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UMI MICHIGAN DIETITIANS AND THE AGING: A N ASSESSMENT OF ATTITUDES, KNOWLEDGE, AND PROBLEM SOLVING APPROACH By Mary Margaret Barth Noel A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Family and Child Ecology 1988 Copyright by MARY MARGARET BARTH NOEL 1988 ABSTRACT MICHIGAN DIETITIANS AND THE AGING: AN ASSESSMENT OF ATTITUDES, KNOWLEDGE, AND PROBLEM SOLVING APPROACH By Mary Margaret Barth Noel The objective of this research was to assess the attitudes and knowledge of Michigan dietitians about aging. Dietitians' attitudes and knowledge about aging are important because of the potential influence on nutrition services provided to older adults. Four instruments were used: a demographics measure, the Wall-Oyer Attitudes Toward Aging, the Palmore Facts on Aging and three problem solving questions to assess the use of the human ecological perspective. The dietitians surveyed were active members of the American Dietetic Association in Michigan in 1986. dietitians with 738 responding The survey was mailed to 1408 (52.4%). The responding dietitians were predominantly under 40, well-educated and female, which was consistent with the 1986 national census of dietitians. The results indicated that dietitians hold positive attitudes toward older adults in most areas. An exception was that a majority of dietitians perceived older adults as resistant to treatment. Although knowledge about aging by dietitians generally was adequate, questions consistently answered incorrectly were in the areas of economic and health status of older adults. These are critical areas of deficiency in knowledge by dietitians since food and nutrition issues often involve money and health. In the problem solving section, the dietitians usually focused on one specific environment or area of concern. The full range of all possible environments with which older adults interact usually was not considered. The diversity of older adults' needs was not reflected in the responses. It was concluded that continuing education as well as comprehensive undergraduate courses that include aging would have a positive influence on Michigan dietitians' attitudes and knowledge about aging. Also, further research is needed to determine if-dietitians and other hea.lth professionals understand older adults within their total context, or through a human ecological perspective. To George, Katherine and Joseph for their continued love and support throughout my program and research. ACKNOWLEDGMENTS This research would not have been possible without the concern and support of many people. I would like to especially thank my research advisor. Dr. Barbara Ames, and m y committee of Dr. Margaret Bubolz, Dr. Wanda C h e n o w e t h , Dr. Linda Nelson and Dr. Donald Tavano, as well as Dr. A n d r e w Porter, Dr. Sally Pratt, and Jan Vredevoogd. Also, a special thank you to my family, George, Katy and Joey, for their encouragement and eternal faith in my ability to reach m y goal. Also, my gratitude to my friends, especially Mary and Tim Jones, who helped me when they could and encouraged me when I needed it. benefited from the help of all of you. iii I have TABLE OF CONTENTS List of Tables vi List of Figures viii Chapter I INTRODUCTION Background of the Problem Purpose of the Study Definitions Conceptual Framework Summary 1 1 7 7 9 14 LITERATURE REVIEW Introduction Role of Dietitians Problems in Studying Nutrition of Aging Attitudes Towards Aging Knowledge of Aging Ecology of Nutrition and Aging Summary 16 16 16 18 20 23 25 27 III RESEARCH DESIGN AND METHODOLOGY Overview Sample and Data Collection Procedure Research Design and Instrumentation Limitations Analysis Summary 29 29 29 31 37 38 42 IV RESULTS Demographic Data Age, Education and Gender of Dietitians Professional Interest Personal and Professional Experiences with Aging Human Ecological Training Wall-Oyer Attitudes Towards Aging Inventory Palmore Facts on Aging Correlations of Demographic Characteristics Attitudes and Knowledge About Aging Correlations of Demographic Characteristics with the Total Attitudes and Knowledge Instruments Multiple Regressions for Demographic Characteristics and Parts of Wall-Oyer Attitudes Towards Aging Inventory Multiple Regressions for Demographic Characteristics and Parts of Palmore 44 44 44 53 55 II iv 58 59 64 69 69 70 81 Facts on Aging Instrument Multiple Regresions for the Attitude Factors and the Knowledge Factors Problem Solving Section to Determine the Ecological Perspective Description of Answers Problem Solving Questionnaire Responses in Relation to Place of Graduation Correlations Between Demographic Characteristics and the Problem Solving Measure Problem Solving Questionnaire Responses Correlated to the Attitudes and Knowledge Measures Summary of Data V SUMMARY, IMPLICATIONS AND RECOMMENDATIONS Summary Attitudes on Aging Knowledge about Aging Demographic Characteristics Related to Attitudes and Knowledge about Aging Problem Solving Measure Implications and Recommendations Dietetics Education Professional Practice Recommendations for Revised Research Framework Recommendations for Further Research D O W Appendix A E F G Research Approval by the University Committee on Research Involving Human Subjects Letter to Dietitians Questionnaire to Dietitians Correct Answers and Scoring for Parts II, III, and IV of the Questionnaire to Dietitians A Human Ecosystem Illustrating Relationships between Environments and the Individual Minimum Academic Requirements of the American Dietetic Association for Dietitians Letter from Wall and Oyer regarding Attitudes on Aging Inventory Bibliography 90 91 91 94 94 96 96 99 99 100 101 101 104 106 106 110 113 116 118 120 122 132 139 141 14 3 146 v LIST OF TABLES The Absolute and Relative Size of U.S. Aging Population Group (1945-2050) 2 Long-Term Federal Outlay Trends as a Percentage of GNP 5 Age-Related Medical Statistics 21 4 Characteristics of Respondents as compared to the American Dietetic Association Survey 46 5 Bachelor's Degrees 47 6 Master's Degrees 47 7 Doctoral Degrees 48 8 Number of Years as Registered Dietitian 48 9 Degree Granting University or College 49 10 Number of Courses in Aging 50 11 Percent of Respondents Who Studied Aging As Part of a Comprehensive Course 51 12 Time Spent as Part of Post-Baccalaureate Dietetic Training with Aging 52 13 Self-Evaluation of Training in Geriatrics Relative to the Dietitian's Need for Working with Aging 52 14 Continuing Education Programs/Workshops 53 15 Membership in Gerontology Professional Groups 54 16 Contact with Elderly as a Child 55 17 Type of Professional Experience with Elderly as Dietitian 56 18 Type of Personal Experience with Elderly 57 19 Dietitians Who Took Courses in Human Ecology 20 Dietitians Who Took Courses with Human Ecology as Part of a Comprehensive Course vi (HE) (HE) 58 Page Table 21 Dietitians: Results of Wall-Oyer Attitudes on Aging Inventory in Percentages 61 22 Dietitians: 63 23 Dietitians: Results of Palmore Facts on Aging in Percentage 65 24 Commonly Held Misconceptions by Dietitians 67 25 Common Misconceptions That Responding Dietitians Do Not Hold 68 26 Misconceptions Held by Respondents Not Commonly Held by Other Groups 68 27 Correlations Between Demographic Characteristics and Total Scores on Attitudes and Knowledge Measures 70 28 Factor Analysis of Attitudes 72 29 Multiple Regressions For and Number of Years as a 76 30 Multiple Regressions for Attitude 1, Controlling for Age and Number of Years as a Registered Dietitian 77 31 Multiple Regressions for Attitude 2, Controlling for Age and Number of Years as a Registered Dietitian 78 32 Multiple Regressions for Attitude 3, Controlling for Age and Number of Years as a Registered Dietitian 79 33 Summary of Multiple Regressions for Attitude 1,2, 3 when Controlling for Age and Number of Years as a Registered Dietitian 80 34 Multiple Regressions for and Number of Years as a 85 35 Multiple Regressions for Knowledge 1, Controlling for Age and Number of Years as a Registered Dietitian 86 36 Multiple Regressions for Knowledge 2, Controlling for Age and Number of Years as a Registered Dietitian 87 37 Multiple Regressions for Knowledge 3, Controlling for Age and Number of Years as a Registered Dietitian 88 Negative Attitudes Towards Aging Attitudes, Controlling for Age Registered Dietitian Knowledge, Controlling for Age Registered Dietitian vii Table Page 38 Summary of Multiple Regressions for Knowledge 1, 2, 3 when Controlling for Age and Number of Years as a Registered Dietitian 89 39 Multiple Regressions for Attitudes 1, 2, 3 with Knowledge 1, 2, 3 and Total Knowledge, Controlling for Age and Years as a Registered Dietitian 90 40 Correlations Among Demographic Characteristics and the Ecological Questionnaire 95 41 Correlations Between Scores on the Instruments 96 viii LIST OF FIGURES Figure Page 1 Research Framework 13 2 Problem Solving Questions 93 3 Revised Research Model 115 ix CHAPTER I INTRODUCTION The population of the United States is undergoing a significant change. The number and percent of the total population constituted by older adults (65 years of age or older) in the United States is large and increasing. Michigan is no exception to this trend. One of the major needs of this older segment of our society is appropriate nutrition because good nutrition is a key to good health, and good health among this large and increasing segment of the population will be economically and socially advantageous to society. As the older population increases, the need for nutrition education and services also increases. Although dietitians are the primary providers of nutrition education and services, very little is known about their knowledge or attitudes concerning aging, or the extent to which they consider the total context of older adults when presented with their nutrition problems. In learning more about dietitians, the ultimate goal is to improve services to older people by better preparing dietitians to meet their needs. Background of the Problem Both the average life expectancy and the percentage of the popula­ tion over 60 are increasing. The age group with the greatest increase in numbers is the group over 85 years of age, which is expected to at least double in number by the year 2000 (Atchley, 1985) 1 (Table 1). Table 1 The Absolute and Relative Size of U.S. Aging Population Group (1945 - 2050) Aged as a percentage of Total Population Aged 80+ as a percentage of Total Aged Year 65+ (Population in millions) 1945 10.5 7.5 13.3 1965 19.0 9.3 16.5 1985* 29.3 11.8 21.7 2005* 37.5 13.8 30.9 2025* 60.8 19.4 24.4 2050* 69.7 21.1 38.3 Source: U.S. Bureau of Census, Current Population Report, 1979. *Data for 1945-1980 actual; for 1985-2050 are based on projections based on mid-range series of census and social security actuaries. With the growing number and proportion of older people in the population, health is of particular concern due to its influence on both the quality of life of older individuals and the use of societal resources. Nutrition is a part of health as well as a part of the treatment of diseases of the aging. Nutrition for the aging involves several issues. These may include social issues such as loneliness or biological issues such as the decreasing caloric needs at a time when nutrient needs stay the same. The strong interrelationship between health and nutrition in older adults has long been recognized because a variety of medical problems may be 3 caused or intensified by poor nutrition (Sandstead, 1985). The occur­ rence of heart disease, stroke, cancer and other chronic afflictions can reflect lifelong environmental factors and health behaviors such as poor nutrition and lack of exercise (Surgeon General's Report on Health Promotion and Disease Prevention, 1979). Public officials have realized the interrelation of health to food and nutrition through policy deci­ sions that provide food programs for women, infants and children food stamps, and senior food sites. Yet, most health care providers have little training in nutrition or aging Se n g e r , O'Brien, & Barker, 1985). (WIC), (National Research Council, 1985; Nutrition in the health care field is within the scope of practice of the dietitian. "The dietitian is a translator of the science of nutrition into the skill of furnishing optimal nourishment to people." 1985, p. 5). (American Dietetic Association (ADA) Those who provide and determine nutrition services and policies are the dietitians in institutions, the community and government. Although other health professionals have been assessed as to their knowledge and attitudes about aging, dietitians have not (Wilson & Whittington, 1985). Dietitians have training in nutrition, biochemistry, and physiology as well as social sciences, management, and education (Appendix F, Minimum Academic Requirements of ADA for Dietitians). Yet, dietitians may have little knowledge about the social, psychological and physiological process of aging (Hutchinson, 1984). Their educational programs usually encompass specialty subjects such as life-cycle nutri­ tion, but the undergraduate college education of dietitians does not usually include any required topics in aging or its special needs (Sims, Smiciklas-Wright, & Shannon, 1984). Furthermore, dietetic internships and other post-baccalaureate training may have varying lengths of exposure to facilities for and services to the aging (Shoaf & Kotanchek, 1987). Often dietary care as well as medical care is necessary due to problems common in older adults such as heart disease, diabetes and obesity. The cost of these problems to the individual can be helpless­ ness and the inability to care for oneself. The cost to society also can be great due to the range of services required by older persons with multiple health problems. cause for this phenomenon. The changing demographics are not the only The very old, who have higher than average medical expenses relative to the younger aged, are a part of the demogra­ phic picture. Increasing general health care costs per capita are important in contributing to the health care financing costs since these costs have greatly exceeded the rate of increase of the GNP per capita for years (U.S. Bureau of Census, 1984). This rate of growth can be expected to continue unless major policy changes occur (Table 2). Table 2 Long Term Federal Outlay Trends as Percentage of GNP Year Pension Programs Health Care Financing Programs 1965 4.1 0.3 1975 6.4 2.0 1985 6.6 2.7 1995 6.0 3.6 2005 5.6 4.2 Source: Palmer and Gould. 1986, page 312. Through its policy makers, society is looking for a means to diminish these costs as well as improve the quality of life for older adults. Preventive programs encouraging improvement of nutrition and increased physical activity are current recommendations for older adults (Surgeon General's Report, 1979). The demographics of Michigan are similar to the national statistics on the percentage of aging adults who are a part of the population. 