowledge items (seven general items and six clinical items) in the post-test. Post-test item analysis results showed adequate indices of discrimination and difficulty (See Appendix 6). The Kuder Richardson Reliability was 0.62, also considered adequate (Mitchell & Jolley, 2001). Attitudes towards older adults (pre-and post-tests). Because the Wall- Oyer Aging Inventory can assess attitudes towards older adults from both personal and general perspectives, it was selected to measure the students' attitudes towards working with older adults. The original items of the instrument were developed based on the intuitive and reasoned notions of Wall and Oyer in the department of Speech and Hearing Science at Ohio Sate University. Test- retest reliability using the Pearson correlation was r = 0.62 (p<0.05) for the 82 personal dimension and r = 0.72 (p<0.05) for the general dimension of the inventory. Five senior professors in speech and hearing, communication and change, aging and family relations checked the content validity (Noel, 1988). For this study, internal reliability, Cronbach’s alpha was 0.80 in both pre- and post-tests. The possible range of scores was between 1.00 (negative attitudes) and 5.00 (positive attitudes). Despite good reliability, one limitation of this instrument is that there is no functional cutoff-point established to indicate positive or negative attitudes. Data Analysis Descriptive statistical analyses (mean, standard deviation, and frequency) were performed to describe the subjects and response to each variable on the pre-and post-tests including knowledge about older adults, knowledge about geriatric nutrition, attitudes towards older adults, and interest in and preference for working with each age group. To examine the relation of interest in and preference for working with older adults with knowledge about older adults and geriatric nutrition and attitudes toward older adults, the Pearson correlation coefficients were calculated. To examine changes in knowledge about older adults, knowledge about geriatric nutrition and attitudes toward older adults after the 90-minute lecture and taking a Community Nutrition class, the student’s t-test was used. To examine change in preference for working with older adults, the Wilcoxon test (Nonparametric two related sample test) was performed. 83 RESULTS Dempgraphics The average age of subjects was approximately 21 years old, and most were females as shown in Table 4.1. The majority were majors in dietetics or nutritional sciences in their junior or senior years. Table 4.1 Demographics of subjects who completed both pre- and post- tests (n = 89) Dietetics and Nutritional Variable All students ( n = 89 ) Science students (n = 74) Age (mean 1: SD year) 20.7 :t 4.1 21.1 :t 3.0 Major (%) Dietetics 49.4 59.5 Nutritional Science 28.1 33.8 Others1 22.5 6.6 Gender (%) Female 89.1 89.1 Male 10.9 10.9 School year (%) Sophomore 7.9 8.1 Junior 57.3 62.2 Senior 32.6 28.4 Others2 2.2 1.4 Racel ethnicity (%) Non Hispanic White 83.1 83.8 African American 3.4 2.7 Asian/Pacific Islander 12.4 13.5 Others 1.1 0 1 Double majors including dietetics or nutritional sciences 2 Health related major including Health & Humanities, Education, Family Consumer Science, Food Sciences, and General Management 84 Beginning of old age More students tended to define the beginning of old age as a higher chronological age in post-test than in the pre-test (Table 4.2). However, there was no significant difference between the pre and post-test (Chi-square and paired t-test). The Spearrnan correlation coefficient between the pre- and post- tests was 0.38 (p<0.01). Table 4.2 Percentage of students responding the listed age group to the Item, “When does old age begin?” 2:23:23 55 or less 60 65 70 3:: A" subjects Pre-test 3.4 27.0 25.8 27.0 15.7 (n = 89) Post-test 3.5 17.6 31.8 32.9 14.1 Dietetics and Nutritional Pre-test 4.1 23.3 27.4 45.2 1 3.7 science students (n = 74) Post-test 4.3 18.6 31.4 32.9 12.9 Importance of environmental sociafiflars fomofessional iob preference Family advice was the most influential factor in job preference and 87.5% and 81.5% of students ranked family advice as important or very important. Societal needs also were an important factor in job preference (71.5% and 75%, rated it important or very important in the pre- and post-tests, respectively). Approximately 70% of students reported that their professors’ counseling was an influential factor in their job preference. Responses to these items are in Table 4.3. 85 Table 4.3 Percentage of degree of importance of social and environmental factors in job preference Very Not Not at all Importance important Important Neutral important important All students (n= 89 ) Family's Pre-test 42.0 45.5 8.0 4.5 0 39"“ Post-test 33.3 48.6 13.9 1.4 2.8 Friends’ Pre-test 8.0 40.9 30.7 18.2 2.3 ammdes Post-test 13.9 37.5 25.0 19.4 4.2 Professor's Pre-test 19.3 56.8 19.3 4.5 0 °°”"s°""9 Post-test 23.6 45.8 23.6 6.9 0 Mass Pre-test 1 .1 30.7 31 .8 28.4 8.0 Media influences Post-test 2.8 22.2 37.4 31 .9 8.3 S oci etY'S Pre-test 29.5 42.0 20.5 8.0 0 needs Post-test 25.0 50.0 19.4 4.2 1.4 Dietetics and Nutritional Science students (n= 74 ) F amily’s Pre-test 39.7 45.2 9.6 5.5 0 39"“ Post-test 33.3 48.6 13.9 1.4 2.8 amdes Post-test 13.9 37.5 25.0 19.4 4.2 Professor's Pre-test 19.2 57.5 17.8 5.5 0 °°”"s°""9 Post-test 23.6 45.8 23.6 6.9 0 Mass Pre-test 1 .4 31 .5 30.1 30.1 6.8 Media influences Post-test 2.8 22.2 34.7 31.9 8.3 S oci ety' s Pre-test 28.8 42.5 19.2 9.6 0 "Beds Post-test 25.0 50.0 19.4 4.2 1.4 86 Interest in working with a certain age group The interest in working with a certain age group was asked only in the post-test and is shown in Table 4.4. Vocational interest in working with older adults was rated significantly lower than for all the other groups (ANOVA, Bonferroni comparison a= 0.05 level, p<0.001). Table 4.4 Mean of interest level to work with different age groups using Likert Scale (post-test) Older Infants Children Adolescents Adults adults All students 3.75i1.08 4.03:0.90 4.13:0.93 3.84:1:0.97 3.03:1.13 (n=89) Dietetics/nutritional science students 3.76i1.67 4.011093 4.17:t0.86 3.96i0.86 31311.08 (n=74) * Likert scale: 1: not at all interested to 5 = very interested Preference for working with a certain age group In the pre-test, the preference for working with older adults by ranking was significantly low as shown in the Table 4.5. In the pre-test, 38% of students chose older adults as a least preferred group with whom to work, but at the post- test 56% responded that older adults was the least preferred group. There was a significant difference between pre and post-tests (NPAR Wilcoxon test, p<0.05). In other words, after the 90-minute lecture in the community nutrition course, students reported reduced preference for working with older adults. 87 Table 4.5 Percentage of job preference for working with a certain age group using rank order Preference 1 2 3 4 5 All students (n = 89) |nfants Pre-test 7.9 12.4 23.6 24.7 31 .5 Post-test 10.1 25.8 19.1 20.2 24.72 Pre-test 37.1 19.1 24.7 10.1 9.0 Children Post-test 34.8 16.9 28.1 15.7 4.5 Pre-test 25.8 33.7 18.0 7.9 14.6 Adolescents Post-test 28.1 31.5 22.5 10.1 7.9 Adults Pre-test 24.7 13.5 14.6 27.0 20.2 Post-test 23.6 18.0 20.2 33.7 4.5 Older Pre—test 4.5 12.4 19.1 25.8 38.2 Adults Post-test 5.6 7.9 12.4 18.0 56.2 Dietetics and Nutritional Science students (n = 74) Infants Pre'teSt 8.1 12.2 24.3 23.0 32.4 Post-test 12.2 24.3 18.9 21.6 23.0 . Pre-test 36.5 16.2 25.2 12.2 9.5 Children Post-test 33.8 16.2 28.4 17.7 4.1 Pre-test 24.3 35.1 17.6 9.5 13.5 Adolescents Post-test 28.4 31.1 21.6 10.8 8.1 Adults Pre-test 25.7 14.9 16.2 25.7 17.6 Post-test 23.0 21.6 20.3 32.4 2.7 Older Pre-test 5.4 13.5 17.6 25.7 37.8 Adults Post-test 5.4 6.8 13.5 14.9 59.5 ' Rank order: 1 (most preferred) to 5 (least preferred) Knowledge abggt older adLItS and geriatric nutritionI and attitudes toward older adufls The average score for knowledge about older adults, 10.8 (43% correct response) was low, and there was no significant difference between the average scores at the pre- and post-tests comparing only the common items (Table 4.6). 88 The average score for the knowledge about geriatric nutrition was 12.5 (54% correct response) and there was no significant difference in scores between pre and post-tests. The average attitudes score, 3.50 at the pre-test, was significantly higher than that of post-test, 3.35 (p<0.001). Twenty-two students’ attitudes towards older adults improved; ten students remained unchanged; and 57 students’ attitudes shifted negatively. Figure 4.2 shows the negative shift in attitudes towards older adults following the 90-minute lecture. Table 4.6 Student Responses to Knowledge and Attitudes Mean 1 SD of raw score (% correct) Pre-test Post-test All students (n=89) Knowledge about older adults 6.03 i 2.22 (46%) 6.37 i 2.27 (49%) (1 3 items) Knowledge about geriatric 5.73 i 1.88 (57%) 5.81 i 2.22 (58%) nutrition (10 items) Attitudes toward older adults“M 3.51 i 0.4 3.37 i 0.40 (1 to 5 scale) Dietetics and Nutritional Science students (n=74) Knowledge about older adults 6.04 i 2.20 (46%) 6.36 :1: 2.30 (49%) (13 items) Knowledge about geriatric 5.90 i 1.81 (59%) 5.93 :i: 2.13 (59%) nutrition (10 items) Attitudes toward older adults” 3.50 1: 0.41 3.35 :t 0.39 (1 to 5) p<0.001 89 N 01 N O .A (II A O Frequency 2.25— 2.50- 2.75— 3.00- 3.25— 3.5- 3.75- 4.00— 4.25- 2.50 2.75 3.00 3.25 3.5 3.75 4.00 4.25 4.5 Attitude score I Pre-test I Post-test Figure 4.2 Distribution of attitudes towards older adults at pre- and post-tests From the paired t-test for each set of items, seven of 22 items contributed to the shift to more negative attitudes toward older adults. The following seven items were: 1) older people generally are not interested in younger people and their concerns; 2) ordinarily I would not feel comfortable working on the health problems of the elderly; 3) working in a stroke-rehabilitation program for the elderly would probably be poor investment of time; 4) I would not want to work in a medical setting for older adults who are psychologically disengaged from daily 90 events; 5) I feel many older people are opinionated and it is difficult to work with them; 6) I would typically find working with older people and their physiological problems depressing; and 7) I would find it difficult to develop programs for working with the health problems of older adults. Aggdation between knowledge about older adults and geriatric nutrition, attitudes toward older adglts and preference for working with older adults There was a weak, but significant, positive correlation between knowledge about older adults and knowledge about geriatric nutrition (r = 0.23, p<0.01) at the pre-test as shown in Table 4.7. Attitudes towards older adults also were weakly correlated with the preference for working with older adults (r=0.21, p<0.05) at the pre-test. Table 4.7 Correlation Coefficients between knowledge and attitudes at the pre-test (n=89) Preference for Knowledge Knowledge working with about older about geriatric older adults adults nutrition Knowledge about older 0 15 adufls ' Knowledge about geriatric nutrition -0.08 023* Attitudes toward older adults 021* 0.12 0.04 * <0.05, **<0.01 91 There was a weak, but significant, positive correlation between scores of knowledge about older adults and those for geriatric nutrition at the post-test (r= 0.38, p<0.01) as shown in Table 4.8. Knowledge about older adults weakly correlated with attitudes (r=0.38, p<0.01). There was a positive relationship between the attitudes score and interest in working with older adults using a Likert scale (r= 0.50, p<0.01), but there was no significant relationship between knowledge about older adults or knowledge about geriatric nutrition and Interest in working with older adults. Table 4.8 Correlation Coefficients between knowledge and attitudes at the post-test (n=89) Interest in Preference for Knowledge Knowledge working with working with about older about geriatric older adults older adults adults nutrition Preference to 0.42“ work Knowledge about older adults 0.08 011 Knowledge about .. . tric nutrition -0.07 016 0.38 Attitudes toward .. .. I I adults 0.50 0.19 0.22 0.19 ’ <0.05, “<0.01 DISCUSSION Somewhat contrary to anticipated outcomes, this study offers empirical evidence that content limited to information about nutritional risks of older adults and senior nutrition programs did not positively influence either students’ 92 attitudes or preference for working with this age group in pre-health professionals in a community nutrition course. After taking the course on community nutrition that included only one lecture on nutritional risk of older adults and nutrition programs for older adults, students' attitudes towards older adults and their preference for working with older adults slightly, but significantly, declined. Students showed the lowest preference for working with older adults compared to that of other age groups. At the post-test, there was a significant, positive relationship between attitudes toward older adults and preference for working with this age group suggesting that positive attitudes will influence preference. The low level of knowledge about older adults by nutrition students is consistent with the findings of Kaempfer et al. (2002). Other studies with students in medicine, nursing, social work and other majors support this lack of knowledge about older adults by college students (Fitzgerald, 2003; Gellis, Sherman, & Lawrence, 2003; Hylton, Francis, & Matthew, 2003; O’Hanlon et al., 1993) Similar to the findings of Fitzgerald et al. (2003) and Edwards and Aldous (1996) with medical students, in the present study students’ attitudes towards older adults were slightly positive. Kaempfer et al. (2002) found that nutrition students' attitudes towards older adults were neutral. Consistent with other studies of students in dietetics, medicine, nursing, social work and allied health, students least preferred to work with older adults among all age groups (Carmel et al., 1992; Kaempfer et al., 2002; MacNeil, 1991). This study reconfirmed such a pattern of students’ low preference for working with older adults. 93 The lack of an association between knowledge about older adults and attitudes towards older adults in this study is in contrast to studies with students in medicine, nursing and social work where knowledge and attitudes were related (Fitzgerald et al. 2003; O’Hanlon et al., 1993; Perrotta et al., 1981; Shahidi & Devlen, 1993; Reed, Beall, 8. Baumhover, 1992). Findings from other studies suggested that attitudes towards older adults might be modifiable by increasing students’ knowledge about older adults, because they assumed students’ stereotypes on older adults come from lack of knowledge about older adults. The positive relationship between attitudes towards older adults and preference for working with this age group at the pre-test is consistent with studies of students in medical, nursing, and social work (Gomez, Young, 8. Gomez, 1991; Fitzgerald, 2003). Other studies, however, found positive attitudes towards older adults did not coincide with a preference for working with this age group (Greenhill, 1983; Gunter, 1971; Kayser & Minningerode, 1975; Robb, 1979). Even though cross-sectional findings about the relationship between attitudes towards older adults and preference for working with this age group are contradictory, improving students’ attitudes towards older adults may be an effective way to increase students’ work preference with older adults. A major strength of this study was to assess nutrition students’ knowledge about older adults and about geriatric nutrition, their attitudes towards older adults and their preference for working with this age group. Few studies have focused on nutrition students’ knowledge, attitudes towards and preference for working with older adults. This was the first study to assess nutrition students’ 94 knowledge about geriatric nutrition to examine its relation to knowledge about older adults and preference for working with this age group. Knowledge about geriatric nutrition, however, was not likely to be the major factor influencing students’ attitudes or work preference with older adults. One limitation of this study is that the reliability of Facts on Aging Quiz was low, even after reducing the number of items from 25 to 13 based on the item analysis. This finding might be explained, in part, by students’ lack of knowledge about older adults. These baseline findings offer preliminary insights into students’ lack of knowledge about older adults, geriatric nutrition, neutral to slightly positive attitudes towards older adults, and their low preference for working with this age group. In addition, the slight, but significant, decreased attitude score towards older adults and preference for working with older adults after a lecture on senior nutrition and meal programs demonstrated what might be concern about effect of a traditional lecture on students’ attitudes towards older adults. The assessment of students’ attitudes towards older adults using the psychometric instrument did little to inform how those attitudes were established, or related to low preference for working with older adults. This limitation of using a psychometric instrument might be addressed instead by use of qualitative techniques to explore nutrition students’ attitudes towards older adults. It is unrealistic to expect one lecture to improve attitudes of nutrition students toward older adults. Either additional content or other additional teaching techniques are likely needed. Also, for attitude change to occur, pedagogy should ideally be based on behavior theory, which addresses attitude change. 95 CHAPTER 5 Dietetics and Nutritional Sciences Students’ Attitudes towards Working with Older adults ABSTRACT The purposes of this study were to explore dietetics and nutritional sciences students’ attitudes towards working with older adults compared to attitudes towards other age groups; to investigate how attitudes towards working with older adults relate to preference for working with older adults; and to explore factors influencing those attitudes, such as previous experiences, beliefs about older adults, perceived self-efficacy in and perceived satisfaction of working with clients as a health professional. Triangulated qualitative research methods (four focus groups and 10 in-depth interviews with 27 students) were used. Transcripts from audio-tapings and field notes were analyzed using open and axial coding methods. Students reported both positive and negative attitudes towards working with older adults, as well as with infants, children, adolescents and adults. Students’ beliefs about each group and working with each age group influenced their attitudes towards working with a particular group. Major emerging themes were ease of communication, the clients’ willingness to Ieam and change, and clients’ interest in nutrition and health. Students who preferred working with older adults had more positive beliefs about older adults and more positive attitudes towards working with older adults compared to those who did 96 not. They also perceived barriers to working with older adults, such as “older adults are set in their ways and not willing to change", but still valued helping older adults, because older adults were viewed as appreciative and needing their help. Positive experiences with grandparents or other aged family members, or work experiences in a nursing home with older adults led some students to have a high comfort level with older adults. Perceived satisfaction with and perceived confidence in working with a certain age group related to preference for working with older adults. These findings provide insight into multiple facets of students’ beliefs about and attitudes towards working with older adults. Improving students’ attitudes towards working with older adults might be a key to interventions to encourage dietetics and nutritional sciences students to become interested in geriatric nutrition and health. INTRODUCTION In spite of the increase in people over age 65, there is a shortage of health professionals qualified in geriatrics and gerontology (Kovner et al, 2002; Reuben et al., 1991). This shortage is a major concern for health care in the US (Kovner et al., 2002). Further compounding the shortage of health professionals is that students majoring in health and allied health professions demonstrating low interest in and preference for working with older adults (Aday 8. Campbell, 1995; Carmel et al., 1992; David-Berman, & Robinson, 1989; Fitzgerald et al., 2003; Gomez et al., 1991; Greenhill, 1983; Hart et al., 1976; Kayser, & Minnigerode, 1975; Mount, 1993; Robb, 1979). Research findings from studies with health 97 professionals and pre-professionals have shown that a major contributing factor to low interest was negative attitudes towards older adults and towards aging. Nutrition students’ interests and preferences for working with older adults and their attitudes towards working with older adults have not been examined in- depth, despite the importance of nutrition in preventing and delaying the progress of diet-related chronic diseases. Only few studies have been conducted regarding nutrition students’ attitudes towards older adults (Kaempfer et al., 2002; Rasor-Greenhalgh et al., 1993). Several studies have shown the benefits of nutrition in helping to managing older adults’ health status (Institute of Medicine, 2000; Jonnalagadda, 2004; Sahyoun, Pratt & Anderson, 2004). Thus, Registered Dietitians are needed, who are willing to provide nutrition services, develop nutrition programs, conduct research in geriatric and gerontology and advocate for health policy decisions for our aging population Within the last 30 years, general attitudes towards older adults and aging have been assessed in studies of college students majoring in medicine, nursing, social work and other allied health professions. These studies have primarily used quantitative instruments with Likert scales, and findings have been inconsistent in that attitudes towards older adults by these pre-health professional groups have ranged from negative to slightly positive. Assessment of attitudes towards older adults using psychometric instmments might have two limitations. First, the instruments might be prematurely based on assumptions about how and why students form and hold certain attitudes. Secondly, scale instruments are of limited use to explore reasons for values and probe for 98 insights in to how negative attitudes might be improved. Thus, this study was designed using qualitative research methods to explore the goal and values related to career choices in nutrition students. Because a unique role of dietitians and nutritionists is to help clients and patients improve their health through dietary change rather than via medicine or surgery, their attitudes towards working with older adults might differ from those in other health professions. The purposes of this study were to: 1) explore dietetics and nutritional sciences students’ attitudes towards working with older adults compared to working with other age groups; 2) explore the differences in attitudes towards working with older adults between students who preferred to work with older adults and those who did not; and 3) explore influential factors on attitudes towards working with older adults. METHODS Participants Subjects were 27 students majoring in dietetics or nutritional sciences at a land-grant university in a north central United States. The students were recruited via e-mail, flyers and visits to nutrition classes. Students willing to participate in this study completed an initial survey indicating availability to attend a focus group or an in-depth interview, as well as their preference for working with certain age groups, i.e., infants, children, adolescents, adults and older adults. Fifty-nine students responded to the recruitment efforts. Fifteen students 99 ranked older adults as the first or second choice of age group with which they preferred to work; 12 students ranked older adults as their third choice; and 31 students ranked them as their fourth or fifth choice. Thirty-two students out of the 58 students who responded to the recruitment agreed to participate in the study. They received a coupon ($1.25) to a campus snack shop as an incentive. Procedures After approval by the University Institutional Review Board, two moderators (interviewers) were trained according to interview guidelines (Greenbaum, 2000). One moderator was a non-Hispanic, white masters’ degree student in human nutrition and dietetics. The other moderator was a dietetics senior who was a non-Hispanic, white American. One pilot focus group was conducted with the students who ranked older adults as their third preference among the five age groups. After a debriefing session with these students, the focus group moderator and the researcher reworded several questions. Four focus groups and 10 in—depth interviews were conducted separately following recommended procedures, half with students who preferred to work with older adults and half with those students who did not. Several focus group schedules were set up according to the availability of moderator and assistant moderator. Students’ availability was queried and then four or five students were scheduled as one of four groups. Ten students who were willing to participant in the study were not available for any one of these scheduled focus groups, so individual in-depth interviews were arranged. 100 Focus groups were conducted in a conference room at the university and took about one hour. After a brief introduction, the focus group moderator reviewed the consent form with the participants and explained their right to withdraw from the research at any time. Additionally, the moderator explained the confidentiality of participation and described the research in general. Before starting the actual discussion, participants signed a consent form. Participants completed a short survey on their demographics, the courses they had taken related to aging, and their attitudes towards working with each age group, i.e., infants, children, adolescents, adults and older adults. Next, the moderator explained the procedures and led the discussion according to structured questions. The researcher took field notes to aid in distinguishing voices when multiple participants spoke at the same time. Inquiries and probes for more information followed the interview questions. The moderator managed the discussion time to allow each participant to have an equal chance to participate. Two audiotape recorders were used for each focus group to ensure that the discussion was recorded. For the in-depth interviews, neariy identical procedures were followed, with the exception that the interviews took only 20-30 minutes. Instruments 1. Demographics and attitudes towards working with certain age groups A one-page demographic questionnaire included items on gender, race/ethnicity, age, major, classes taken related to aging, and future job plans or preferred profession. Students described their beliefs about working with 101 different age groups in the questionnaire in order to prevent influencing each other during the group discussions. 2. Focus group and in-depth interview questions Standard focus group and in-depth interview questions are generally composed of five types of questions, such as the opening, an introduction, transitions, the key and ending questions (Krueger 8. Casey, 2000). The key questions for this study were developed to explore students’ attitudes towards working with older adults compared to other age groups, i.e., infants, children, adolescents, and adults. Questions about contributing factors to their attitudes were developed based on the Theory of Planned Health Behavior and the findings from Part I of this dissertation. The key interview questions are in Table 5.1. Table 5.1 Research questions and key Interview questions Research Questions Key Interview Questions 1. What are the attitudes toward Please complete the following sentences. each age grOup including > Working with infants would be . infants, children, adolescents, > Working with children would be _. adults or older adults? > Working with adolescents would be > Working with adults would be _. > Working with older adults would be . What factors affected these responses? . What experiences do you have with each age group? 2. How does perceived job 0 What would make you feel confident to work with satisfaction and professional your preferred age group? confidence influence students’ 0 What would make you feel not confident to work with attitudes towards various age your preferred age group? QIOUPS 0f clients? 0 Which ”up is most fulfilling to work with? 102 Table 5.1 (cont’d) Research Questions Key Interview Questions o What would make you satisfied with working with your preferred age group? a What would make you dissatisfied to work with your preferred age group? 3A. What factors affect a With what age do you prefer to work? students’ preference for o What things made you prefer to work with this age working with a certain age group? group over other age QTOUPS? o What kind of experience do you have with your preferred age group? 0 How often do you interact with your preferred age group 38. How important is the age c What things will you consider when you are looking for group of clients in students’ a job and job selection? job selection? 0 What things are the most important factors when you will consider a job? 0 How important is the age group of your clients for your job selection? Data analysis Descriptive statistics were performed on the quantitative data from the demographic survey. Content analysis of the qualitative data followed prescribed steps. First, the audio taped data from each focus group and each in-depth interview were transcribed verbatim by an undergraduate assistant, and then the researcher reviewed all the transcripts for accuracy. Secondly, the researcher and one masters student independently coded the transcripts. Each transcript was coded using the open coding method (Strauss, 1987) where the researcher underlined key words, phrases or sentences related to the research questions. After open coding all the transcripts, similar concepts or ideas were categorized into one group (axial coding) (Strauss, 1987) and overarching themes were 103 identified. Then the researcher compared material (contents) within categories and across categories. When necessary, categories were reorganized appropriately. For example, one category might be split into two categories or multiple categories merged into one category. Finally, the researcher checked and discussed the coding, categories and themes with those done by the other independent coder to reach coding consensus and find the common themes. The inter-rater reliability of the open coding by the two independent coders for the focus group was 0.85 and for the in-depth interview was 0.74. RESULTS Demgraphics Most students were females, Non-Hispanic white, majoring in dietetics and aged 20 to 39 years old (average age = 25.8 i 5.1yr). Twenty students out of 27 took a class(es) which covered some content on aging (Table 5.2). Mnts’ attitudes towards working with older adults compared to different age rou s Students were asked to complete the sentence, "Working with a certain age group, i.e., infants, children, adolescents, adults or older adults would be ”. As summarized in Tables 5.3 to 5.7, most students used one or more adjectives to complete these sentences and then discussed reasons for their selection. Students showed positive and/or negative attitudes towards working with infants, children, adolescents, and adults, as well as with older adults. Students described feelings about working with a certain age group by 104 positive adjectives such as comfortable, fun, interesting, enjoyable, exciting, rewarding, beneficial, eventual, easy, good, flexible, nice, or (intellectual) challenging, which implied positive and favorable attitudes towards working with a specific age group. Table 5.2 Characteristics of participants Class taken Desired Subjects Sex1 Age Race2 Major3 Year4 related to Profession Job agi_ng5 Plan Participants who did NOT prefer to work with older adults (n=14) Focus group participants A F 20 W NS F - Undecided NHD B M 23 W NS S Human Physician Sexuality C F 22 W D J - Public Health D F 23 W NS 8 - Optometry Clinical E F 24 W DI NS S NHD dietitian Biology of . . . F F 26 W D S aging Dietitian School lunch G F 23 W D S NHD dietitian H F 23 H D S NHD Food service I F 22 W NS .I CN, ELHD Pediatrician Interview participants J F 24 w D s NHD 9'”9.sa'°5 °' dietitian K F 23 W D S NHD Dietitian NHD, CN, Marketing “- F 36 W D S ELHD Food products M F 23 W D S NHD Dietitian NHD, Human Physician N F 26 W D S jenetics Assistant 1 M (Male), F (Female) 2 W (White, Non-Hispanic), H (Hispanic), AIP (Asian/Pacific Island), B (African American) 3 D (Dietetics), NS (Nutritional Science) 4 F (Freshman), S (Sophomore), J (Junior), S (Senior) 5 Class: Community Nutrition (CN), Nutrition and Human Development (NHD), Ecology of Lifespan Human Development in the Family (ELHD) 105 Table 5.2 (cont’d) Class taken Desired Subjects Sex1 Age Race” Major3 Year‘ related to Profession Job aging” Plan Participants who preferred to work with older adults (n= 13) Focus group participants A F 23 W D S NHD Food industry B F 22 NF NS J - Not sure C F 24 W D S NHD Food service ' Community D F 31 W D S NHD nutrition Personal . . . E F 26 B D S health Dietitian F F 38 W D S NHD Dietitian c F 39 Other D s m? "m Dietitian Long term Medical H F 23 W NS S health aide research] course Physician Interview participants I F 25 W D S - Dietitian J F 25 W D S NHD, CN Dietitian Nutrition K F 33 W D S ' counseling L F 26 W D S - Dietitian Public health, M F 23 W D S NHD Gerontology On the other hand, students’ negative and unfavorable attitudes towards working with a certain age group were expressed with negative adjectives such as boring, challenging, depressing, difficult, fnrstrating, intimidating, nervous, sad, scary, trying, tough, or okay. “Challenging” was used both positively and negatively. Some students expressed working with a certain age group as 1 M (Male), F (Female) 2 W (White, Non-Hispanic), H (Hispanic), AIP (Asian/Pacific Island), 8 (African American) 3 D (Dietetics), NS (Nutritional Science) 4 F (Freshman), S (Sophomore), J (Junior), S (Senior) 5 Class: Community Nutrition (CN), Nutrition and Human Development (NHD), Ecology of Lifespan Human Development in the Family (ELHD) 106 challenging in terms of using knowledge or applying their knowledge and in that context, challenging had a positive connotation. On the other hand, other students mentioned that working with a certain age group was challenging due to perceived barriers. In this case, “challenging“ received a negative connotation. Students’ attitudes towards working with different age groups were established based on their beliefs and feelings about each age group and beliefs about working with those age groups. Emerging themes about working with a certain age group across the age groups included ease of communication, clients’ receptivity to information and willingness to change, ease to get along with clients, and comfort level of working with a client age group. But the frequency of mentions of such themes differed by age group of clients. Infants. Because infants cannot talk, difficulty in communication was a major barrier to working with them along with the high vulnerability of infants and the demanding need for care and attention (Table 5.3). “Fulfilling and challenging it is primarily unique because they cannot communicate and they cannot express themselves in anyway. it would be challenging because the only communication you have with an infant is through a parent. So you are limited as to what sort of influence you may have.” “Difficult It’s communication, you just don’t know what’s wrong at that age and they can’t help you, at least with an older child you have that interaction." However, infants’ rapid developmental stage also appealed to some students who perceived their help with this age group would be rewarding. 107 2oz. 9.0 55 2o... 8:85... 8:32... oEom “Econ—cot v E 3.8.6.... .2. (2 .A 5 3020.. E 059053 SE... - 82392 52 8.5302 93 3:8:— 3 9.9.2.96 26:52.2... 3 e. 88.36.... 9.6: E .8663... E 5.... Em... so. 8 A 5 9......5. E E 85...... 96. . 6.5.98 nozzmoa Sm E 9.2.6... >=mcozoEo .5 8.9.2.8.... 3 .66 e. 3...... n .. $2 3239: A: €0.th co_.co_c:EEoov 3:9 .9. .. "ozuouoc .25 25.8.. so... 35.... .25 3:36.. £2 E Stooge... A 5 9.6.95. .. : 9.6.6.26. . s e. 95.... 29. oh 35.3.. 3 3.... 5.8.. Em... 6.9. oh 35.8.. E 8.8.. 96. . $4"... 2.0? £933 .EnEoE 2.8m. ”oocotooxo p.532... $11.5 «$43.3 goats... 2.8m.— noocotooxe 2532.. so... 52. 2:25 8:3... Enos 8:35 5.3 9.2.6.5 «.23 5.... 9.2.25 32.3 in... 9.2.... .8... 5.... 3.5; o. 5...... 52 e... 6...... seesaw oncoooo. ho sauces—ooh can 85...: 5:5 95:25 $3.58 neonate uco £2.2— hcoozam «6 can... 8 cu... 8.2.5 .86 5.... #6; 2 8.6.5... 6...... 9852.0. 108 A: 9.0.030. .3 9.58.08 E 0. 52.. 20.. 8. 32.000: A... 020.05.; .__0:.0 .. 0:0 0.5.000 00.30520 8:02. 3 0. 26.0 20... :20; 0:0 0.0.. oh .8 020.020. .5 0:255 .. .3. 05.8.05. 3 08.20.. - ”028.00.. 50.0 0202. $2 $2 .12. .0200... 0.22398 0025.... ans .0205. 0.22.098 002.6... E 520...: E 0202. 5.2. 022.098 0: 0>0.. . E 0.8.... E 0.85... E .00 0.0 .0... .. E 00020: 5..., 022.098 .0 0000.265. 0>0: 2: 00 . 2.0.8.220 A... 0.000.. :0 200:0:00 - Am. 0292.020 3 0.00 0:0 5.2000 2 .o. 0 0.500. - . Am. 2000 .A S 5 200.053 ...0:.0 .. 82.082 E .858 8.8.5558. .0. .oc - =85... .. : 8...... .0. .858 8.8.5558. .0. .2. - 00 8:02. ”02.0002 :60 8:02. 3. 9.0.02.0. E 0. 20203.9... 000 o... .3 .5. E 0.8 - 3. 020.030. Sm E 0.88.8 .2. .. 5 88.8 .E .855 08.. .3 9...... "028000: E c2200 5002:3228. 2.0. .o: - "020000: E C0200 5002:0228. 2.0. .o: - 0:0 0.5.000 2.0... 8:02. 0:0 03:00.. 00 8:02. 5 .3588; A 5 020.030. .5 20.. 0:0 02>00 .2. 028.02. :2. 0220.. .3 020.030. A 5 >000 .5 :0”. E 05.0.0.2. 0:0 020020 - A 3 02.00.02. "028.00.. 50.0 8:02. 828.00; E 0. 0202. 0.0.. o... Ens 002.0598 002.6... 02 3n£000=22nx0 002.6... 02 .3"... 0.58 .8... 5.; 52.. o. .08... 52 0.0 2.; 0.88.0 .0 W... 0.08 .8... 5.; 59... o. 88.0... 9.; 0.8.5.0 .958. 0.0 2....» 109 Children. Problems with communication due to limited cognitive ability and lack of interest in nutrition were major barriers to working with children. Most students, however, believed that children were willing to Ieam and receptive to new information (Table 5.4). “Enjoyable, I think at this age they are willing to Ieam and listen and accept changes.” “Fulfilling and challenging there is more flexibility than infants they still can’t really communicate with you on a very clear accurate level. They don’t have the cognitive ability to reason or to understand how their choices impact their lives”. “Challenging, because their parents influence their food choices. Depending how old the children are, they might not really care, and get their dislikes from their parents”. Adolescents. Most students had many types of experience with adolescents. Some students described their experiences with adolescents from their own experience of being an adolescent. Students described the major barriers to working with adolescents as peer pressures, stubbornness, desire for independence, unwillingness to listen and change, and low interest in nutrition (Table 5.5). “Difficult, they may not be willing to listen.” “Stressful, just because they already have their opinions formed. They are not going to listen to you when they have their own mindset.” 110 Be? 95 can. Son. 85:58 2:83..." 2.50 30:03.02“. . E 88%.. E Eon. 5.3 9.2m .ou .occmo . E as... E 5o... 5.; 9.2m 8.. 6&8 _ 82. .. E as? E 822:: 58m. 28 22. - .. E 32:8 E 8E2 82823588 - .. E .5056 . E 2%.... 2638 3o. - .A 5 9.9.2.20 E 3coEEoo o. coco - .va 9.9.2.20 E 80.05 coo. 22.. co 9:93 .3 8053:... - 323qu 20225.33 c2230 ”25¢qu 50232.33 5.5.30 3 9.2952 A 5 9.322;. 25309. 9.2.: - E 22x2. Sm E 8:53.. E c225: 2228:: .2. - E :2 E 88:8 88 E .. E 8.5% E =. em .65 ._ . AN. 9.9.2.20 8E3 cozonaEEoo new 3.3.... 93.58 26. - 3:32.050 3 costs: 3993:: .o: .. 32.30: 3. costs: c. 8.3.9:. .o: - .9532. A... 35% 02.268 26. - new 3.23.. ...oEo>u£o..u :8u_.:0 new ozufioa 532. 5.6.20 R. 9.6539 8. Eon. 9o; coo _ 2. >95 :2 m :. Em... come. :8 . .. E fies .82 E 2.6828 seats - E 02.86 - am. 05699:. 96:20 - 3 9.2959 A: 9.305 - .. E :2 E 9.382 - .. E .85 .E :2 E 9282 - .. E283? E Eng 2 8:28 - .. E 23.28 E 8:20 2 92.; - .. E .2828 E Eng 2 2...? - E 56:22. E .52 2 92:3, - 82.33. ...o>u£2u 22230 62:qu ...o2¢>w£o..a c2220 8T5 0.83 52.5.? 25.32 .5960... 2.2m. 305.535 2.25:. .mncv $35.9 4.333 .uonEoE 2.96. 325.396 23.5.5 Son 52. 2:25 c2230 2:03 c2220 5.3 95.3.5 «Egon 5.3 9.3.25 $2.3 .32.. 2.38 .83 5.; v.62 2 .22.. 52 an on; 2:85 3:232 ho 325309: use 5.6.30 5.? 95:03 3.532 3.03:3 new $2.2. Eco—0:5 in 22¢... 8 W5 23% 52o 5.; v.53 2 8:29.. 2.; 2:835 111 A... 0002.00 000.. 3. .0200 00.80.000.800 - .A F. 9.0.0.50. .. E 05.00 C. .0:.:0>m C. 000. .00.. :0 00.. 0000. - 82.000: 3. 050000.00 .005 - 0:0 0.5.000 02032.0... 00.0.20 E 8.20300 E 0. £0... 22. oh "02:00.... 32 $2 .0"... 80.0.5 0000.898 0:030... .0"... 80.0.5 0000.898 0:020... E 0292.20 A F. :0. 82.000: 05 25.00.. E 8:0..090 02.5.. 2,2. _ .3 520.20 2... . 3. >03 0>..0>0..c. c. E02. 2000. :00 _ E 505 2 20.2 c8 . 2. 02.0000. - C. .00. 0530.0 .. 2. 050.030. 3. 9.20.88 0. 00.00.02. - E S. E S. a. 05500. c. 00022:. - 8.5.000 C. 0. 00...>..00 :0. 5.3 E0... 2000. 0... 82:00; ...00.0>0£0.0 00.0.20 Sn... 000000098 00030.0 02 fin... 000000098 00030.0 02 E00 E00 0.003 00.0.20 0.00.5 00.0.20 5.3 00000.5 08:00 5.3 0:000; 0.2.00 .3"... 2.2.0 00.0 5.; 0.5; 2 .22.. #02 0.0 2.; 28020 .m _.u... 0.300 .00.0 5.3 0003 0. 00.8.0.0 02; 02000.0 .0008. 0.0 203 112 0.0.5 000 000. 0.00. 00000000. 0.00030 00.00 3000000.“. _ E 00.5. .. E .5085 E .95 .0... 05.5.05. .0.. .85... .8. 00.002.000 "02.0002 E .005 .. E 00.5030. E 05.5.0.5 E 0.8.0.0 82.0000 000 020.000 E 00.00.05. .3. 5:. 8.5.000 AN. 0.00. 0. 0.0.0. .00000 . a. 5.09. .50 8.5.5 52.0 0.8 .2. - .A .. .000000000. 00 0. .00.... .. . E 00.0.. o. .00; .9. - AF. 00000. .030000 000 .0.000 00000.00. - A... 0000000 >000. - AN. 05000.0 .000 - E 50000 - E .0.... o. 59.8.. - An. 52.020 - AN. 000 0.0.3.30 .0 - 5020.60.20 0.0000200< E 0. 52.. 0.0.. o. 50 E 50; .0... .05... so... - A... .000000000. 00 0. .002, - AF. 05000.0 .000 - E 02.258 - ...00.0>00.0.0 0.00000.00< Ar. 0.00. 0.0.0. 000 . E o... o. 8500. 00...... 20%. - AF. 05000.0 .000 - E 58. o. 00......) - ...00.0>00.0.0 0.00000.00< Ameucmoco 000000.000 00 00.00 .0003 ..00.00.0> 0000.05. 0.0.0. ”00000098 00030.0 AF. 0000000 08: .. E 9...... .E 008. .. E .5085 .0. 05.5.05. .3. 58...... E 05002.20 "0.0.0002 $2 "02.0000 000 0.00000 E 00.00.05. E 0002.20 0:. "020000 AF. 00.....00 .0000 0.00 .00 - A0. 00.0.. 0. .003 .00 - Am. 05000.0 .000 - Am. 0000....0 - A: 0.00 .00000 0. .00.00.0. . ...00.0>00.0.0 800000.02 (.2 A: E00. 0000.0 00... .0 .0. 0 .0000 . E 0.000000. Q... _ AF. 00.. 0. 00.0.. .00 - AF. 05000.0 .000 - ...00.0>00 300000.000. 8..u0. 0000 0.00000.000 00 00.00 .000... ..00.00.0> 000.000. 0.0.0. 8000.898 00030.0 ...00 0.00.5 ...00 0.00.0 300000.000 300000.000 .0.: 00.0.3.5 0.0.0.0 .0.; 000.25 0.2.00 .3"... 0.000 .020 5.; to; o. 0.0.. 502 0.0 2.; 0.50.5.0 0000000. .0 P500000... 000 0.00000.00< 0...... 00.0.0.5 00.0.50. 0000....0 000 0.0000 0.00020 0.0 0.00... A0 .uc. 0.500 .00.0 0...; 000.5 0. 00.8.0.0 00.... 0.00005 113 A 5 gauge E 58an - $35 5:20 E 2385 58 - 323qu 595 3:33.23 8239: :65: 8:33.02 52 E 938.25 3 39m 33 .m - 32:3“. (2 "25.3.... 52¢ 8:33.02 2.9.5 .3225 35.398 2332.. Ann... 532.: 35.396 «.3321 58. 2:03 52. 2:25 3:33.23 8:33.25 5.3 8:55 82.8 5.; 22.63 «5.8 Ens $53 Ego 5;, v.53 2 335 .52 2.. 2? 9:035 , 8 W5 23% .86 5? v.63 9 8535 2.3 £53m 8.2.8. 9m 2%» 114 “Difficult, difficult time in their lives and so many changes are going on with them. That stems from my niece who is in her adolescent years and my husband's son, who is now 18. Seeing him go through his adolescent years, there's just so much going on that something like nutrition would fall somewhere low in their priority list. I think it would be difficult, because they simply don’t care at that point, unless there is something wrong with them “ “It would be challenging to reach them, because they are at an awkward age.” Adults. Adults were viewed as the easiest group with whom to communicate, as understanding nutrition more than other groups, and providing feedback to the health care professional. Students thought that they could Ieam from adults while working with them. However, some students viewed this age group as beginning to be set in their ways and unwilling to listen or change (Table 5.6). “Enjoyable, l have always liked to Ieam and teach others, ...leamed from their experiences... “ “Rewarding, because usually when people this age seek the help of a dietitian, they want to change something. They know this is what I want to change and this is what I want to do. So I think it would be great to help them and see them change.” “Boring and not as challenging (intellectually), just because they are probably more stuck in their ways and don’t want to listen to what you have to say and what could help them diet wise.” 115 295 go 55 90E 3:03:08 3:83» oEow $2.269". . E 855.56 2628:25 so: 116 E 963 ..o 32.9 m c_ somehow coo _ A : €056 3 Bacon comcaoboE 9 29m: 2 @553 .o: - E 29.6: E 2:88. - .A 3 8E5 3 an; .35 s .8 - ”95.3.“. 2a 3.33 323qu 93 3.32 2."... woo—.2898 2.032.. oz fins 32.2.3.6 2539:. oz A 5 9:8 A gmsocogocoe .. (2 .A c 9.58.55 3 am; .35 s a... - 82392 ...ouafiéeu 3.23 25182 $2 $2 $2 8530: 32232. new 0223i (2 ucu 25.3.". 52 E ...m_ 09.9.0 89: com o... E E9: 2 EmQQE ..m__E_m o>mc _ 3 Bacon 9.3.9. E E9: E2.— Ewo. coo _ AS m. 09.9.0 505 com o... .A 5 9.6532 A: E E9: E9. Ema. coo _ .A 3 958.25 E05 o. 999 :8 .o 3.25 52> 9.2m “on :8 _ Amy 96.639 A: Em...“ comm. coo. A 5 uoom A: 355 5398 can 505 3833:: :8 _ .A c 838.25 E cam: 2 3:3, - .A : game?» 3 x888. 9: 96 - .A c .88 E 232%.... 2 2% - A a .38 E cozcofi >8 - .A c .38 5 «3882265 - .S «39.258 E 99. En; - .A s 30:82 E 288 do 22.9 - .A s 80:28 E 355 2 mc____; - 32:90.; 2a 3.23 "25.3.. ...oEoE 3.23 6.1.5 x5; ...onEmE 2E5 Boston—xv 2.032“. fins v.53 ...moE:_o> ...mEoBoo ...onEmE >__E£ 325.398 2.032.“. ...on 2:25 ...on 2:03 3.2.5 5.? 9.3.25 £33m 3.25 5.3 95:25 £23m §a5 3.38 .220 53, {as 2 Sosa 52 an on; scouaw 8 Rs 9.28. .86 .23 v.83 2 8555 on; 953.0. 02893.. *0 32.3.5: 65 «=55 5.? 9.3.03 «@332 moo-Eta one 3.2.3 .3535 m6 2%... .632 6:55:20 ”255qu E 3.9332 A: .32; nc>=aaoc Ea 2538 com: 2 95:3 8: - 9m; .55 :_ “mm - Eu 3.32 09.23 8 Eu? >05 z Em A: «>25 .35 c. “on .. 0298 3.32 E E9: 299 :8 _ A3 m_ 09.20 :05 mom o._. 5 Emo_c:EEoo 8 5mm - A 5 32523.50 >cmE - E 99. 8 mucmco 2 95:3 3: - E 858.55 E as; =2. 5 .3 - 35¢ch 32:20 8.23 A: ...m_ :55 22 9 Sn 3 $8.265 ho v.8. - E 85539 E xomaomé we 96 - E 86532 E $ng 2 9:3 8: - A 5 83.5 A: 29: 2993:: - A C 9.65:2". A: «o: 6550 A 3 0.33.30 A: 99. x08 - A 5 En: 62.8808 cam E8. 2 @553 .058 - A 5 Emma Amy @3832;ch - A 3 38 A3 so: 9m 29:0 new @955 2 A 5 50:33 A8 :2»: 8 @553 .. ”3:30: 95:; Ba E9: ho mEomv maooa Ac bot? - ”323n— oEo>w£2u 3.33 uca 05.3.". ...¢>u£a._a 332 Ann... 320:: 3.55%» «:25... Ann... .5225 «2.8398 mac—>2."— ...on ...3 2:03 2:03 8.23 3.25 5.3 95:03 £23m 5.3 acute; : u..o..am $35 $.38 .83 53, v.83 2 .32“. ‘52 an 9.; 253m 8 W5 9.3m 3% é; {o3 o. 8535 2.3 £5.25 6.28. 3 2:8. 117 Older adults. Most students believed that older adults were set in their ways, not willing to change, not willing to get help, did not care about nutrition and health, and had lots of hardship (T able 5.7). “’Rewarding, just because they are so happy to see you. Some of the nurses aren’t happy, because that is their job. If you take your job and have fun with it. They are just more pleasant with you and want to see you. Some people don’t get visitors, things like that. They give back to you, too.” “Very interesting and rewarding This has been an area that has kind of missed older adults in that they kind of forget about the preventive techniques and feel like after you get to a certain point, just let them fall off the scale. I feel there are many techniques that can be implemented at that age and started, rather than if you haven’t done it your whole life, then you are a lost cause. I feel like that is something I could combine public health in that experience in older adults and the baby boomers are getting older. It’s going to be a big problem and there will always be older adults, and that is not only job security. It is going to affect everyone.” “Very interesting, many different nutritional needs are being challenged and they are demanding needs, and again this is from a medical nutrition therapy perspective, highly demanding. Older adults are living chronic diseases.” “Challenging, but I think it would be pretty much more rewarding because, I think older adults have a lot more hardships. They have lost so many people like their friends. It’s like every time I talk to them, they are going to a funeral. I think lots of times when someone loses their wife or husband, they can get really depressed, and you have a lot more to overcome with that. It’s more difficult to deal with that generation as far as their beliefs; I want to say moral stands or something along those lines. You need to adapt to that, but that would be interesting to me.” 118 0.63 000 :05 0.05 00:00:08 0.00030 00.00 “5:00.000”. . 8? 0.0 2.80 .220 E 02: A 5 2 205 29 oh 5.8; .05 52m. 28 258 .220 .A c .68 E 00:83 2 822:2 202 .A 5 0502228 E «3808.305 2.... 2.28 .220 80.: E00. :00 _ 0:0 00:? 0.0 3.000 000.0 .A 5 :2 8V 020000.500 0.0 0:000 .020 E 055225 .82 22 c8 _ 0. A s 0326.00 E 9: :32 :8 2.38 .220 . 3 050.030.. 5:5 .5 052030.. E 805 50> 000.0 .00 :00 _ A c 85:8 82. 3 co 2.... 8 238 - Q 2.82% 530 .A s 80.35% E 88: 052523 - .Q 92202.. E 82222 0 .2 m - .A : €2.00 3 02 0° 08: 228 2 05:3, 6: - .A c 055 E 22. $0 2 05:? .8 - .3 0522.20 E 2.02. 502235 58m 28 22. - .5 0:08:20 Q 082228. 2 05:? .2. - "020000: AB 903 :05 :_ «0m - ”020000: Avv E00030 \903 .__05 E .00 - 0:0 02:00.“. 00\0>0£0.0 3.000 000.0 000 023000 ...0>0£0..0 3.300 000.0 80 205 2 020.0. :00 00 02000 000.0 53> 000.0 00 :00 _ E 0005 3 000000000 000 0000000 000: - .ANV 030080.00 E 00> 00 0.000 020 0“ >000. - A 3 .0000 3 0E 000 2 >000; - A: 0:500:05 8v 650.030. 3 000020 2 >000. - >__0200__0E_ E 00:02 5.00: 08.9000 .30 00:00.20. 3 0.00.005 0.0000 0005 000 :0 - "020.000 0>0= 02:00 00.0 “0>_~_00n_ 50205 02:00 ..00.0 ...00 0.003 ...00 0.303 02:00 00.0 3.000 000.0 5.3 022.25 22.00 5.; 0:332. £200 . A _. Fumfl auras 059.4??? 5 000000003 0.5205 000000096 0:0; 0900.00 ..00E0E €000 "00000098. 0=£>2m 0W5 2.80 .020 5.; to; 2 .205 52 20 2.; 25020 002029 ...0 0:0; 0026.0. ..00E06 2:00.— ."000000006 00030.:— 8 F5 2.32... 020 2.; v.33 2 02.205 2E 25020 0000000.. *0 P>0:0=00.¢ 0:0 330< 0005 5.3 9.0003 00.032 0003.30 0:0 «00:00 .300030 hm 0.00... 119 E 0.0 5 050.030. E 8.9.2.20 "0.50002 E 8.08.05 E .00.; .00 00.00000. 0.00.05 0.0000 .0 20..0> - 0.0.. 000 00.. 0. E .509. 2.0 8.0.2.. 52... 28 .2. - E 06; ..02 c. .8 - ...008>0£0.0 0:000 .00.0 .Nu0. .020 «00 00000098 00030.0 3. 000000 0. .003 .00 .. E 0.0; ..o... ... .0.. - (.2 E 2.08.2... (.2 8.00. .00.0 .00 00000098 00030.0 E m. 22.. 0.2. 2 .3 225.. ..o .o. 0 20.. 8.50002 02300.20 00000 80.0 "05.000 0.60.0.0 3.000 .020 .30. 8.000 80.0 5...» 000000098 oz 3.0. 00.000 80.0 5..., 000000098 02 .3 000000 0. 0.05 .0. 0.0.. 0... 3 0000000 0000 A... 2:00.. 000 00.....00. .0000 0.00 .00 - .E 0:20.00... E 008: 8.2052. - .. 0 2.00.2.0. E 88$... 0.8.... 9...... - .A 5 .505... .5 00.30.0000 .00 00 00 0000.305. .0 0.00. - 52 .. 0 2.0.2.20 E 208220.03 ..o... c. .3 - "3.00002 ...00.0>0£0.0 3.000 80.0 ”02.0002 (.2 G W5 .9"... 0.000 0150.00 0. 000000098 $0.0... 000000098 000.... 0030.0. 0000.0... 2.0.0. 8000.898 00030.0 .3"... 2.2.0 .8... 5.; ...o; 2 .22. ..02 a... 2.; 0:820 .00.00.0> .0 v.82. 0028.0. 0000.0... 2.0.0. “00000098 00030... a W... 0.80 .8... 2.; ...o; 2 02.20... 2.; 2.820 0.0000 fin 030... 120 “Difficult at times, if they were reluctant to change their ways. My father, I can drive nutrition as much as I want, but he has pretty much said I have eaten this way all my life and I am going to continue to eat this way. But I know that there are others like my mother and aunt who are very receptive to what does this chondroitin do. They would be a group that would be willing to Ieam, because they have the most to benefit from it”. “Challenging primarily, because I think they would be very set in their ways, just like a lot of adults would be, but I do think it is something I would enjoy. I do have a pretty strong bond with my grandparents. Also being able to help them once, they were kind of helping their children and grandchildren, maybe when they needed help was a rewarding.” “Challenging because I may be stereotyping them, but people in this age group are usually set in their ways, and it is hard to get them to change habits. If you are trying to teach them things they should be doing, they may have been doing it for 70 years. It is just hard to get them to want to change, so I think it would be challenging, but I wouldn’t mind doing it." “Challenging, due to complex health problems and polypharmacy issues. I think many times, in classes when you start talking about geriatrics or older individuals, you have all this stuff going on which makes it very challenging. But I think if you are really into medicine or really into nutrition, it would be a good challenge, in a good way. You can really put your education to the test. I think that would give you a chance to grow, because of all the different issues they have at one time.” 121 WWW wWW—Wtsmm—M As shown Table 5.7, most students, whether they preferred to work with older adults or not, thought older adults were set in their ways and were unwilling to Ieam or change. More students who preferred to work with older adults, however, valued helping older adults. Such students viewed the work as rewarding, because they could Ieam from older adults, such clients would be appreciative of help, and nutrition would benefit older adults. Additionally, due to previous experiences those students felt comfortable to work with older adults. Most of these students had good relationships with their grandparents or other aged relatives and had volunteer or work experiences in a nursing home. In contrast, most students who did not prefer to work with older adults had strong, negative beliefs about older adults including that older adults were set in their ways, they did not care about nutrition and health, and they lacked ability to understand nutritional benefits (Table 5.7). Such beliefs were major barriers to work with older adults for those students. Although some students who did not prefer to work with older adults stated positive beliefs about and benefits to working with older adults, these students perceived more barriers to work with older adults. This related to their low preference for working with older adults. Factors affecting students’ attitudes towards working with clients In addition to previous experience with people in the client age group as the major contributing factor to students’ attitudes towards working with clients, students’ perceived satisfaction with and confidence in their work were explored 122 and summarized in Tables 5.8 and 5.11. Students discussed the following questions. 1) Which group is most fulfilling to work with? 2) What would make you satisfied working with your preferred age group? 3) What would make you dissatisfied to work with your preferred age group? 4) What would make you feel confident to work with your preferred age group? 5) What would make you feel not confident to work with your preferred age group? There was no difference in the trend of responses of students between focus groups and individual interviews, so the merged data were analyzed for all participants. The separate data analysis between students who preferred to work with older adults and those who did not can be found in Appendix 20 and 21 (Tables 5.9 and 5.10). A. Perceived satisfaction and dissatisfaction Four themes were identified as major factors affecting students’ perceived satisfaction: personal values, clients’ attitudes, results of their work, and barriers. Because most students valued helping people, they thought if their work benefited their clients, they would feel satisfaction. In contrast, while most students might have felt satisfaction from the results of their work, more students mentioned they might be dissatisfied with clients’ attitudes, including lack of clients’ motivation, cooperation, trust, respect or appreciation and some barriers to working with clients. 123 Table 5.8 Factors affecting students’ perceived satisfaction and dissatlsfaction (n=27) Theme Context Satisfaction Dissatisfaction Personal values Clients’ attitudes Result of my work Barriers Others 0 Fits my interests (1) 0 Help people who want to change (2) . Help clients who are in needs (4) 0 Clients seek my help (1) 0 Clients appreciate me (2) o l benefit my clients (16) - I make a difference in client’s health Ilife - My work can prevent chronic diseases - I make clients happy - Clients enjoy having me - The impact of my work lasts . Diversity of work (1) (Frequency of responses)‘ 124 0 Clients have no motivation (6) - not willing to listen - not willing to try/change - refuses my advice 0 Clients do not cooperate (1) 0 Clients do not care about nutrition/health (2) . Clients do not appreciate me (2) . Clients do not respect me (3) 0 Clients do not trust me (2) 0 There is no improvement! progress (5) 0 There is no cooperation from family members (2) 0 Politics in the work place prevents me from doing my best (1) 0 Funding is lacking (1) o Monotonous work (1) 0 My approach is limited (1) o Coworkers give me negative feedback (1) . Patients die (1) o I do not do my best (2) . I get paid a small salary (1) The quotes below are from students who selected working with older adults as more satisfying than working with other age groups. “Older adults are the most appreciative and are happy. They need the interaction, if they are lonely and their spouse has died, they need just to talk, not even just nutritional counseling, just talking with them I think is rewarding.” “Older adults because they are fun, and I just find it really rewarding--not so much the food aspect, but just how much they enjoy having you around. I loved working in a nursing home with my mom, even when I worked there, seeing my face and touch completely brightened their day. . .” “Older adults have so many other conditions and hardships More obstacles to overcome So my job would be more important or valuable or taken to heanf B. Perceived confidence and lack of confidence Four themes were identified as factors affecting students’ perceived confidence and lack of confidence in their work: perceived readiness to do counseling, clients’ attitudes, the process and interaction with clients, and results of their work as shown in Table 5.11. There was no difference in the trends of responses, so the merged data were analyzed with all participants together. The separate data analysis between students who preferred to work with older adults and those who did not can be found in Appendix 22 and 23 (Tables 5.12 and 13). Students perceived that they would have confidence in working with clients as a health professionals in the following situations: 1) when the students had the necessary knowledge and information from their education and 125 experience; 2) when clients showed motivation] cooperation/respect; 3) when the students could relate to clients, answer their questions and know what they are doing; and 4) when the students received positive feedback from clients and their family, helped the clients benefit, improved the comfort of clients’ lives even without improvement, and saw improvement or changed behaviors. In contrast, the students reported that the factors that made them feel not confident were things such as 1) when the students were not ready due to lack of knowledge or experience; 2) when the clients had negative attitudes, including no motivation/respect/trust; 3) when the students were unable to answer questions, made mistakes, were corrected by co-workers, and 4) when the results were negative like the clients’ death, negative feedback from clients, no improvement and constant failure. Table 5.11 Factors affecting students’ professional confidence Context Theme Confidence Lack of confidence Perceived . Education (5) 0 Lack of education (1) readiness 4» Knowledge (5) 0 Lack of knowledge (2) . Experience (9) 0 Lack of experience (7) 0 Ability to apply (2) Client’s attitudes . Motivated (1) o No motivation (3) o Cooperative (1) o No respect/trust (2) 0 Showing respect (1) Process/interaction o Can relate to clients (2) o Discomfort (1) With clients . Can answer questions (1) 0 Cannot answer questions (3) . Know what I am doing (1) o I make mistakes (1) (Frequency of responses)‘ 126 Table 5.11 (cont’d) Context Theme Confidence Lack of confidence Results of work o Positive feedback from 0 Negative feedback (1) clients or family (3) e No improvement/failing (3) 0 Make clients’ benefit (10) 0 Clients’ death/losing clients - Enlighten clients (2) - Make clients change/ improved — Make clients comfortable Others 0 Beyond specialty (2) 0 Different opinion from coworkers (2) Egctors affecting students’ preference for working with a certain age group Four questions were used to explore the factors affecting students’ preference for working with a certain age group: 1)With what age do you prefer to work?; 2) What things made you prefer to work with this age group?; 3) What kind of experience do you have with your preferred age group?; and 4) How often do you interact with your preferred age group? There was no difference in the trend of responses, so the data was analyzed with all participants. A separate data analysis between students who preferred to work with older adults and those who did not is in Appendix 24 (Table 5.14). Most students had limited experience in interacting or working with various age groups, so most preferred to work with the age group, with which they had experience. Five themes were found and summarized in Table 5.15. The major themes were: 1)the students’ comfort level to be with/ or around a certain age group; 2) the clients’ attitudes towards health professionals, i.e., willingness to 127 listen and try and appreciativeness; and 3) results of work such as making a difference or having an ii influence. Having had previous experiences with a certain age group influenced the students’ beliefs about the clients’ attitudes, their own comfort level with clients, and the results of their work with that age group. Students who preferred to work with older adults mentioned that they were comfortable being around older adults. Students found older adults very appreciative based on their previous/current interactions with their aged family members or work and volunteer experiences with older adults. Table 5.15 Factors affecting students’ preference for working with a certain age group Themes Contents Comfort (18)* o I have been around a certain age group (5) o l have had positive previous/current experiences with a certain age group (8) . I can get along/relate or handle with a certain age group (5) Clients’ attitudes (3) . Clients are willing to listen and try (1 ) 0 Client are very appreciative (2) Results of work (6) o I can benefit clients (rewarding) (6) 0 My work can make difference or has more impact (Frequency mentloned)* Factors affecting students’ iob selection To explore the importance of the age group in job selection, students were asked about factors they would consider in job selection. There was no difference in the trend of responses of students between focus groups and individual in-depth interviews, so the merged data were analyzed with all 128 participants together. A separate data analysis between the students who preferred to work with older adults and those who did not is in Appendix 26 (Table 5.16). The major factors affecting job selection were summarized into eight themes as shown in Table 5.17: 1) the personal value and internal rewards (contribution, helping people, make differences, fulfillment and happiness); 2) the perceived readiness (comfort level and confidence); 3) availability of job or job security; 4) work environment (the quality of facilities, work setting, opportunity for self-development, coworkers, the philosophy, ability to have a family life, ethics of organization; 5) physical location (close to family, rural or urban area, safety); 6) characteristics of tasks (interactions with people, counseling, no paper/desk work, diversity of work, etc); 7) characteristics of clients/patients (age, socio economic status, whether people seek help or not, not sick); and 8) external rewards (salary and benefits). When asked what kinds of factors were considered when selecting a job, most students did not mention age of client. But when later asked, “How important is the age group of your clients for your job selection?” half of the students answered that the clients’ age group is important. Those students had limited experiences with various age groups and they wanted to avoid working with (a) certain age group(s) due to lack of confidence and poor comfort level with those age groups. Students who had previous good experiences with a certain age group often preferred to work with that age group. 129 Table 5.11 Factors affecting students’ job selection Themes Content Personal value (10)* Perceived readiness (3) Job availability lsecurity (8) Work environment (30) Location (1 3) Characteristics of task (12) Characteristics of clients (6) External rewards (9) 0 Contribution, help people, make difference a lntemal reward (Happiness, fulfillment) 0 Comfort 0 Good at it 0 Quality of facility (new, fully equipped) . Work Setting (clinical, community) 0 Opportunities for self development (move up, self establishment, stepping stone experiences) 0 Co-workers (colleagues or boss: good relationship with colleagues or boss and get help from them, employers care about employees) . Can have family life 0 Philosophy, ethics or mission of organization . Close to family, rural or urban area . Interaction with people, hands-on experience, no desk/paper/lab work, don't deal with money, diversity, research 0 Age, SES, seek my help, not sick 0 Salary, benefit (Frequency mentioned)* DISCUSSION The most useful finding from this study was how important students reported their level of comfort an their clients’ receptivity to their advice to be in their self-confidence to work with their preferred client group. Implications of this finding for education of nutrition students might be to increase expose to participant client groups within positive contexts. Also educations might explain how within all client age group some people will be ready for change while other will not. 130 It was interesting to find that most students who preferred to work with older adults still perceived barriers to working with this group, such as “older adults are set in their ways and not willing to change”, “older adults have a lot of hardships”, and “older adults do not want help”. Such students, however, overcame these barriers, because, based on previous experiences, they knew that they could get well along with older adults and that helping older adults was very rewarding experience and they were very appreciative. Potential barriers to working with across all age group groups, which were more likely to lead students’ negative attitudes towards working with a certain age group, included difficulty in communication, lack of willingness to Ieam and change, and lack of interest in nutrition and health. Those barriers were overshadowed by the students’ perceived satisfaction and confidence in working with a certain age group as well as their comfort level with a certain age group. In this study, qualitative research methods provided more in-depth information on nutrition students’ attitudes towards working with older adults and preference for working with this age group compared to those of other age groups and how those attitudes and preference were established. Such a comprehensive information could not be elucidated in the first part of this dissertation study, where assessment of students’ attitudes towards older adults and preference for working with a certain age group were conducted using an established psychometric instrument. In addition to attitudes, there were many actors that influenced students’ preference .for working with a certain age group including: previous experience, perceived clients’ attitudes towards nutritionists 131 or Registered Dietitians, anticipated results of work and perceived satisfaction, confidence, and comfort level with a certain age group. Further, preference for working with a certain age group was one of various considered factors by students in job selection, including personal value, lntemal or external rewards, job availability or security, location of job, work environment, and characteristics of task. No study was identified in which researchers assessed attitudes towards working with all five age groups of infants, children, adolescents, adults and older adults using qualitative research methods. Several studies, however, have measured attitudes towards older adults compared to young adults. Slotterback and Saamio (1996) assessed undergraduate students’ attitudes towards older adults compared to young adults and middle-aged adults using psychometric scales and open-ended questions. They found that students’ global attitudes towards older adults were more negative than those towards other groups, and (in the open-ended task, the students portrayed older adults more negatively tahn younger or middle-aged adults. Students described older adults with words like “retired, talkative, canes, fragile, gray hair, hard of hearing, slow moving, slow, sick, tired, wrinkles, conservative, caring, friendly, funny, giving, happy, kind, loving, nice, (sweet, crabby, gmmpy, lonely, old-fashioned, rude, sad, stubborn, and wise.” The current study focused on attitudes towards working with older adults as a pre-health professional, so the findings differed from those of Slotterback and Saamio. Consistent with the findings of this study, Slotterback and Saamio found that students had a more positive image of middle-aged 132 adults than that of young adults and older adults. It seemed that students perceived the fewest barriers to working with middle-aged adults compared to any other group. In this study, most students believed that older adults were set in their ways, stubborn and not willing to change. This finding is similar to those by Mosher-Ashley and Ball (1999), who assessed college students’ attitudes towards older adults in business, psychology, occupational therapy and nursing. They found that only 29% of students thought older adults were open to ideas and 30% believed older adults were narrow minded. Moeller (1982) and Panek (1982) also found that students reported older adults to be rigid and inflexible. Students’ preference for working with older adults related to their positive attitudes towards working with older adults, to the students’ perceived satisfaction with and confidence in working with older adults, and to their comfort level to work with older adults. These findings in this part added some information to the conceptual map of attitudes changes and preference development in Part I as follows. For these students, beliefs about a certain age group influenced beliefs about working with a certain age group. Perceived satisfaction with working with a certain age group influenced preference for working with a certain age group along with attitudes towards working with a certain age group. Comfort level with a certain age group, clients’ attitudes towards nutritionists or Registered Dietitians and anticipated results of work also influenced students’ preference for working with a certain age group. These factors — perceived satisfaction, comfort level, clients’ 133 attitudes and anticipated results are new insights about attitude formation in pre- health professionals that could inform pedagogy. The strength of this study was that qualitative research methods were used to explore nutrition students’ attitudes towards working with older adults with respect to their unique role as pre-health professionals. This qualitative approach avoided the bias sometimes inherent in predetermined categories in psychometric instmments. Another strength was the comparison of students’ attitudes towards working with older adults versus working with other age groups, i.e., infants, children, adolescents and adults. One of the limitations of this study was that some students’ experiences with age groups other than older adults were not probed completely. If students did happen to mention such experiences, however, then these were captured in the transcripts. These findings provide important information to develop interventions to improve nutrition students’ attitudes towards working with older adults and to improve the curricula in dietetics programs. Nutrition curricula that can provide direct interactions with older adults as a pre-health professional will likely result in improved attitudes towards working with older adults. Such interactions should help students increase their comfort level with working with older adults and reduce stereotypical perceptions as they experience that older adults are as varied as any other age group. Students would be able to Ieam that some older adults care about nutrition and health and are willing to change dietary habits. In addition, older adults can be very appreciative and patient, so students should feel rewarded working with this group. All of these things would help students 134 reduce their barriers to working with older adults and to have increased confidence in working with them as pre-health professionals. 