1981, about 10% of Michigan's population was over 65 years of age. In In 1981, 5% of Michigan's aged population, about 46,500, lived in nursing homes. The percentage of the population as well as the number in nursing homes will double by 2030 Dietitians (Britton, 1984). (Michigan Department of Social Services, 1984). generally provide nutrition services to older adults The trained, qualified dietitian (known as a registered dietitian) who is a member of the American Dietetic Association can belong to optional specialty dietetic professional groups. Two of these professional groups have aging as the primary or major area of concern. These practice groups are the Gerontological Nutrition group and the Consultant Dietitians in Health Care Facilities group long-term care facilities). (primarily Other specialty groups such as Public Health Nutritionists, Diabetes Care and Education, and Nutrition Education for the Public have secondary interest in aging because the aged are major populations addressed by these groups. None of the specialty groups have educational or other membership requirements. that when membership dues are paid, an The only qualification is additional amount of money ($10-515) is paid to each group the dietitian notes on the membership form. Usually dietitians belong to the group related to their practice area, but this is not always the case. The informal education of dietitians through a network of articles and personal development might contribute to their knowledge of the nutritional needs of the aging, but it is difficult to assess the impact or comprehensiveness of such an approach. Dietitians may have levels of knowledge and attitudes similar to the general public because they have had little formal gerontological education, and informal education is difficult to assess. Providers will need to increase their understanding of the aging process, and their knowledge and attitudes will have impor­ tant implications for the types of services they provide. As the trained experts in nutrition, dietitians should be providing leadership in nutrition for the aging and their families. The first step towards d i etitians providing that leadership is to assess their knowledge and attitudes about aging. attitudes are noted, If low knowledge levels and negative then programs can be designed for improving these basic areas. If high levels of knowledge and positive attitudes towards aging are found among dietitians, then additional skills such as problem solving and leadership development programs could be developed. Purpose of the Study The overall purpose of this research was to assess the knowledge and attitudes of Michigan dietitians about aging. This is a starting point of determining better information about the quality and amount of help available to older people in the area of nutrition. As nutrition experts, dietitians have not been assessed for their attitudes and knowledge about aging as other health professionals have been. Prior to determining the extent to which dietitians work with older adults, it is important to discern what dietitians know about older adults. In order to reach this goal, the following specific objectives were developed: 1. To determine what attitudes Michigan dietitians hold concerning aging. 2. To determine the knowledge about aging Michigan dietitians hold. 3. To determine if age, education, professional interest, and professional and personal experiences with aging are related to Michigan dietitians' attitudes and knowledge about aging. 4. To determine to what extent Michigan dietitians use a human ecological perspective in problem solving, and what is the relationship between the ecological perspective and their attitudes and knowledge about aging. Definitions Attitudes. Kalish (1985) defines an attitude as an enduring tendency to think, feel, and behave in a consistently favorable or unfavorable fashion toward a concrete thing including a person or abstract thing or idea. The instrument used in this study to assess 8 attitudes on aging is the Wal l-Oyer Attitudes Toward Aging Inventory. This inventory measures the preconceived notions or prejudices persons have about the aging, feelings about older persons and interest in dealing with older people. Wall-Oyer did not present a definition of an attitude with their instrument. Conceptually, attitudes about aging in this survey are defined by this researcher as prejudices, feelings and interests in older persons. Operationally, attitudes about aging will be measured by the Attitudes Towards Aging Inventory by Wall-Oyer which is a 22-item instrument using a Likert scale. Knowledge of A g ing. Knowledge of aging is defined as information, ideas or understanding gained through experience, observation or study (Purtilo, 1973). Knowledge of aging is factual information that an individual possesses, or is able to demonstrate on a test of facts on aging. Operationally, knowledge of aging was measured by Palmore's 25- statement true or false Facts on Aging inventory. Human E c o l o g i c a l P e r s p e c t i v e . An ecological perspective on situa­ tions or events would include an understanding of individual and family issues w i t h i n the hu m a n behavioral environment, the human constructed e n v ironment and the natural environment as they impact upon human experiences, attitudes, beliefs and situations. The human ecological p e r spective takes into account culture and values that influence human relationships and the m o difications humans make to their environments. This is an important p e r spective because humans are interdependent creatures rather than independent organisms. The human ecological p e rspective provides a h o l istic view of individuals in association with the physical, biological and social conditions and events around them. Because older adults are the most heterogeneous age group of individuals (Weg, 1982), this perspective is particularly valuable. Professional Interest. Professional interest was indicated by the affiliation with a professional group or groups expressly for the understanding or sharing of information about aging persons and/or services to the aging. Professional Experience with A g ing. Experiences reported by the dietitian as related to his/her career in dietetics that dealt primarily with aging persons and/or services to the aging. Personal Experiences with Aging Persons. Experiences reported by the dietitian regarding his/her personal life as related to aging persons. Active Dietitian. Dietetic Association Active dietitians are defined by the American (ADA) constitution as "any person who possesses or satisfies the education, experience, endorsement, and supervision qualifications prescribed by the Executive Board and whose application has been evaluated and approved by the membership committee may become an active member of the Association." Constitution 1967, p. 3.) (American Dietetic Association Active dietitians in Michigan were used as a representative group of the ADA since Wenberg (1975) showed that this group is similar to the general ADA membership. Conceptual Framework Due to the complexity and multifaceted nature of the health and nutrition problems that the aging face, a human ecological perspective was chosen as the conceptual framework. 10 A human ecological model follows a general ecological model that views organisms as interacting with their environment. The organism, its environ­ ment and their interaction is called an ecosystem. . . . Our model gives attention to the spatial dimension of organisms in relation to their environment and also takes account of cultures and values that influence human relationships and people's adjustments to and modifications of their environ­ ment. (Bubolz, Eicher and Sontag, 1979, p. 28). The attitudes and knowledge of dietitians are important within the total context of how the problems of the aging are viewed. If aging is not viewed ecologically, then the nutrition services that dietitians provide will be limited, short-sighted and not helpful to the aging adult. Nutrition services can be inadequate if viewed only within the context of the aging individual. Aging adults need to be considered within the context of their families, communities, and the resources these systems provide. A human ecological perspective is the framework that considers the multifaceted dimensions of the human being. perspective considers individuals human behavioral environments This (physical and mental), their families, (social, values, policies, laws, religious and community relations), human constructed environments (housing, transportation, and community services) and the natural environment (weather, geography and natural resources, such as water). Each of these environments is an element to consider in reviewing the situation and circumstances of individual life problems. The older adult has developed many linkages to each of these environments throughout a lifetime. Interactions which occur in the various environments influence the quality of daily living. The interchanges between the older adult and each system in each environment become more important with time; a loss (such as loss of a spouse or close friend, selling of a familiar home, 11 change in community and climate) in any system could precipitate a crisis in the older adult. Older adults who are viewed by many as highly resistant to change may actually undergo more changes in their later years than at any other time. These changes occur in their families and their social relations, in housing and sometimes the natural environ­ ment. The changes and interactions of older adults are important to their well-being— including their health and nutrition. Recently, Fanelli and Abernethy developed a nutrition questionnaire to assess the nutritional needs of older adults 1986). (Fanelli & Abernethy, Though it was not developed within a human ecological framework, the information contained in it corresponds to the elements of the ecological framework. However, family is the one area which a human ecological model identifies that was not strongly delineated in the Fanelli-Abernethy questionnaire or in other nutrition sources. Families are not considered in nutrition assessments of older adults by some researchers (Fanelli & Abernethy, 1986). The human ecological model maintains that the family is an important factor in considering the concerns of humans. Family is recognized as the principal teacher of nutrition and food habits. The aging person's involvement with a family enhances the social aspects of eating (Schlenker, 1984). Yet, often nutrition assessments of older adults omit family as one of the considerations. The human ecological perspective takes family into consideration in its impact on the individual. Through the human ecological perspective important areas are considered, such as inter­ relationships of the older individual with the family, the community or 12 the natural environment. With this perspective, a thorough view of the give and take between individuals and their world can occur. Since many dietitians in Michigan have graduated from Michigan State University, a major proponent of the human ecological model, there could be a difference in their approach to nutrition services as compared to approaches utilized by dietitians from other schools. How training in the human ecological conceptual framework develops a particular type of knowledge and influences attitudes in the area of nutrition has not been investigated. The human ecological perspective could be a useful means of assessing how dietitians' attitudes and knowledge influence their professional practice with older persons. The life experiences of older adults are so diverse that many aspects of family and community must be considered to understand fully their needs. The ecological perspective provides the framework for assessing these diverse interrelationships in older adults' lives. The ecological framework was proposed in order to clarify the complex relationships between variables in this study. The independent variables of age, education, professional interest, and professional and personal experiences were predicted to influence the dependent variables of attitudes and knowledge about aging of Michigan dietitians. Both of these variables could influence the ecological perspective on aging in viewing the nutrition concerns of older adults through their individual interrelationships with family, community, policy, and natural environments (Figure 1). 13 Dependent Variables Independent Variables Age of Dietitian Education Related to Professional Interest in Aging Professional Experiences/Training in Aging Personal Experiences in Aging Attitudes about Aging of Michigan Dietitians Knowledge about Aging of Michigan Dietitians A' Related s. to Related to V The Ecological Perspective in Viewing Nutrition Concerns of Older Adults (Individual interrelationships with family, community, government and natural environments) Figure 1. Research Framework The actual attitudes and knowledge of Michigan dietitians are important, but how these attitudes and knowledge affect decisions or problems involving older adults is the crucial clinical question. This study investigates attitudes and knowledge about aging so that additional questions about providing services to older adults can be studied. ecological perspective provides a holistic approach for viewing environments in which individuals function and encountered by the older adult. The (a) the (b) the nutrition problems This framework provides a means for assessing the impact of factors such as the individual's physical and psychological status, family issues, community resources, policy, including health and ecomomic, and characteristics of the natural environment. 14 The reason that attitudes towards and knowledge of aging are crucial to all health professionals is the influence these attitudes and knowledge may have on clinical judgments affecting older adults. The ecological perspective is a framework for testing clinical judgments to determine how broadly or encompassing various areas are considered related to the needs of the older adult. Therefore, it is necessary to assess the attitudes and knowledge of dietitians about aging, related to their problem solving processes. The ecological perspective provides a potential means for analyzing the issues which Michigan dietitians view as concerns in the nutrition problems of older adults. Summary Despite the fact that more of the U.S. population is living longer and may have specialized nutritional needs, health professionals generally are not trained in nutrition for the aging (Hutchinson, 1984). Although the needs of older adults vary widely due to life experiences, health professionals often fail to understand these diverse needs 1982). (Weg, Other health professionals have shown a lack of desire to work with the older adult (Geiger, 1978). This may be due to their lack of education and insufficient professional or personal experience with older adults as well as a lack of holistic understanding of the multifaceted problems of older adults. Although professional dietitians provide nutrition and food services to the aging population, they have not been assessed as to their knowledge or attitudes towards the aging. A better understanding of the attitudes and knowledge about aging could help define the education dietitians need. The human ecological perspective 15 provides a framework to study the clinical judgment of dietitians when dealing with older adults. Also important is the effect that these attitudes and knowledge have on the decisions about the nutritional problems of older adults because they directly affect the quality of services the aging receive. CHAPTER II L I TERATURE R E VIEW introduction The literature review summarizes pertinent information on dietitians, nutrition of the aging, and attitudes and knowledge of health professionals about aging. Because the human ecological framework is the conceptual basis for this study, research in the use of this framework in nutrition and aging also is discussed. The first area covers dietitians, because this is the group which the research was conducted. The second area includes nutrition of the aging because this is the content area for the research. The third reviews attitudes towards aging; the fourth covers knowledge of aging. The final area of the literature review is the ecology of nutrition and aging. Role of Dietitians The person who is concerned with proper nourishment of individuals and groups has functioned as a dietitian long before the title existed. Concern about the relationship between what people eat and drink to health goes back as far as 2500 B.C. as recorded on stone tablets in Babylonia (ADA, 1985). The American Dietetic Association incorporated in 1927 with a formal decision on the title of dietitian occurring in 1930 (ADA, 1985). 