135 CHAPTER 6 Improving Dietetics and Nutritional Science Students’ Attitudes towards Working with Older Adults ABSTRACT Despite the need for nutritionists to work with older adults, research has shown that few nutrition students are interested in working with this age group, and their low interest relates to their negative or neutral attitudes towards this group. The purpose of this study was to develop, implement and evaluate an intervention to improve dietetics and nutritional sciences students’ attitudes towards working with older adults, using a quasi-experimental study design. Subjects were 100 students who completed both pre- and post-tests of assessment in a community nutrition course. Students were assigned to conduct a dietary behavior change project with either older adults (intervention group, n=52) or with young adults (comparison group, n=48). Each student conducted three individual interviews with their client and participated in a small guided group discussion after the individual interviews with other students who had clients in the same age group. The intervention effect was evaluated using mixed methods to assess knowledge about aging, attitudes towards older adults, and interest in and preference for working with older adults. General Linear Model Multivariate/Univariate Analysis and content analysis of students’ written responses to structured reflection items were conducted on the quantitative and qualitative data, respectively. At baseline, the attitudes of both groups towards older adults were slightly positive. After the assignment, the intervention group 136 had greater improvement of attitudes towards older adults relative to the comparison group (p<0.05). Most students in the intervention group reported that their beliefs about older adults had positively changed and that the value of working with this age group was improved. Opportunities for guided interaction with older adults in the community should be included in the nutrition curricula to help students improve their attitudes towards working with older adults, as well as improve confidence in working with older adults. INTRODUCTION The majority of older adults are healthy, active, and live within the general community, but most adults over 65 years old (88%) also have at least one chronic condition or diet-related chronic disease (Hoffman, 8 Sung, 1996) and use more health care services than other age groups. Despite the need, there is a shortage of health professionals who are qualified in geriatrics and gerontology. Geriatrics and gerontology educators in medicine, nursing and social work have focused on conducting interventions to improve students’ attitudes towards older aduhs. There has been only one study with dietetics students regarding their preference for working with older adults. The study showed that dietetics students had low preference for working with older adults (Kaempfer et al., 2002), in spite of increasing needs for qualified nutritionists and Registered Dietitians (RDs) who are interested in and willing to serve this age group. This lack of nutritionists and RDs is a concern, because good eating habits can help people 137 control their diseases, as well as maintain or improve their health status. There will be increased needs for nutritionists/Registered Dietitians to work with older adults as the aging population (65 years or over) continues to increase. To correspond to these needs, dietetics and nutritional sciences programs should design curricula to provide opportunities for students to interact with older adults. Rhee et al. (2004), however, found that only 20% of undergraduate dietetics programs reported having an entire course on aging for dietetics students. Most dietetics programs have emphasized maternal and child nutrition more than geriatric nutrition at both the undergraduate and graduate levels (Rhee et al., 2004). The barriers to inclusion of additional coursework on aging were “the curriculum is already full” and “lack of faculty expertise”. The researchers suggested that field experience or course assignments might help enhance dietetics students’ knowledge about older adults and challenge negative stereotypes without greatly expanding the required courses for students. Educators in the health professionals have designed interventions to improve students’ attitudes towards older adults, but few have been based on behavioral theory. Techniques typically used by researchers to change attitudes have included one or more of three major methods proposed by Glass and Knott (1982) and Triandis (1971 ): 1) increasing information or knowledge, e.g., about the aging process; 2) holding group discussion with peers, e.g., about attitudes and feelings about older adults; and 3) structuring direct experiences with the sample or concept, e.g., with older adults. 138 Theoretical basis for changing attitudes have been proposed by several researchers. Seefeldt (1987) suggested that the conditions for positive attitude development were: 1) direct contact when equal status between groups is maintained; 2) intimate, rather than casual, contact that is pleasant and rewarding for both groups; and 3) functional interaction where both parties are involved in goal setting and participate equally in important activities. Both Heider’s (1958) balance theory and Homan’s (1974) exchange theory suggested that positive attitudes develop when people discover similarities as a result of contact. The intervention used in this study was based on the Theory of Planned Behavior (TPB) (Fishbein & Ajzen, 1975) and the suggestions of Seefeldt (1987). The Theory of Planned Behavior proposes that attitudes are affected by a combination of changes in subjects’ beliefs, values, and self efficacy and which result in intent to change a specific behavior (Fishbein & Ajzen, 1975). The purposes of this intervention were to: 1) positively influence students’ attitudes towards older adults; 2) help students gain professional confidence in working with older adults; and 3) test if the intervention was effective. (Data from comparison group was used for analysis in quantitative component of this study). The expected outcomes of this study were to develop an intervention that minimized the barrier of an already crowded class schedule and curriculum, as well as to maximize the students’ experiences in working with clients of diverse backgrounds in a manner structured to maximize positive outcomes. 139 METHODS Research Design This study used a pre- and post-test design with an intervention. All nutrition students in a junior level course on community nutrition were randomly assigned to work with either an older adult (intervention group) or with a young adult (comparison group) to conduct an assigned project on a dietary behavior change. Changes in knowledge about older adults, attitudes towards older adults, and interest in and preference for working with older adults were assessed before and after the intervention using psychometric scales. In addition, changes in attitudes towards older adults and towards working with older adults were explored through content analysis of students’ reports from the experiential assignment Part A (individual reflections on this assignment) and in Part B (the group reflections on this assignment). lntervenjtion Assignment The intervention was composed of two components: 1) the experiential assignment Part A included direct interaction with a client to complete a dietary change assignment who was willing to change a dietary behavior (half of the students were assigned to an older adult 265 yr and half assigned to work with a young adult (20—30 yr), and 2) the experiential assignment Part B was a small group discussion about the assignment by students (n=4-5) who had all worked with a client from the same age group (Appendix 13 for the dietary behavior 140 change assignment). Part A of this assignment was nearly identical to one of two final project options used in this course for the previous three years. However, the course instructor had never previously assigned the students’ choice of clients, and few students had worked with clients over 55 years of age. Part A. The purpose of the experiential assignment Part A for this intervention was to give students an opportunity to interact with an older adult or a young adult to help a client change a dietary behavior as a pre-health professional. Half the students were randomly assigned to work with older adults and half to work with older adults using the function “random sample of cases” in the Statistical Package for the Social Sciences (SPSS, 2004). Because this assignment was behaviorally based on the Transtheoretical Model (Prochaska, Norcross, Fowler, Follick, & Abrams, 1992), all clients had to be willing to change a dietary behavior. The goal setting that students practiced with clients is a technique only appropriated for those ready to change. The objectives of Part A of this experiential assignment were: 1) to build students’ skills in identifying clients’ self perceived needs, wants, health goals and motivation for change; 2) to change students’ attitudes about the importance of Ieaming about the clients’ needs and wants with professional counseling; and 3) to experience the importance of setting one small goal at a time (through a behavioral change objective) in order to increase the client’s self-efficacy for dietary change, as well as their own self-efficacy as health professionals. Each student found one client from her/his assigned age group by herself /himself or through the aid of a researcher (SYL). Criteria to be a client for this 141 assignment were: 1) not a family member or close friend, e.g., grandparents, sister, brother, boyfriend, or girlfriend; 2) not an institutionalized person, because of limited dietary choices or preplanned meals; and 3) someone willing to change a dietary behavior. These criteria did not eliminate people in assisted living or in campus resident halls. Diversity in clientele was desirable in terms of age, health and socioeconomic status. To be prepared to assist students in the intervention group to find clients, the researcher recruited 77 older adults from congregate meal sites, senior centers, the university's retiree association and retirement living facilities (See Appendix 14). In addition, eight young adults from the university who were willing to change a dietary behavior were recruited to help students in the comparison group (See Appendix 15). Twenty-five students in the intervention group needed a contact from the list of older adults and two students in the comparison group requested a contact for a young adult. In the first meeting with their client, students conducted a dietary assessment (24-hour dietary recall), interviewed the client about lifestyle and dietary patterns, identified the client’s perceived needs, wants, health goals and beliefs, and discussed willingness and interest to change a dietary behavior. The second meeting was conducted after the student completed a nutrient analysis of the client’s diet from the 24-hour dietary recall. At this meeting, and together with the client, the student developed three specific and measurable behavioral objectives for dietary change. The client then chose only one of the three objectives on which to work over the next three days and kept dietary records for each day for subsequent analysis by the student. At the third and final meeting, the student 142 provided feedback on the client’s progress and discussed the client’s perceptions of success and barriers to change. In this assignment, students described their relationship with the client in addition to stating the number and length of interactions with the client. Part B. The instructor randomly assigned students to a group of four to five others with whom to complete Part B of this assignment using the function of “random sample of cases” in the Statistical Package for the Social Sciences (SPSS, 2004). Three to five students who worked with a client from the same age group held a small group discussion. The purpose of this part was to provide students the opportunity to compare and contrast their individual experiences and share findings with their peers. The discussion questions were designed to help students recognize heterogeneity of age and health status within each age group. For example, “Describe in general terms each of your clients, noting similarities and differences in age, lifestyle, health status, living arrangements, their needs and wants. The duration of group discussions was approximately 30 minutes and concluded with a short report written by the entire group for which they shared the grade. Students described their reflections on the assignment following key questions stated in Table 6.1. Table 6.1 Research questions and questions in the assignment Research Question Questions in experiential assignment report 4. In what ways are students’ attitudes towards older adults and working with older adults influenced by completing the experiential alignment? 4A. How are students’ beliefs about older . How have your perception and beliefs adults and working with older adults about your client age group changed after influenced by interacting with older completing the assignment Part A and if adults? so, how and why? 143 Table 6.1 (cont’d) 48. How are students’ beliefs about older o Have any of your perceptions and beliefs adults and working with older adults about your client age group and working influenced by participating in the small with your client group changed after your group discussion? group discussion? If, so, how and why? 4C. How are students’ values on working 0 Have any values in working with your client with older adults influenced by age group changed after completing the interacting with older adults? assignment Part A and if so, how and why? 40. How are their values on working with 0 Have any of your values on working with older adults influenced by participating your client age group changed after in the small group discussion? completing the assignment Part B group discussion, and, if so, how and why? 5. How do changes in students’ perceived e What was the hardest part and why? self-efficacy in working with older adults . What kind of information, skills and relate to changes in their attitudes previous experiences helped you with this (values and beliefs) towards working with assignment? older adults? . What changes were there in your confidence in ability to work with your client as a pre-health professional? 6. How do changes in students’ perceived . What was the most satisfactory part and satisfaction with working with older adults why? relate to changes in their attitudes . What changes were there in your (values and beliefs) towards working with perceived satisfaction in working with a older adults? client as a pre—health professional? Key questions were comparable for the comparison group who worked with young adults Participants and recruitment Potential participants were students enrolled in a junior level course on community nutrition, Fall 2004 (n=129). The students were majoring in dietetics, nutritional sciences or double majors (in dietetics and nutritional sciences) at a land-grant university in the north central United States. After the researcher briefly described the purpose of this study, students were invited to participate in each assessment (pre- and post-tests). As an incentive, students received 1 point extra credit (out of 200 total points for the course) for completing each assessment. 144 Procedures After approval by University Institutional Review Board, the researcher invited students in the course to complete an 11-page, multiple-choice, 15-20 minute, self-administered in-class assessment (Appendix 16 for the pre-test instruments) early in the fallsemester. Students were offered an alternative in- class activity for extra credit if they chose to not to participate in the assessment (Appendix 17 for the alternative activity). Prior to the intervention, students Ieamed how to write behavioral objectives from class lectures and activities on nutrition education and behavior change. This assignment provided the opportunity for students to experience and apply such didactic knowledge, as well as to develop their confidence to do so. The instructor assigned students to their respective group and distributed the assignment. Students submitted the completed dietary behavior change assignment for a grade. Students were asked to give the researcher permission to review and use their assignment, without grade penalty; all students agreed to permit the researcher to review their reports (the consent form in Appendix 18). During the last two weeks of class, the students were recruited to participate in the post-test, a 6-page, multiple—choice, 10 minute, self- administered in-class assessment (See Appendix 19). An in-class extra credit activity was offered again for those who might choose not to complete the assessment (See Appendix 16 for the alternative activity). 145 Variables The pre- and post assessments of students used two sets of instruments to measure key variables. These are described in the following paragraphs. Demographics (pre-test only). Students reported their age, gender, academic major, school year, ethnicity/race, and list of courses taken related to aging. In addition, they were asked about their career plans following graduation. Definition of older adults (pre- and post-tests). Students selected what they perceived to be the beginning age of ‘oId’ adulthood from 55, 60, 65, 70, 75 years old, and other. Interest in working with different age groups (pre- and post-tests). Interest in working with different age groups, i.e., infants, children, adolescents, adults, and older adults, was measured using a Likert Scale, with response options from 1 = not at all interested to 5 = very interested. This allowed some students the possibility of having the same level of interest in working with each of the five age groups. Preference for working with these age groups (pre- and post-tests). Preference for working with the same five age groups, was ranked from 1 = most prefemed to 5 = least prefemed in pre- and post-tests. Preference for working with older adults differs from interest in working with older adults, because for the latter, students were required to rank or prioritize each age group based on their interest. Interaction and experience with older adults (pre-test only). Students were asked to rate the overall quality of their previous experience(s) with older adults 146 using a Likert scale (1 = very positive to 5 = very negative). Interaction with grandparents and work or volunteer experiences with older adults were explored by five items, which probed for length, frequency and quality of such interactions. Knowledge about older adults (pre and post-tests). Knowledge about older adults was assessed using the Facts on Aging Quiz, which has been widely used to assess knowledge on older adults (Palmore, 1998). Thirteen items, which remained after item analysis, were administered and had a Kuder Richardson Reliability = 0.35. Attitudes towards older adults (pre-and post-tests). Because the Wall- Oyer Aging Inventory can assess attitudes towards older adults from both personal and general perspectives, it was used to measure the students’ ' attitudes towards working with older adults. lntemal reliability Cronbach’s alpha was 0.75 and 0.82 in both pre- and post-tests, respectively. Despite good reliability, one limitation of this instmment is that no cut-point has been standardized as indicating positive or negative attitudes. In this study, the score range between 1.00 and 2.74 was considered as negative; 2.75 to 3.25, neutral; and the score range between 3.25 and 5.00, positive. Data Analysis From the pre-and post-tests, descriptive statistics (mean, standard deviation, and frequency) were used to describe the participants, as well as the variables for knowledge about older adults, attitudes towards older adults, interest in working with a certain age group and preference for working with a certain age group. Differences were calculated in scores for knowledge about 147 older adults, attitudes towards older adults, and interest in working with a certain age group at pre- and post-tests. These scores were compared between intervention and comparison groups. Because there was a correlation between attitudes towards older adults and interest in working with older adults, General Linear Model (GLM) Multivariate analysis was used to test whether there were significant differences in knowledge about older adults, attitudes towards older adults, and interest in working with older adults as a unit between intervention and comparison groups. The value of knowledge about older adults, attitudes towards older adults and interest in working with older adults at pre-test were entered as covariates. GLM Univariate Analysis was then performed to test for a significant change in each variable. The score of knowledge about older adults in the comparison group was significantly higher than that of the intervention group at pre-test, so the value at pre-test was entered as a covariate for GLM Univariate Analysis. The difference in the frequency of students’ preference for working with older adults was calculated and the difference between intervention and comparison groups was tested using independent t-test. The Pearson’s correlation among the scores of knowledge, attitudes, interest, and preference was calculated, as well as the correlation among changes in those variables after intervention. Students’ reports for the selected nine questions from the assignment Parts A and B (underlined in Appendix 13) were analyzed using content analysis and logical analysis (Patton, 1987). How students’ beliefs about older adults and about working with older adults changed, and how such changes related to 148 changes in attitudes, self-efficacy, and perceived satisfaction in working with older adults were investigated. Two independent coders used the codes and categories developed in the qualitative research in Part II of this study to explore students’ attitudes towards working with older adults. New codes were added as new themes were identified. Inter-rater reliability of the coding by two independent coders was 0.88 for the individual reflection and 0.86 for group reflection analysis. A cross-classification matrix was generated to explore the emergent pattern of linkages among changes in beliefs about older adults and working with older adults and in self-efficacy and satisfaction to work with older adults (logical analysis) (Patton, 1987). RESULTS One hundred of the 129 students in the course who were majors in dietetics or nutritional sciences completed both the pre- and post-tests. All 100 students gave permission to use their responses for this study. Most students were non-Hispanic white, female, dietetics students in their junior or senior years as shown in Table 6.2. There were no significant differences for average age of students, distribution of majors, gender, year of school or race/ethnicity. Table 6.2 Demographics of subjects who completed both pre- and post- tests (n =100) Variable All subjects Intervention Comparison (N=100) (n=52) 4n =48) Age (year) (Mean i SD) 20.9 :t 3.1 21.5 i 4.0 20.4 :I: 1.8 149 Table 6.2 (cont’d) Variable All subjects Intervention Comparison (N=100) (n=52) (n =48 ) Major (%) Dietetics 61 32 29 Nutritional Science 37 19 18 Double major 2 1 1 Gender (%) Fema'e 88 42 46 ”3'9 12 6 6 School year (%) Sophomore 15 4 11 Jun” 51 28 23 39"” 33 19 14 Others1 1 1 0 Race/ethnicity (%) Non-Hispanic white 79 38 41 African American 7 5 2 Asian/Pacific Islander 8 3 5 Others 3 3 0 ' Exchange student Only 16% of students responded that they had taken a class(es) that included aging content. Those classes were Human Development, Life Cycle Nutrition, Long Term Nursing Care, Psychology, and others. Most (80%) rated their experience with older adults as positive or very positive. Approximately 60% of students reported that their relationships with grandparents were very close or close, and 71% of students contacted grandparents at least once a 150 month. Only 16 students, however, had lived with their grandparents. More than half of students (59%) had visited long-term care facilities, and 43% had had volunteer experiences with older adults in a nursing home, a retirement home or a hospital. There was no significant difference between the intervention and comparison groups on these variables. Most students defined the beginning of old age as 65 or 70 as shown in Table 6.3. At the pre-test, there was no significant difference between intervention and comparison groups in defining “the beginning age of old age” (Non parametric, Chi-square test). After the intervention, more students in the intervention group defined “the beginning of old age” as a higher chronological age (Chi-square = 9.914, p<0.05). Table 6.3 Frequency of students responding with an age group to the item, “When does old age begin?” Age of older 55 or 75 or 1 adults less 60 65 70 over Others All subjects Intervention a. (n =52) Pre-test 3 12 20 11 5 1 Post-test ° 2 4 20 15 8 2 Comparison _ (n =48 ) Pre test 3 9 16 16 4 o Post-test 3 4 18 17 6 o 1Others: “You’re as old as you feel” * p<0.05 a and b: significant difference between pre- and post-tests by non-parametric Chi-square test 151 Changes in students’ knowledge about older adults, attitudes towards older adults and interest in and preference for working with older adults At the pre-test, the average score for knowledge about older adults for the intervention group was lower than that of the comparison group (Table 6.4), but there was no significant difference between groups in attitudes towards older adults and interest in working with them (Table 6.5). In fact, the students’ average scores for attitudes towards older adults were slightly positive in both groups. Students’ interest in working with older adults was rated significantly lower than for other age groups (Table 6.5), and more than half of students ranked older adults as least preferred to work with at the pre-test (Table 6.6A). After the intervention, students’ average scores of knowledge about older adults, attitudes towards older adults and interest in working with older adults were significantly increased based on the result of GLM Multivariate Analysis (Wilks’ Lambda = 0.915, F=2.895, p <0.05). The increase in the average knowledge score about older adults for the intervention group (0.79) seems to be larger than that of the comparisons group (-0.19), but was not significant in the GLM Univariate Analysis (F=2.068, p=0.154, Partial 112 =0.021, Observed power = 0.294). Corresponding to the results from the GLM multivariate analysis, the score of attitudes towards older adults for the intervention group increased compared to that of comparison group (0.13 versus -0.03, F=5.042, p<0.05, Partial 112 =0.049, Observed power = 0.604). Students’ interest in working with older adults for the intervention group also increased compared to that of the 152 comparison group (0.35 versus - 0.08, F=3.777, p=0.055, Partial n2=0.037, Observed power = 0.486). Along with changes in interest in working with older adults, the intervention group showed a slight, but significant, increase in preference for working with older adults compared to that of the comparison group (Independent t-test, p<0.05) (Table 6.7). At the same time, preference for working with adults decreased compared to that of the comparison group (p<0.01). Table 6.4 Students’ average scores for knowledge about older adults and attitudes towards older adults Knowledge Attitudes (Mean i SD) (Mean 1: SD) All subjects (N=100) 6.9 i 1.9 3.47 :l: 0.36 ”9433‘ (2 -11) (2.68-4.41) Intervention (n=52) 6.5:18a 3451035 P'e'teSt (3 -10) (2.82-4.36) 7.3 :l: 2.1 3.58 i 0.42 ”was" (2 -11) ' (2.68—4.55) Change 0.79 12.40 0.13 :1: 0.36 "‘ Comparison (n=48) 7.3 i 2.0 b' 3.49 i 0.39 ”9433‘ (2 -11) (2.68-4.41) 7.1 i 2.2 3.45 i 0.44 P°St’t°s‘ (2 -11) (2.45-4.41) Change -0.19 i1 .83 41.03 i 0.36 ’ Knowledge of aging: 0 to 13 (higher score indicates greater knowledge) Attitudes towards older adults: 1 to 5 (higher score indicates positive attitudes) * p<0.05 a, b: Significant difference in the score of knowledge about older adults between pre- and post-test, independent t-test. x, y: Significant changes in the score of knowledge about older adults and attitudes towards older adults between pre- and post-test, General Linear Model Univariate Analysis. 153 comtmano an-E con .63 Eotehcom 53> <>Oz< .>_m>zooam9 .502on new .65 um 8:90 60m Embtfi comics 8:29.20 0:35.53 5 .m .Eodvq 1. .5.on .. .modvq . ..96. 285:3 $68835 ~09 u m 9 066963.. am we “on n- 6.68 tax: r0.—.H 00.0. 50.0 H 9.0 00,—. H 30 N00 H 2.0 00.9 H 00.0. 0065.0 can! a r... H v.0 :6 0.0 H Nd 2:5 0.0 H :4 2:5 0.0 H 06 m... H 0.0 «magnet 5 a u.» we .1. S. N- 4. 3V 3 a me me a we $3.20 as u 5 a :6 :8 a comtmano N..._.H 00.0 00.0 H v0.0- 00.? H 00.0- 05.0 H 00.0 ..0.0 H 0.20 emcuzo cues a 0._. H m." 0.0 H 0.0 .6 0.0 H :V :5 0.0 H 0.». 0.? H 06 «evince. . a 3 we a we we a N4 3 a 3. 3 a as 33...... an n 5 a N P :6 :6 :6 rs coaceteE. . . . . . . . . . . - 30.. u 20 aerNn .2600H0m «:60..va 216.. HHFV :5meme $395 mucous—55‘ 8.2.6 820 3.22 358223 5.2.5 8:8... 3526.50 6.3m tax... 05m: 80:90 00a 223:“. 5.3 05:33 5 328:. bacon—5m 0.0 Each 154 age group by rank order Table 6.6A Frequencies of students’ preference for working with a certain Most Least preferred . preferred Preference 1 2 3 4 5 All students (n = 100) at pre-test Infants 29 14 14 21 22 Children 24 35 22 1 1 8 Adolescents 27 21 32 1 2 8 Adults 24 20 21 28 7 Older Adults 1 12 13 22 52 Intervention (n =52) Infants Pre-test 18 7 7 9 1 1 Post-test 18 13 8 4 9 Pre-test 12 23 13 3 1 Ch'ldre" Post-test 13 20 14 4 1 Adolescents Pre-test 1 3 9 19 8 3 Post-test 13 7 17 9 6 Adults Pre-test 1 1 8 12 1 7 4 Post-test 5 7 6 26 8 Older Pre-test 0 7 3 12 30 Adults Post-test 5 4 8 8 27 Comparison (11 = 48) Infants Pre-test 1 1 7 7 12 1 1 Post-test 10 5 6 1 1 16 , Pre-test 12 12 9 8 7 Ch'm'e" Post-test 7 15 17 7 2 Adolescents Pre-test 14 12 13 4 5 Post-test 14 12 12 7 3 Adults Pre-test 13 12 9 1 1 3 Post-test 15 13 9 9 2 Older Pre-test 1 5 10 10 22 Adults Post-test 2 3 4 14 25 Rank order: 1 = most prefemed to 5 = least preferred 155 Because of cell sizes less than five responses, the first and second response categories were grouped as one, as were the fourth and fifth response categories (Table 6.63). At the pre-test, more students in the intervention than those of the comparison group ranked older adults as their fourth or fifth choices (Chi-square=7.254, p<0.05). After intervention, more students in the intervention group ranked preference for working with older adults as their first, second or third choice, compared to the comparison group (Chi-square=6.717, p<0.05). After the intervention, there was a significant change in the preferences in the intervention group. In contrast, after the intervention, more students in the comparison group ranked older adults as their fourth or fifth choices compared to their pre-test choices (Chi-square=10.456, p<0.01). Table 6.68 Frequencies of students’ preference for working with older adults by rank order Intervention (n = 52) 1" or 2"" choice 3" choice 4‘“ or 5‘h choice Pre-test "‘ 7 3 42 Old Ad Its °' " Post-test "‘ 9 8 35 Comparison (11 = 48) Pre-test " 6 1O 32 Older Adults Pam.“ ., 5 4 39 a, b: Significant difference between pre- and post-test by non-parametric Chi-square at p<0.05 level. x, y: Significant difference between intervention and comparison groups at pre-and post-tests, respectively, by non-parametric Chi-square at p<0.05 level. 156 Table 6.7 Changes1 In preference for working with a certain age group between pre- and post-tests Infants Children Adolescents Adults Older adults Intervention 0.29 :t 1.13‘ -0.04 :l: 0.77 -0.17 i 1.25 -0.58 i 0.33 i 1.29* (n=52) 1 .1 1“ Comparison 027:1: 1.12 0.08 :l: 1.29 0.02 :t 1.25 0.19 1: 1.30 -0.21 :1: 1.11 (n=48) * p<0.05, ** p<0.01, independent t-test 'Positive value of change = increase in preference; Negative value of change = decrease in preference. Relationships between students’ knowledge about older adults, attitudes towards adults, and interest in and preference for working with older adults are summarized in Appendix26 (Table 6.8). At the pre-test, there was no significant relationship between the average score for knowledge about older adults and the average score for attitudes towards working with older adults. Students’ attitudes towards older adults were positively related to their interest in working with older adults (r= 0.38, p<0.01) and also to their preference for working with older adults (r= 0.27, p<0.01). At the post-test, there was a small, positive relationship between knowledge about older adults and attitudes towards working with older adults (r=0.29, p<0.01). Students’ attitudes towards older adults were positively and moderately related to their interest in working with older adults (r= 0.52, p<0.01) as well as their preference for working with older adults (r= 0.51, p<0.01). The correlations between attitudes and interest and preference increased in strength after the intervention. The relationship of changes in knowledge about older adults, attitudes towards older adults and interest in working with older adults is summarized in 157 Table 6.9. The improved attitudes towards older adults after the intervention were significantly related to the increased interest in working with older adults (r=0.24, p <0.05) and also to increased preference for working with older adults (r=0.29, p<0.05) after the intervention. The change in the score of knowledge about older adults was not significantly related to changes in the attitudes towards older adults or interest in and preference for working with older adults. Table 6.9 Correlation matrix for changes between groups from pre- to post- tests for knowledge, attitudes, interest and preference for working with older adults Changes in Changes in Changes in knowledge attitudes Interest Changes in attitudes All (N=100) 0.17 Intervention (n=52) 0.18 Comparison (n=48) 0.05 Changes in interest All (N=100) 0.04 0.24* Intervention (n=52) -0.11 0.20 Comparison (n=48) 0.16 0.21 Changes in preference All (N=100) 0.00 0.29“ 0.43“ Intervention (n=52) 0.02 0.28” 0.44“ Comparison (n=48) -0.16 0.22 0.37‘ *p <0.05 and ”p<0.01 Changes in beliefs and values after the experiential assignment Most students (73%) in the intervention group met with their clients at least three times. The first meeting for the intervention group took 60.4 i 26.1 minutes (n=46). Thirty-five clients were female and 17 clients were male. Thirty- 158 four students out of 52 in the intervention group showed an increase in their scores for attitudes towards older adults at the post-test. Among those 34 students, 27 students reported their beliefs about older adults positively changed or they had newly developed positive beliefs about older adults. Thirteen students out of the 18 whose attitude scores decreased or stayed the same also expressed changes in their beliefs about older adults after the intervention. Students who reported their beliefs did not change mentioned that they already had positive beliefs about older adults from previous volunteer or work experiences, or were already close to older adults in their family. Those students mentioned that they had always enjoyed working with older adults and thought health and nutrition were important for people of that age. Half of the students in the intervention group reported that they valued working with older adults more after the intervention. Among those 34 students who had a positive change in attitudes, 21 students reported that they valued working with older adults more after the intervention. Five students out of 18 whose attitude scores decreased or stayed the same also expressed changes in their value working with older adults the intervention. A. Changes in beliefs about older adults after the individual interviews A number of thematic beliefs about older adults (Table 6.10) emerged from the analysis of students’ reflection papers such as: their lifestyle; their cognitive function and physical health; their motivation or willingness to change; their concern about diet, nutrition or health; their personality or mood; and the 159 heterogeneity of older adults. Each of these beliefs is discussed in detail in the following paragraphs. Table 6.10 Changes in students’ beliefs about older adults after the intervention (Frequency mentioned)* Before After Older adults Older adults... Life style Are dependent :> Are independent (1 )* Are sedentary => Are active (4) Are not busy => Are busy (1) :> Have healthy eating Physical and Are unhealthy :> Are healthy (3) cognitive status Motlvationlwllllngnes s to changes Concern about diet/nutritionlhealth Personality/Mood Heterogeneity Have bad memory Are set in their ways/ Are not willing to change Are not ready to change Have no motivation Are not willing to listen Not receptive Are uncooperative Stubborn Do not care about their diet/ nutrition/health Are impatient Are insensitive Are unhappy, in bad mood, crabby, angry, mean Private/stubbom Are all same :> Have good memory (1) :> Are willing to change (15) :5 Are ready to change (2) 0 Have motivation (2) :> Are willing to listen (3) :> Are receptive (2) :> Are cooperative (2) :> Take my advice seriously (2) :> Do care about their diet/nutrition] health (3) :> Are patient (1) :5 Are sensitive (1) :> Are happy, in an upbeat mood (6) => Are open-minded (2) :> Cannot be grouped as one group of older adults (2L Lifestyle. Before conducting the assignment, many students believed that older adults were dependent, sedentary, and not busy. After completing the 160 assignment, more students appreciated that older adults were independent, active and busy. “I realized that older people don’t necessarily have to depend on other people to do things for them.” “I thought people in this age group would be more sedentary. . , but all of that changed once I spoke with Joe.” Cognitive function and physical health. Students expected older adults to be unhealthy and to have a poor memory, but following the assignment, students recognized that many older adults were healthy and had good memories. “I thought that l was going to have hard time getting information from my client doing the 24-hr recall... She impressed me with how well she was able to recall her food, food sizes, and any condiments she added. “I think that most of my preconceived notions that I received about older adults came from the media and l presumed that they were all either lonely or sickly people. I realized that getting older does not mean that you just get sick and sit around waiting for the end. I understand that there are healthy older individuals that do a lot of the same things that I do.” Motivation/willingness to change. Many students thought that older adults were set in their ways or stubborn, not willing to change or not ready to change their diet, not willing to listen or not receptive, not cooperative, and not motivated to change their diet. After the assignment, students said that older adults were willing or ready to change, willing to listen, receptive, motivated, and cooperative, and took advice seriously. This was the most frequently mentioned response category. 161 “I often thought that older adults were set in their ways and were not interested in making changes. This practice helped me to realize that older adults are willing to change. Many of them just need the correct information and assistance. Now I see older adults as a more important part of the nutrition and health spectrum”. “They are as eager to Ieam as young people and for them, diet and nutrition can affect their quality of life in a more significant way.” Concern about diet/nutrition/health. Previously, many students believed that older adults did not care about their health and diet. But aftenlvards, students realized older adults cared about their health and nutrition, possibly more than young adults. “I have discovered that the older population is much more conscious of their eating habits than I realized.” “I found that older adults are becoming increasingly concerned about their health, and appear even more concerned about health than their younger adult counterparts.” Personality/Mood. Many students believed that older adults were impatient, insensitive, unhappy, crabby, angry. mean, and private. They later realized that many older adults are patient, sensitive, happy, in an upbeat mood and open-minded. “My perception of older adults was impatient, insensitive and unhappy about life. My client was very patient, relaxed and extremely happy." “I had a preconceived notion that most older adults were cranky and difficult to work with. Through interviewing my client, both of these beliefs were dispelled. Mary was always in an upbeat mood and willing to help in any way she could. 162 Heterogeneity. Aftenlvards, students reported that older adults could not be categorized as one group of older adults, because older adults were not all the same people. “I now understand that like young adults you get people of all kinds. Some are stubborn and some are ready and eager to change, like my client.” Several students mentioned that they developed new beliefs about older adults (frequency of response) such as: older adults are knowledgeable (2); older adults are interested in younger generations or care about young adults (2); older women have similar perceptions of body image to that of young women (1 ); older adults care about nutrition (1 ); older adults are willing to live healthy lives (1 ); older adults are willing to change (2); older adults are eager to get involved (1 ); older adults are open-minded/receptive (2); older adults are just like other people (1 ); and older adults need and want help (1 ). B. Changes in beliefs about older adults after the small group discussion Twelve out of 14 student discussion groups in the intervention reported that their beliefs about older adults had changed. Most groups mentioned that older adults could not be categorized into one group. Major themes of change in beliefs were the older adults’ willingness to change their diet, their concern or interest about nutrition and health, and the importance of nutrition and health for older adults. 163 C. Changes in value of working with older adults after the individual interviews Several themes emerged that related to the reasons for change in values of working with older adults after the intervention as shown in Table 6.11. Table 6.11 Reasons for increasing students’ value on working with older adults after intervention (Frequency mentioned)* The reason for increased value Learning 0 Older adults are knowledgeable (4)“ something from older adults 0 I learn from older adults (4) . I Ieam a different perspective from older adults (1) Importance of 0 Nutrition and health are important for older adults (9) nutrition and health for older adults Older adults’ . Older adults care about diet, nutrition, and health (3) willingness to be , , healthy 0 Older adults value my oplnlon (1) 0 Older adults take my advice seriously (1) 0 Older adults are interested in what I am saying (1) 0 Older adults seek my advice (1) . Older adults are excited to work with me (1) Learning something from older adults. Students perceived they could Ieam something from older adults because older adults were knowledgeable and had different perspectives. “I suppose that I didn’t give enough credit to this age group in the past for being able to maintain their youth. I feel that there is quite a bit of value in working with this age group. Greg was able to share some of his life experiences with me, and able to really open my eyes to a different perspective on life. There is a lot of value in that.” “I think that I would benefit significantly from working with my client’s age group. I found Pam to be very 164 knowledgeable about many things that l was just Ieaming. I think their experiences and guidance are something that I would be able to utilize in my own personal experiences.” “After completing this assignment, I feel that I value the thoughts, ideas and opinions of older adults a lot more. I realized that older adults are not given enough credit for their sharpness and knowledge, because of the label society has put on them as unfortunately, a waste of time.” “There was a lot of information there and l Ieamed that I can get a lot of knowledge while working with older adults.” Importance of nutrition and health for older adults. Students reported that nutrition and health were important for older adults, so their work was valuable to older adults. Interestingly, after the intervention all those who had reported that nutrition and health were important to older adults, changed in their beliefs about older adults’ willingness to change/listen. “Mary helped me to realize that her diet and her lifestyle are just as important as mine.” “I was under the impression that older people were hard to work with. I felt there was absolutely no purpose in doing a project on dietary change with an older adult. Originally, I wanted to change to a younger adult when l was assigned to an older adult. I realized that their dietary health is of the same importance as younger adults, if not more.” “I Ieamed that health seems to become even more important to individuals as they age, and providing them with simple objectives that they can attain really does make a difference in motivating them to be more heakhyf “Now I think it is even more important to provide nutritional information to older adults. They are at an 165 age where they can prolong their lives by eating fight” Older adults’ willingness to be healthy. Students realized that older adults cared about nutrition and health, listened to students’ advice, and took it seriously. “At first, when I was assigned this age group I thought it was going to be a waste of time, but seeing how excited my client was to change, the value of me wanting help her changed dramatically.” “The value of working with my client's age group changed because the elderly do care about health and fitness. It’s just that younger people have the perception that once you get older you can become unhealthy. The elderly do want to stay current with nutrition, the problem is getting someone to sit down and take the time to speak with them and show them new ideas and ways.” “I felt like my suggestions were taken to heart and that my client really wanted to receive my opinion. I felt like I was a valued source of information to my client.” “I was very impressed how enthusiastic my patient was. I value my client a lot more because although he does have a lot to say he is still interested in hearing what I have to say and interested in Ieaming more. “I gained much more respect for this age group, realizing that they are just as, if not more, concerned with health issues as younger people. They also seem most willing to change and take the suggestions of health professional very seriously.” “Before this assignment, I was unaware of the needs, wants, and goals of older adults. Now, thanks to John, I have a better understanding of what the goals are of the older generation. For instance, I would have never guessed that a 67 year old male would be‘ determined to walk the Fifth Third River Bank Run. 166 This assignment helped mold and shape my current values of the older generation”. D. Changes in value of working with order adults after the small group discussion Nine out of 14 student discussion groups in the intervention group reported that their value of working with older adults increased. Such an increase in value was due to positive changes in beliefs about older adults and their recognition of the importance of nutrition and health. Changes in confidence in workingwith older adlits Thirty-six students out of 52 reported increase in confidence in working with older adults. Twenty-four students out of 34 students whose attitudes changed positively reported their confidence in working with older adults increased. Twelve students out of 18 students whose attitudes changed negatively or stayed the same still showed improved confidence in working with older adults after completing the assignment. Several themes emerged that related to the reasons for increased in confidence in working with older adults after the intervention as shown in Table 6.12. Table 6.12 Reasons for increasing students’ confidence in working with older adults after intervention Themes The reason for increase in confidence Experiences Doing this assignment (12) Doing this assignment was easy and enjoyable (1) Good My skills were good (1) skills/ability My communication skills were good (4) My data analysis skills were good (1) I can answer questions (1) 167 Table 6.12 (cont’d) Themes The reason for increase in confidence I can apply my knowledge (2) My manner as a professional was good (4) Attitudes of older My client took my advice seriously (2) adults My client gave me positive feedback (2) My client showed respect/trust to me (1) My client treated me as a professional (1) My client looked up to me (1) Results of work My client achieved her goal (1) My client’s diet improved (1) Experiences. Students said their confidence in working with older adults increased by just doing the assignment. This was the most frequent response category “I feel more confident after this assignment as a pre- health professional. Now that l have experience doing a dietary change with an older adult, I feel much more prepared to do it in the future.” “This experience gave me additional confidence for working with clients as a pre-health professional. I feel as though I did have confidence before this, but that the additional practice only improved my confidence. I will feel more prepared for the next time I am placed in a similar situation.” “I would say that after working with John, I feel that I am much more confident in my dietary skills. I think that by doing a dietary change on John gave me hands on experience; whereas before I just knew the information, but had not really had the chance to .apply it to an individual.” Skills/Ability. Their communication skills and abilities in dietary analysis, ability to apply their knowledge to their project and ability to answer their clients’ questions, and their professional manner made them more confident. 168 “This project certainly changed my sense of confidence when dealing with clients as a potential professional. I t has led me to se that I have acquired many skills over the years that make me apt to communicating with people. I was surprised but pleased at my ability to conduct myself with good manners and professionalism.” Attitudes of older adults. Clients’ willingness to take students’ advice, give positive feedback, and respect/tnlst the students also increased students’ confidence. “After I began working on the assignment... I was surprised to see that my client looked to me as a health professional, and treated me with a great deal of respect regardless of the fact that she is much older than I am. She treated me as though I was an actual dietitian assessing her diet and she trusted me with all of the information she presented to me during our time together. The confidence my client placed in me made me a great deal more confident in my job as a pre-health professional.” “. .. I realized that Lily had respect for what I had to say and was, essentially looking to me for advice. This helped to increase my confidence immensely.” “I think every experience one gets to work in a situation with a real client will help them to gain experience and confidence. This assignment especially helped me in gaining confidence to give dietary advice because my client really looked to me and depended on me for my suggestions when we were deciding on her dietary objectives.” “There was definitely change in my confidence following my work with a client as a pre-health professional. I had always felt a little unsure about my knowledge and the fact that I am not a professional made me doubt whether someone would take my advice seriously. I discovered that even though my client knew a lot, that she was still 169 interested and eager to hear about what I had Ieamed and how it appeared to help her.” “I feel that I am slightly more confident as I was able to use the knowledge that I have Ieamed in class on a real client. My client thought that I did a good job and she seemed happy about the information I gave her.” Results of work. Students also reported that they became more confident when they saw their clients achieving goals and improving their diet. “This project helped me to build on the amount of confidence I have to work with patients decades older than myself. I was excited to see that I could plan areas for improvement with my client, and then really see these goals being met.” Changes in satisfaction of working with older adults Only 10 students out of 52 in the intervention group stated that their satisfaction with working with older adults changed. Nine students out of 34 whose attitudes changed positively reported their satisfaction of working with older adults changed. Only one student out of 18 whose attitudes negatively changed or stayed the same reported the satisfaction with working with older adults changed. The reasons for increased satisfaction include: my client was excited and I can relate to her (1 ); my client changed her diet (1 ); there is more than a nutrition component, not measured by the scale (1 ); it was a rewarding experience (1 ); there was something to Ieam (1 ); to help people is rewarding (1 ); this was a hands-on-expen'ence (1 ); and my client and I achieved our goals with each other (1 ). Only one student indicated her satisfaction decreased, because she could not answer some questions her client asked. 170 DISCUSSION This study provides support for the influence of direct and guided interactions with older adults willing to change a dietary behavior on improvement in nutrition students’ attitudes towards older adults. Although students and clients were not on the same level as Seefelft (1987) recommended for changing attitudes, the relationship was intimate and required functional interaction that included goal setting and achieving a goal. Therefore, students’ attitudes towards older adults improved after the intervention, likely due to increased comfort levels. Such changes might be explained, in part, by changes in students’ beliefs about older adults and working with older adults, values of working with older adults, and self-efflcacyin working with this age group as a health professional. In addition, several students mentioned that older adults were similar in surprising ways to young adults, so relating was easier than anticipated. These findings are consistent with other studies. Rasor-Greenhalgh et al. (1993) found that nutritional assessment on healthy older adults improved dietetics students’ attitudes towards older adults. Other studies with medical, nursing, or other allied health students showed that a course on aging including direct contact with older adults, and a geriatric rotation had a positive impact on students’ attitudes towards older adults, regardless of the location of the contacts, such as in nursing homes, home visits, or primary care settings (Adelman, Fields, & Jutagir, 1992; Dellasega, & Curriero, 1991; Galbraith & Suttie, 1987; Greenhill & Baker, 1986; Hartley, Bentz, & Eillis, 1995; lntrieri et al., 1993; O’Hanlon & 171 Brookover, 2002; Puentes & Cayer, 2001; Ward et al., 1998; Warren, Painter,& Rudisill, 1983; Wilson & Hafferty, 1980). Findings from the content analysis showed how changes in students’ beliefs, values and self-efficacy related to changes in students’ attitudes. Before the intervention, the negative beliefs held by nutrition students about older adults were consistent with common myths reported in previous studies, such as older adults are economically insecure, lonely, resistant to change, have poor physical or mental health, cognitive or intellectual function, or are disagreeable, inactive, economically burdensome, dependent, dull, socially withdrawn, and more disruptive of family harmony than youth or adults (Spence et al, 1968; Harrigan & Farmer, 2000; Hawkins, 1996; Hickey & Kalish, 1968; Tuckman & Lorge, 1953). After the intervention, those negative beliefs changed positively and led students to increase the value on working with older adults. Although most students’ negative beliefs about older adults became positive after the intervention, some students mentioned that their beliefs did not change because they already had positive beliefs about older adults from previous experiences. This finding is consistent with findings from Greenhill & Baker (1986) where nursing students who initially had positive attitudes remained unchanged. Most students reported that their self-efficacy in working with older adults as a pre-health professional increased. Such an increase in their self-efficacy seemed to be not so much just from interacting with older adults, but also from interacting in role as a pre-health professional. The implication is that this guided experience assured nutrition students that they could be perceived professionally 172 by people 40 years or older than them. This increase in self-efficacy is similar to the finding by Ward et al. (1998), who examined the effect of intergenerational massage on students’ attitudes towards older adults in allied health and found increases in students’ confidence through via massage skill. Unexpectedly, in this current study, only a few students reported that their satisfaction in working with older adults changed. Consistent with other studies of dietetics, medical, nursing, and social work students (Fitzgerald et al., 2003; Kaemfer et al., 2002; Reed et al. 1992), in this study, students' knowledge about older adults was low. Students’ knowledge did not change after the intervention. It might be there was only one lecture on senior nutrition and meal programs. Other studies in which the intervention was a course on aging included a lecture, simulation of physical changes with aging, and interaction with older adults in the community or institution, showed significant increases in knowledge about older adults (Bavis-Berrnan, 1995; Carmel, Cwikel, & Galinsky, 1992; Puentes 8 Cayer, 2001). These interventions were of a longer period than in this study and provided more information about aging and older adults. In contrast to findings in this study, previous studies have shown no significant increase or even a significant decrease in work preference with older adults after taking a course on aging (Carmel et al., 1992; David-Bennan 8: Robinson, 1989). Although the preference for working with older adults increased significantly after the intervention in this study, only 14 students in the intervention group demonstrated this improvement and overall the older adult 173 group still remained the least preferred group with which to work, even by the intervention group of students. These findings lend support for the Theory of Planned Behavior (Fishbein 8 Ajzen, 1975), as well as to the balance and exchange theories stressing pleasant, functional contacts between groups to foster positive attitude changes (Heider, 1958; Homan, 1974). When the results of both the quantitative and qualitative components of this study are analyzed, the improvement of students’ attitudes towards older adults can be explained by positive changes in students’ beliefs and the increased value of working with older adults. Unfortunately, change in self-efficacy in working with older adults was not measured using a psychometric instrument so this construct could not be examined quantitatively in relation to changes in attitudes or preference for working with older adults. Based on the findings from the qualitative components, increased self-efficacy seemed to help students improve students’ attitudes and increase their preference. Increased satisfaction with working with older adults was expected to contribute to changes in attitudes towards and preference for working with older adults. Thus, satisfaction was a concept added in the conceptual model in for this study, but it did not appear to play a major role from the qualitative findings with these pre-health professionals. Increased comfort level of working with older adults as a pre-health professional, was another important construct added to the conceptual model. Improved comfort level did appear to positively influence changes in students’ attitudes towards and preference for working with 174 older adults. Unfortunately, like self-efficacy, comfort level was not measured in a quantitative way, so its role in attitude change must be explored further. This study had a number of strengths that are listed as follows. First, the intervention was developed based on a conceptual model, which was constructed from earlier findings with dietetics and nutritional sciences students, as well as, adapted from the Theory of Planned Behavior. Secondly, there was a comparable comparison group, similar to the intervention grow in terms of demographics and previous experiences with older adults. Third, the intervention effects were evaluated using mixed methods, which provided in-depth and comprehensive insight of how and why students’ attitudes towards older adults changed. There are, however, several limitations of this study. First, the interaction between the intervention group and the comparison group could not be controlled, so there might have been contamination effects between the two groups. Secondly, students’ interactions with older adults beyond the intervention could not be controlled. Third, because the same instrument was used at the pre- and post-tests, the subjects might have demonstrated a practice effect on the post- test. Fourth, some constructs in the conceptual model, such as self-efficacy in and satisfaction with working with older adults and comfort level with older adults were not measured using psychometric instmments, so definitive relationships could not be made between changes in those three constructs and changes in attitudes towards and preference for working with older adults. Fifth, most nutritionists who work in geriatric care will likely work with older adults in nursing 175 homes or assisted living and have clientele much less willing or able to make dietary changes. Nevertheless, this activity with a healthy older adults sample willing to change a dietary behavior was an entree into increasing student comfort levels to work with older adults. Finally, it is not possible to generalize the findings beyond this sample. These findings have implications for dietetics and nutritional sciences . curricula that aim to improve students’ attitudes towards working with older adults through making positive changes in students’ beliefs about older adults and increasing self-efficacy in working this age group as pre-health professionals. The results from this study suggest that structured, hands-on experience that allows direct interaction with older adults as pre-health professionals is an essential component of improving students’ attitudes towards working with older adults. Sharing experiences through a structured small group discussion with peers, however, did not show additional influence on changes in students’ attitudes towards older adults, except for recognizing the heterogeneity of older adufls. Based on the findings from this study, direction interactions with older adults as a pre-health professional seemed to be a powerful teaching technique to improve students’ attitudes towards older adults, especially at this junior class level. Students could use their knowledge and apply it in conducting their projects and this helped students become more confident. Considering that most students had stereotypes of older adults and older adults were their least preferred with whom to work, early guided interventions such as this are 176 important. For large introductory nutrition courses, student presentations about their positive experiences of working with older adults might be a more economical way to change students’ negative beliefs about older adults. In addition, guest speakers such as Registered Dietitians who are working with older adults or coordinators of senior meal programs could also share their positive experiences and this might be a good technique to gain students’ attention and deliver course material within context. In this study, some students mentioned how they were impressed by healthy and active older adults who were knowledgeable and interested in nutrition and health and who were capable and wanted to change dietary behaviors. Therefore, it might also be possible to change students’ beliefs by inviting older adult guest speakers who can demonstrate their interest in nutrition and health and relate successful stories of dietary behavior change. 177 CHAPTER 7 CONCLUSIONS AND RECOMMENDATIONS FOR FUTURE STUDIES Summary of study and findings To establish baseline data for an intervention to improve students’ attitudes towards older adults, dietetics and nutritional sciences students’ knowledge about older adults and about geriatric nutrition, their attitudes towards older adults and preference for working with older adults were assessed in Part I of this study. The Theory of Planned Behavior was the conceptual model for the study. The construct, knowledge about older adults, was added to the model, because it was expected to influence students’ attitudes towards older adults based on the literature reviewed. The findings from Part I of the study, however, indicated that students lacked knowledge about older adults and about geriatric nutrition and had a low preference for working with older adults compared to infants, children, adolescents, and adults. Despite this finding, students still had slightly positive attitudes towards older adults that did relate to their preference for working with older adults, but students’ attitudes did not relate to their knowledge about older adults. As expected, there was no change in knowledge about older adults or about geriatric nutrition after one 90-minute lecture on senior nutrition and programs in a course on community nutrition. Students’ attitudes towards older adults and preference for working with older adults declined, however, after the lecture. 