16 (ADA) was (and spelling) The president of ADA in 1964 17 realized the need for advanced study and specialization within the profession. Work began to investigate requiring credentials within the profession. Voluntary registration that includes an examination and continuing education requirements was initiated in 1969. registered dietitian The ADA (RD) became the form for certification of dietitians (ADA, 1985). Special interest groups have existed in ADA for many years; in 1979 dietetic practice groups (DPG) became an important part of ADA structure. Major interests of the membership, not necessarily areas of practice, were identified by DPGs. gerontology — Two of the DPGs are specifically interested in Gerontological Nutrition Group and Consultant Dietitians in Health Care Facilities. The latter group's interest is due to the large percentage of the population of older adults in nursing homes — major type of health care facility where dietitians consult. a The Consultant Dietitians in Health Care Facilities Group is the largest single practice group in the ADA membership (3,871 out of 26,653) whereas the Gerontological Nutrition Group is average in size (1,334 members) (ADA, 1985). The ADA has asserted its commitment to improving the institutional status and health of older adults through support of nutrition education for older adults, research on the aging process, and nutrition caregiving activities (Journal of the American Dietetic Association, 1981). In addition, dietitians' involvement in nutrition and aging can be demonstrated by the varying populations dealt with by dietitians, the interest of practice groups in the nutritional concerns of older adults and positions taken by ADA for nutrition issues for older adults. 18 Michigan dietitians as representative of the national membership in ADA in that education, practice locations, and other factors, are similar (Wenberg, 1975). Problems in Studying Nutrition of Aging The study of the nutrition of aging is complex because of the multifaceted nature of gerontology. Older persons are probably the most heterogeneous of all subgroups in the population. These diverse individuals have unique genetic identities, fulfilled during interaction with unique life histories. They are more different from each other than ever before— although they may face similar life stage challenges. People age differently from one another, in both rate and substance of change. In each person, organ systems age at distinctive rates in a variety of ways. (Weg, 1982, p. 81) Weg goes on in her "Position Paper on a Model of Normal Aging" to discuss gerontology. As a field of inquiry, it is developmental and processoriented, with the commitment to understand the mechanisms and trajectory of lifelong changes with time, in the psychological, affectional, social, physical, and spiritual dimensions of human development with time. As a field of inquiry and practice, it has major implications for clinical geriatric investigation, teaching, and practice. A model of normal aging seeks to distinguish disease from changes with time, to integrate all perspectives into the whole person, and to know their interaction, (p. 82) This diversity of the aging population along with the complexities of multiple areas influencing the older adult has made consistent nutrition data on the aging adult difficult to obtain (Roe, 1983). Even as recently as 1985 Sandstead wrote that ". . . it is evident that our ignorance about the relations between nutrition and aging far exceeds our knowledge." (1985, p. 171). Even though the same nutrients are essential for individuals of all ages, changes accompanying the aging process may call for variations in the amounts required by aging adults (Love, 19 1982). Though the Recommended Dietary Allowances (National Research Council, 1980) list the oldest age group as 51 years and older, it is likely that the vigorous 65 year old has little in common with the frail 91 year old in nutritional needs (Hutchinson, 1984). Nutrition also is affected by the diversity in psychological, physiological, and social well-being. A few sources consider the ecological approach suggested by this diversity not (Robson, Larkin, Sandretto, & Tadayyon, 1972), but most do (Fanelli & Abernethy, 1986; Mullis & Bowen, 1985). Steinbaugh (1984) identifies three areas which are of special nutritional concern in studying nutrition and aging. First is the newness or "youthfulness" of gerontology, especially of nutrition in aging. The nutrition of aging has not been studied with the elderly viewed as a distinct and different segment of adults. Studies have been conducted that grouped adults from 25 to 65 years of age, or 65 and older (Sandstead, 1985). Therefore, any unique nutritional differences within the over 65 population have not been distinguished. The situation is changing in that the elderly, including the very old, are becoming the focus of age specific research. Second is the definition of "normalcy." The definition of normality, and therefore abnormality, is critical to the study of nutrition and aging and of nutrition assessment of the elderly. The difficulty is that chronic and clearly pathological conditions such as arthritis, heart disease or diabetes mellitus can often be controlled sufficiently so that elderly individuals can lead fairly normal active lives. Should the operational definition of normality not allow for such conditions? From a practical and a statis­ tical viewpoint are not these conditions more or less typical and usual? Also many conditions formerly thought to be an inevitable part of the aging process are now considered pathological conditions which may be related to nutritional intake. For example, an alteration of mental state may be the 20 result of dehydration caused by inadequate fluid intake. (Steinbaugh, 1984, p. 10). The third issue is the lack of recognized anthropometric and biochemical standards of normalcy for the elderly (Steinbaugh, 1984). To make accurate determinations of the nutritional status of older adults, comparisons are made between clinical assessments of individuals with appropriate standards of what is considered healthy and normal. Age and gender-specific normative data for older adults, especially those age 7 5 and older, are not available for many nutritional parameters. In summary, many questions about the aging in nutrition and physi­ ology/biochemistry remain. Because of the heterogeneous nature of the aging population, there needs to be a broad perspective, an ecological review of aging adults and their nutrition concerns (Delahanty, 1984). Yet, because of the relative youth of the field of gerontology, the difficulty of defining ''normalcy'1 in aging, and the lack of recognized anthropometric and biochemical standards for the elderly, our perspective is limited because some specifics are not known. Attitudes Towards Aging Attitudes seem to indicate interest in serving the needs of older adults. These perceptions can influence the quality, type, and amount of professional assistance available to older persons (Kosberg, 1983). Studies of medical students and physicians have shown poor attitudes as well as a lack of interest in providing care to older adults al., 1985; Geiger, 1978; Holtzman, Tocue, & Beck, 1979). (Senger et As older adults increase in number and require more health services, the attitudes and 21 types of services health professionals provide will be crucial in meeting their needs. Ray, Raciti and Ford (1985), in their review of psychiatrists, state an important point in the concern with attitudes of all helping professions. Harboring negative sentiments toward elderly people can exacer­ bate their difficulties by becoming a self-fulfilling prophecy. To prevent self-fulfilling negative stereotypes of the aged from being realized, members of the helping profes­ sions must first clarify and understand their own attitudes towards this population, (p. 500) Attitudes carried into adulthood occur through personal and profes­ sional experiences. In recent years, more attention has been paid to the attitudes of health professionals toward the aging population. Health professionals are a crucial part of the lives of older adults because of their increasing use of physicians, other health professionals, and health care facilities. This increase is shown by the increase in admis­ sions of older adults in both short term and long term care (Table 3). Table 3 Age Related Medical Statistics Percentage of elderly with limitation of activity due to chronic disease Rate of admission to short term hospital/1000 population for persons in this age group 65-74 41% 29 15 74-84 51% 451 68 85 and older 60% 509 216 Age (years) Source: Rate of admission to nursing home per 1000 for same age group 1978 National Center for Health Statistics Current Population Reports Series, No. 85, in U.S. Bureau of Census (1984). 22 Of the health professions surveyed, negative attitudes or "ageism” have been noted in physicians and residents (Callen, Ingham, & Lower, 1982; Holtzman, Tocue, & Beck, 1979; Senger et al., 1985; Maxwell & Sullivan, 1980), medical students professionals (Senger et al., 1985), rehabilitation (Benedict & Ganikos, 1981), dentists Ratener, & Conrad, 1982) and dental students (Kiyak, Milgrom, (Claus, 1982). Positive attitudes towards the aging have been noted in administrators and direct service workers in agencies dealing with older adults Shaw, & Klein, 1983). The nursing profession literature has mixed results of both negative and positive attitudes 1982). (Kabacoff, Putnam, Ingham and Fielding (Goebel, 1984; Olsen, (1985) concluded that the research on nurses' attitudes towards aging showed these inconsistent results due to sampling, measures used and data analysis. The research to date has focused primarily on general perceptions and attitudes toward the aging which are unrelated to specific older individuals or specific contexts (Green, 1981). the reason for contradictory results. This is probably part of General perceptions and attitudes are viewed as first steps in studying knowledge. Green (1981) also stated that future work should focus on the impact of attitudes and the context within which the attitudes are held. The health education literature review shows that through gerontol­ ogy education attitudes of a variety of health professions improved (Woolliscroft, Calhoun, Maxim, & Wolf, 1984; Greene, 1983; Sims et al., 1984; Ray, et al., 1985). Greene's findings are encouraging in that training and education can have positive effects on modifying attitudes towards the aging. Greene's research was based on the belief that formal 23 education focusing on didactic methods— but including experiential opportunities— can produce improvements in attitude. Woolliscroft et al. (1984) demonstrated that medical students had positive attitudes towards the elderly when their curricula incorporated community settings for the elderly. Dietitians provide services to all age groups in hospitals and nursing homes as well as in community settings. Assessment guidelines and services recognize the need for nutrition services for older adults, yet dietitians as a group have not had their attitudes nor their participation in gerontological services assessed (Mullis and Bowen, 1985). Knowledge of Aging Several studies have assessed the level of knowledge of aging among various types of health professionals. To date, dietitians have not been surveyed for their knowledge about aging. Palmore (1977) developed a "Facts on Aging" quiz which has been utilized to measure knowledge of basic physical, mental, and social factors involved in aging, along with misconceptions about aging. Because it is short and has a true-false format, the Palmore quiz has been extensively used in surveying health professionals such as physicians, medical residents and students, physician assistants, and dentists (Michielutte & Diseker, 1984-85; West & Levy, 1984; Belgrave, Lavin, Breslau, & Haug, 1982; Geboy, 1982). Attitudes and knowledge are often difficult to separate. Kosberg (1983) pointed out that health professionals may not be providing services to the elderly as a matter of choice and may have negative stereotypical attitudes towards older adults. Kosberg (1983) also 24 suggested three specific mechanisms which could be used to foster positive attitudes among health care professionals: formal education, continuing education programs, and staff assessment of positive attitudes towards elderly persons. Through education and knowledge, it is proposed that some attitudes can be changed in health professionals. Even if education does not fully change attitudes towards the aging based on cultural biases, knowledge of the normal aging process can correct misconceptions (Kosberg, 1983). Palmore's Facts on Aging different studies misconceptions. 