178 Such findings supported the need to explore factors, other than knowledge, which could affect students’ attitudes towards older adults and increase the preference for working with them. It was also important to Ieam how positively to affect such attitudes within the constraints of a full course and dietetics curriculum. The assessment of students’ attitudes towards older adults using Likert scaled instruments in Part I did not provide insight into factors that might influence students’ attitudes towards older adults and their low preference for working with older adults. In addition, the Likert scaled instmment that had been used with other pre-health professionals was for general attitudes about older adults and did not relate directly to students who had a career focus in nutrition. This is important, because nutrition differs from other health care areas in terms of its emphasis on prevention of disease and disease management using a lifestyle approach. Such an approach requires considerable participation and commitment from clients and patients, as well as, their willingness to make dietary behavior changes. For these reasons in the second part of this study, qualitative research techniques were used to explore nutrition students’ attitudes towards working with older adults and factors affecting the formation of those attitudes. Findings from the four focus groups and 10 in-depth interviews conducted in Part II showed that dietetics and nutritional sciences students’ beliefs about older adults and their beliefs about working with older adults were established based on whether or not they had previous experiences with older adults. Furthermore, those beliefs influenced the students’ perceived satisfaction and confidence in 179 working with older adults. Students’ attitudes towards, perceived satisfaction and confidence in working with older adults, and comfort level with older adults all influenced students’ preference for working with this age group. Whether or not students preferred to work with older adults, most still believed that older adults were set in their ways, not willing to change, and not interested in nutrition and health. Students who preferred to work with older adults believed, however, that they could get along well with older adults and were comfortable them. Such students also believed that working with older adults was rewarding based upon their previous work and volunteer experiences. Some students who preferred to work with older adults did report beliefs that older adults were ready to change and cared about nutrition and health. Regardless of the preferred age group, students showed positive attitudes towards working with a particular age group, if they believed that the client age group was easy to communicate with, willing to Ieam and change dietary habits, and interested in nutrition and health. The exact opposite was true for those students who had negative attitudes towards working with a specific age group. Hence, it appeared important to help nutrition students recognize that some older adults were willing to and interested in changing their diets, as well as, interested in nutrition as were people in other age groups. These findings suggested that the best way to improve students’ attitudes towards older adults would be direct and positive interaction with older adults which would also help increase confidence and comfort level with older adults. The findings from Part II also 180 contributed two new constructs to the conceptual model. These were satisfaction in working with older adults and comfort level to be with older adults. In the third and last part of study, an intervention was developed by modifying an existing assignment to require students to work with older adults with the intention of improving their attitudes towards working with older adults. Students in the community nutrition class were assigned to work in the role of a pre-health professional with either older adults (intervention group) or young adults (comparison group) to complete a final project on dietary behavior change. In order to participate as a client for this assignment, every client in each age group had to be willing to work with a pre-health professional student to change a dietary behavior. Students met three times with their clients and met once in a structured, small group discussion with their peers. The intervention effect was evaluated using mixed methods. The results of the intervention group were compared to those of the comparison group for the quantitative analysis. Here the students’ knowledge about older adults, attitudes towards older adults and preference for working with older adults were assessed using the psychometric Instruments refined in the first part of this dissertation research. In addition, students submitted their written reflections on the intervention based on structured questions that were analyzed using qualitative analysis techniques. Findings from Part III following the intervention demonstrated that students’ direct interactions with older adults improved both their attitudes and their preference for working with this group. As expected, students’ knowledge about older adults was unchanged, probably because there was only one lecture 181 on senior nutrition and meal programs. From the qualitative part of the analysis, most students reported that their beliefs about older adults and beliefs about working with older adults changed positively or that positive beliefs were newly established. Students mentioned they valued working with older adults more and that their confidence as a pre-health professional had increased. Surprisingly though, few students reported that their satisfaction to work with older adults had increased. Finally, although the one-on-one interactions between students and older adults improved students’ attitudes towards older adults, the subsequent small group discussion had only small effects to enhance students’ understanding of the heterogeneity among older adults. Theoretical Approach The conceptual model visually summarizing these findings is in Figure 7.1. In the first part of this study, a modified Theory of Planned Behavior was used as the conceptual model for attitude formation and intent to work with a particular age group. In this model, the attitudes towards working with older adults could be predicted by student’s beliefs about working with older adults and the value about working with older adults. Knowledge of older adults as a function of beliefs about older adults was added to the conceptual model to predict attitudes. Also the importance of knowledge in the formation of attitudes towards older adults was based on the literature reviewed from studies with other health professions. From the model, both attitudes towards and self-efficacy in working older adults were expected to predict preference for working with this age group. The construct of subjective norms from TPB was excluded from the conceptual 182 model, because no evidence was found in the literature review for its importance on attitudes towards older adults. Using psychometric instruments to assess students’ knowledge, attitudes, preference and interest, it was determined that values for these were low to neutral. Also, it was apparent that students’ knowledge about older adults was not related to their attitudes towards this age group. Self-efficacy was not measured, because no appropriate instrument was available and the time frame was insufficient to develop one. In the second part of study, influential factors affecting formation of students’ attitudes towards working with a certain age group were explored using triangulated qualitative research methods using focus groups and in-depth interviews. Perceived satisfaction to work with a certain age group was added to the conceptual model, because of students’ comments and some findings reported in the literature that supported its role in attitude formation. From this conceptual framework, students’ beliefs about a specific age group, about working with that age group, and the value of such work all appeared to influence their attitude formation. Such beliefs and values were from their previous experiences with a specific age group. Students’ perceived self-efficacy and satisfaction to work with a specific age group affected their preference for working with that group. Other factors emerging from Part II of this study were the students’ comfort level to be with a specific age group, clients’ perceived attitudes towards working with nutritionists or Registered Dietitians, and results of the work done with clients. In the Theory of Planned Behavior, behavioral intention, which in 183 this study was preference for working with a certain age group, could be a major factor influencing behavior. In this study, however, besides preference for working with a certain age group, other factors affecting job selection were reported by students. The other factors were personal values, lntemal or external rewards of the work, availability and location of the job, the work environment, and characteristics of tasks required. In the third part of this study, the intervention was designed based on the conceptual model from Part II and the effect was evaluated using mixed methods. Some constructs including attitudes towards older adults and preference for and interest in working with older adults were assessed using psychometric instruments. Other constructs, such as—beliefs about older adults and working with older adults, the value of work with older adults, satisfaction with and self- efficacy in working with older adults—were explored by content analysis of the students’ written reflections on the intervention. After the intervention, students’ beliefs about older adults and working with older adults, the value of and self- efficacy in working with older adults, and their comfort level to work with older adults were major factors affecting improved students’ attitudes towards older adults and increased preference to work with older adults. These results were consistent with the findings in Part II. Unexpectedly, only a few students mentioned satisfaction with working with older adults. $0 adding the construct, satisfaction to working with older adults, into the conceptual model remains questionable. This construct might carry more importance for practicing and experienced health professionals, than for these junior level students. 184 F5»-.. '_ Strengths and Limitations There are several strengths of this dissertation research. This was the first in-depth study with dietetics and nutrition sciences students to explore their attitudes towards working with older adults compared to other age groups as a nutrition pre-health professional. This study was conducted in three phases, making it possible to systematically develop the intervention for Part III, based on the findings from Parts I and Il. Both the delivery method, i.e., the intervention activity, as well as, the context of the message to change students’ attitudes towards older adults was developed during the research integrating results from early findings. The intervention itself was based on a modification of behavioral change theory and adaptations made from the findings from Parts I and II. Finally, the effect of the intervention was evaluated using mixed methods, where qualitative components could be used to explain why and how the quantitative results were obtained. There are also several limitations of this research. First, the sample was not representative of all college dietetics and nutritional sciences students, so it is not possible to generalize the findings beyond it. The instrument for assessing knowledge about older adults in Parts I and Ill had low lntemal reliability with the subjects in this study, as compared to good reliability with other groups of pre- health professionals. This difference might be explained by the nutrition students’ low level of knowledge about older adults, because most had had only i one introductory nutrition course. Also, there might have been practice effects of the questionnaire with pre- and post-tests in Parts I and Ill (Angiullo et al., 1996). 185 In Part II the students’ previous experiences with age groups other than older adults were not probed in sufficient depth to understand their attitudes towards working with these age groups. The experimental activity in the intervention was limited to interaction with healthy older adults willing to change a dietary behavior, but most nutritionists who work in geriatric care will likely work with older adults in nursing homes or assisted living and have clientele much less willing or able to make dietary changes. Finally, even though mixed methods were used to evaluate the effect of the intervention, some constructs in the conceptual model, such as self-efficacy in and satisfaction working with older adults and comfort level to be with older adults were not measured using psychometric instruments, limiting identification of definitive relationships in Part III. Implications for Pedagogy The intervention component comprised of a structured series of interactions with an older adult as a pre-health professional to help the older adult change a desired dietary behavior, did successfully improve dietetics and nutritional sciences students’ attitudes towards working with older adults and increased their preference for working with this group. This dietary behavioral change project did not require of the instructor additional skills in geriatric nutrition, but did provide students the opportunity for an enriched experience to work with older adults as a pre-health professional. About half of the students in the intervention group requested help finding an older adult client, a task requiring a small amount of extra time by faculty, but easily handled in advance via contacts with alumni groups and senior meal programs. 186 Another important implication for teaching is to base assignments upon behavioral theory where possible. Not only was this research based upon the Theory of Planned Behavior, but also the selection of clients who were willing to change a behavior was an application of Stages of Change Theory (Prochaska et al., 1992). That is behavioral goal setting approaches are appropriate only for those ready and willing to make a change. Students Ieam abstract concepts best when there are opportunities to apply theory to practice as they did with the intervention assignment. Other practical applications of this research on attitude change would be for instructors to find ways to convey to students that older adults are a heterogeneous group, most of whom are quite interested in making the most of their remaining years via good health practices. In addition to frequently being more interested in diet and health than are young adults, older adults typically are more patient in working with pre-health professionals. Lack of interest in nutrition by clients and low comfort level by the students were two important potential barriers for students in pre-health professions to developing positives attitudes. These barriers might be addressed by asking former students who had had rewarding experiences with older adults in a pre-health professional capacity to speak to the class. Alternatively, healthy personable seniors who have worked well with pre-health professionals might speak to a class about their experiences. Recommendations for future studies Based on the findings from this study, several recommendations can be made for research on attitudes towards older adults in pre-health professionals 187 and health professionals. First, three constructs—students’ self-efficacy and satisfaction in working with older adults, and comfort level to be with older adults- -were not measured using psychometric instruments in this study. This limited investigation on the relationships among attitudes towards older adults and preference for working with older adults and these three constructs. Because adequate instmments for measuring these constructs were not located, developing psychometric instruments to assess these constructs would be an important first step of study to examine influential effects of these three constructs on changes in attitudes towards older adults and preference for working with older adults. Secondly, it would be interesting to examine the changes in attitudes towards older adults and preference for working with older adults after students complete the dietetics internship. Such an analysis would help determine if internships provided adequate preparation for future dietitians. Several students in Part II mentioned that they expected to have more experience with a broad ' age range of patients and clients during an upcoming internship. Third, the positive relationship between attitudes of health care professionals towards older adults and the quality of care they give to older adults has been assumed. However, it would be appropriate to examine how quality of nutrition care actually relates to Registered Dietitians’ attitudes towards older adults. Additional analyses might be, to examine how Registered Dietitians’ attitudes relate to the outcomes of nutrition care and service, as well as, to the satisfaction of older adult patients and clients. 188 It is important that we have an improved understanding of how to improve quality of care for older adults. Additionally, we must know more about how to adequately prepare health professionals to meet the current and future needs of an increasingly aging population. 189 605050 00 EeEEam use .606! 3306280 ...h 959... etc; 0c a... .mdm $0350 .3026 30025038 30390 2650 M £03 00 938m. m 80336 900:0 m awesome”. m ton—Eco x08 *0 0030:309ch EmEcQSco v_._/’o>> 06:36.. 83.... \ \/._. \. £56.65 £0010 mm>\ s—i 0:90 60m 58.8 m 55, 0:26; 5 5856.260 .cmtoae_\ 0:90 00m 53.8 m 53> one; 2 855090 0 5? 0:253 «.2039 $0302 l I [’0 ’0 ,0 ’D 052959 .mEQS B:_m> .mcoflmn. 02. 059039 .mEmfim 0:20 000 58.8 "—23.3820 5.3... a an 05:33 Sons e:_u> o i 0 ’0 0:90 00m 50:8 8 55, 050.6; 5:, 00003003 0028.00 x53 ”6 3.36m. 0:20 60a Eaton a 5; 05x33 Sean £23m M 000325 .9025 _ 03.9 .2850 0:90 000 Emtoo a Scam £2.60 190 Appendices 191 Name: Appendix 1 Alternative option for extra credit in 2002 Nutrition Concerns for Seniors (For 1 pt Extra Credit) Student ID: Purpose of assignment 1. To explain an example of assessing and addressing the nutritional status of an older adults using bio-psycho-social model Directions Please write your answer on the back of this page 1. 2. 3. Think of an example of an older person you know from your family, friends, acquaintances or from the media and describe in a few sentences Describe both positive factors and risk factors for the person’s nutritional and health status. Then draw a bio-psycho-social model of these factors which could affect their nutritional health Factors affecting nutritional status in older adults are: a. b. C. Physiological changes in the body with aging (eg. digestive, respiratory, or cognitive functions) Socio-economic changes (retirement, changes in income & living arrangements etc.) Having chronic diseases or chronic conditions such as diabetes, hypertension, cardiovascular diseases, stroke, arthritis, etc Describe how a health professional might address some of the risk factors within each sphere of the bio-psycho-social model. Conclude with some benefits and barriers to health professionals for working with older people. 192 Appendix 2 Pre-test (original instrument) in 2002 Knowledge & Attitudes for Working with Older Adults This survey is being conducted by: Sharon Hoerr, RD, PhD (hoerrs@msu.edu) Seung-yeon Lee, MS (leeseu15@msu.edu) Department of Food Science and Human Nutrition College of Human Ecology Michigan State University 204 GM. Trout FSHN Building East Lansing, MI 48824 (517) 355-8474 (X 110) Thank you for agreeing to respond to this survey! Information from this survey will be used to develop interventions for pre- health professionals to improve knowledge and attitudes toward aging. 193 Knowledge & Attitudes for working with Older Adults Student’s ID: . (Please record accurately to receive your extra credit) If you are interested in this research, you can participate in the survey. If you are not interested in participation, you can choose to complete the alternative one point extra credit one page assignment on nutrition concerns for seniors (Guidelines will be provided upon your request). Participation is voluntary and by completing this survey, you indicate your consent. All answers are completely confidential. We can only use the group’s answers, not individual ones. Your privacy will be protected to the maximum extent allowable by law. You can discontinue your participation at any time without penalty and you can refuse to answer a certain question. This sheet with your student ID number will be kept separate from your survey response. After 3 years, both this sheet and your survey response will be destroyed. Extra credit points towards your course grade will be given to you, if you complete these questionnaires. Please answer each question on the questionnaire. Beginning on page 5 (Part IV) also mark each answer on the scantron. The purpose of this sprvev is to afssess vopr knowledge of agipgandflderlv Mntion and attflrdes toward older adults to help ups develop an intervention program for pre-health professionals. If you have any questions, please contact Dr. Sharon Hoerr or Seung-yeon Lee via the information on the front page of this packet. In case you have questions or concerns about your rights as a research participant, please feel free to contact Ashir Kumar, MD, Michigan State University's Chair of University Committee on Research Involving Human Subjects at (517) 355-2180, or through email at ." The entire questionnaire takes 20-30 minutes to complete. Please answer the questions honestly and completely. © Thank you for your participation! © FOOD SCIENCE HUMAN NUTRITION MICHIGAN STATE U N W E R s [T Y 194 Part I. General questions about you Please circle one 1. Your gender (circle one) a. Male b. Female 2. How old are you? years old 3. What is your race/ethnicity? (Clrcle one) White, non-Hispanic Hispanic African American Asian/Pacific Islander American Indian/Alaska Native Other (Specify: ) ”99999 4. What is your major? a. Dietetics b. Nutritional Science c. Health & Humanities d. Health related major (Specify: ) 5. Your student status is . (Circle one) Freshman Sophomore Junior Senior Other 9.0-99'!” 6. At which age would you describe the beginning of “old age”? (Circle one) a. 55 b. 60 c. 65 d.70 e.75+ 9. Other . 7. Have you had any class related to aging or older adults? Yes No If yes, please list those courses. 195 In relation to your professional job preference, how important are these following to you: Very important Important Neutral Not so important 9.0-9579’ Not at all important Circle a response for each one lmxzrftyant ‘ mggm 8. Your family’s advice 3 b c d e 9. Your friend’s attitudes a b c d e 10. Your professor’s counseling a b c d e 11. Mass media Influences a b c d e 12. Helping to meet society’s needs a b c d e Part II. Job preference 13. Please rank your preference for working with each age group (1 to 5) ( ) Infants ( ) Children ( ) Adolescents ( ) Adults ( ) Old adults 14. Please rank your preference to do the following types of work as a health professional (1 to 6) ) Working in a hospital )Working at a nursing home or Iong-terrn care facility ) Working in out-patient facility )Working in community setting ( ( ( ( )Working in private practice ( ( ) Other (specify: ) 196 Part III. Interaction and Experiences with Older Adults Below are questions about your experience with older adults. Please circle the response that best fits. 15. How would you rate your experiences overall with older adults? (Clrcle one) Positive Very positive Neutral Negative Very negative 16. In the next row below list the older adults with whom you Interact the most. Ex: Grandfather-mother's side; an older neighbor etc. 16. List the older adults with whom you Interact the most EXAMPLE Grandfather on mother’s side ‘ 17. Have you ever lived wlth this person? (Clrcle Yes or No for each person on you list) Yes No Yes No Yes No Yes No 18. Check any of the following when you Interacted with this person In preschool «I In elementary school \I In middle school In high school Now 19. How close were you to this person? (Check one for each person) Very close Close x] Somewhat close Not at all close 20. The health status of this person In general was (Circle one) Physical health Good Poor Good Poor Good Poor Good Poor Physical health Good Poor Good Poor Good Poor Good Poor 21. The health status of this person In general was (Circle one) 21X/wk 21X/mo V 23X/yr 21X/yr < 1X/yror never 22. How often did you 197 ‘ 22. How often did you contact this person by mail, phone or email? Check for each person) 21X/wk 21XImo 23X/yr 21X/yr I < 1X / yr or never 23. What were the purposes of your contracts? (Check all applied for each person) Family gatherirg \I Refiqious activity Holidays/birthdays ‘l Mealtimes Shopping Counseling/advice Recreation/hobby Social Other(specify) Part IV. Knowledge about Aging1 Please circle the letter of the most accurate answer and also fill in the corresponding bubble on the scantron sheet. 1. The proportion of people over 65 who are sensible (have impaired memory, disorientation, or dementia) is About 1 in 100 + About 1 in 10 About 1 in 2 The majority Don’t know sense 2. The senses that tend to weaken in old age are Sight and hearing Taste and smell Sight, hearing, and touch All five senses Don't know 9.0-9.5!" l.Facts on Aging Quiz, Part I 198 3. The majority of old couples a. Have little or no interest in sex b. Are not able to have sexual relations Continue to enjoy sexual relations Think sex is for only the young e. Don’t know 99 4. Lung vital capacity in old age a. Tends to decline b. Stays the same among nonsmokers (14) c. Tends to increase among healthy old people d. Is unrelated to age e. Don’t know 5. Happiness among old people is a. Rare b. Less common than among younger people c. About as common as among younger people d. More common than among younger people e. Don’t know 6. Physical strength a. Trends to decline with age b. Trends to remain the same among health old people c. Trends to increase among healthy old people d. Is unrelated to age e. Don’t know 7. The percentage of people over 65 In long-stay Institution (such as nursing homes, mental hospitals and homes for the aged) Is 5% 1 0% 25% 50% Don’t know 999?? 8. The accident rate per drive over age 65 Is a. Higher than for those under 65 b. About the same as for those under65 c. Lower than for those under 65 d. Unknown e. Don’t know 199 9. Most workers over 65 a. Work less effectively than younger workers b. Work as effectively as younger workers 0. Work more effectively than younger workers d. Are preferred by most employers e. Don’t know 10. The proportion of people over 65 who are able to do their normal activities is One tenth One quarter One half More than three fourths Don’t know EDP-99'5” 11. Adaptability to change among people over 65 Is Rare Present among about half Present among most More common than among younger people e. Don't know 999? 12. As for old people learning new things a. Most are unable to Ieam at any speed b. Most are able to Ieam, but at a slower speed c. Most are able to Ieam as fast as younger people (I. Learning speed is unrelated to age 9. Don’t know 13. Depression ls more frequent among @999? People over 65 Adults under 65 Young people Children Don’t know 14. Older people tend to react Slower than younger people At about the same speed as younger people Faster than younger people Slower or faster than others, depending on the type of test\ Don’t know 15. Old people tend to be 9999 SD More alike than younger people As alike as younger people Less alike than younger people More alike in some respects and less alike in others Don’t know 16. More old people say 9.0-99'!“ They are seldom bored They are usually bored They are often bored Life is monotonous Don't know 17. The proportion of old people who are socially isolated ls weeps Almost all About half Less than a fourth Almost none Don’t know 200 18. The accident rate among workers over 65 tends to be a. b. c. d. e. Higher than among younger workers About same as among younger worker Lower than among younger workers Unknown because there are so few workers over 65 Don’t know 19. The proportion of the US population new age 65 or over ls weave 3% 1 3% 23% 33% Don’t know 20. Medical practitioners tend to give older patients: a. b. c. d. e. Lower priority than younger patients The same priority as younger patients Higher priority than younger patients Higher priority if they have Medicaid Don’t know 21. The poverty rate (as defined by the federal government) among old people is b. Higher than among children under age 18 Higher than among all persons under65 About the same as among person under65 Lower than among persons under 65 Don’t know 22. Most old people are Still employed Employed or would like to be employed Employed, do housework or volunteer work, or would like to do some kind of work Not interested in any work Don’t know 23. Rellglosity tends to has 9.9- lncrease in old age Decrease in old age Be greater in the older generation than in the younger Be unrelated to age\ Don’t know 24. Most old people say that 9.0-99'.” Are seldom angry Are often angry Are often grouchy Often lose their tempers Don’t know 25. The health and economic status of old people (compared with younger people) in the year 2010 will 999?? Be higher than now Be about the same as now Be lower than now Show no consistent trend Don't know Part V. Attitudes toward Older Adults and Aging2 Please Indicate how you agree the following items a= Strongly agree b=Agree c=Neutral d=Disagree e=Strongiy disagree Strongly agree Strongly disagree 26. Older people usually understand the problems encountered by the a b c d e young 27. Older people are often critical of a b c d e younger generations 28. Most older people have a good sense of humor a b c d e 29. Most older people have active social lives a b c d e 2Wail-Oyer Attitudes on Aging Inventory 201 Strongly agree Strongly disagree 30. Most older people prefer to be Independent and live In their own homes 31. Many older people are less tidy about themselves than younger people 32. Younger people can usually benefit from the wisdom of older people 33. Working with older adults in terms of improving their functioning often can be a rewardinlexperience 34. Older people generally are not interested In younger people and their concerns 35. Most older people are amenable to change 36. Ordinarily I would not feel comfortable working on the health problems of the elderly 37. Working in a stroke- rehabilitation program for the elderly would probably be a poor investment of time 38. i usually feel as relaxed around older people as I do around younger people 39. I would not want to work in a medical setting for older adults who are psychologically diseng_a_g£d from daily events 40. I feel many older people are opinionated and It Is difficult to work with them 41. i would not be Interested in devoting a major portion of my practice to specializing in Elatrlc care 42. I would like to develop a practice catering to the special needs of older adults 43. I would typically find working with older people and their physical problems depressing 202 Strongly agree Strongly disagree 44. I would find it difficult to develop programs for working with the a b c d e health problems of older people 45. Usually I enjoy communicating a b c d e with older people 46. As a health professional I expect to encounter some resistance a b c d e from older adults in a treatment PM") 47. i would Ieam a great deal a b c d e working with older people Part VI. Knowledge of Elderly Nutrition 48. Nutrients that may not be well digested and/or absorbed by the elderly are 9.0.09) 49. Fat, calcium, and vitamin B12 Starch, iodine, and biotin Protein, phosphorous, and thiamin Vitamin C, riboflavin, and niacin In normal aging, changes In dietary requirements Include a. Increased need for fat b. Decreased need for sodium C. Increased need for vitamin D d. Decreased need for fiber 50. The most prominent effect of aging on gastrointestinal function Involves the a. Esophagus b. Stomach c. Mouth d. Pancreas 203 a. 09;: a. b. c. d. pope 51. Older adults are susceptible to dehydration because Diets are often low in sodium and chloride Diets lack folic acid Metabolic rates increase Sensitivity to thirst decreases 52. In the older person, loss of lean body mass and decreasing physical activity leads to A decease in energy needs An increase in energy needs A desire for more sugar-containing foods A desire for foods containing more salt 53. The best choice for dietary fiber Is Tomato without the skin Banana Bran flaskes Cream of wheat 54. Assessment of older adults presents a challenge because problem can result from non-dietary causes such as a. Dehydration b. Lack of nutrition knowledge c. Frequent use of prescription drugs d. Lack of exercise 55. The most reliable diagnostic indicator of protein energy malnutrition In older adults Low mid-arm circumference Edema Poor wound healing Low serum albumin 99?? 56. Which is the best method for dietary intake assessment on a nursing home resident with a decline In cognitive function? a. 24 hour food recall b. Food monitoring c. Food frequency questionnaire d. Physical assessment 57. The greatest risk for nutrient deficiency In older adults Is for wmmmc Protein Vitamin B12 Carbohydrate 99?? 58. Individuals diagnosed with coronary heart diseases are encouraged by the National Cholesterol Education Program to limit their saturated fat Intakes to less calories? 30% 7% 1 0% 20% pops 204 59. If an older adults shows declining cognitive function, which of the following vitamins might be deficient? a. Vltamln B12 b. Vitamin Be c. Folate d. Any of the above 60. An important element In diabetic diets for most older adults is a. Sufficient calories for weight gain b. Elimination of sugar 0. Vitamin supplementation d. Increased intake of dietary fiber 61. Which of following Is not related to development of osteoporosis in older women? a. Lack of estrogen after menopause b. Low calcium intake 0. Low vitamin A intake d. Poor vitamin D status 62. If an older person has lactose intolerance a. No dairy products can be consumed b. Small amounts of dairy products may be tolerated c. Exercise should be avoided to prevent lactic acid build-up d. Less fiber should be given to stabilize the GI tract 64. A good source of potassium for people on diuretics is? Milk Apple juice Banana White bread 999s 65. Using mineral oil as a laxative can promote deficiencies of a. B-vitamins b. Vitamin C c. Minerals d. Vitamin A, D, E,K 66. Iron deficiency Is associated with all the following, except a. Ulcers b. Antacid intake 0. Aspirin d. High vitaminCintake 67. If an older person ls consuming a poor diet and takes at least three prescription intervention would be a. Nutrition counseling b. Recommend a vitamin/mineral supplement c. Weekly weighting d. Discontinue all over the counter medications 205 68. Which of the following is false and about the Nutrition Screening Initiative? a. Targets the nutritional status of the elderIy b. Can diagnose the specific conditions c. Was established by collaborated efforts by health professionals d. Includes social economic risk factors 69. Poor nutritional status can result from all of the following except Multiple chronic conditions Poverty Eating dessert Social isolation page 70. Which of the following ls false about the Elderly Nutrition Program except a. It Is for people over age 65 b. It has both nutrition and social services c. It includes home delivery meals d. It includes congregate meals Appendix 3 Post-test instrument in 2002 Knowledge & Attitudes for Working with Older Adults This survey is being conducted by: Sharon Hoerr, RD, PhD (hoerrs@msu.edu) Seung-yeon Lee, MS (leeseu15@msu.edu) Department of Food Science and Human Nutrition College of Human Ecology Michigan State University 204 GM. Trout FSHN Building East Lansing, MI 48824 (517) 355-8474 (X 110) Thank you for agreeing to respond to this survey! Information from this survey will be used to develop interventions for pre- health professionals to improve knowledge and attitudes toward aging. Knowledge & Attitudes for working with Older Adults Student’s ID: . (Please record accurately to receive your extra credit) If you are interested in this research, you can participate in the survey. If you are not interested in participation, you can choose to complete the alternative one point extra credit one page assignment on nutrition concerns for seniors (Guidelines will be provided upon your request). Participation is voluntary and by completing this survey, you indicate your consent. All answers are completely confidential. We can only use the group’s answers, not individual ones. Your privacy will be protected to the maximum extent allowable by law. You can discontinue your participation at any time without penalty and you can refuse to answer a certain question. This sheet with your student ID number will be kept separate from your survey response. After 3 years, both this sheet and your survey response will be destroyed. Extra credit points towards your course grade will be given to you, if you complete these questionnaires. Please answer each question on the questionnaire. Beginning on page 5 (Part IV) also mark each answer on the scantron. The purpose of this survey is to assess your knowledge of aging and elderly nutrition and attitudes toward older adults to help us develop an intervention program for pre-health professionals. If you have any questions, please contact Dr. Sharon Hoerr or Seung-yeon Lee via the information on the front page of this packet. In case you have questions or concerns about your rights as a research participant, please feel free to contact Ashir Kumar, MD, Michigan State University's Chair of University Committee on Research Involving Human Subjects at (517) 355- 2180, or through email at ." The entire questionnaire takes 20-30 minutes to complete. Please answer the questions honestly and completely. © Thank you for your participation! © FOOD SCIENCE HUMAN NUTRITION MICHIGAN STATE U N w E R SIT Y 207 Part l. General questions Please circle one 1. At which age would you describe the beginning of “old age”? (Circle one) a. 55 b. 60 c. 65 d.70 e.75+ 9. Other . in relation to your professional job preference, how Important are the following to you: a. Very Important b. Important c. Not sure d. Not so important e. Not at all important Very Not at all Important important 2. Your family’s advice a b c d e 3. Your friend’s attitudes a b c d e 4. Your professor’s counseling a b c d e 5. Mass media influences a b c d e 6. Helping to meet society’s needs a b c d e Part II. Job preference Please Indicate how much you are Interested in working with each age group Mtg/reamed Not at all 7. Infants a b c d e 8. Child a b c d e 9. Adolescents a b c d e 10. Adults a b c d e 11. Older adults a B c d e 208 12. Please rank your preference for working with each age group (1- the highest preference; 5- the lowest preference). Use each number only once. ( ) Infants ( ) Children ( ) Adolescents ( ) Adults ( ) Old adults 13. Please rank your preference to do the following types of work as a health professional (1- the highest preference; 6- the lowest preference). Use each number only once. ( ) Working in a hospital ( ) Working at a nursing home or long-term care facility ( ) Working in out-patient facility ( ) Working in private practice ( ) Working in community setting ( ) Other (specify) Part V. Knowledge about Aging1 Please circle the letter of the most accurate answer and also fill in the corresponding bubble on the scantron sheet. 3. Happiness among old people Is 1 . The senses that tend to weaken in old age are a. Rare b. Less common than among younger a. Sight and hearing 99°33"? b. Taste and smell c. About as common as among c. Sight, hearing, and touch younger peeple d. All five senses d. More'common than among younger peop e 2. The majority of old couples 4. Most workers over 55 a. Have little or no interest in sex . b. Are not able to have sexual relations a. Work '953 effectively than younger . . . rkers c. Continue to enjoy sexual relations wo . . . b. Work as effectively as younger d. Think sex rs for only the young workers . 0. Work more effectively than younger 1. Fact on Aging Quiz 1 workers d. Are preferred by most employers 209 5. The proportion of people over 65 who are able to do their normal activities Is a. One tenth b. One quarter 0. One half d. More than three fourths 6. As for old people Ieaming new things a. Most are unable to Ieam at any speed b. Most are able to Ieam, but at a slower speed c. Most are able to Ieam as fast as younger people d. Learning speed is unrelated to age 7. Old people tend to be More alike than younger people As alike as younger people Less alike than younger people More alike in some respects and less alike in others 99?? 8. More old people, than young people, say They are seldom bored They are usually bored They are often bored Life is monotonous 99¢? 9. The proportion of old people who are socially Isolated ls Almost all About half Less than a fourth Almost none page 210 10. Health practitioners tend to give older patients: a. Lower priority than younger patients b. The same priority as younger patients c. Higher priority than younger patients d. Higher priority if they have Medicaid 11. The poverty rate (as defined by the federal government) among old people Is a. Higher than among children under age 18 b. Higher than among all persons under65 c. About the same as among person under 65 d. Lower than among persons under65 12. Most old people say they a. Are seldom angry b. Are often angry c. Are often grouchy d. Often lose their tempers 13. The health and economic status of old people (compared with younger people) in the year 2010 will Be higher than now Be about the same as now Be lower than now Show no consistent trend 99?? Part IV. Attitudes toward Older Adults and Aging2 Please indicate how you agree the following Items A = Strongly agree b = Agree c = Neutral d = Disagree e = Strongly disagree Strongly Strongly agree disagree 14. Older people usually understand the problems a b c d e encountered by the young 15. Older people are often critical of younger a b c d generations e 16. Most older people have a good sense of humor 8 b c d e 17. Most older people have active social lives a b c d e 18. Most older people prefer to be Independent and a b c d e Iive In their own homes 19. Many older people are less tidy about themselves a b c d e than younger people 20. Younger people can usually benefit from the a b c d e wisdom of older people 21. Working with older adults in terms of Improving their functioning often can be a rewarding a b c d e expeflence 22. Older people generally are not interested In a b c d e younger peeple and their concerns 23. Most older people are amenable to change a b c d e 24. Ordinarily I would not feel comfortable working on a b c d e the health problems of the elderly 25. Working in a stroke-rehabilitation program for the te'lderly would probably be a poor lnvestrnent of a b c d e me 2. Wall-Oyer Attitudes on Aging inventory 211 Strongly Strongly agree disagree 26. I usually feel as relaxed around older people as l a b c (I do around younger people e 27. I would not want to work In a medical setting for older adults who are psychologically disengaged a b c d e from daily events 28. I feel many older people are opinionated and it Is a b c d difficult to work with them e 29. I would not be Interested In devoting a major portion of my practice to specializing in geriatric a b c d e care 30. I would like to develop a practice catering to the a b c d e special needs of older adults 31 . I would typically find working with older people a b c d e and their physical problems depressing 32. I would flnd it difficult to develop programs for a b c d e working with the health problems of older people 33. Usually i enjoy communicating with older people a b c d e 34. As a health professional I expect to encounter some resistance from older adults in a treatment a b c d e program 35. I p233: learn a great deal working with older a b c d e Part V. Knowledge of Elderly Nutrition 36. Nutrients that may not be well 37. Older adults are susceptible to digested and/or absorbed by the dehydration because elderly are a. Diets are often low in sodium and a. Fat, calcium, and vitamin B12 chlonde . _ b. Starch, iodine, and biotin b- 33:33? forc 39"! C. Protein, phosphorus, and thiamin c. e ,9 'c ra es Increase d. Vitamin C, riboflavin, and niacin d' Sensrtivrty to thirst decreases 212 38. In the older person, loss of lean body mass and decreasing physical activity leads to a. A decrease in energy needs b. An increase in energy needs c. A desire for more sugar-containing foods d. A desire for foods containing more salt 39. Assessment of older adults presents a challenge because problems can result from non- dIetary causes such as Dehydration Lack of nutrition knowledge Frequent use of prescription drugs Lack of exercise 99?? 40. The most valid diagnostic Indicator of protein energy malnutrition In older adults is Low mid-arm circumference Edema Poor wound healing Low serum albumin 99?? 41 . The greatest risk for nutrient deflclency In older adults Is for Vitamin C Protein Vitamin D Carbohydrate 99?? 42. An Important element in diabetic diets for most older adults is Sufficient calories for weight gain Elimination of sugar Vitamin supplementation Increased intake of dietary fiber 99?? 213 43. 44. 45. 46. If older adults show declining cognitive function, which of the following nutrients might be deficient? Vitamin A 8 C Vitamin Bg& B12 Iron 8. calcium Protein & fiber 99?? Which of following ls _n_ot_ related to develop of osteoporosis in older women? a. Lack of estrogen after menopause b. Low calcium intake c. Low vitamin A intake d. Poor vitamin D status If an older person has lactose Intolerance a. No dairy products can be consumed b. Small amounts of dairy products may be tolerated c. A moderate amount of fiber will enhance calcium absorption d. Less fiber should be given to stabilize the GI tract Using mineral oil as a laxative can promote deficiencies of a. B-vitamins b. VitaminC c. Minerals d. Vitamin A, D, E,K 47. If an older person consumes a poor diet and takes at least three prescription medications, an appropriate intervention would be 3. Nutrition counseling b. Recommend a vitamin/mineral supplement c. Weekly weighing d. Discontinue all over the counter medications 48. All of the following are true c. It was established and is used by a about the nutrition Screening wide variety of health lnltlatlve excem professionals e. It Includes social economic risk a. It targets the nutritional status of factors elderly b. It generates treatment options * If you are interested In further participation in this research (e.g. focus group (discussions about your job preference and perceived benefits and barriers to working with older adults), check below and write your e-mail address. I am interested in further participation of this research Please contact me via email (My e-rnail address: ). *If you could receive a newsletter about elderly nutrition, job availability for working or a volunteering with older adults, which do you prefer? (Please mark one) Via e-mail ( ) Hard copy of newsletter ( ) Thank you for your time! 214 Appendix 4 Traditional lecture outlines in 2002 Hoerr (HNF 375) Lecture 11: US Dept Health 8. Human Services; Nutrition Needs 8 Food Programs for Older Adults Motivations: 1. All health professionals need to be able to recognize and understand DHHS programs and services with which they will work. 2. Senior meal programs serve millions, enhance the well-being of a rapidly growing segment of our population, and help keep seniors out of high priced long-term care. Objectives: 1. Recognize the agencies and organizations within DHHS and their functions and activities. Why are HCFA and DRG's important? Describe the trends in demographics and economics for older Americans. What implications do these trends have for health and social policies and programs? Discuss the changing nutrient needs of the elderly. What are the recommendations for age-related changes in vitamin-mineral needs; what physical, social, psychological, economic and environmental changes that accompany old age affect dietary intake? Describe the Nutritional Screening Initiative, Level I. Describe the Older Americans Act and the functions of the Administration on Aging (AOA). How are Michigan Area Agencies on Aging organized to deliver services? What role do nutritionists play? Describe eligibility requirements and services delivered for Congregate Meals and Home Delivered meal programs. What types of special diets are available? What is unique about the diet quality in Michigan's program? How have DRG's affected demand for home delivered meals? Recommended: .9 O O 9.. To volunteer for Home Delivered Meals. 483-4150 or 349-1172 Find web-related sites on/for Seniors: www.nhlbi.nih.gov; Position of the American Dietetic Association: nutrition, aging, and the continuum of care, JADA; 2000;100:580—595. Rosenburg IH. Vitamin needs of older Americans: Vitamin Nutrition lnfonnation Service Back grounder. 1999;7z1-10. Weimer JP. Factors affecting nutrient intake of elderly. Washington DC: USDA, Food & Rural Economics Division. No 769, 20pp 1998. http://www.usda.gov.cnpp/ Nutrition & aging; Leading a healthy, active life http://www.gao.gov.index.html Options for improving nutrition for older Americans. 215 O ht_tp:/Iwww.exclusivelyseniors.com/resources.asp> for those working with older adults Lecture #1 1 . DHHS 8 Nutrition for Older Adults l. Dept Health 8 Human Services (used to be DHEW or Dept Health, Education 8 Welfare) A. Human Development B. Public Health Service C. National Institutes of Health (See Boyle, p. 91) D. Health Care Financing Administration (HCFA) (Sounds like hikfa) II. Aging Trends www.aging.stats.gov A. Demographics of Aging B. Economics of Aging ill. Nutrient Needs of Older Adults RDA’s Age-related changes in nutrient needs Factors that affect food intake: At Risk Indicators for Malnutrition in Older Adults (Cornell Study) National Nutrition Screening Initiative. (See Lee text 8 know DETERMINE» IV. Older Americans Act 8 AOA. Many seniors are at nutritional risk. A. Older Americans Act, 1978, provided Congregate Meals 8 Home Delivered Meals B. State Office on Aging C. Area Offices on Aging (AOA) D. AOA’s Local Service contracts: V. Congregate Meals 8 Home Delivered Meals Funding is mixed from both DHHS 8 USDA Food preparation for Congregate Meals 8 HDM Michigan Congregate meals 8 HDM meals by law must have: Congregate Meals Horne Delivered Meals (Call 483-4150 to volunteer) mppw> W905”? 216 Appendix 5 Item analysis results of knowledge about older adults (FAQ) Pretest Posttest Items Diff 1’ Discz’ Diff Disc 1. The proportion of people over 65 who are senile (have impaired memory, disorientation, or 61 11 dementia) is 2. The senses that tend to weaken In old age are 44 22 45 56 3. The majority of old couples 45 30 26 52 4. Lung vital capacity in old age 39 19 5. Happiness among old people Is 46 30 45 59 6.Physical strength 12 11 7. The percentage of people over 65 in long-stay institution (such as nursing homes, mental 82 44 hospitals and homes for the aged) is 8. The accident rate per driver over age 65 is 81 19 9. Most workers over 65 . 61 59 50 44 10. The proportion of people over 65 who are able to do their normal activities Is 49 52 55 59 11. Adaptability to change among people over 65 is 83 22 12. As for old people learning new things 42 26 34 4 13. Depression is more frequent among 75 48 217 14. Older people tend to react 39 11 15. Old people tend to be 51 26 89 7 16. More old people say 64 48 55 56 17. The proportion of old people who are socially isolated Is ‘8 52 39 ‘4 18. The accident rate among workers over 65 tends to 89 19 be 19. The proportion of the US. population now age 65 92 11 or over is 20. Medical practitioners tend to give older patients 70 37 65 30 21. The poverty rate (as deflned by the federal government) among old people is 78 37 76 3° 22. Most old people are 7 7 23. Religiosity tend to 66 19 24. Most old people say they 60 41 34 56 25. The heath and economic status of old people (compared with younger people) In the year 47 22 47 30 201 0 will 1) Index of Difficulty: Desirable = 20-80 2) Index of Discrimination: Desirable 2 20 218 Appendix 6 Item analysis results of knowledge about geriatric nutrition Pretest Posttest Items Diff " Disc” Diff Disc 1 . Nutrients that may not be well digested and Ior absorbed by the elderly are 38 52 43 52 2. In normal aging, changes in dietary requirements include 48 15 3. The most prominent effect of aging on gastrointestinal function involves the 80 37 4. Older adults are susceptible to dehydration because 28 44 31 44 5. In the older person, loss of lean body mass and decreasing physical activity 21 22 23 67 leadsto 6.The best choice for dietary fiber is 9 22 7. Assessment of older adults presents a challenge because problems can result 34 56 38 56 from non-dietary causes such as 8. The most reliable diagnostic Indicator of protein energy malnutrition In older 70 22 75 22 adults 9. Which is the best method for dietary intake assessment on a nursing home resident 13 33 with a decline in cognitive function? 10. The greatest risk for nutrient deficiency In older adults is for 55 37 42 30 11. Individuals diagnosed with coronary heart diseases are encouraged by the National Cholesterol Education Program to limit their 76 7 Saturated fat intakes to less than what percentage of total calories? 12. If an older adults shows declining cognitive function, which of the following vitamins might be deficient? (reworded) 35 0 75 22 219 13. An Important element In diabetic diets for most older adult Is 77 33 41 14. Which of following Is ppt related to development of osteoporosis In older women? 26 26 25 41 15. If an older person has lactose Intolerance 36 63 16. For an older person to consume calcium form dairy foods according to recommendations, how many serving should be consumed? 89 19 17. A good source of potassium for people on diuretics is? 26 16. Using mineral oil as a laxative can promote deficiencies of 31 36 19. Iron deficiency is associated with all the following, except 70 20. If an older person is consuming a poor diet and takes at least three prescription medications, an appropriate interventions would be 33 36 21. Which of the following ls false about the Nutrition Screening Initiative? 26 63 22. Poor nutritional status can result from all of the following except 17 41 23. Which of the following is false about the Elderly Nutrition Program except 77 1) Index of Difficulty: Desirable = 20-80 2) Index of Discrimination: Desirable 2 20 220 5:5 saw 5022.: 835:2 case: .25 8:28 :8". 0c «5:288 05230 So: so 02 08:0 3.3.3..” Ensues»... . .382 ms .3: ccc>.0c=cm 2230 23.00» 500%. 0.... dz 58: ._ c230 accuse 030E 506.0625 anoibbo esp—H Lo 2 n . 5 ”iii. too: :90: into» 0... :05 B 300.39: masseus— mes—.0 $9.5m team a on 025000.. 53> .60: women on, E:— scape—om .0: :05 00> .300 .00—zoo: on. E? 0:00.553 iguana. 009.005 05.53.3320 on :25 3003.00203— 0..on Ema am: 3 50:3 Emcee so. 00125035 090200 Econ—5:2 565303 E Eco—.30 5.02.. ..o ..oEoMI 0:305 catchy—0 fined—.50 02 v 0:20 =25 0. 0333005 .50... H 50235 .0.—6332. .Bcouaum 090650 3535:: 503305 0.3.05 3 m_ >235 He 030.50 0:... =aco_mm£o._0-c..0 5.06: a mm 3303.: .mco_umoo> 50> chasm 00:20 0050385 .50 50.. $00.0 _= r80 .50 3:093:00 LoH 0:05.309 .60 .520 n x_t:e00< 221 Appendix 8 Recruitment focus group including brief survey Recruitment for Focus Groups Vocational interest of dietetics/nutritional science students to work with certain age groups You are invited to participate in a focus group. This focus group is to explore the factors affecting your preferences to work with certain age groups and your attitudes toward certain age groups. The overall purpose of this study is to develop, implement and evaluate an intervention program to increase work preference of dietetics/nutritional science students to work with older adults. By sharing your perspectives, you will contribute to developing an intervention program. This research is being conducted by a doctoral student, Seung-yeon Lee and Sharon L Hoerr, RD, PhD from Department of Food Science and Human Nutrition at MSU. Within a small group of about five students, you will be asked to discuss your preference to work with certain age groups and your attitudes toward certain age groups. All perspectives are welcome. The discussion will take approximately 60 minutes and be audio-taped. All remarks are completely confidential. We will only use the group answers, not individual ones. Your privacy will be protected to the maximum extent allowable by law. You can discontinue your participation at any time without penalty. The audio-tape will be used for transcription purposes only and will be destroyed following the transcription. Your consent form information will be kept in a locked file separate from the transcription of the audiotape. Only researchers will have access and use these materials. Your name or any identifier will not appear on the transcription and will not be associated with the study findings in any way. You will receive an ice cream coupon to the MSU Dairy Store and refreshments will be served during the focus group. Selection for participation will be determined after reviewing your responses to a brief survey: Job Preference to Work with Certain Age Groups. If you would like to participate in a focus group, please Indicate your name and Interest here and return this with the completed survey on the next page. Name (Print): Gender: Male Female Major: Phone: E-mail address: If you have questions, please contact Dr Sharon Hoerr or Seung-yeon (“Sin Young”) Lee. Sharon L Hoerr, RD, PhD (hoerrs@msu.edu; (517) 3558474 (X 110) Seung-yeon Lee, MS (leeseu15@msu.edu; (517) 355-8474 (X 156) Department of Food Science and Human Nutrition, College of Human Ecology Michigan State University 63 Thank you for your help! © 222 Job Preference to Work with Certain Age Groups Please indicate how Interested you are to work with each age group Very Interested Somewhat Interested Neutral Not so interested Not at all interested --2 Very Not at all interested intemsted ~ 1. Infants A b c d e 2. Children a b c d e 3. Adolescents a b c d e 4. Adults 3 b c d e 5. Older adults a b c d e 6. Please rank your preference to work with each age group. (1- highest preference; 5- lowest preference) Use each number only once. ( ) Infants ( ) Children ( ) Adolescents ( ) Adults ( ) Old adults Please indicate with an “X” your available times to participate In a 1 hour small group discussion (or please specify your available times). Mon Tues Weds Thurs Fflday Sat Sun Morning After- noon Evening 223 Appendix 9 Consent form for focus groups Brief Survey and Focus group Vocational interest of dietetics/nutritional science students to work with certain age groups Thank you for agreeing to participate in this study. Your participation is completely voluntary and you are free to refuse this request without penalty. During participation in this study, you can refuse to answer any particular questions and also you can withdraw at any time without any penalty. Participants agree not to discuss focus group proceedings with anyone outside of the focus group. We are trying to find out factors that might affect your preference to work with certain age groups and your attitudes toward certain age groups. You will be asked to complete brief survey about you and then asked to participate in discussion about your preference to work with and attitudes toward certain age groups. Please plan to discuss your opinions honestly. The discussion will take approximately 60 minutes and will be audio taped. The audio-tape will be used for transcription purposes only and will be destroyed following transcription. Your name or any identifier will not appear on the transcription and will not be associated with the study findings in any way. Only researchers will have access and use these materials. Your privacy will be protected to the maximum extent allowable by the law. All data, including audiotapes, will be kept confidential in a locked file and reported on a group basis only. Your consent form information will also be kept in a locked file separate from the transcription of audiotape. After 3 years, the consent form will be destroyed. You can discontinue your participation at any time without penalty. You will receive an ice cream coupon to the MSU Dairy Store and refreshments will be served during the focus group. Your willingness to participate In this study Is Indicated by your signature below. Name (Print): (Signature): Date: Phone: E-mail address: You can request information regarding the project at any time to investigators, Sharon L. Hoerr or Seung-yeon Lee, Department of Food Science and Human Nutrition. If you have any questions about being a human subjects in research you may contact the University Committee on Research Involving Human Subjects, Chair, Ashir Kumar, MD. at 355.2180 or UCRIHS@msu.edu. Investigators: Sharon L. Hoerr, RD, PhD Professor, hoerrstilotmsuedu, Ph) 517.355.8474 (X110), Seung-yeon Lee, MS, Graduate student, Ieeseu15@msu.edu, Ph) 517.355.8474 (X156), Department of Food Science and Human Nutrition, College of Human Ecology, at Michigan State University 224 Appendix 10 Brief survey to assess students’ preference for working with older adults General Questions About You 1. Your gender (Circle one) a. Male b. Female 2. In which year were you born? 19___ 3. What is your race/ethnicity? (Clrcle one) White, non-Hispanic Hispanic African American Asian/Pacific Islander American Indian/Alaska Native f. Others 999-95793 4. What is your major? (Circle one) a. Dietetics b. Nutritional Science c. Both d. Other 5. Your student status is (Circle one) Freshman Sophomore Junior Senior Other 909.015.!» 6. At which age would you describe the beginning of old age? (Circle one) a. 55 b. 60 c. 65 d.70 e.75+ 9. Other . 7. Have you had any classes related to aging or older adults? (Check one) Yes No If yes, please list these courses. 225 8. At this time, what profession or job do you plan to do, after you graduate? 9. Please complete the following sentences. What are some things that make you feel this way? Working with infants would be Working with children would be Working with adolescents would be Working with adults would be Working with older adults would be 226 Appendix 11 Structured questions for focus groups and in-depth interview Questions for the focus group 8 in-depth Interview Vocational interest of dietetics/nutritional science students to work with certain age groups Opening I’d like to welcome you to our focus group and thank you for joining our discussion. My name is from Department of Human Nutrition. Assisting me is also from the same department. We will be asking you some questions about your perceived benefits and barriers to working with older adults. There is no right or wrong answer. We are interested in both your positive and negative comments. The information obtained during this study may help us to better understand why some people want to work with older adults or why others don’t. We are trying to get idea on how best to develop an intervention to improve attitudes toward older adults and increase preferences to work with older adults. Before we begin, let me explain what we will be doing in a little more detail. This is strictly a research project. We will be audio-taping the interview, so we don’t miss any comments. Please speak clearly. No names will be included in any report and your comments are confidential. Our interview will last 20-30 minutes Icebreakers OK, let’s start. Please tell us your name and your major. Introduction How did you decide your major? What factors affected your decision? Main questions What do you plan to do with your major after you graduate? What things will you consider when you select your job? What are the most important factors? How important is the age group of your clients for your job selection? With what age do you prefer to work? What things or experiences made you interested to work with this preferred age group? What kind of experience do you have with your preferred age group? Who has influenced your interest to work with this particular age group? (For example, your family member, friends, or teacher) (Before asking these questions below, students will be asked to fill in blanks on the paper to prevent contamination from each other) 227 Please complete the following sentences. Working with infants would be Working with children would be Working with adolescents would be Working with adults would be Working with older adults would be What are some things that make you feel this way? What do you like/or dislike about working with each age group? (What is the value to you of working with each age group?) What makes (made or would make) you feel confident to work with your preferred age group? What makes (made or would make) you feel not confident to work with this age group? What makes (made or would make) you satisfied to work with your preferred age group? What makes (made or would make) you unsatisfied to work with this age group? How often do you interact with your preferred age group? Ending Is there anything else you’d like to add? Thank you for your time! 228 Appendix 12 Consent form for in-depth interviews lnforrned Consent Form: Brief Survey and ln-depth Interview Vocational interest of dietetics/nutritional science students to work with certain age groups Thank you for agreeing to participate in this study. Your participation is completely voluntary and you are free to refuse this request without penalty. During participation in this study, you can refuse to answer any particular questions and also you can withdraw at any time without any penalty. We are trying to find out factors that might affect your preference to work with certain age groups and your attitudes toward certain age groups. You will be asked to complete brief survey about you and then asked to participate in discussion about your preference to work with and attitudes toward certain age groups. Please plan to discuss your opinions honestly. The discussion will take approximately 20-30 minutes and will be audio taped. The audio-tape will be used for transcription purposes only and will be destroyed following transcription. Your name or any identifier will not appear on the transcription and will not be associated with the study findings in any way. Only researchers will have access and use these materials. Your privacy will be protected to the maximum extent allowable by the law. All data, including audiotapes, will be kept confidential in a locked file and reported on a group basis only. Your consent form information will also be kept in a locked file separate from the transcription of audiotape. After 3 years, the consent form will be destroyed. You can discontinue your participation at any time without penalty. You will receive an ice cream coupon to the MSU Dairy Store and refreshments will be served during the focus group. Your willingness to participate In this study is Indicated by your signature below. Name (Print): (Signature): Date: Phone: E-mail address: You can request information regarding the project at any time to investigators, Sharon L. Hoerr or Seung-yeon Lee, Department of Food Science and Human Nutrition. If you have any questions about being a human subjects in research you may contact the University Committee on Research Involving Human Subjects, Chair, Ashir Kumar, MD. at 355.2180 or UCRIHS@msu.edu . Investigators: Sharon L. Hoerr, RD, PhD Professor, hoerrs@pilot.msu.edu, Ph) 517.355.8474 (X110). Seung-yeon Lee, MS, Graduate student, leeseu15@msu.edu, Ph) 517.355.8474 (X156), Department of Food Science and Human Nutrition, College of Human Ecology, at Michigan State University 229 Appendix 13 Dietary behavior change assignment HNF 375 Dr. Hoerr Dept. of Food Science Human Nutrition Michigan State University 2004 Final Pralect 1 Individual Dietary ange 40 pt) Behavioral modification with rei orcement; Stages of Change Theory; Incorporation of client’s needs and wants; Client Confidentiality Dietary Assessment Writing Behavioral Ob'ectives Skill and Confidence uilding Student Objectives: (Keep these things in mind while doing the assignment.) 1. Practice 24-hour recall and/or food record method of food intake. 2. Evaluate dietary intake using prescriptive methods (such as meeting the FGP and percentage of the recommended levels of nutrients and fiber). 3. Use food recall and diet history questions to elicit your client’s lifestyle and dietary patterns (both positive and negative aspects). 4. Identify your client’s perceived needs, wants, health goals and motivation for change and compare across several clients of similar ages. 5. Identify your client’s stage of readiness to change that behavior based on intention and time. Recognize that this project will work pm with someone in the Contemplation or Preparation Stage. (If your client is in Precontemplation and does not really want to change, find another client who does!) 6. With your client 's input, help identify dietary behaviors for possible change. Then, create measurable behavioral objectives to achieve that change. 