1 . (1977) in samples of 3,351 people in 25 (Palmore, 1980) evaluated the most frequently held The most frequently held misconceptions were: That more than 10% of the aged are in long-term institutions 2. That most aged are set in their ways and unable to change 3. That the majority of the aged are bored 4. That over 15% of the population are 65 or older 5. That the majority of the aged are in poverty 6. That the majority of the aged are often irritated or angry In identifying groups with misconceptions, Palmore (1980) found little difference in mean Facts on Aging Quiz scores based on gender, race or even age when education was held constant. Miller and Dodder (1980) evaluated Palmore's Facts on Aging quiz as reliable, but found several major problems with the scale. These problems included vague terminology and the need for "Don't know" respon­ ses. Courtenay and Weidemann (198 5) determined that a third response of "Don't Know" does remove the risk of correct guesses. Laner (1981) demonstrated that the Palmore Facts on Aging did measure knowledge and 25 also measured change in knowledge about aging in social gerontology classes through pretest/posttest. Laner (1981) called for research to determine the nature of the relationship between knowledge increases and attitude change using the Palmore Facts on Aging. Ecology of Nutrition and Aging Professionals providing nutrition knowledge about the heterogeneous group of older adults must take into account the physiological, mental, social, environmental, and economic changes associated with aging as well as specific age related nutrition issues. The study of nutrition in the aging population must reflect an ecological approach which considers the nature of the multiple influences (Hutchinson, 1984). This lends support to the ecological framework as a perspective to view these influences. The same issues that are addressed by Sims, Paolucci and Morris (1981) for children are concerns for older adults. Sims et al. stated that . . . it is proposed that an ecological model is most ap­ propriate for explicating the complex syndrome of malnutri­ tion. Because nutrient intake may be influenced by environmen­ tal characteristics, an ecological model facilitates the study of nutritional status of children in relation to those factors which characterize his near environment, i.e., his family, (p. 34) The factors which have been identified as affecting food choices are physiological, psychological, social, and economic (Schlenker, 1984). Although usually considered singularly, all act in combination. To understand the nutritional status of older adults, the combination of factors in the ecological framework is necessary, in older adults food behaviors reflect lifelong habits and attitudes as influenced by changing environments, lifestyle, health, and economic status. Life events such 26 as bereavement or divorce can influence food intake and nutritional status. Interrelationships between the nutritional status and the environments of the individual vary according to a system of checks and balances between the influences. Schlenker (1984) gives an example of the unpredictable nature of environmental influence on older adults: Although factors such as living alone or having less money to spend on food do lead to poor nutrient intake in some older people, this is not true of all older people. The stereotype of the older person subsisting on tea and toast is not substan­ tiated by survey data from the United States or Great Britain. (p. 183-184) If only one or two sets of environmental influences are considered, then unrealistic conclusions and predictions may be made. An ecological perspective is a more balanced perspective on the older adult because it keeps observations of the very sick or the very poor from creating prejudicial attitudes about all older adults. In the study of the nutrition concerns of the aging person, the ecological framework provides an objective perspective of the issues affecting older adults' nutri­ tional status. In classical terms, ecology may be defined as the science of relationships between organisms and their environment. An ecological perspective in the study of living systems enables one to consider the whole rather than isolated component parts * in the analysis of any system . . . human ecology attempts to develop a conceptual framework whereby the convergent com­ plexity of the relationship of total man to his total environ­ ment is recognized . . . the study of nutrition is actually a subset of ecology because the whole of an organism's environ­ ment must be examined in order to achieve a valid assessment of nutritional status. (Sims, et al., 1981, p. 27) Jackson (1966) reinforced this idea that the study of nutritional status of individuals is actually a subset of ecology. Because of the wide range of influences on older adults, the literature reiterates that 27 many considerations should be reviewed in relation to older adults (Hutchinson, 1984; Schlenker, 1984). For example, the lack of eating by an older adult could be influenced by the lack of food, lack of interest in food, the lack of money, or the lack of transportation to sources of food. This lends support to the ecological framework as a perspective to view these influences. The dietitian as the nutrition expert needs to understand the complexity of issues affecting older adults, whether the terminology of ecology is used to explain the nutritional assessment process or other holistic terminology is used. As Sims et al. (1981) described, the task of nutritional assessment is an exceedingly complex matter and difficult to achieve for systems in the life or behavioral sciences. conceptual framework in which to identify Without a the subsets or parts, the task moves from difficult to impossible. Fanelli and Abernethy assessment of older adults. (1986) identified the elements of nutrition Yet, without an ecological framework encom­ passing individual issues, family concerns, community, and other environ­ ments in which to organize the elements of assessment, issues are missed. Then nutritional assessments become tools that often fail to consider the important interactions between the individual, family, community, and other environments. Summary In the United States the older adult population is increasing in both numbers and proportion of the total population. Older adults have more intensive health needs and therefore use more health services than younger people. Health professionals' attitudes and knowledge towards 28 aging can affect the type and quality of services provided for older adults. Surveys of health professionals regarding attitudes and knowledge about aging have shown negative attitudes and misconceptions about aging. As providers of needed nutrition services to older adults, dieti­ tians must understand and have positive attitudes towards the aging. Yet, little is known about the knowledge and attitudes of this important group. This lack of basic information is exacerbated by the multifaceted nature of nutrition concerns of the aging requiring an assessment as to whether dietitians perceive the nutrition problems of older adults in their total context. Older adults are a heterogeneous group affected by physiological, mental, social, physical and economic factors. These multiple influences are reflected in an ecological approach which organizes the areas into a systematic framework that can be reviewed logically in the context of the individual older person or groups of older adults. CHAPTER III RESEARCH DESIGN AND METHODOLOGY Overview The overall purpose of this research was to assess the knowledge and attitudes of Michigan dietitians about aging. In order to reach this goal, the following specific objectives were developed to guide this research: 1. To determine what attitudes Michigan dietitians hold concerning . aging. 2. To determine the knowledge about aging Michigan dietitians hold. 3. To determine if age, education, professional interest, and professional and personal experiences with aging are related to Michigan dietitians' attitudes and knowledge about aging. 4. To determine to what extent Michigan dietitians use a human ecological perspective in problem solving, as well as the relationship between the ecological perspective and their attitudes and knowledge about aging. Sample and Data Collection Procedure Prior to starting this research project, the research proposal was submitted to the University Committee on Research Involving Human Subjects (UCRIHS). June 3, 1986 Approval for the research project was received on (Appendix A). Because responses of the participant dietitians were completely anonymous, written informed consent was not possible. Therefore, in the contact letter, the participants were informed that they gave their 29 30 consent to participate by returning the questionnaire (Appendix B ) . The confidentiality of the participants was maintained by not having any code or identification numbers on the questionnaire or the return envelopes. The coding for analysis occurred as the questionnaires were returned. Active members of the American Dietetic Association comprised the population for this study. tative Michigan was selected purposely as represen­ of the American Dietetic Association. active dietitians in the state of Michigan the American Dietetic Association. The The sampling frame was all (1408 members) who belong to response rate was 52.4% (738 respondents). Michigan dietitians have been documented to be a representative sample in parameters such as age, educational level, size of facility in which employed, location, and type of employment when compared to the American Dietetic Association (Wenberg, 1975). Additional demographic information was collected from the ADA 1981 and 1986 censuses to verify that Michigan dietitians remain representative of the national group. According to the 1986 membership census, the typical American Dietetic Association (ADA) member is young, college-educated, white and female. More than 63% of all ADA members are younger than 40 years of age, with 97% female and 87% white (American Dietetic Association, 1985; Baldyga, 1983; B y r k , 1987). A questionnaire with accompanying letter and a stamped, selfaddressed envelope was sent to each active dietitian in Michigan, accord­ ing to ADA as of March 1986. This questionnaire was mailed on 15 June 1986, with a requested return date of 15 July 1986. Surveys were 31 accepted until 15 August 1986, however. Three surveys came in later than that date and were not included in the analysis. Though 1,436 active dietitians in Michigan were members of ADA in March 1986, the 28 persons not included in the study were: 18 whose addresses were outside of Michigan and/or the United States, eight who participated in the pilot study, one who was on the advisory committee for this research, and the researcher. Therefore, the survey was mailed to 1408 active dietitians in Michigan. A return rate of 50 percent generally has been considered adequate (Babbie, 1983) or appropriate when the respondents are representative of the group as a whole. rate for this questionnaire was 52.4% The response (738 out of 1408), and the respon­ dents were representative of the ADA census studies. Research D e sign and Instrumentation The questionnaire consisted of four instruments. These included a demographic measure, the Wall-Oyer Attitudes Toward Aging Inventory, Palmore Facts on Aging, and a problem solving component designed to address the dietitian's ecological perspective. The initial demographic instrument was used to develop baseline information on the dietitians (Appendix C ) . This instrument requested information on training and experience the respondents had in the area of aging. It also covered basic pertinent information on age of the dietitian and how long he/she had been a registered dietitian. The second section of the questionnaire was the Wall-Oyer Attitudes Towards Aging Inventory (Appendix C ) . This scale was selected because it has been used with other health professionals to survey attitudes. perceptions or attitudes measures such as Tuckman-Lorge Other (Tuckman & Lorge, 32 1953) are more difficult to use due to the length of questionnaire or answer format. The Wall-Oyer is a 22-item, Likert-type scale, and was considered short enough to include with the other parts of the question­ naire. The attitude measure came before the knowledge measurement, so later scales would not influence attitudinal responses. The Wall-Oyer Attitudes Toward Aging Inventory has been tested on medical and speech therapy students at two universities. The instrument was designed to have two dimensions— personal and general. It has been found upon re-administration in previous tests to be reliable G). (Appendix The original items of the instrument were developed based upon intuitive and reasoned notions of Wall and Oyer of the Speech and Hearing Science Section at Ohio State University. Wall and Oyer stated that the items were representative of content being measured on attitudes about aging based upon several years of working with speech and hearing undergraduate and graduate students in classroom and clinical settings. Additionally, written student narratives concerning their attitudes toward aging and older people were used as a basis to help develop the instrument. The test item format utilizes a Likert-type scale with equal positive and negative phrasing of the items. Once these items were developed, each item was judged for its relevance to attitudes toward aging by five senior professors who had worked in a variety of areas related to aging and older adults. This group determined what was considered a positive or negative attitude on the Inventory. Based upon the responses of these judges, items were either included or excluded from the final test instrument (Wall & Oyer, 1983; L . G . Wall & H.J. Oyer, 33 personal communication, April 22, 1986; Appendix G ) . A minor modifi­ cation, as suggested by the computer program design staff at Michigan State University, was made by reversing the scoring sheet to the score of 1^being STRONGLY DISAGREE and the score of 5_ being STRONGLY AGREE, because "agree" items are usually on the right on most tests. The questions are mixed as to whether agree or disagree reflect positive attitudes. The third section of the questionnaire consisted of the Facts on Aging test by Palmore (Appendix C ) . This test has been administered to numerous students and health professional groups so that information on knowledge and interest in geriatrics can be documented. naire also has been critiqued by many reviewers Laner, 1981; Courtenay & Weidemann, 1985). with the forced choice This question­ (Miller & Dodder, 1980; The critics are concerned (true-false) with no opportunity for "don't knows," as well as concern for potential attitudes blended with facts. This measure was selected because it does represent a number of facts on aging, and has been administered to many health professional groups. However, because so much cultural bias is a part of our knowledge about aging, questions have been raised as to whether it tests knowledge or attitudes. The Palmore Facts on Aging is a 25-question, true-false format that can be answered within a few minutes. Other knowledge of aging tests are generally not available or easy to administer, or used to any extent with health care professionals (Miller, 1977). The fourth and final part of the questionnaire was a set of three essay questions with the objective of integrating nutrition knowledge on aging with problem solving. The intent of this section was to determine 34 to what extent dietitians use the human ecological perspective in solving problems of older clients. The human ecological framework provides a system for analysis of the interrelationships individuals have with family, community, policy, and natural environments. The questions in this section were based on common nutrition issues of older adults that required solutions dependent on the life circumstances of the older person. Each of the environments could provide important insights to possible problem areas and their solutions. Therefore, information from each environment of individual, family, community, and policy was needed to identify potential problems and their solutions for the older person in the question. A preliminary pilot study was conducted. Initially, an open-ended essay questionnaire was developed by this researcher to test the use of the ecological approach to aging and nutrition. Eight Michigan dieti­ tians known to the researcher answered this part of the questionnaire so that direct feedback could be obtained. final survey of Michigan dietitians. This group was omitted from the They varied in age and practice background; seven were female and one was male. Two of the dietitians in the pilot study were previously employed by the Michigan Office for Services to the Aging. After this pilot, the essay questions were revised based on suggestions and answers given by the initial group (Appendix D ) . The answers were categorized according to an ecological framework with four categories: policy (Appendix E ) . individual, family, community, and The problems to be solved were designed to review the possible factors affecting the nutritional status of older adults. 