7. Practice written and oral communication skills. 8. Practice client confidentiality at all the times. 1 CAUTION: Do p91 ask your boyfriend, girlfriend, best friend, parent, grandparent, or someone in your family to be your client for this project. Also do not use this project as an opportunity to Q someone’s dietary habits! 230 9. Build skills and confidence to interact as a health professional with a client. 10. Experience the heterogeneity of people’s dietary intakes, health beliefs, and values and demonstrate ability to elicit these fiom clients. DIRECTONS for Part A: (This assignment is based on your interaction with your client. ALL of the following steps must be completed with his/her input) Part A: Individual dietary change behavior assignment You will be randomly assigned to work with a client, either a young adult 20-30 yr of age or an older adult 265 yr. You will be provided a contact if you desire, or you may find your own client, if you follow the guidelines here. Client guidelines: Your clients cann_ot be your family members or close friends, e.g., grandparents, sister, brother, boyfi'iend, or girlfiiend. Institutionalized people cann_ot, be clients, because they don’t have much choice in their diet. However, college students having in residence balls or senior in assistant living (not nursing homes) are eligible to be clients. 1. Keep Objectives 1-5 in mind while doing this part. a. Dietary Assessment: (4 pt) Assess your client’s dietary behavior for one day using the 24-hour recall method. Include a nutrient spreadsheet in which you to_tal the nutrients and a food group analysis. Be sure you analyze the sugar intake. Websites: USDA Nutrient Analysis, www.n2_11.usda.gov/fnic/foodcomn/; check on sugar content of selected food. Univ. of Illinois Nutrient Analysis, www.2_ig.uiuc.edu/~food-lab/n_at_/. You may also use Nutritionist Pro or other sofiware. Type up your own personal analysis and comments about your client’s diet and lifestyle (such as, how fi'equently they eat breakfast, what kind of foods they cat, are they willing to try new foods, etc). Describe your client’s age, occupation, gender, height, weight, activity, physical health, etc. b. Description of client’s lifestyle and dietary patterns. (2 pt) Include personal comments about the client’s current lifestyle; general description of the client’s habits; assets (1 pt) and deficits (1 pt). List your client’s dietary assets as well as deficits. Examples of assets are: has money; has transportation to shop; knows how to cook; likes lots of different foods, etc. Examples of deficits might be: hates to cook; doesn’t like any vegetables; has no family or friends; etc. c. Client’s Perceived Needs, Wants, Health Goals, Motivation (3 pt) for change, stage of readiness to change. Type up your client’s perceived needs, wants, health goals, motivation for change, and their stage of readiness to change (Objective 5). Do 112! attempt to change a behavior by this method or for this assignment, if your client is in Pre- Contemplation. 2. Three Bebavioral Objectives and One Non-food Reward. (6 pt) (Objective 6) After reviewing the information you have gained from your client and the food recall/record analysis, identify three behaviors for possible change. Discuss these with your client and together agree on three objectives. Describe how you each compromised to agree on these three objectives. 231 Write three measurable dietary behavioral objectives to improve three behaviors for change. For each of these three objectives, specify the action to be taken, the target behavior, the time Me, the environmental context, and criteria for evaluation and success. You must have correctly specified behavioral objectives, which are measurable, time specified and food related. Identify only one non-food reward for accomplishment of the objective your client selects. Check the behavioral objectives and non food reward by emailing Dr. Hoerr two weeks before proceeding with the next step. Print & include her emailed response in which your objectives were approved. Highlight the objective that you and your client selected afier approval by Dr. Hoerr. Some examples of behavioral objectives are listed here. i. Reduce calories consumed by replacing two glasses of PowerAde at dinner with two 8-ounce glasses of water four times a week. ii. Increase fiber intake and reduce fat by eating l-cup high fiber cereal like Raisin Bran or Fruit & Fiber, instead of a bagel and cream cheese, three days a week. iii. Increase intake of dark green or yellow vegetables by eating at least 1/2 cup either at lunch or diner four days a week. This can be done by adding ‘/2 cup green beans or chopped broccoli to canned soup or spaghetti; by taking 1/2 cup carrots or green peppers for lunch; or by adding side salad with green peas, carrots, broccoli, tomatoes and/or peppers. iv. Reward for accomplishing one objective is to take an evening off to go to a movie with friends. 3. Post Dietary Assessment (8pt) Have your client record his/her diet intake and patterns (time, location of meal, etc). Use the Healthy Eating Index at httg\\l47.208.9.133 to analyze at least three days of food intake patterns reflecting your client’s progress with the behavioral objective. Turn in the HEI printout for your client’s food intake where the food is displayed with the serving sizes (add the times of day eaten to the printout), nutrient intakes, and food HEI score for each day (9 printouts total)2. If meal patterns were part of the behavioral objective, then add meals as well to the food intake printouts. Include in the 3-day evaluation of how the client thought he/she did, your own evaluation of how the client did and possible reasons. 4. Communication skills and Editing (2pt) (Objective 7) Your paper must be free of spelling and grammatical errors. Describe how you practiced oral and written communication skills and got help with your writing. Use complete sentences and grammar check on your word processor, AND ask fi-iends to help with editing. Examples of some of past typos on student papers: “For the sake of animosity, we’ll call my client Jessica”. “Add minuets of weight lifting”. “Eat one bowel of cereal”. Keep your client’s information private and confidential. Do not discuss your client by their real name with other students or with the instructor (Objective 8). 2 If a reduction in sugar intake is a behavioral objective, then you will need to use additional food consumption sources such as food labels and Bowes & Church to analyze the sugar intake. 232 5. Your evaluation and your client’s evaluation of this practice (Objective 9). (3pt) 5a. Have your grceptions and beliefs about your client age ggoup and working with your client ggoup changed afier completing this assignment Part A and if so how and why? 5b. Have the value of worlfirthh youL client age ggup changed after completing this assignment Part A and if SQ how and why? So. What was the hardest part (e.g., communicating with your client, doing a 24 hr dietary recall interview, compromising on goals) and why? 5d. What kind of information, skills and previous experiences helped you with this assignment? 5e. Were there clgges in your confidence in ability to workfiwith a client as a pre- malth professional and if so, how Qd Wm 5f. What was the most satisfactory part and why? l Were there flames in your perceived satisfaction to work with a client as a pre- hggth professional and if so, how and why? 5h. How did this assignment help you prepare for a career as a health professional? 5i. What did you expect to learn but didn’t? 5j. What would you do differently next time? The grade for this part will be based on thoughtfulness and completeness of responses. 6. Describe in one - two sentences your relationship with your client and how you found him or her. (2pt) e.g., My client was some one I did not know well prior to this assignment and I located by asking around where I work in a residence hall kitchen. Record the dates and times of meetings with your client e.g., 11/13/2004, from 10:20 AM to 11:00 AM 1) from to 2) from to 3) from to Be sure to submit each of the following items for Part A for 30 pt. Cover page and items 1-6 labeled (Make an extra copy of the assignment for you to keep). Cover page with your name, class, title of assignment, and your phone number. 1. a. 24 hr dietary recall nutrient and food group analysis (4pt) b. Description of client’s lifestyle and dietary patterns (2pt) c. Client’s Perceived Needs, Wants, Health Goals, Motivations (3pt) Three behavioral Objectives and One Non-food Reward, approved by Dr Hoerr (6pt) Post Dietary Assessment for 3 days of food intake (8pt) Description of oral and written communication skills (2pt) Evaluation - both your and your client’s of this project (3pt) Relation and interaction with client (2pt) 3" 9‘9?!” 233 Part B: Group Discussion and Analysis of Dietary Behavior Change Experience (10 pt). Attach one typed response from the entire group to these 4 items. This Part B will require 1-2 group meetings prior to submission. Names, e—mail address and phone numbers of each student in your group 1) DIRECTONS Part B: Part B is based on interactions and discussion within your group after completion of Part A. ALL of the following questions must be completed with group input. Answer the following questions after discussion with your group. Each group turns in only one Form B for the entire group. Retype each question and your group’s response. (1 Opt) 1. Read each student’s Part A of this assignment (providing editorial comments where appropriate). Describe in general terms each of the five clients, noting similarities and differences in age, lifestyle, health status, living arrangement, needs and wants of. (1.5pt) 2. Considering your clients’ beliefs, perceptions and desires to change their dietary behaviors, describe how the five clients were similar and were different.(1 .Spt) 3. Describe what each student in the group learned from working with their client. Compare and contrast the students’ interactions with their clients and whether the students’ attitudes changed, and, if so, how. (1.5pt) 4. Describe what you Ieamed by listening to other students’ experiences with their clients and complete the following sentences.(1.5pt) This project made us think about This project made us question This project was worthwhile, because For next year’s class, please consider doing... 5. Ifiwe any of your perceptions and beliefsfiabout your client age ggoup and working with your client aggroup changgdafler the group discussion and if so. how and why? (2pt) 6. Have any of your values about working with your client age ggoup changed after the group discgsion and if so. how a_nd why? ( 291) Be sure to submit only one Part B attached to all 5 student’s Part A. This will be a large packet of material from each group of 5 students. 234 Appendix 14 Recruitment of older adults (65 years old or over) Research title: Improving attitudes toward working with older adults, implications to dietetics pedagogy Recruitment of older adults (65 year or over) interested in working with a MSU students on a dietary change The purposes of this assignment are to provide MSU students the opportunities to interact and work with older adults as a health pre- professionals as a part of a study intervention. This assignment requires a student to interview you three times regarding your dietary intake, your life style, your perceived needs and goals for dietary change, and evaluation of your dietary change behavior. The time required of you is about 90 minutes divided over a 3 -6 week period in November, 2004. If you are interested in being a “client” of a student and helping students to conduct this assignment, please return your name and contact information to me. A student will contact you for interviews in late October. Name (Print): Phone: Address: E-mail address: If you have questions, please contact Seung-yeon Lee or Dr Sharon Hoerr. Seung-yeon Lee, MS (leeseu15@msu.edu) (517) 355-8474 (X 156) Sharon Hoerr, RD, PhD (hoerrs@msu.edu) (517) 355-8474 (X 110) 204, GM Trout, Department of Food Science and Human Nutrition, College of Human Ecology, Michigan State University, East Lansing, MI 48824 © Thank you for your help! © 235 Appendix 15 Recruitment of young adults (20-30 years old) Research title: Improving attitudes toward working with older adults, implications to dietetics pedagogy Recruitment of young adults (20-30 years old) interested in working with a MSU students on a dietary change The purposes of this assignment are to provide MSU students the opportunities to interact and work with young adults as a health pre- professional as a part of a study intervention. This assignment requires a student to interview you three times regarding your dietary intake, your life style, your perceived needs and goals for dietary change, and evaluation of your dietary change behavior. The time required of you is about 90 minutes divided over a 3 -6 week period in November, 2004. If you are interested in being a “client” of a student and helping students to conduct this assignment, please return your name and contact information to me. A student will contact you for interviews in late October. Name (Print): Phone: Address: E-mail address: If you have questions, please contact Seung-yeon Lee or Dr Sharon Hoerr. Seung-yeon Lee, MS (leeseu1 5@msu.edu) (517) 355-8474 (X 156) Sharon Hoerr, RD, PhD (hoerrs@msu.edu) (517)355-8474 (X 110) 204, GM Trout, Department of Food Science and Human Nutrition, College of Human Ecology, Michigan State University, East Lansing, MI 48824 © Thank you for your help! © 236 Appendix 16 Pre-test instrument in 2004 Knowledge, Attitudes, Interest and Experience with Older Adults This survey is being conducted by: Seung-yeon Lee, MS (Ieeseu15@msu.edu) Sharon Hoerr, RD, PhD (hoerrs@msu.edu) Department of Food Science and Human Nutrition College of Human Ecology Michigan State University 204 GM. Trout FSHN Building East Lansing, MI 48824 (517) 355-8474 (X 156) Thank you for agreeing to respond to this survey! 237 Research title: Improving attitudes toward working with older adults, implications to dietetics pedagogy Knowledge, Attitudes, interest and Experience with Older Adults Student’s name: . (Please record accurately to receive extra credit) The purposes of this survey are to assess knowledge of aging, attitudes toward aging, Interest In working with older adults and experiences with older adults. If you are not interested in completing this survey, you may choose to complete an alternative one point extra credit one page assignment on nutrition concerns for seniors (Guidelines will be provided upon request). Participation is voluntary and by completing this survey, you indicate your consent. All answers are completely confidential. We can only use the group’s answers, not individual ones. Your privacy will be protected to the maximum extent allowable bylaw. You can discontinue your participation at any time without penalty and you can refuse to answer a certain question. This sheet with your student ID number will be kept separate from your survey response. After 3 years, both this sheet and your survey response will be destroyed. Extra credit points towards your course grade will be given to you, if you complete these questionnaires. Please answer each item on the survey. Beginning on page 7 (Part V) also mark each answer on the scantron. If you have any questions, please contact Seung-yeon Lee, PhD candidate or Dr. Sharon Hoerr via the information on the front page of this packet. In case you have questions or concerns about your rights as a research participant, please feel free to contact Peter Vasilenko, Ph.D, Michigan State University's Chair of University Committee on Research Involving Human Subjects at (517) 355-2180, or through email at ." The entire Questionnaire takes about 20-30 minutes to commte. Please answer honestly ml completely. © Thank you for your participation! © FOOD SCIENCE HUMAN NUTRITION MICHIGAN STATE U N IV E R S IT Y 238 Part I. General questions Please circle one 1. Your gender (circle one) a. Male b. Female 2. How old are you? years old 3. What is your race/ethnicity? (Clrcle one) 9. White, non-Hispanic h. Hispanic i. African American j. Asian/Pacific Islander k. American Indian/Alaska Native I. Other (Specify: ) 4. What Is your major? e. Dietetics f. Nutritional Science 9. Health & Humanities h. Other (Specify: ) 5. Your student status is . (Circle one) Freshman Sophomore Junior Senior Other ‘z=-.-‘:rro .-~ 6. At which age would you describe the beginning of “old age”? (Circle one) a. 55 b. 60 c. 65 d.70 e.75+ 9. Other 7. Have you,had any class related to aging or older adults? Yes No If yes, please list those courses. 8. Do you intend to work as a health professional after graduation? a. If yes, please specify area or job b. Haven’t decided yet. 0. Other 239 Part II. Interest In working with different age groups and different settings (9 - 13) Please circle the letter which Indicates your Interest In working with each age group 14. Please rank your preference for working with each age group “Jr’s?“ Not at all 9. Infants a b d e 10. Child a b d e 11. Adolescents a b d e 12. Adults a b d e 13. Older adults a b d e (1 =highest preference; 5=Iowest preference). Use each number only once. ( ) Infants ) Children ) Adolescents ) Adults ) Old adults 15. Please rank your preference to do the following types of work as a health professional (1 =highest preference; 6=lowest preference). Use each number only once. ( ( ( ( ( ( ) Working in a hospital )Working at a nursing home or Iong-tenn care facility ) Working in out-patient facility )Working in private practice )Working in community setting ) Other (specify) 240 Part III. Interaction and Experiences with Older Adults Below are questions about your experience with older adults. Please circle the response that best fits. 16. How would you rate your experiences overall with older adults? (Circle one) a. Very positive b. Positive c. Neutral d. Negative e. Very negative 17. Do you Iive/have you ever lived with your grandparents? Yes (How long? ) No 18. How often doldid you have contact with grandparents by In person, by phone or by mail? (Circle one) At least once a week At least once a month At least three times a year At least once a year Less than once a year or never Not available c9999? 19. How would you describe your relationship with your grandparents? (Circle one) a. Very close b. Close c. Somewhat close d. Not at all close e. Not available 20. Have you ever visited long term care facilities to visit your all! grandparents or other older adults? e.g. nursing home Yes (How frequently? ) No 21 . Do you/have you ever worked for or volunteered with older adult? Yes No If yes, How long doldid you work or volunteer? Where doldid you work or volunteer? What’s your role for work/volunteer? 241 Part IV. Knowledge about Aging1 Please circle the letter of the most accurate answer AND fill In the corresponding bubble on the scantron sheet. 1. The senses that tend to weaken In old age are a. Sight and hearing b. Taste and smell c Sight, hearing, and touch d. All five senses 2. The majority of old couples 3. Have little or no interest in sex b. Are not able to have sexual relations 0. Continue to enjoy sexual relations d. Think sex is for only the young 3. Happiness among old people Is a. Rare b. Less common than among younger people c. About as common as among younger people d. More common than among younger people 4. Most workers over 65 a. Work less effectively than younger workers b. Work as effectively as younger workers 0. Work more effectively than younger workers (1. Are preferred by most employers 1. Fact on Aging Quiz 1 242 5. The proportion of people over 65 who are able to do their normal activities is One tenth One quarter One half More than three fourths 9999 6. As for old people learning new things a. Most are unable to Ieam at any speed b. Most are able to Ieam, but at a slower speed c. Most are able to Ieam as fast as younger people d. Learning speed is unrelated to age 7. Old people tend to be More alike than younger people As alike as younger people Less alike than younger people More alike in some respects and less alike in others 999'!” 8. More old people, than young people, say They are seldom bored They are usually bored They are often bored Life is monotonous 99g? 9. The proportion of old people who are socially isolated Is Almost all About half Less than a fourth Almost none page 10. Health practitioners tend to give older patients: a. Lower priority than younger patients b. The same priority as younger patients c. Higher priority than younger patients (1. Higher priority if they have Medicaid 11. The poverty rate (as defined by the federal government) among old people is a. Higher than among children under age 18 b. Higher than among all persons under65 About the same as among Person under 65 e. Lower than among persons under65 P-P 12. Most old people say they 9999 Are seldom angry Are often angry Are often grouchy Often lose their tempers 13. The health and economic status of old people (compared with younger people) in the year 2010 will 99?? Part V. Attitudes toward Aging2 Be higher than now Be about the same as now Be lower than now Show no consistent trend Please indicate how you agree the following items a= Strongly agree b=Agree c=Neutral d=Disagree e=Strongly disagree Strongly agree Strongly disagree 14. Older people usually understand the problems encountered by the young a b c d e 15. Older people are often critical of a b c d a younger generations 16. Most older people have a good sense of humor a b c d e 17. Most older people have active social W” a b c d e 2. Wall-Oyer Attitudes on Aging Inventory 243 Strongly agree Strongly disagree 18. Most older people prefer to be Independent and live In their own homes 19. Many older people are less tidy about themselves than younger people 20. Younger people can usually benefit from the wisdom of older people 21. Working with older adults In terms of Improving their functioning often can be a rewarding experience 22. Older people generally are not interested In younger people and their concerns 23. Most older people are amenable to change 24. Ordinarily I would not feel comfortable working on the health problems of the elderly 25. Working in a stroke-rehabilitation program for the elderly would probably be a poor investment of time 26. I usually feel as relaxed around older people as I do around younger people 27. I would not want to work in a medical setting for older adults who are psychologically disengaged from daily events 28. I feel many older people are opinionated and it is difficult to work with them 29. I would not be interested in devoting a major portion of my practice to specializing In geriatric care 30. I would like to develop a practice catering to the special needs of older adults 31. I would typically flnd working with older people and their physical problems depressing 244 Strongly agree Strongly disagree 32. i would find it difficult to develop programs for working with the health a b c d 9 problems of older people 33. Usually i enjoy communicating with older people 34. As a health professional I expect to encounter some resistance from older a b c d e adults In a treatment program 35. I would Ieam a great deal working with older people Thank you for your time! 245 Appendix 17 Alternative activity for extra credit In 2004 HNF 375 Dept FSHN Hoerr 2004 Michigan State University Nutrition Concerns for Seniors (For1 pt Extra Credit) Name: . Student ID: Purpose of assignment 1. To explain an example of assessing and addressing the nutritional status of an older adults using bio-psycho-social model Directions Please write your answer on the back of this page 1. Think of an example of an older person you know from your family, friends, acquaintances or from the media and describe this person in a few sentences. 2. Describe both positive factors and risk factors for the person’s nutritional and health status. 3. Then, draw a bio-psycho-social model of these factors which could affect their nutritional health. Factors affecting the nutritional status in older adults are: a. Physiological changes in the body with aging (e.g., digestive, respiratory, or Cognitive functions) b. Socio-economic changes (retirement, changes in income & living arrangements etc.) c. Having chronic diseases or chronic conditions such as diabetes, hypertension, cardiovascular diseases, stroke, arthritis, etc 4. Describe how a health professional might address some of the risk factors within each sphere of the bio-psycho-social model. Conclude with some benefits and barriers to health professionals for working with older people. 246 Appendix 18 Consent form from student for obtaining approval for using data Research title: Improving attitudes toward working with older adults, implications to dietetics pedagogy Thank you for your willingness to share your written report of the dietary behavior change assignment. Neither your name nor any identifier will appear on any results report in this study. Only researchers will use these materials. Your privacy will be protected to the maximum extent allowable by the law. All data will be kept confidential and reported on a group basis only. Your consent form lnfonnation will be kept separate from the assignment. After keeping for 3 years, the consent form will be destroyed. You can discontinue your participation at any time without penalty. Consent: I volunteer to allow the researcher to review my dietary behavior change assignment in this study as part of her dissertation research. You can request information regarding the project at any time from Seung-yeon Lee, MS, PhD candidate, Dr Sharon L. Hoerr, RD, PhD at 355.8474 (ext 110), Department of Food Science and Human Nutrition. If you have any questions about being a human subject in research you may contact the University Committee on Research Involving Human Subjects, Chair, Peter Vasilenko at 355.2180 or UCRIHSQmsuedu or 202 Olds Hall, Michigan State University, East Lansing, MI 48824-1046 You are free to refuse this request without penalty. You demonstrate your willingness to allow the researcher use lnfonnation from your assignment report in her dissertation research by your signature and contact information below. Name (Print): (Signature): Date: Phone: E-mail address: Investigators: Seung-yeon Lee, MS, PhD candidate, leeseu15@msu.edu, Ph) 517.355.8474 (ext 156) and Sharon L. Hoerr, RD, PhD Professor, hoerrs@pilot.msu.edu 204 GM Trout, Department of Food Science and Human Nutrition at Michigan State University, College of Human Ecology, East Lansing, MI 48824 247 Appendix 19 Post-test instrument in 2004 Knowledge, Attitudes, Interest and Experience with Older Adults This survey is being conducted by: Seung-yeon Lee, MS (leeseu15@msu.edu) Sharon Hoerr, RD, PhD (hoerrs@msu.edu) Department of Food Science and Human Nutrition College of Human Ecology Michigan State University 204 GM. Trout FSHN Building East Lansing, MI 48824 (517) 355-8474 (X 156) Thank you for agreeing to respond to this survey! 248 Research title: Improving attitudes toward working with older adults, implications to dietetics pedagogy Knowledge, Attitudes, Interest and Experience with Older Adults Student’s name: . (Please record accurately to receive extra credit) The purposes of this survey are to assess knowledge of aging, attitudes toward aging, interest in working with older adults and experiences with older aduus. If you are not interested in completing this survey, you may choose to complete an alternative one point extra credit one page assignment on nutrition concerns for seniors (Guidelines will be provided upon request). Participation is voluntary and by completing this survey, you indicate your consent. All answers are completely confidential. We can only use the group’s answers, not individual ones. Your privacy will be protected to the maximum extent allowable by law. You can discontinue your participation at any time without penalty and you can refuse to answer a certain question. This sheet with your student ID number will be kept separate from your survey response. After 3 years, both this sheet and your survey response will be destroyed. Extra credit points towards your course grade will be given to you, if you complete these questionnaires. Please answer each item on the survey. Beginning on page 3 (Part III) also mark each answer on the scantron. If you have any questions, please contact Seung-yeon Lee or Dr. Sharon Hoerr via the information on the front page of this packet. In case you have questions or concerns about your rights as a research participant, please feel free to contact Peter Vasilenko, Ph.D, Michigan State University's Chair of University Committee on Research Involving Human Subjects at (517) 355—2180, or through email at .” The entl_re questionnaire takes about 10 minutes to corn Iete. Please answer honestl and completely. © Thank you for your participation! © FOOD SCIENCE HUMAN NUTRITION MICHIGAN STATE U N IV E R S IT Y 249 Part I. General questions Please circle one 1. At which age would you describe the beginning of “old age”? a. 55 b. 60 c. 65 d.70 e.75+ 9. Other Part II. Interest in working with different age groups and different settings (2 - 6) Please circle the letter which indicates your interest In working with each age group Very Not at all Interested Interest 1. Infants a b c d e 2. Child a b c d e 3. Adolescents a b c d e 4. Adults a b c d e 5. Older adults a b c d e 7. Please rank your preference for working with each age group (1 =highest preference; 5=Iowest preference). Use each number only once. ( ) Infants ( ) Children ( ) Adolescents ( ) Adults ( ) Old adults 8. Please rank your preference to do the following types of work as a health professional (1 =highest preference; 6=lowest preference). Use each number only once. ) Working in a hospital ) Working at a nursing home or long-term care facility ) Working in out-patient facility ) Working in community setting ( ( ( ( ) Working in private practice ( ( ) Other (specify) 250 Part III. Knowledge about Aging’ Please circle the letter of the most accurate answer AND fill in the corresponding bubble on the scantron sheet. 1. The senses that tend to weaken in old age are a. Sight and hearing b. Taste and smell c. Sight, hearing, and touch d. All five senses 2. The majority of old couples a. Have little or no interest in sex b. Are not able to have sexual relations c. Continue to enjoy sexual relations d. Think sex is for only the young 3. Happiness among old people is a. Rare b. Less common than among younger people c. About as common as among younger people (I. More common than among younger people 4. Most workers over 65 a. Work less effectively than younger workers b. Work as effectively as younger workers 0. Work more effectively than younger workers (1. Are preferred by most employers I. Fact on Aging Quiz I 251 5. The proportion of people over 65 who are able to do their normal activities Is a. One tenth b. One quarter c. One half d. More than three fourths 6. As for old people Ieaming new things a. Most are unable to Ieam at any speed b. Most are able to learn, but at a slower speed c. Most are able to Ieam as fast as younger people d. Learning speed is unrelated to age 7. Old people tend to be More alike than younger people As alike as younger people Less alike than younger people More alike in some respects and less alike in others 99?? 8. More old people, than young people, say They are seldom bored They are usually bored They are often bored Life is monotonous page 9. The proportion of old people who are socially isolated is a. Almost all b. About half c. Less than afourth d. Almost none 10. Health practitioners tend to give older patients: a. Lower priority than younger patients b. The same priority as younger patients 0. Higher priority than younger patients d. Higher priority if they have Medicaid 11. The poverty rate (as defined by the federal government) among old people is a. Higher than among children under age 18 6. Higher than among all persons under65 c. About the same as among person under 65 d. Lower than among persons under65 12. Most old people say they Are seldom angry Are often angry Are often grouchy Often lose their tempers page 13. The health and economic status of old people (compared with younger people) in the year 2010 will Be higher than now Be about the same as now Be lower than now Show no consistent trend 9999 Part IV. Attitudes toward Older Adults and Aging2 Please indicate how you agree the following items a= Strongly agree b=Agree c=Neutral d=Disagree e=Strongly disagree Strongly Strongly agree disagree 14. Older people usually understand the a b c d e problems encountered by the young 15. Older people are often critical of a b c d e younger generations 16. Most older people have a good sense of humor a b C d e 2. Wall-Oyer Attitudes on Aging Inventory 252 Strongly agree Strongly disagree 17. Most older people have active social lives 18. Most older people prefer to be independent and live In their own homes 19. Many older people are less tidy about themselves than younger people 20. Younger people can usually benefit from the wisdom of older people 21. Working with older adults In terms of improving their functioning often can be a rewarding experience 22. Older people generally are not interested in younger people and their concerns 23. Most older people are amenable to change 24. Ordinarily lwould not feel comfortable working on the health problems of the elderly 25. Working in a stroke-rehabilitation program for the elderly would probably be a poor investment of time 26. I usually feel as relaxed around older people as I do around younger people 27. I would not want to work in a medical setting for older adults who are psychologically disengaged from daily events 28. I feel many older people are opinionated and It is difficult to work with them 29. I would not be Interested in devoting a major portion of my practice to specializing in geriatric care 30. I would like to develop a practice catering to the special needs of older adults 253 Strongly agree Strongly disagree 31. I would typically find working with older people and their physical a b c d e problems depressing 32. I would find It difficult to develop programs for working with the health a b c d e problems of older people 33. Usually I enjoy communicating wlth a b c d e older people 34. As a health professional I expect to encounter some resistance from older a b c d 6 adults In a treatment program 35. I would Ieam a great deal working with a b c d 9 older people Thank you for your time! 254 Appendix 20 Table 5.9 Factors affecting students’ perceived satisfaction with working with a certain age group Theme Students who preferred to work Students who did not prefer with older adults to work with older adults Personal values 0 Fits my interests (1)* . Fits my interests (0) 0 Helping people who want to 0 Helping people who want change (1) to change (1) . Helping people who are in needs (4) Clients’ attitudes - Clients seek my help (0) 0 Clients seek my help ( 1) . Clients appreciate me (1) 0 Clients appreciate me (1) Result of my work 0 l benefit my clients (9) o l benefit my clients (7) Others 0 Diversity of work (1) 0 Diversity of work (1) (Frequency of responses)* 255 Appendix 21 Table 5.10 Factors affecting students’ perceived dissatisfaction with working with a certain age group Theme Students who preferred to work Students who did not prefer to with older adults work with older adults Clients' attitudes 0 Clients have no motivation - Clients have no motivation (3) (3)* 0 Clients do not cooperate (1) 0 Clients do not care about nutrition/health (2) 0 Clients do not appreciate me (2) 0 Clients do not respect me (3) 0 Clients do not trust me (2) Result of my c There is no improvement! 