35 Question ("Mrs. S. site. (1) considers resources for older adults as its focus. (age 75) is considering attending a group or congregate eating What factors do you feel would be important in making this a successful experience for Mrs. S.?") concerns of older adults as its focus. nutritional assessment of Mr. T. Question ("You are asked to do a (age 80) at his annual health visit. What would you include in your assessment?” ) . considers personal needs as its focus. three-day diet record of Mrs. A. (2) considers health The last question (3) ("You are asked to review a (age 65). Upon comparison with the Recommended Dietary Allowances, Mrs. A's diet record is found low in calories, protein and Vitamin A. What other information would you want before making your recommendations?"). These questions cover tasks which are typical to dietitians and the services they provide. The factors in each question are actually the same in that the possible answers for each question cover the same areas. These areas are as follows: Individual issues: Special diet Individual medical problems Personal food likes/dislikes Physical handicaps Mental awareness Food aversions Lifelong food habits Impact on individual of surroundings Chronic diseases Personal educational level Family Issues: Loneliness Bereavement Recent loss of spouse or family member Values or beliefs Family support 36 Community and Friend Issues; Loneliness Tran sporta t ion Housing resources (including cooking facilities) Social isolation or network Adequate support and resource network Economic, Health and/or Policy Issues; Adequate income and/or retirement pension Adequate medical resources such as insurance, income and availability of medical facilities Safe housing-crime and sanitation Availability of senior centers Adequate variety of housing such as senior apartments Points were assigned to each category of issues with the individual issues weighted most heavily nutrition given this area. (four points) due to the general concerns in Personal well-being is usually foremost to the individual older person as well as to the dietitian. For example, physical status and personal food preferences of a client would usually be the initial areas considered by the dietitian in an assessment. other issue areas were assigned two points. possible for each question. The A total score of ten was The questions and possible answers were determined by the pilot study group's answers and additional information they provided as well as literature reviews, especially Schlenker (1984). The three questions in total took about ten to twenty minutes to answer. The researcher scored all three questions based on the above areas listed. This allowed for consistency in the scoring. The reliability of these questions was tested through a pilot study to ensure that the same data were reported by each participant in the pilot study before ques­ tionnaires were mailed to Michigan dietitians. Because this three part 37 questionnaire has not been used previously, broader testing for reliab­ ility is needed. The measure does reflect the areas considered by dietitians in reviewing older patients. The answers and their format are designed to reflect the human ecological perspective except for one area, the natural environment. This area was not considered in the answers for the questions because it was not considered in the literature reviews by any author or in the pilot study by any participant. It is generally considered to be an acceptable standard of practice when current prac­ titioners and experts (literature sources) cite a concern. This was not the case for the natural environment, therefore it was not included. No dietitian gave a response on these questions regarding the natural environment. The depth of each answer was not taken into account in the scoring. In other words, additional answers in the same category did not score any additional points. The breadth of the answers was considered the important concern, with additional points given for each category that an answer included (Appendix D ) , because this measure was designed to assess how broadly dietitians view the nutritional concerns of older adults. Limitations The human ecological model is complex, is part of the problem solving process of a remains unexplored. and testing as to whether it professional dietitian Since this was the first attempt to analyze the concept of ecological thinking by dietitians, the questions were openended. The scoring of each question was based on how many categories of possible answers were given rather than the depth of each category. If an essay question was not answered, it was considered as missing data, 38 not as a zero score. This was the case in all sections. varied according to section and question. lowest response rate Missing data The fourth section had the (634 out of 738 respondents). made to consider each answer of the respondent. Every attempt was This was to ensure fairness to the respondents, but this could have increased the total scores for this section. The researcher scored the essay section, which could have introduced bias in the scoring. This section was scored without knowledge of any other section of the questionnaire. Dietitians elected to be included in this study. Answers to the survey might not be indicative of non-responding dietitians. limitation was the length of the questionnaire. It contained nine pages and required from twenty to thirty minutes to complete. commented negatively on its length. Another Two dietitians This may have affected return rate since this survey was answered voluntarily. No follow-up or remailing of questionnaire was attempted in this survey. This could have affected the total number of respondents, since remailing of the questionnaire could have increased the return rate. Analysis Four objectives were addressed in this study: 1. To determine what attitudes Michigan dietitians hold concerning aging. 2. To determine the knowledge about aging Michigan dietitians hold. 3. To determine if age, education, professional interest, and professional and personal experience with aging are related to Michigan dietitians' attitudes and knowledge about aging. 4. To determine to what extent Michigan dietitians use a human ecological perspective in problem solving, and what is the relationship between the ecological perspective and their attitudes and knowledge about aging? 39 The data were prepared by computer key punch operators with entry of each questionnaire by code number. twice for accuracy. The data entries were cross checked Analysis was based on the following: 1. The demographic description of the respondents and how they compare to Michigan dietitians and ADA census study of dietitians 2. The correlations among demographic characteristics, attitudes, and knowledge 3. The nature of Michigan dietitians' attitudes about aging 4. The nature of Michigan dietitians' knowledge of aging 5. The nature of the ecological perspective in problem solving a. description of the answers given b. its relationship to place of graduation c. its relationship to attitudes and knowledge of aging The demographic data were analyzed using frequencies or counts of the actual occurrence of each event so that comparisons could be made with the ADA censuses. These data were grouped into indicative patterns to be used in later analyses with the attitudes and knowledge measures. These included education, professional experience and personal experience, when comparing the data of the dietitians responding to this survey to the ADA censuses, these dietitians were similar in age, education, and gender. The second area of analysis was to determine correlations between the demographic characteristics and the attitudes and knowledge measures. The attitudes and knowledge instruments scores were interval data. Pearson Product Moment Correlation was used for this analysis. The By this means linear correlations between the demographic data and the entire attitudes and knowledge measure could be noted. This did not determine a 40 cause and effect relationship, but was helpful in showing a relationship between the independent variables and the dependent variables of at­ titudes and knowledge. ly significant. An alpha level of .05 was considered statistical­ Because a more complete understanding of the attitudes and knowledge measures was necessary, additional analysis was conducted. Factor analysis was used for the Wall-Oyer Attitudes Towards Aging Inventory and the Palmore Facts on Aging quiz because it provided a means for discovering patterns among the variations in the questions in these instruments. Factor analysis is considered an efficient method of discovering predominant patterns among questions (Babbie, 1983). Three principle factors were derived from the Wall-Oyer Attitudes Toward Aging instrument. (For simplicity, these factors were designated Attitude 1, Attitude 2, and Attitude 3.) Attitude 1 included questions about the interest of the dietitian in working with or providing services to older adults. Reliability analysis of this factor had an alpha of .83, with a reliability score of 1 representing a perfect association. This factor had the strongest reliability score of the three attitude factors. Attitude 2 was composed of questions denoting how the dietitian benefits or perceived benefits from interactions with older adults. analysis of this factor had an alpha of .64. Reliability The third attitude factor, Attitude 3, combined questions about the perceived characteristics of older adults. Reliability analysis of this factor had an alpha of .66 which is similar to Attitude 2. As a means of grouping the different questions within the Palmore Facts on Aging, three different subsets of the instrument were determined by the researcher based on the content of the questions rather than 41 factor loading values. Therefore, the reliability analysis for these factors were designated Knowledge 1, Knowledge 2, and Knowledge 3. Knowledge 1 was created from the questions about the social/psychological interactive ability of older adults (reliability analysis alpha .53). Knowledge 2 consisted of questions about the physical ability and health of older adults (reliability analysis alpha .41). Knowledge 3 was created from the questions about the demographics of older adults (reliability analysis alpha .38). Two questions from the Palmore Facts on Aging did not seem to belong to any of the three factors and were omitted from all three knowledge factors. Because knowledge of the facts on aging can be independent facts known separately from other facts, a knowledge test might be expected to have specific questions that do not group or form a factor. The Palmore Facts on Aging did not have strong reliability on its three separate factors for the association of the questions within that factor. However, the factor analysis provided an efficient means for discovering predominant patterns among a large number of variables (Babbie, 1983). Multiple regression was used to examine the relationships between attitudes and knowledge and selected independent variables. Age of the dietitian and the number of years as a registered dietitian were the independent variables controlled for by the multiple regression statis­ tical technique. Multiple regressions were calculated with each of the attitudes and knowledge factors and with education, professional experience, and personal experience indicators. The use of multiple regression analysis for statistical inferences is based on the assumptions of random sampling, the absence of nonsampling errors and 42 continuous interval data. As Babbie (1983) states, social science research seldom satisfies all the assumptions completely, and caution must be used in assessing the results of the multiple regressions in this study. In considering the response to the problem solving section, it is important to realize that this was a first attempt to assess the use of a human ecological perspective through responses on problem solving questions. Therefore, general descriptions of the answers as well as the number of points actually received by the responding dietitians were calculated. The relationship between place of graduation and the problem solving total score was computed by Pearson Product Moment Correlation. The Pearson Product Moment Correlation also was used in determining the relationship between the attitudes, knowledge and problem solving measures. Summary This study, which utilized a mailed questionnaire, measured attitudes and knowledge of Michigan dietitians about aging. The sample included 1408 dietitians in Michigan who were active members of the American Dietetic Association as of March 1986; they were not a part of the pilot study nor affiliated with the study. Each dietitian received an introductory letter, questionnaire, and stamped, addressed return envelope. The questionnaires were coded upon return. Any questions not answered were noted as missing data rather than incorrect or negative responses. Of those receiving questionnaires, 738 dietitians returned the questionnaire for a response rate of 52.4%. The four instruments used in this study were a demographics measure, the Wall-Oyer Attitudes Toward Aging Inventory, Palmore Facts on Aging, and a problem solving component designed to address the dietitians' human ecological perspective. The responses were noted as to the correct or positive answer, and the frequencies with which answers occurred. Pearson Product Moment Correlation, factor analysis, and multiple regressions were used in the data analysis. Also, the responses on the problem solving component were described with an emphasis on the human ecologica1 approach. CHAPTER IV RESULTS This research study was designed to assess Michigan dietitians' attitudes about and knowledge of aging. Health and nutrition have become crucial issues to both the quality and length of life. An understanding of aging is essential for dietitians who provide services to older persons. Demographic Data Aget Education and Gender of Dietitians The initial demographic questionnaire was used to develop baseline information on Michigan’s dietitians. This questionnaire gave informa­ tion on training and experiences the respondents have had in the area of aging. It also covered basic pertinent information on gender and age (Table 4). This survey of Michigan dietitians compares closely with the last two published censuses of dietitians in the United States Byrk, 1987). (Baldyga, 1983; Of those responding to this questionnaire, 65.9 percent were under 40 and 97.7 percent were female, as compared to the ADA samples of 61 to 63 percent under 40 and 97.3 to 97.7 percent female. 44 45 The sampling frame for this questionnaire was active dietitians of the American Dietetic Association in Michigan. To be an active dietitian means that one has at least a bachelor's degree. were reported in this survey. Only degrees completed Previous ADA census studies (Baldyga, 1983; Byrk, 1987) have included all members of the American Dietetic Association, including those with non-bachelor degrees and degrees in progress. The Michigan respondents were similar to the general popula­ tion of ADA dietitians in the 1986 census study with 35.8% of the Michigan respondents having master's as compared to 36.2% of the 1986 ADA census, and 2.8% of the Michigan respondents having doctorates as compared to 3.1% of the 1986 ADA census. Tables 4 through 8 indicate the educational level of the Michigan respondents. female. Most degrees (Table 5). degree The typical Michigan respondent was a young, well-educated, (60.3%) were granted in the last twenty years A large proportion of the respondents reported a master's (35.8%) (Table 6). Dietitians in this survey reported having about the same percentage of doctoral degrees (2.8%) as compared to the American Dietetic Association census studies with 1.7% (1986) (Table 7). Many respondents dietitians ten or fewer years (1981) and 3.1% (58.9%) reported being registered (Table 8). The university listed most often as the degree granting institution for bachelor's (25.1%) and master's (16.9%) degrees was Michigan State University (Table 9). The response rate for the 1986 ADA census study was 66.7% (Byrk, 1987) as compared to the response rate for this Michigan survey of dietitians at 52.4%. The two groups of dietitians were similar in 46 gender, age and educational levels, indicating that this survey was as representative of dietitians as the 1986 ADA census study. Table 4 Characteristics Of Respondents As Compared To The American Dietetic Association Survey Michigan Questionnaire on Aging RESPONSE RATE N = 1408 52.4% Gender: (of those responding) 97.7% Female (721 responses) Age: 4.8% 21-25 26-30 23.1% 25.6% 31-35 12.4% 36-40 9.5% 41-45 5.8% 46-50 5.6% 51-55 56-60 7.1% 4.1% 61-65 2.0% 66 or older no response .04 Degree: Bachelor's degree 94.6%* earned Master's degrees 35.8% earned Doctorate degree 2.8% earned 1981, American Dietetic Association Census N = 42,200 92% 1986, ADA Census (Active) N = 52,145 66.7% 97.3% 97.7% 6.2% 25.3% 17.3% 12.0% 8.5% 7.4% 7.3% 7.2% 4.0% 4.0% None calculated 3.9% 20.6% 24.5% 14.4% 10.0% 7.1% 6.9% 6.0% 4.6% 2.0% 55.3%** 49.2%** 28.8%** 36.2%** 1.7%** 3.1%** * Only sent to active membership dietitians **These do not total 100% due to ADA categories highest degree attained or working towards whereas Questionnaire on Aging only counted degrees attained. 47 Table 5 Bachelors' Degrees Year Received Bachelor's Degree n = 738 Prior to 1966 Between 1967 and Did not respond 1985 30.9 60.3 8.8 Table 6 Master's Degrees n = 738 % Total with Master's Degrees Area of Study Received Master's Degree Foods and Nutrition Institutional Administration Public Health Business Education Exercise Physiology Food Science Communication Other No Response 35.8 Percent of Total Master's Degrees 48.2 13.0 11.9 5.1 13.0 1.6 2.0 0.4 4.7 0.1 Year Received Master's Degree Prior to 1969 Between 1970 and 1986 No Response 19.7 70.2 0.04 Number 264 48 Table 7 Doctoral Degrees n = 738 % 2.8 Total with Doctoral Degrees Area of Study Received Doctoral Degree Number 21 Percent of Total Doctoral Degrees Foods and nutrition 40.0 8 Education Exercise physiology Other No response 35.0 10.0 15.0 10.0 7 2 3 2 Year Received Doctoral Degree 0.0 5.3 94.7 0.0 Prior to 1968 Prior to 1969 Between 1970 and 1986 No response Table 8 Number Of Years As Registered Dietitian Number of Years n = 738 Less than 1 year I-10 years II-16 years 17 years (maximum number years can be registered) % 1.4 57.5 18.0 24.5 49 Table 9 Degree Granting University or College Bachelor's Degree Master's Degree Doctoral Degree University/Co11ege n = 738 No. % % No. 185 25.1 43 16.9 2 Eastern Michigan University 45 6.1 20 7.8 - Western Michigan University 31 4.2 11 4.3 2 Central Michigan University 16 2.2 10 3.9 - - Mercy College 36 4.9 1 0.4 1 5.3 Wayne State University 57 7.7 29 11.4 1 5.3 University of Michigan 10 1.4 30 11.8 3 15.8 Purdue University 15 2.0 3 1.2 - 284 38.5 108 42.4 10 Michigan State University Other No. % 10.5 10.5 52.6 50 The education of dietitians in aging seems to be limited. In this study, 74.3% report having had no courses in aging, but when aging is considered a part of a more comprehensive course as listed by respon­ dents, 19.5% had no coursework on aging (Tables 10 and 11). Table 10 Number Of Courses In Aging Total Number of Courses Number of Respondents n = 738 Percent 0 548 74.3 1 136 18.4 2 36 4.9 3 10 1.4 4 4 0.5 No response 4 0.5 51 Table 11 Percent of Respondents Who Studied Aging As Part of a Comprehensive Course Total Number of Courses Number of Respondents n = 738 Percent 0 144 19.5 1 313 42.4 2 184 24.9 3 63 8.5 4 30 4.1 4 0.5 No response Post-baccalaureate training is a requirement to become a registered dietitian. This experience assists the dietitian in using factual knowledge for practical application. However, 55.6% of respondents reported a week or less in their post-baccalaureate training in aging programs or working with the elderly (Table 12). 52 Table 12 Time Spent As Part Of Post-Baccalaureate Dietetic Training With Aging Time Number of Respondents n = 738 Percent 0-1 week 411 55.6 2 weeks - 2 months 222 30.1 2-3 months 38 5.1 4 or more months 56 7.6 No response 11 1.5 In evaluation of their training in geriatrics* 50.3% described the training in geriatrics relative to their need as inadequate or very inadequate (Table 13). Table 13 Self-Evaluation Of Training In Geriatrics Relative To The Dietitian's Need For Working With Aging Ranking Number respondents n = 738 Percent Very inadequate 158 21.4 Inadequate 312 28.8 Neutral 194 26.3 Adequate 133 18.0 Very adequate 26 3.5 No response 14 1.9 53 Professional Interest Respondents did not attend a high number of continuing education programs in aging. In regard to workshops on aging, 48.2% had not attended any in the last five years (Table 14). For ease in reporting, workshops on human and family ecology also are reported in Table 14. Table 14 Continuing Education Programs/Workshops On Human or Family Ecology n = 738 On Elderly n = 738 Continuing Education Programs/Workshops Number Percent Number Percent None 356 48.2 533 72.2 1 196 26.6 109 14.8 2 109 14.8 31 4.2 3 33 4.5 21 2.8 39 5.3 27 3.7 5 0.7 17 2.3 4 or more No response 54 The survey also showed that nearly nine out of ten respondents do not belong to a professional group related to gerontology (Table 15). Table 15 Membership in Gerontology Professional Groups Number of Gerontology Professional Groups Number n = 738 Percent 0 660 89.4 1 61 8.3 2 11 1.5 3 4 0.6 4 1 0.2 The ADA groups most often reported were the Gerontological Nutrition group and Consultant Dietitians to Health Care Facilities which serves facilities for the aging adult. The only group listed outside ADA was the American Association for Retired Persons (AARP) which is not recog­ nized as a professional group though listed as such by the dietitians. No one mentioned other professional gerontological associations such as the Gerontological Society of America. such associations, most membership. Of those mentioning membership in (79.2%) mentioned only one gerontological group 55 Personal and Professional Bxperiences with Aging Over 59% of the respondents reported quite often or a great deal of experience with their grandparents. Also, over 40% reported this same level of contact as children with older nonrelatives (Table 16). Table 16 Contact As A Child With Elderly Contact with Grandparents Contact with Nonrelative Amount of Contact Number n = 738 Percent Number n = 738 Percent None 60 8.1 41 5.6 Very little 79 10.7 135 18.3 Some 161 21.8 261 35.4 Quite Often 153 20.7 170 23.0 Great deal 284 38.5 129 17.5 1 0.1 2 0.3 No response 56 Professional experience with elderly persons was considerable, with only 3.7% reporting no professional experience with the elderly. professional experiences Most (84.1%) reported were with hospital patients. Hospice patients were reported the least with only 9.8% reporting experience with this group of elderly persons (Table 17). Table 17 Type Of Professional Experience As Dietitian With Elderly Type Professional Experience Number n = 738 Percent 27 3.7 Family, friends, neighbors 494 66.9 Nursing home 349 47.3 Home care 136 18.4 Patients in hospital 621 84.1 72 9.8 Government nutrition program 132 17.9 Other 134 18.2 None Patients in hospice 57 Responding dietitians also related many personal adult experiences with the elderly. More than 95% had social contact with the elderly, and over 36% have been involved in multi-generational living experiences. Only 2.2% reported no personal experience with the elderly (Table 18). Table 18 Type Of Personal Experience With Elderly Type Personal Experience Number n = 738 Percent 16 2.2 Social contact with elderly 704 95.4 Family work with elderly 239 32.4 Multi-generational living with self-sufficient elderly 175 23.7 Nursing home 344 46.6 Active care of elderly such as hospice 46 6.2 Multi-generational living with dependent elderly 93 12.5 Other 38 5.1 None 58 Human Ecological Training Many respondents do not recall or report training in human ecology as a recognized entity. Even though many recently graduated from univer­ sities that have human ecology as a part of their philosophy, more than 37% reported no comprehensive course in human ecology or related content within another course. About 6% reported not knowing what human ecology is (Tables 19 and 20). Table 19 Dietitians Who Took Courses in Human Ecology Total Number of Courses Number n = 738 (HE) Percent 0 212 29.8 1 191 25.9 2 120 16.3 3 93 12.6 4 59 8.0 Don't know what HE is 51 6.9 No response 12 1.6 59 Table 20 Dietitians W h o Took Courses With Human Ecology As Part of a Comprehensive Course Number n = 738 Total Number of Courses (HE) Percent 0 274 37.1 1 203 27.5 2 108 14.6 3 43 5.8 4 43 5.8 Don't know what HE is 49 6.6 18 2.4 no response Few of the dietitians had taken any continuing education courses in human ecology, with 72.2% reporting no such course work or workshop in the last five years (Table 14). They reported no contact with the concept of human or family ecology. Wall-Oyer Attitudes Towards Aging Inventory The responding dietitians generally expressed positive attitudes toward aging. Most questions on this section were answered in a positive direction with at least 60% responding positively to 15 out of 22 statements. Results are summarized in Table 21. The most striking result of the Wall-Oyer Inventory was the number of dietitians who thought older adults would resist in a treatment program (Item 21 in Table 21). No other studies are known to this researcher related to dietitians' expectations of resistance in clients. It was difficult therefore to know if this is the perception only about older adults or other age groups as well. Among the responding dieti­ tians, 60.6% expected resistance, while another 13.7% were undecided, leaving only 24.2% not expecting resistance from older people in treat­ ment programs. Table 21 Dietitians: Results of Wall-Over Attitudes on Aoino Inventory in Percentages n = 739 Question 1. 2. 3. 4. 5. 6. 7. 8. 9. Strongly Disagree Disagree Undecided Agree Strongly Agree Left Blank Older people usually understand the problems encountered by the young. (Positive-*) 1.5 26.2 17.9 49.6 3.7 1.2 Older people are often critical of younger generations. (<- Positive) 0.7 29.5 14.0 49.3 5.4 1.1 Most older people have a good sense of humor. (Positive -*) 0.1 8.3 19.2 62.1 8.3 2.0 Most older people have active social lives. (Positive -») 2.0 31.4 17.5 43.2 54.5 1.4 Most older people prefer to be independent and live in their own homes. (Positive-*) 0.3 1.1 1.1 38.8 57.7 1.1 17.5 57.7 9.9 12.2 1.8 0.9 Younger people can usually benefit from the wisdom of older people. (Positive -*) 0.3 1.1 3.0 51.4 43.2 1.1 Working with older adults in terms of improving their functioning often can be a rewarding experience. (Positive -*) 0 0.4 6.2 51.1 41.5 0.8 Older people generally are not interested in younger people and their concerns, ( f - Positive) 24.3 65.4 5.7 2.3 0.8 0.9 5.7 42.7 26.4 22.6 0.9 1.6 29.1 54.2 6.4 7.6 1.8 0.9 Many older people are less tidy about themselves than younger people. ( < - Positive) 10. Most older people are amenable to change. (Positive -») 11. Ordinarily I would not feel comfortable working on the medical problems of the elderly. (<- Positive) Table 21 (Continued) Strongly Disagree Disagree Undecided Agree Strongly Agree Left Blank 27.4 50.9 13.4 5.6 1.6 1.1 13. 1usually feel as relaxed around older people as 1do around younger people. (Positive ->) 0.4 7.6 5.7 62.2 23.0 1.1 14. I would not want to work in a medical setting for older adults who are psychologically disengaged from daily events. («- Positive) 7.7 28.9 22.8 32.1 38.5 1.1 15. I feel many older people are opinionated and difficult to work with. (<— Positive) 7.0 64.2 14.2 12.3 0.7 0.7 16. 1would not be interested in devoting a major portion of my practice to specializing in geriatric care. (<— Positive) 10.6 32.1 21.7 29.1 4.9 1.6 17. I would like to develop a practice catering to the special needs of the elderly. (Positive -*) 6.2 33.7 34.6 19.0 5.0 1.5 18. I would typically find working with older people and their physical problems depressing. (<- Positive) 8.1 54.7 19.6 15.0 1.4 1.1 19. 1would find it difficult to develop programs for working with the medical problems of older people. (<- Positive) 9.5 58.5 16.1 13.3 1.4 1.2 20. UsuaByler^oy communicating with older people. (Positive -») 0.4 2.3 4.3 70.3 20.9 1.8 21. As a dietitian 1expect to encounter some resistance from older adults in a treatment program. («- Positive) 1.8 22.4 13.7 57.6 3.0 1.6 22. 