0 There is no improvement/ work progress (4) progress (1) Barriers - There is no cooperation from 0 Politics in the work place family members (2) prevents me from doing my 0 Funding is lacking (1) best (1) Others 0 Patients die (1) 0 My approach is limited (1) o I get paid a small salary (1) o Coworkers give me negative feedback (1) o I do not do my best (2) (Frequency of responses)* 256 Appendix 22 Table 5.12 Factors affecting students’ perceived confidence In working with a certain age group Students who preferred to Theme work with older adults Students who did not prefer to work with older adults Perceived readiness o Education (3)* a Knowledge (4) 0 Experience (6) e Ability to apply (1) Client’s attitudes Process/Interaction 0 Can answer questions (1) with clients Results of work a Positive feedback from clients or family (1) a Make clients benefits (5) 0 Education (2) 0 Knowledge (1) 0 Experience (3) e Ability to apply (1) o Motivated (1) o Cooperative (1) a Showing respect (1) 0 Can relate to clients (2) . Positive feedback from clients or family (2) a Make clients benefits (5) (Frequency of responses)* 257 Appendix 23 Table 5.13 Factors affecting students’ lack of perceived confidence In working with a certain age group Students who preferred to Students who did not prefer to Theme work with older adults work with older adults Perceived readiness 0 Lack of knowledge (2)‘ 0 Lack of education (1) 0 Lack of experience (2) 0 Lack of experience (5) Client’s attitudes o No motivation (2) o No motivation (1) o No respect/trust (1) o No respect/trust (1) Process/interaction 0 Cannot answer questions with clients (3) o I make mistakes (1) Results of work 0 Negative feedback (1) o No improvement/failing (2) o No improvement/failing (1) 0 Clients’ death/losing clients (2) Others 0 Different opinion from 0 Beyond specialty (2) coworkers (1) 0 Different opinion from coworkers (1 ) (Frequency of responseS)’ 258 Appendix 24 Table 5.14 Factors affecting students’ preference for working with a certain age Group Themes Students who preferred to Students who did not prefer to work with older adults work with older adults Comfort 0 Being around a certain age 0 Being around a certain age group (3)* a Positive previous/current experiences with a certain age group (6) 0 Being able to getting along/relate or handle with a certain age group (4) Clients’ attitudes 0 Clients are willing to listen and try (1) a Client are very appreciative (1) Results of work a I can benefit clients (1) group (2) o I have had positive previous/current experiences with a certain age group (2) o I can get along/relate or handle with (1) a Client are very appreciative (1) o I can benefit clients (5) (Frequency of responses)’ 259 Appendix 25 Table 5.16 Factors affecting students’ job selection (Frequency) Students who preferred Students who did not to work with older adults prefer to work with older adults Personal value (10)* 4 6 Perceived readiness (3) o 3 Job availability (6) 4 4 [Job security (2) Work environment (30) 21 9 Location (13) 6 7 Characteristics of task (12) 5 7 Characteristics of clients (6) 1 5 External rewards (9) 7 2 (Frequency of responses)‘ 260 EN 6288 a N oco papa a e up .599. ooo moov o. 2.on romeo o8? re So :53 romeo «moo 8T5 ooeaoEoo ..oooo roooo 2 so Loso sumo oomo oooo anus coocoaoi ..oooo romeo Boo ..Svo 13.8 :33 ooho Aooeuzv .2 «85.22“. :33 $3. mono. romeo . Boo o3.o 875 coeaoEoo ..Noeo Boo roooo ..Novo ..Nmeo oooo- anus 8:856. :23 emoo- roomo ..okeo ..oooo ouoo- Aooeuzv __< 38.3... 23 oumo memo ..omoo .omoo 8H5 oouaoEoo Loco 9.3 :23 .. ano «moo anus 8:822... roomo mono- :83 :83 9.3 so W2C =< «sausage Eo- mowo- oooo rm 5o 3T5 ooozomEoo «moo om to oomo mono Sons 8:832. «moo- oooo- onto ..o So aoeuzv .2 «63238: romeo Fomo roomo sous ooocooEoo :Nooo Ammo too- Sons 83832:. romeo ..Emo ooso Aooeuzv .2. $8282.“. ammo 88 sens cowoomEoo to So too. amus 8:829; :33 oooo aoenzv __< 585:. VN r .o gin“ cowtmmEoO «who anus coocotes Boo 82qu .2 $533.32 «.323... «doc—5:3 ”33.265. €35.22“. «.328:— Fdeu3§< fieuuotsocx campfiumoa users... «a 3:96 :omtwnEoo can 5.23225 E 8.35 320 5.3 9.3.2: .8 35.29:. new $235 .mepazzu 632265. he 3:23:80 :ozfleteo 9c 2%... on 5283 261 Appendix 27 UCRIHS Approval 262 OFFICE or RESEARCH ETHICS AND STANDARDS University Committee on Research Involving Human Subjects Michigan State University 202 Olds Hall East Lansing. MI 48824 517/355-2180 FAX: 517/432-4503 Web: www humanresearch msu ecu E-Mail ucrihs@msu.edu MSU IS an attrmratireacfim, equal-opportunity institution. MICHIGAN STATE U N I v E R s I T Y Revision Application Approval August 12. 2005 T01 Sharon L HOERR 130 Trout Food Science and Human Nutrition MSU Re: IRB 0 02-600 Category EXPEDITED 2-6. 27 Revision Approval Date: August 12. 2005 Project Expiration Date: January 28. 2006 Title: IMPROVING DIETETICS AND NUTRITIONAL SCIENCES STUDENTS' ATTITUDES TOWARDS WORKING WITH OLDER ADULTS: PEDAGOGICAL IMPLICATIONS The University Committee on Research Involving Human Subjects (UCRIHS) has completed their review of your project. I am pleased to advise you that the revision has been approved. The review by the committee has found that your revision is consistent with the continued protection of the rights and welfare of human subjects. and meets the requirements of MSU's Federal Wide Assurance and the Federal Guidelines (45 CFR 46 and 21 CF R Part 50). The protection of human subjects In research is a partnership between the IRS and the investigators. We look forward to working with you as we both fulfill our responsibilities. Renewals: UCRIHS approval is valid until the expiration date listed above. If you are continuing your project. you must submit an Application for Renewal application at least one month before expiration. It the project is com pleted, please submit an Application for Permanent Closure. Revisions: UCRIHS must review any changes in the project, prior to Initiation of the change. Please submit an Application for Revision to have your changes reviewed. It changes are made at the time of renewal, please include an Appllcetlon for Revision with the renewal application. Problems: If issues should arise during the conduct of the research, such as unanticipated problems. adverse events. or any problem that may increase the risk to the human subjects. notify UCRIHS promptly. Forms are available to report these issues. Please use the IRB number listed above on any forms submitted which relate to this project. or on any correSpondence with UCRIHS. Good luck in your research. If we can be of further assistance. please contact us at 517-355-2180 or via email at UCRIHS@m§u.edg. Thank you for your cooperation. Sincerely, We: Peter Vasilenko, PhD. UCRIHS Chalr CI Seung-Yeon Lee 204 GM Trout, Dept FSHN 263 Appendix 28 Approval of the use of reprints for Facts on Aging Quiz 264 springer publishing comp “f 536 Broadway, New York, N. Y. 10012-3955 Tel. (212) 431-4370, Fax: (212) 941-7842 * “ 4 Seung-yeon Lee Please refer to 204 GM Trout Bldg this number in Dept of Food Science correspondence: Michigan State University . East Lansing MI 48823 BPL 02 - 82 _‘ Dear Seung-yeon Lee, Thank you for your request of 22 September 2002 to make reproductions from our publication Palmore: THE FACTS ON AGING QUIZ 2E; 1998 You request permission to make 519 copies of the following material : The Facts on Aging Quiz Multiple Choice, pp 5-8 The results of your reprint are requested for inclusion in: Doctoral Disertation: Changing Knowledge and Attitudes Toward Working With Older Adults..., Seung-yeon Lee, Michigan State University: 2004 our permission is granted for non-exclusive world rights for this use only, and does not cover copyrighted material from other sources. The work with the material used must be published within 2 years from the date of applicant’s signature. If this does not occur, or if after publication the work remains out of print for a period of 6 months, this permission will terminate. Furthermore, the permission is contingent upon conditions checked below: _x_ Use is for Thesis, Research, or Dissertation only. Please include stamped, self-addressed envelope. Applicants provide their own copies. WWW. Any publicetion including the requested material requires a new request for permission to reprint.) Permission of the Author(s). _x_ Use of a credit line on every copy printed specifying title, author, copyright notice, and "Springer Publishing Company, Inc., New York 10012“ as publisher, with the words "used by permission". . A permission fee of $__.__ per copy plus $__.__ Administration fee payable as of the date this permission goes into effect. WWW mrothy Rouwenberg, Permissions Coordinator Date: 30 September 2002 265 Springer Publishing Company 11 West 42nd Street, New York, NY 10036-8002 Tel: 212 431-4370 I Fax: 212 941-7842 1- www.8pringerPub.com Seung-yeon Lee | Please refer to | 136 GM Trout Bldg | this number in | Dept. Food Science | correspondence: | Michigan State University | | East Lansing MI 48824 | | Dear Ms. Lee, Thank you for your request of 15 August 2004 to make reproductions from our publication Palmore: THE FACTS ON AGING QUIZ 2E; 1998 You request permission to make 300 copies of the following material The Facts on Aging Quiz, pp 3-5 The results of your reprint are requested for inclusion in: Research Dissertation: “Nursing Students’ Knowledge.... in Working with Older Adults," Michigan State University; 2004 Our permission is granted for non-exclusive world rights for this use only, and does not cover copyrighted material from other sources. The work with the material used must be published within 2 years from the date of applicant's signature. If this does not occur, or if after publication the work remains out of print for a period of 6 months, this permission will terminate. Furthermore, the permission is contingent upon conditions checked below: _X_ Use is for Thesis, Research, or Dissertation only. Please include stamped, self—addressed envelope. Applicants provide their own copies. (Permission for Dissertation/Thesis/Study covers only the non— published version of the manuscript. Any publication including the requested material requires a new request for permission to reprint.) Permission of the Author(s). X Use of a credit line on every copy printed specifying title, author, copyright notice, and "Springer Publishing Company, Inc., New York 10012" as publisher, with the words "used by permission". A permission fee of $__.__ per copy plus $__.__ Administration fee payable as of the date this permission goes into effect. Wag/WW Dorothy Kouwenberg, Permissions Coordinator Date: 19 August 2004 266 Appendix 29 Approval of the use of reprints for Wall-Oyer Attitudes on Aging Inventory 267 Pagelotl Seugggoon Lee From: ”cflgw" To: "Seung-yeon Lee” Sent: Friday. July 26, 2002 12:04 PM Subject: Re: For getting permission to use Wall-Oyer Attitudes on Aing Inventory > Dear Seung-yeon Lee I just received your e-mail as I have been out of the state. Yes you have permission to use the instrument which Dr. Oyer and I designed. I wish you the best in your endeavor. Lida Wall Dear Dr Wall, > Hello, how are you? > > I am Seung-yeon Lee, PhD student in FSHN, MSU. > I am interested in attitudes toward aging and I am plan to > do my research for a dissertation related to it. I am > searching instruments for measuring attitudes toward > aging. > > I'd like to use your Wall-Oyer Attitudes on Aging > lnventory(which was used by Dr Noel and Dr Ames and > published in 1989, in JADA). I am not sure I will adjust > it, ifI can use it. > > Could you give me a permission to use it? > > Thank you! I will wait for your response. > Have a good day! > > Seung-yeon :) > > > > Seung-yeon Lee > 132 G M Trout FSHN Building > Dept of Food Science 81 Human Nutrition > Michigan State University > East Lansing MI 48824 > Tel : 517-355-8474, ext 156 > Fax: 517-353-8963 > E-mail : Ieeseu15@msu.edu > > 268 REFERENCES 269 REFERENCES Academy of Family Physicians, American Dietetic Association & National Council on The Aging, INC. (1997). Nutrition Screening Initiative: the role of nutrition in chronic disease care: A self-administrated home study course. Access: http://www.aa1‘p.org[x1 61 54.me Aday, R. H., & Campbell, M. J. (1995). Changing nursing students’ attitudes. Educational Gerontology, 21, 247-260. Adelman, R,D,, Fields, 8,0,, §_Jutagir, R. (1992). Geriatric education. Part II: The effect of a well elderly program on medical student attitudes toward geriatric patients. Joumal of the American Geriatric Society. 40, 970-3. American Dietetic Association (2004). Special Report on Medicare HR1, Retrieved Feb 3, 2005, from http://wwweatright.orglMember/ Policylnitiatives/83_18190.cfm?CFlD=10332092&CFTOKEN=79105914 American Dietetics Association (2004). Food & Nutrition Conference & Expo (FNCE) Program preview. Access from ADA : http://www.eatright.org/Public/Files/ProgramPreview-RedDot.pr Angiullo, L., Whitboume, S. K., & Powers, C. (1996). The effects of instruction and experience on college students’ attitudes toward the elderly. Educational Gerontology. 22, 483-495. Bachelder, J. (1989). Effectiveness of a simulation activity to promote positive attitudes and perceptions of the elderly. Educational Gerontology, 15, 363- 375. Bandura, A. (1991). Social Cognitive Theory of Self Regulation. Organizational Behavior and Human Decision Processes, 50, 248-285. Beland, F. & Maheux, B. (1990). Medical care for the elderly: attitudes of medical caregivers. Joumal of Aging and Health, 2, 194-99. Benson, E. R. (1982). Attitudes toward the elderly: A survey of recent nursing literature. Journal of Gerontological Nursing, 8, 279-281. Bomstein, R. (1986). The number, identity, meaning, and salience of descriptive attributes in adult person perception. lntemational Joumal of Aging and Human Development, 23, 127-140. 270 Braithwaite, V. A. (1986). Old age stereotypes: Reconciling contradictions. Journal of Gerontology , 41, 353-360. Campbell, M. (1971). Study of the attitudes of nursing personnel toward the geriatric patient. Nursing Research, 20, 147-151. Carmel, S., Cwikel, J., 8 Galinsky, D. (1992). Changes in knowledge, attitudes, and work preferences following courses in gerontology among medical, nursing, and social work students. Educational Gerontology. 18, 329-342. Chapman, N. J., & Neal, M. B. (1990). The effects of intergenerational experiences on adolescents and older adults. Gerontologist, 30, 825-832. Chumbler, N.R., & Robbins, J.M. (1996). Rewards of entering pediatric medicine and attitudes toward older adults. Journal of the American Podiatric Medical Association, 86, 288-294. Committee on Nutrition Services for Medicare Beneficiaries, Institute of Medicine (2000). The Role of Nutrition in Maintaining Health IN the Nations’ Elderly: Evaluation Coverage of Nutrition Services for the Medicare Population. Washington, DC: National Academy Press. Crogan, N. L., Shultz, J. A., & Massey, L. K. (2001). Nutrition knowledge of nurses in long-term care facilities. Journal of Continuing Education in Nursing, 35, 171-176. Dail, P. W. & Johnson, J. E. (1985). Measuring change in undergraduate students' perceptions about aging using the Palmore Facts on Aging Quiz. Gerontology and Geriatrics Education, 5, 61-67. Davis-Bergman, J., & Robinson, J. D. (1989). Knowledge on aging and preferences to work with elderly. Gerontology and Geriatric Education, 10, 23-33. Dellasega, C., & Curriero, F. (1991). The effects of institutional and community experiences on nursing students’ intentions toward work with the elderly. Joumal of Nursing Education, 30, 405-41 0. Doka, K. J. (1986). Adolescent attitudes and beliefs toward aging and the elderly. lntemational Journal of Aging and Human Development, 22, 173-187. Duerson, M. C., Thomas, J. W., Chang, J., & Stevens, C. B. (1992). Medical students’ knowledge and misconceptions about aging: responses to Palmore’s facts on aging quizzes. Gerontologist, 32, 171-174. 271 Eagly, A.H., 8 Chaiken, S. (1993). Psychology of attitudes. Fort Worth, TX : Harcourt Brace Jovanovich College Publishers. Eddy, D. (1986). Before and after attitudes toward aging in a BSN program. Journal of Gerontological Nursing, 12, 30-34. Edwards, M. J., 8 Aldous, l. R. (1996). Attitudes to and knowledge about elderly people: a comparative analysis of students of medicine, English and computer science and their teachers. Medical Education, 30, 221-225. Fishbein, M. 8 Ajzen, I. (1975). Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley. Fitzgerald, J.T., Wray, L. A., Halter, J. B., Williams, B. C., 8 Supiano, M. A. (2003). Relating medical students’ knowledge, attitudes, and experience to an interest in geriatric medicine. Gerontologist, 43, 849-855. Futrell, M., 8 Jones, W. (1977). Attitudes of physicians, nurses, and social workers toward the elderly and health maintenance services for the aged: Implications for health manpower policy. Joumal of Gerontological Nursing, 3, 42-46. Galbraith, M. W., 8 Suttie, S. M. (1987). Attitudes of nursing students toward the elderly. 13, Educational Gerontology, 13, 213-223. Gellis, Z., Sherman, S., 8 Lawrence, F. (2003). First year graduate social work students’ knowledge of and attitude toward older adults. Educational Gerontology, 29, 1-16. Glass, J.C., 8 Knott, E. S.(1982). Effectiveness of a workshop in aging in changing middle-aged adults’ attitudes toward the aged. Educational Gerontology, 8, 359-372. Golde, P., 8 Kogan, N. (1959). A sentence completion procedure for assessing attitudes toward old people. Joumal of Gerontology, 14, 355—3. Gomez, G.E., Young, E. A., 8 Gomez, E. A. (1991). Attitude toward the elderly, fear of death, and work preference of baccalaureate nursing students. Gerontology and Geriatrics Education, 11, 45-55. Greenbaum, T. (2000). Moderating focus groups: a practical guide for group facilitation. Thousand Oaks, CA: Sage Publications. Greenhill, D. E. (1983). An evaluation of nursing students’ attitudes and Interest in working with older people. Gerontology and Geriatrics Education, 4, 83- 88. 272 Greenhill, ED, 8 Baker, MP. (1986). The effects of a well older adult clinical experience on students' knowledge and attitudes. Journal of Nursing Education, 25, 145-7. Gunter, L. (1971). Students' attitudes toward geriatric nursing. Nursing Outlook, 19, 466-469. Hamon, R. R., 8 Koch, D. K. (1993). Elder mentor relationship: An experiential Ieaming tool. Educational Gerontology, 19, 147-159. Harris, D. K., Changas, P. S., 8 Palmore, E. B. (1996). Palmore’s first fact on aging quiz in a multiple-choice format. Educational Gerontology, 22, 555- 589. Hartley, C. L., Bentz, P. M., Ellis, J. R. (1995). Effect of early nursing home placement on student attitudes toward the elderly. Journal of Nursing Education, 34, 128-130. H.R.561 Medicare, Medicaid, and SCHIP Benefits Improvement and Projection Act of 2000. SEC. 105. Coverage of medical nutrition therapy services for beneficiaries with diabetes or a renal disease. Access: thomas.loc.gov/ Harris, LA, 8 Dollinger, S. (2001). Participation in course on aging: Knowledge, attitudes, and anxiety about aging in oneself and others. Educational Gerontology, 26, 657-667. Hart, L. K., Freel, M. I., 8 Crowell, CM. (1976). Changing attitudes toward the aged and interest in caring for the aged. JoumaI of Gerontological Nursing, 2, 10-6. Hatton, J. (1977). Nurses' attitudes toward the aged: Relationship to nursing care. Journal of Gerontological Nursing, 3, 21 -26. Health Resources and Services Administration. (1995). A national agenda for geriatric education: White papers. Washington, DC: US. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health professions. Heider, F. (1958). The psychology of interpersonal relations. New York: Wiley. Hickey, T., 8 Kalish, R. A. (1968). Young people's perceptions of adults. Journal of Gerontology. 23, 215-219. Hoffman, 0., Rice, D., 8 Sung, H.Y. (1996). Persons with chronic conditions. Their prevalence and costs. Journal of Medical Association, 276, 1473-9. 273 Homans, G. (1974). Social behavior. Its elementary forms. New York: Harcourt Brace Jovanovich. Hummert, M. L. (1990). Multiple stereotypes of elderly and young adults: A comparison of structure and evaluations. Psychology and Aging, 5, 182- 193. Hummert, M., Garstka, T., Shaner, J., 8 Strahm, S. (1994). Stereotypes of the elderly held by young, middle-aged and elderly adults. Journal of Gerontology, 49, 240-249. Hutchinson, M. (1985). Educational needs of gerontological dietitians. Gerontology and Geriatrics Education, 4, 15 -18. lngham, R., 8 Fielding, P. (1985). A review of the nursing literature on attitudes towards older people. lntemational Journal of Nursing Studies, 22, 171- 181. Institute of Medicine, Committee on Nutrition Services for Medicare Beneficiaries. The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Service for the Medicare Population. Washington, DC: National Academy Press; 2000. lnteieri, R.C., Kelly, J.A., Brown, M. M., 8 Castilla, C. (1993). Improving medical students' attitudes toward and skills with the elderly. Gerontologist, 33, 373-378. Jonnalagadda, S. (2004). Effectiveness of Medical Nutrition Therapy: Importance of documenting and monitoring nutrition outcomes. Journal of Dietetics Associations, 104, 1788-1792. Kaempfer, D., Wellman, N. S., 8 Himburg, S. P. (2002). Dietetics students’ low knowledge, attitudes, and work preferences towards older adults indicate need for improved education about aging. Journal of American Dietetic Association, 102, 197 -202. Kayser, J. S., 8 Minnigerode, F. A. (1975). Increasing nursing students' interest on working with aged patients. Nursing Research, 24, 23—26. Kirby, J. R., Machlin, S. R., 8 Thorpe, J. M. (2004). Research Findings #16: Patterns of Ambulatory Care Use: Changes From 1987 to 1996. June 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/paperslrf16_01-0026/rf16.htm 274 Kite, M. E., 8 Johnson, B. T. (1988). Attitudes toward older and younger adults: A meta-analysis. Psychology and Aging, 3, 233-244. Kite, M. E., Deaux, K., 8 Miele, M. (1991). Stereotypes of young and old: Does age outweigh gender? Psychology and Aging, 6, 19-27. Knapp, J. L. 8 Stubblefield, J. (2000). Changes students' perceptions of aging: The impact of an intergenerational service Ieaming course. Educational Gerontology, 26, 61 1-621 . Knowles, L. N., 8 Server, V. T. Jr. (1985). Attitudes affect quality care. Joumal of Gerontological Nursing, 11 , 35-39. Knox, V. J., Gekoski, W. L., 8 Johnson, E. A. (1986). Contact with and perceptions of the elderly. The Gerontologist, 26, 309-313. Kogan, N. (1961 ). Attitudes toward old people: the development of a scale and an examination of correlates. Journal of Abnormal and Social Psychology, 62, 44-54. Kogan, N. (19793). Attitudes toward old people. The Journal of Social Psychology, 37, 249-260. Kogan, N. (1979b). Beliefs, attitudes, and stereotypes about old people. Research on Aging, 1, 11-36. Kosberg, J., 8 Harris, L. (1978). Attitudes toward elderly clients. Health and Social Work, 3, 67-90. Kovner, C.T., Mezey, M., 8 Harrington, C.(2002). Who cares for older adults? Workforce implications of an aging society. Health Affairs (MiIIwood), 21, 78-89. Krueger, R. A., 8 Casey, M, A. (2000). Focus groups: a practical guide for applied research. Thousand Oaks, CA: Sage Publications. Larkin, E., 8 Newman, S. (1997). lntergenerational studies: A multi—disciplinary. E. In Brabazonm, K., 8 Disch, R. (Eds.), lntergenerational Approaches in Aging: Implications for Education, Policy and Practice. New York, NY: The Haworth Press. MacNeil, R. D. (1991). Attitudes toward the aged and identified employment preferences of therapeutic recreation students. Educational Gerontology, 17, 543-558. 275 Maxwell, A. J., 8 Sullivan, N. (1980). Attitudes toward the geriatric patient among family practice residents. Joumal of the American Geriatrics Society, 28, 341-345. Menz, H.B., Stewart, F. A., 8 Dates, M.J. (2003). Knowledge of aging and attitudes toward older people. Joumal of the American Podiatric Medication Association, 93, 1 1-17. Meyer, M., Hassanein, R., 8 Bahr, R. (1980). A comparison of attitudes toward the aged held by professional nurses. Image, 12, 62-66. Mills, J. (1972). Attitudes of undergraduate students concerning geriatric patients. American Journal of Occupational Therapy, 26, 200-203. Mitchell, M. L. 8 Jolley, J. M. (2001). Research Design Explained (4th ed. ). Pacific Grove, CA: Wadsworth. Access: httpzllspsgclarion.edu/mm/RiDE3/C3IC3Handout32.html Moeller, T. G. (1982). Does taking developmental psychology affect students' reactions of aging? Teaching of Psychology, 9, 95-99. Montano, D. E., Kasprzyk, D, 8 Taplin, S. H. (1996). The theory of reasoned action and the theory of planned behavior. In Glanz, K., 8 Lewis, F. M. Rimer, B. K (Eds), Health behavior and health education. (pp. 85-138). San Francisco : Jossey-Bass Publishers. Masher-Ashley, P. M., 8 Ball, P. (1999). Attitudes of college students toward elderly persons and their perceptions of themselves at age 75. Educational Gerontology, 25, 89-102. Mount, J. (1993). Effect of a practicum with well elderly on physical therapy students' attitudes towards older people and their intention to work with the elderly. Gerontology and Geriatrics Education, 13, 13-24. Murden, R. A., Meir, D. E., Bloom, P. A., 8 Tideiksaar, R. (1986). Responses of four-year medical students to a required clerkship in geriatrics. Journal of Medical Education, 61, 569-578. Murphy-Russell, 8., Die, A. H. 8 Walker, J. L. (1986). Changing attitudes toward the elderly: the impact of three methods of attitude changes. Educational Gerontology, 12, 241-251. Newman, 8., Ward, C., Smith, T., McCre, 8 J., Wilson, J. (1997). lntergenerational Programs: Past Present and Future. Washington, DC: Taylor 8 Francis. 276 Noel, M. M. B. (1988). Michigan dietitians and the aging: An assessment of attitudes, knowledge and problem solving approach (Doctoral dissertation, Michigan State University, 1988). Noel, MM, 8 Ames, B.D.(1989). Attitudes, knowledge, and problem-solving approach of Michigan dietitians about aging. Journal of American Dietetics Association, 89, 1753 — 1757. O’Hanlon, A.M., 8 Brookover, B. C. (2002). Assessing changes in attitudes about aging: Personal reflections and a standardized measure. Educational Gerontology, 28, 711-725. O’Hanlon, A. M., Camp, C. J., 8 Osofsky, H. J. (1993). Knowledge of and attitudes toward aging in young, middle-aged, older college students: A comparison of two measures of knowledge of aging. Educational Gerontology, 19, 753-766. Palmore (1998). The facts on aging quiz. New York, NY: Springer Publishing Company, Inc. Panek, P. E. (1982). Do beginning psychology of aging students believe 10 common myths of aging? Teaching of Psychology, 9, 104-105. Patton, M. Q. (1987). How to use qualitative methods in evaluation. Newbury Park, CA: Sage Publications. Penner, L. A., Ludenia, K., 8 Mead, G. (1983). Staff attitudes: Image or reality? Journal of Gerontological Nursing, 10, 110-117. Perrotta, P., Perkins, D., Schimpfhauser, F., 8 Calkins, E. (1981). Medical student attitudes toward geriatric medicine and patients. Joumal of Medical Education, 56, 478-483. Prochaska, J.O., Norcross, J.O., Fowler, J.L., Follick, M.J. 8 Abrams, DB. (1992). Attendance and outcome in a worksite weight control program: processes and stages of change as process and predictor variables. Additive behaviors, 17, 35-45. Puentes, W. J. 8 Cayer, C (2001). Effects of a modified version of Feeley's campus wellness vacation on baccalaureate registered nurse students' knowledge of and attitudes toward older adults. Journal of Nursing Education, 40, 86-89. Position of American Dietetics Association. (2000). Nutrition, aging and the continuum of care. Joumal American Dietetics Association, 100, 580-595. 277 Rasor-Greenhalgh, S. A., Stombaugh, LA, 8 Garrison, M. E. (1993). Attitudes changes of dietetics students performing nutritional assessment on health elderly. Journal of Nutrition Elderly, 12, 55-64. Reed, C. C., Beall, S. C., 8 Baumhover, L. A. (1992). Gerontological education for students in nursing and social work: Knowledge, attitudes, and perceived barriers. Educational GerontologY. 18, 625-636. Reuben, D. B., Lee, M., Davis, J. W., Jr., Eslami, M. S., Osterweil, D. G., Melchiore, 8., et al. (1998). Development and validation of a geriatrics attitudes scale for primary care residents. Joumal of the American Geriatrics Society, 46, 1425-1430. Reuben, D. B., Bradley, T. B., Zwanziger, J., Vivell, S., Fink, A., Hirsch, S.H., 8 Beck, J.C (1991). Geriatrics faculty in the United States: who are they and what are they doing? Joumal American Geriatric Society, 39, 799-805. Rhee, L.Q., Wellman, N.S., Castellanos, V.H., 8 Himburg, SP. (2004). Continued need for increased emphasis on aging in dietetics education. Joumal of the American Dietetic Association, 104, 645-649. Riley, M W., 8 Riley, J.(1986). Longevity and social structure: The potential of the added years. In A. Pifer and L. Bronte (Eds.), Our aging society: Paradox and promise. New York: W. W. Norton. Robb, S. S. (1979). Attitudes and intentions of baccalaureate nursing students toward the elderly. Nursing Research, 28, 43-50. Rosencranz, H. A., 8 McNevin, T. E. (1969). A factor analysis of attitudes toward the aged. Gerontologist, 9, 55-59. Sachs, M. R., Marchy, M. L., Mast, TA, 8 Ham, R. J. (1984). Influencing medical student' attitudes toward older adults: A curriculum proposal. Gerontology and Geriatric Education, 4, 91-96. Sahyoung, N. R., Pratt, C. A., 8 Anderson, A. (2004). Evaluation of Nutrition education interventions for older adults: A proposed framework. Journal of Dietetics Associations, 104, 58-69. Schwalb, S. J. 8 Sedlacek, E. (1990). Have college students’ attitudes toward older people changed? Joumal of College Student Development, 31, 127- 1 32. Scoring Office, at Michigan State University, Item analysis, Retrieved from ccess: Mtg/lscoring.msu.eduf1tanhand.html 278 Seefeldt, C. (1987). The effect of preschoolers’ visits to nursing home. Gerontologist, 27, 228-232. Shahidi, S. 8 Devlen, J. (1993). Medical students’ attitudes to and knowledge of the aged. Medical Education, 27, 286 -288. Shenk, D., 8 Lee, J. (1995). Meeting the educational needs of service providers: Effects of a continuing education program on self-reported knowledge and attitudes about aging. Gerontological Education, 21, 671-681. Shoemake, A. F. 8 Rowland, V. (1993). Do laboratory experiences change college students’ attitudes toward the elderly? Gerontological Education, 19, 295—309. Shepherd, 8., 8 Achterberg, C. (2003). Qualitative research methods: sampling, data collection, analysis, interpretation, and verification. In: Monsen E, ed. Research: Successful Approaches. 2“d ed. Chicago, IL: American Dietetic Association. Shmotkin, D. Eyal, N. 8 Lomranz, J. (1992). Motivations and attitudes of clinical psychologists regarding treatment of the elderly. Gerontological Education, 19, 295-309. Slotterback, C. S., 8 Saamio, D. A. (1996). Attitudes toward older adults reported by young adults: Variation based on attitudinal taste and attribute categories. Psychology and Aging, 11, 563-571. Smith, M. R., Marcy, M.L., Mast, T. A., 8 Ham, R. J. (1984). Implementation and evaluation of a model geriatrics curriculum. Journal of Medical Education, 59, 416-424. Spence, D., 8 Feigenbaum, E. (1968). Medical students' attitudes toward the geriatric patient. Joumal of Gerontology, 16, 976-983. Stanek, K., Powell, 0., 8 Betts, N. (1991). Nutritional knowledge of nurses in long-term health care facilities. Journal of Elderly Nutrition, 10, 35-48. Statistical Package for the Social Sciences, Inc. (2004). SPSS version 12.01 for Windows. Chicago, IL: SPSS, Inc. Strauss, A. L. (1987). Qualitative analysis for social scientists. New York: Cambridge University Press. 279 Tarbox, A. R., Connors, G. J., 8 Faillace, LA. (1987). Freshman and senior medical students’ attitudes toward the elderly. Journal Medical Education, 62, 582-591. Triandis, H. C. (1971). Attitudes and attitude change. Toronto: Wiley. ToIIett, S. 8 Adamson, C. (1982). The need for gerontologic content within nursing curricular. Journal of Gerontological Nursing, 8, 576-580. US Bureau of the Census (2001), Population projections of the United Sates by age, sex, race and Hispanic origin: 1995 to 2050. Current population reports. Retrieved August 1, 2004. Available at: mpzllwwwcensusgov/prodfl moot-254 130/L251 130b.pgf, US. Bureau of Labor Statistics. Occupational Outlook Quarterly: The 2002-12 job outlook in brief. (2004). US. Department of Health and Human Service. (1999). Chronic disease notes 8 reports, 12(3). http:/lwww.cdc.gov/nccdphp/cdfall99.gdf Accessed at August 1, 2004. U. S. Department of Health and Human Services (2003). Health, United States, 2003 with Urban and Rural Health Chartbook. Ward, C. R., Duquin, M. E., 8 Streetman, H. (1998). Effects of intergenerational massage on future caregivers' attitudes toward aging, the elderly, and caring for the elderly. Educational Gerontology, 24, 3546. Warren, D. L., Painter, A., 8 Rudisill, J. (1983). Effects of geriatric education on the attitudes of medical students. American Geriatric Society, 31, 435-8. Westacott, B. M., 8 Hegeman, C. R. (1996). Service Ieaming in elderly care: A resource manual. Albany, NY: The Foundation for Long Term Care. Williams, R. A., Lusk, S. L., 8 Kline, N. W. (1986). Knowledge of aging and cognitive styles in baccalaureate nursing students. The Gerontologist, 26, 545-550. Wilson, J. F., 8 Hafferty, F. W. (1980). Changes in attitudes toward elderly one year after a seminar on aging and health. Journal of Medical Education, 55, 993-999. Wittig, M. A., 8 Grant-Thompson, S. (1998). The utility of Allport's conditions of intergroup contact for predicting perceptions of improved racial attitudes and beliefs. Journal of Social Issues, 54, 795-812. 280 IIIIIIIIIIIIIIIIIIIIIIIIIIIIII I III IIIIIIII III III III III III III