1would learn a great deal working with older people. (Positive -») 0 2.8 11.1 67.1 17.8 1.2 Question 12. Working in a stroke-rehabilitation program for the elderly would probably be a poor investment of time. (<- Positive) 63 The notable exceptions to the level of generally positive response level are the questions where 40% or more of the dietitians held negative attitudes (Table 22). These items dealt with working with older adults, attributes of older adults (critical of younger people) and older adults' resistance to treatment. The results overall show positive attitudes, though not strongly positive, since 90% of the respondents had eight or fewer strongly positive responses. The other 10% had nine to eighteen strongly positive responses, and no one had 22 strongly positive responses. Table 22 Dietitians: Question Negative Attitudes Towards Aging Percent with Negative Attitude n = 738 Attitude towards Aging Statements 54.4% "Older people are often critical of younger generations" 10 48 .4% "Most older people are amenable to change" 14 39.6% "I would not want to work in a medical setting for older adults who are psycho­ logically disengaged from daily events" 17 39.9% "I would like to develop a practice catering to the special needs of the elderly" 21 60.6% "As a dietitian, I expect to encounter some resistance from older adults in a treatment program" 64 Palmore Facts on Aging The knowledge instrument used was the Palmore Facts on Aging. The basic knowledge of dietitians was good, with almost 60% of the dietitians having scores of 17 out of 25 correct (Table 23). However, a high percentage of the respondents missed several important questions. Over 60% thought that more older people were institutionalized than actually are. In addition, nearly 90% of the responding dietitians thought a higher proportion of the population is elderly than is actually the case. Finally, dietitians awareness regarding the economic status of older adults. (58.3%) lacked In summary, Michigan dietitians generally believed that older adults are sicker and poorer than they really are and that the population of older adults is larger than it really is. Table 23 Dietitians: Results of Palmore Facts on Aoino in Percentages n = 738 Correct Answer True False Left Blank The majority of ok) people (past age 65) are senile (i.e., defective memory, disoriented, or demented). False 0.4 99.1 0.5 2. All five senses tend to decline in old age. True 69.2 29.9 0.8 3. Most ok) people have no interest in, or capacity for, sexual relations. False 4.1 95.0 0.9 4. Lung capacity tends to decline in ok) age. True 69.4 27.4 3.3 5. The majority of ok) people feel miserable most of the time. False 1.8 97.3 0.9 6. Physical strength tends to decline in old age. True 89.3 10.0 0.7 7. At least one-tenth of toe aged are living in long-stay institutions (e.g., nursing homes, mental hospitals, homes for the aged). False 63.0 31.7 5.3 8. Aged drivers have fewer accidents per person than drivers under 65. True 57.2 38.1 4.7 9. Most older workers cannot work as effectively as younger workers. False 12.2 85.6 2.2 10. About 80% of the aged are healthy enough to carry out their normal activities. True 92.3 5.8 1.9 11. Most ok) people are set in their ways and unable to change. False 17.9 80.5 1.6 12. Ok) people usually take longerto learn something new. 13. It is almost impossible for most old people to team new things. True False 46.1 0.7 41.5 98.9 2.6 0.4 14. The reaction time of most old people tends to be slower than reaction time of younger people. True 91.3 7.9 0.8 Question 1. Table 23 (Continued) Correct Answer True False Left Blank 15. in general, most old people are pretty much alike. False 3.4 95.8 0.8 16. The majority of old people are seldom bored. True 40.8 56.6 2.6 17. The majority of old people are socially isolated and lonely. False 33.3 64.1 2.6 18. Older workers have fewer accidents than younger workers. True 66.3 28.3 5.4 19. Over 15% of the U.S. population are now age 65 or over. False 89.4 6.6 3.9 20. Most medical practitioners tend to give low priority to the aged. True 60.7 36.0 3.3 21. The majority of older people have incomes below the poverty level (as defined by the federal government). False 58.3 37.8 3.9 22. The majority of ok) people are working or would like to have some kind of work to do (including housework and volunteer woik). True 87.8 9.6 2.6 23. Older people tend to become more religious as they age. False 61.7 34.0 4.3 24. The majority of ok) people are seldom irritated or angry. True 63.0 33.2 3.8 25. The health and socioeconomic status of older people (compared to younger people) in the year 2000 will probably be about the same as now. False 22.1 74.3 3.7 Question 67 Dietitians hold several misconceptions that are similar to other groups tested (Palmore, 1980) (Table 24). They believed that: institu­ tional rates are higher than the actual, older adults are bored, and the percentage o£ the aging population that is old and poor is larger than is actually the case. Table 24 Commonly Held Misconceptions By Dietitians Responding Question Knowledge of Aging Statements Percent with Incorrect Answer n = 738 1 63.0% "More than 10% of aged are in long-term institutions." 16 56.6% "Most old people are b o red." 19 89.4% "Over 15% of the U.S. population are 65 or o v e r ." 21 58.3% "The majority of older people are in poverty." Other most commonly held misconceptions listed by Palmore, but not commonly held by responding dietitians are that older people are set in their ways and that older people are seldom irritated (Table 25). 68 Table 25 Common Misconceptions That Responding Dietitians Do Not Hold Question Percent with Correct Answer n = 738 Knowledge of Aging Question 11 80.5% "Older people are not set in their ways and are able to change." 24 63.0% "Older people are seldom irritated or angry." In spite of not holding the same misconceptions as other groups, the respondents have a misconception that other groups tested do not have (Table 26). About half of responding dietitians thought that older people do not take longer to learn something new. Table 26 Misconceptions Held By Respondents Not Commonly Held By Other Groups Question 12 Percent with Incorrect Answer n = 738 51.4% Knowledge of Aging Question "older people do not take longer to learn something new." 69 In summary, the responding dietitians generally erred on the side of thinking older people are poorer and more incapacitated than they actually are, except for their rate of learning something new. six questions (of 25) did large percentages In only (more than 50%) of the respondents answer incorrectly. However, economic and health issues, dietitians' weaker areas, are central to the well-being of older adults. Correlations Between Demographic Characteristicsr Attitudes and Knowledge about Aging Correlations of Demographic Characteristics with the Total Attitudes and Knowledge Instruments The total scores for the attitude measure Aging Inventory) and the knowledge measure (the Wall-Oyer Attitude on (Palmore Facts on Aging) were compared by the Pearson Product Moment Correlation which is the appropriate measure for ratio or interval data (Babbie, 1983) m i n e any relationship to the demographic characteristics to deter­ (Table 27). The Wall-Oyer Inventory correlated at statistically significant levels (dQ= .05) with doctorate degree, membership in professional groups related to aging, aging as a part of a comprehensive course in college, continuing education in aging and number of different types of personal experiences in the elderly. The other demographic variables did not correlate significantly with the attitudes measure. The Palmore Facts on Aging score correlated at statistically significant levels (dC= .05) with number of courses in aging, membership in professional groups related to aging, having at least a master's degree, aging as a part of a comprehensive course in college, and number 70 of different types of personal experiences with the elderly. The other demographic variables did not correlate with the knowledge measure. Table 27 Correlations Between Demographic Characteristics and Total Scores on the Attitudes and Knowledge Measures Wall-Oyer Inventory r p Variable Age Number years RD Professional experiences Number of courses aging .0685 Doctorate degree (n = Number courses HE Number prof. groups aging Master's degree Continuing ed HE Aging part comp course Continuing ed aging Personal experiences HE part comp, course Palmore Facts on Aging r P * * * * .03 21) * .2114 .001 (n = 737) * * .1015 .003 (n = 734) .1879 .001 (n = 733) .061 .05 (n = 733) * * * * .0893 .008 (n = 734) * * .1053 .002 (n = 737) .1066 .002 (n = 738) * .0701 .03 (n = 734) * .0814 .06 (n = 734) * (* = NOT STATISTICALLY SIGNIFICANT AT .05 LEVEL) Multiple Regressions for Demographic Characteristics and Parts of Wall-Oyer Attitudes Towards Aging Inventory As a means of grouping the different items within the Wall-Oyer Attitudes Towards Aging Inventory, three different factors of the Inventory were determined using a principle components factor analysis 71 with iteration (Table 28). The item loading and eign value for each factor is noted in Table 28. The set of items is listed according attitude factor to which it is related. For simplification of designation, these factors will be referred to as follows: to the Attitude 1, Attitude 2, and Attitude 3. The factor loadings for Attitude 1 were the strongest and Attitude 3 had the weakest overall factor loadings. But, the attitudes as listed also had substantive meaning, so that these factors had substantive meaning weak in several cases). as well as statistical meaning (though This is explained further after Table 28. The eign value for each factor is the measure of relative importance of the factor. variance. The higher the value the more important the factor is in the The number of factors to be extracted were restricted to three meaningful interpretations. By the nature of the factor analysis, each eign value decreases with each factor. Attitude 1 includes the items about the interest of the dietitian in working with or providing services to older adults. for this subscale was .83. Reliability analysis Attitude 1 included the following seven items from the Wall-Oyer Inventory: Statement number Sta tement 11 "Ordinarily I would not feel comfort­ able working on the medical problems of the elderly." 12 "Working in a stroke-rehabilitation program for the elderly would probably be a poor investment of my time." 14 "I would not want to work in a medical setting for older adults who are psychologically disengaged from daily events." 72 16 "I would not be interested in devoting a major portion of my practice to specializing in geriatric care." 17 "I would like to develop a practice catering to the special needs of the elderly." 18 "I would typically find working with older people and their physical problems depressing." 19 "I would find it difficult to develop programs for working with the medical problems of older people." Table 28 Factor Analysis of Attitudes Attitude 12 14 16 17 18 19 Attitude 1 5 7 8 Attitude 2 13 20 22 1 2 3 4 6 9 10 15 21 Attitude 3 Factor 1 eign value = 4.05 Factor 2 eign value = 1.51 Factor 3 eign value = .88 .49 .47 .72 .80 .66 .67 .48 .28 .29 .01 .07 .09 .16 .16 .02 .06 .08 .08 .11 .12 .08 .07 -.05 .22 .22 .22 .26 .31 .51 .61 .33 .48 .48 .07 .10 .06 .15 .08 .10 .03 .07 -.02 -.03 .02 .06 .09 .26 .07 .18 .12 .28 .14 .05 .27 .02 .09 -.06 .41 .49 .43 .47 .39 .26 .36 .52 .28 73 Attitude 2 is composed of items denoting how the dietitian benefits or perceived benefits from interactions with older adults. analysis for this factor was .64. Reliability Attitude 2 included the following six items from the Wall-Oyer Inventory: Statement number Statement 5 "Most older people prefer to be independent and live in their own homes." 7 "Younger people can usually benefit from the wisdom of older people." 8 "Working with older adults in terms of improving their functioning often can be a rewarding experience." 13 "I usually feel as relaxed around older people as I do around younger people." 20 "Usually I enjoy communicating with older people." 22 "I would learn a great deal working with older people." Attitude 3 combined items about the perceived characteristics of older adults. Reliability analysis for this factor was .66. Attitude 3 included the following nine items from the Wall-Oyer Inventory: Statement number Statement 1 "Older people usually understand the problems encountered by the young." 2 "Older people are often younger generations." critical of 3 "Most older people have of humor." a good sense 4 "Most older people have lives." active social 74 6 "Most older people are less tidy about themselves than younger people." 9 "Older people generally are not interested in younger people and their concerns." 10 "Most older people are amenable to change." 15 "I feel many older people are opinion­ ated and difficult to work with." 21 "As a dietitian, I expect to encounter some resistance from older adults in a treatment program. II Multiple regressions were calculated for each of the three factors with the demographic characteristics of education, professional experi­ ences, and personal experiences. Age of the dietitian and the number of years as a registered dietitian were the independent variables controlled for by the multiple regression. Education indicators included number of dietitians who had courses that included aging, number of courses in human ecology/family ecology, number of professional groups with an interest in aging, having at least a master's degree, having a doctorate degree, number of workshops in human ecology/family ecology, and the number of courses in aging as a part of comprehensive courses. Professional experiences included the number of different types of professional experiences with the aged. Personal experiences with the aged consisted of the number of different types of personal experiences. A significance level of .05 was considered statistically significant (Tables 29-33). Variety of professional experiences with the aged, membership in professional groups for aging, continuing education in aging, and variety of personal experiences with the aged were significant predictors of 75 Attitude 1 (the desire to work with the older adults). None of these variables are factors which are a part of the formal education process. It was either personal experiences outside of schooling, or experiences and work after completion of college that correlated with the desire to work with older adults. The amount of variance (R2) attributed to these variables is 14%. Doctorate degrees, membership in professional groups for aging, continuing education in aging, and personal experiences with the aged were significant predictors of Attitude 2 (the benefits of interactions with older adults). The same variables as correlated with Attitude 1 are important with Attitude 2 except professional experience doctorate degree (Attitude 2). The amount of variance (Attitude 1) and (R2 ) attributed to these variables is 7%. Attitude 3 (characteristics of the older adult) was different in that age was negatively predicted with this subscale. The only positive predictor with Attitude 3 was personal experience with the aged. The one variable that was a predictor of all three attitude factors was personal experience with the aged. Continuing education in aging and membership in professional groups related to aging were predictors with two attitude factors (Attitude 1 and Attitude 2). In summary, variables of personal, professional and education indicators beyond the bac­ calaureate experience of dietitians seem to be the best predictors of positive attitudes towards aging. 76 Table 29 Multiple Regressions for Attitudes, Controlling for Age and Number of Years as a Registered Dietitian F p# R Rz Attitude 1 (desire to work with elderly) 6.46 Educational Indicators (n = 609) Number/Types Professional Experiences with aging 17.87 (n = 699) Number/Types Personal Experiences with aging 14.71 (n = 699) 7.8 All Predictors (n = 607) .000 .32 .10 .000 .26 .07 .000 .000 .24 .38 .06 .14 2.9 .001 .23 .05 5.99 .000 .16 .03 9.60 3.86 .000 .000 .20 .28 .04 .07 3.16 .000 .23 .05 7.87 .000 .18 .03 9.60 3.02 .000 .000 .20 .25 .04 .06 Attitude 2 (benefit from elderly) Educational Indicators (n = 608) Number/Types Professional Experiences with aging (n = 699) Number/Types Personal Experiences with aging (n = 699) All Predictors (n = 606) Attitude 3 (characteristics of elderly) Educational Indicators (n = 602) Number/Types Professional Experiences with aging (n = 691) Number/Types Personal Experiences with aging (n = 691) All Predictors (n = 600) I .05 * level of statistical significance 77 Table 30 Multiple Regression for Attitude 1 (desire to work with elderly) Controlling for Age and Number of Years as Registered Dietitian Beta Educational Indicators (n = 609) Age Number courses aging Doctorate degree Number courses HE Number prof. groups aging Master's degree Continuing ed. HE Aging part comp, course Continuing ed. aging HE part comp, course Number years RD 2.02 * * * 22.25 .000 .66 * * 12.48 .000 52.48 .000 42.99 .000 .42 * * * 7.57 .006 1.64 * * * 14.91 .000 .59 .52 * * 10.06 9.04 .002 .003 Number/Type Personal Experiences with Aging (n = 699) * Age Personal experience .97 * Number years RD Note: * (*) not statistically significant at .05. (#) .05 » level of significance. P# * * * * Number/Type Professional Experiences with Aging (n = 699) * Age Professional experience .97 * Number years RD All Predictors (n - 607) Age Professional experience Number courses HE Doctorate degree Number courses aging Number prof. groups aging Master's degree Continuing ed. HE Aging part comp, course Continuing ed. aging Personal experience HE part comp, course Number years RD F for Beta 78 Table 31 Multiple Regression for Attitude 2 (benefit from elderly) Controlling for Age and Number of Years as a Registered Dietitian Beta Educational Indicators (n = 608) Age Number courses aging Doctorate degrees Number courses HE Number prof. groups aging Master's degree Continuing ed. HE Aging part comp, course Continuing ed. aging HE part comp, course Number years RD 1.32 * 4.97 .026 .63 * * * 8.32 .004 .21 * * 4.84 .028 16.96 .000 Number/Type Personal Experiences with Aging (n = 699) * Age Personal experience .39 * Number years RD 27.76 .000 1.24 * 4.46 .035 .48 * * * 4.79 .029 .19 .29 * * 3.82 10.24 .05 .001 (n = 606) Age Professional experience Number courses HE Doctorate degree Number courses aging Number prof. groups aging Master's degree Continuing ed. HE Aging part comp, course Continuing ed. aging Personal experiences HE past comp, course Number years RD Note: P# * * Number/Type Professional Experiences with Aging (n = 699) * Age Professional experience .28 * Number years RD All Predictors F for Beta * * * (*) not statistically significant at .05. (#) .05 «* level of significance. 79 Table 32 Multiple Regression for Attitude 3 (characteristics of elderly) Controlling for Age and Number of Years as a Registered Dietitian Educational Indicators (n = 602) Age Number courses aging Doctorate degrees Number courses HE Number prof. groups aging M a s t e r 's degree Continuing ed. HE Aging part comp, course Continuing ed. aging HE part comp, course Number years RD Beta F for Beta P# - .69 * * * * * * * * * * 11.98 .001 Humber/Type Professional Experiences with Aging (n = 691) -.66 Age * Professional experience * Number years RD Humber/Type Personal Experiences with Aging (n = 691) -.74 Age .32 Personal experience * Number years RD All Predictors (h = 600) Age Professional experience Number courses HE Doctorate degree Number courses aging Number prof. groups aging Master's degree Continuing ed. HE Aging part comp, course Continuing ed. aging Personal experiences HE past comp, course Number years RD Note: -.75 * * * * * * * * * .31 * * (*) not statistically significant at .05. (#) .05 = level of significance. 13.39 .000 16.22 6.07 .000 .014 13.84 .000 3.99 .046 80 Table 33 Summary of Multiple Regressions for Attitude 1, 2 , 3 When Controlling for Age and Number of Years as a Registered Dietitian Attitude 1 (desire to work with elderly) Predictor Variables Age Prof. experience Number courses HE Doctorate degree Number courses aging Number prof. groups aging Master's degree Continuing ed. HE Aging part comp. course Continuing ed. aging Personal experience HE part comp, course Number years RD — *: Attitude 2 (benefit from elderly) Attitude 3 (characteristics of elderly) * * * * ++ * * * ++ * ++ ++ — * * * * * * * * * * * * * * ++ ++ * * ++ ++ * * * ++ * * or ++: statistically significant variable in determining attitude factors (see Tables 27-30) not statistically significant at .05. Multiple Regressions for Demographic Characteristics and Parts of Palmore Facts on Aging Instrument As a means of grouping the different items within the Palmore Facts on Aging, three different factors of the Instrument were determined by the researcher based on content. For simplification of designation, these will be referred to as follows: Knowledge 1, Knowledge 2, and Knowledge 3. Knowledge 1 was created from the items about the social/psycho­ logical interactive ability of older adults. this factor was .53. Reliability analysis for Knowledge 1 included the following twelve items from the Palmore Facts on Aging instrument: Statement number Statement 1 "The majority of old people are senile." 5 "The majority of old people feel miserable most of the time." 8 "Aged drivers have fewer accidents per person than drivers under age 65." 9 "Most older workers cannot work as effectively as younger workers." 11 "Most old people are set in their ways and unable to change." 15 "In general, most old people are pretty much the same." 16 "The majority of old people are seldom b o red." 17 "The majority of old people are socially isolated and lonely." 18 "Older workers have fewer accidents than younger workers.” 82 22 "The majority of old people are working or would like to have some kind of work to do." 23 "Older people tend to become more religious as they age." 24 "The majority of old people are seldom irritated or angry." Knowledge 2 consisted of the items about the physical ability and health of older adults. Reliability analysis for this factor was .41. Knowledge 2 included the following eight items from the Palmore Facts on Aging Instrument: Statement number Statements "All five senses tend to decline in old age." "Lung capacity tends to decline in old a g e ." "Physical strength tends to decline in old age." 10 "About 80% of the aged are healthy enough to carry out their normal activities." 12 "Old people usually take longer to learn something new." 13 "It is almost impossible for most old people to learn new things." 14 "The reaction time of most old people tends to be slower than reaction time of younger people." 20 "Most medical practitioners tend to give low priority of the aged." Knowledge 3 was created from the items about the demographics of older adults. Reliability analysis for this factor was .38. Knowledge 3 included the following three items from the Palmore Facts on Aging: 83 Statement number Statements 7 "At least one-tenth of the aged are living in long-stay institutions." 19 "Over 15% of the U.S. population are now age 65 or older." 21 "The majority of older people have incomes below the poverty level." Two items from the Palmore Facts on Aging did not seem any of the three subsets and were omitted from the factors. to belong to three knowledge These two items were: Statement number 3 25 Statements "Most older people have no interest in, or capacity, for sexual rela­ tions ." "The health and socioeconomic status of older people (compared to younger people) in the year 2000 will probably be about the same as now." Because knowledge can be independent facts known separately from other facts, it might be expected on a knowledge test to have specific questions that do not group or form a set of items. This also may account for the low reliability analysis. Multiple regressions were calculated for each factor with the demo­ graphic characteristics of education, professional experiences, and personal experiences. Age of the dietitian and the number of years as a registered dietitian were the independent variables controlled for by the multiple regression. Education indicators, professional experiences, and personal experiences were the same variables as designated in the Attitude 1, Attitude 2 and Attitude 3 analysis section. level of .05 was considered statistically significant A significance (Tables 34-38). 84 Age of the dietitian and number of courses in aging as a part of a comprehensive course were significant predictors for Knowledge 1 (social/psychological). variables is 4%. The amount of variance (R2) attributed to these None of the variables were predictors for Knowledge 2 (physical ability/health). The amount of variance (R2) attributed to i these variables is 3%. The age of the dietitian, having at least a master's degree, and variety of personal experiences with older adults were significant predictors of Knowledge 3 (demographics). variance (R2 ) attributed to these variables is 8%. factors, age was an important variable. The amount of In the knowledge The older the dietitian, the more knowledge the dietitian seemed to have. Having at least a master's degree was a predictor for knowledge about the demographics of aging. Coursework on aging as a part of a comprehensive course was a predictor for the knowledge about the social/psychological interactive ability of older adults. The demographic variables and the three knowledge subsets did not demonstrate strong predictors. 85 Table 34 Multiple Regressions for Knowledge, Controlling for Age and Number of Years as a Registered Dietitian P# R 1.92 .034 .19 .04 1.85 .137 .09 .008 3.26 1.87 .021 .031 .12 .20 .015 .04 1.40 .166 .16 .03 1.06 .365 .07 .005 1.03 1.30 .379 .209 .07 .17 .005 .03 4.73 .000 .28 .08 14.70 .000 .24 .06 14.61 4.37 .000 .000 .24 .29 .06 .08 F Rz Knowledge 1 (Social/Psychological) Educational indicators (n = 577) Number/types professional experiences (n = 640) Number/types personal experiences (n = 640) All predictors (n = 555) Knowledge 2 (Physical Ability/Health) Educational indicators aii>a«a tunanphyqotofy P IK d a m t MRt^piRti n v y andpmoptaa food irrvcr lyUrim mana*ynqna food wrvcf rymm rrqnapaaqta Nuotanndbaaaa noraquaa* bodam ay Mncqrbiof baaaiaaa e f |m a a n fM nfam yn of ponofaal AddbdndiaaOon «aaa fiaaqana bodnmaay M anann tn r fiaaqnaa bodqmppy M anana daoaaa P p iq atr bddiamaoy nuonaaiand oomnoaiey hedPi Waaiyaaa badomaarv V M n||m a>r araadpyaff Priiprecaaaaq foanpiaabtc) Daupronaaaiy Kompuwloed *Madqnqan isautm rdm afcatra laam aq d w y e atcauondnoMindi at DaupyakiaMn pum a) a Oaaiyvduarion C o rm n u u n Saancn *M*y bp aoqumd prior lo ariry* n m ^ not oompMod in l a c laqdomam D m m a a w a n Iid if o n u n IM M and id p c l 10 dunpo financialmanaqamani food tame* imam twPamfeed nm andp comaaay) Oataavduanon Dauavaluaoon M am •Adopnd Mr 1. W2 trvBJON trnCTM • NOVtAdtt 1. 1M0 ••Appln is U M n i Alflaw (Canqory q Mart a d » •••Mrwnum Acadanc la q a a n o n b a» ic r r u r d a am p of b a c conpnancoc I d a diet a q o d k o a t i o n a kiw npqpi n m . nor APPENDIX G 144 The Ohio Slate University Speech and Hearing Science Section • 324 Ddrby Hall 154 North Oval Mall Columbus, Ohio 43210-1372 Phone 614 422-8207 22 April 1986 Mary Margaret Noel, MPH, RD Doctoral Candidate in Family Ecology 233 Kensington Rd. East Lansing, MI 48823 Dear M s . Noel: Dr. Oyer and I were happy to hear that you are interested in using the instrument that we developed for assessing attitudes. In response to the questions that you asked concerning the Wall-Oyer Attitudes Towards Aging instrument, please note the following: 1. We are pleased that you are interested in using the instrument with your doctoral research on dietitians' attitudes towards aging and we are happy to grant permission for your use. 2. In addition to our study only Dr. James O'Brien and Dr. Senger have used the instrument to date. 3. Information on the reliability of the instrument is as follows: The Wall-Oyer Attitude Inventory Toward Aging assessed the attitudes of students toward the elderly. The instrument had two dimensions; "personal" and "general". It was found, upon readministration, to be reliable; general dimension r=.72 and personal dimension r=.62 (Pearson product-moment correlations). Test-retest reliability was determined to be significant for both dimensions (p .05). 4. Information on the validity of the instrument is as follows: Content validity: The original items of the Instrument were developed based upon intuitive and reasoned notions of the authors of the instrument. The authors felt that the items were representative of content of the property being measured based upon several years of working with speech and hearing undergraduate and graduate students in the classroom and in the clinical setting. Additionally, written student narratives concerning their attitudes toward aging and older people were used as a basis to help develop the instrument. Test item format resembled a Liekert type of scaling and equal positive and negative phrasing of the items was included. Once these items were developed, each item was judged for its presumed relevance to attitudes toward aging by five competent judges. These five judges were senior professors who have spent numerous years working in the following specialized areas: speech and hearing, communication and attitudes and attitude change, aging and family relations. Based upon the responses of these Department of Communication 145 22 A p r il 1986 Page Two judges, items were either included or excluded from the final test instrument. Construct validity: The authors of the instrument deduced that certain relationships should exist between 1) the attitudes toward aging held by the students 2) theij’- experience with the elderly 3) the amount of factual information the student's possessed 4) the age group a student intended to work with in the future. To this end information concerning Facts on Aging Quiz (Palmore, 1977) was administered. Identification information concerning the amount of contact students with older people was evaluated along with a rank ordering of the age group with which the student preferred to work. As speculated, the students (64%) had only moderate experience or coursework with the elderly. The knowledge score based upon Palmore's Quiz indicated their knowledge of basic social, mental, and physical facts were only slightly better than chance (mean score was 65.4%). Older people were ranked relatively low as a group with which they would like to work. General and personal attitudes were more favorable than unfavorable. It is within this area that we are still intending to gather more empirical evidence. It appears as if there is a relationship between some of the knowledge questions, the attitudinal questions and some of the identifying information; 58 percent of the variance could be accounted for. However, construct validity should be considered to still be in the stage of empirical verification. We hope this information has been helpful to you. We'd be interested in any relevant findings you have should you continue along this line of research. Sincerely, Liaa Lida u. G. Wall wan ✓- n Associate Professor ) Herbert J. 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