Many behavioral models have been used to guide nutrition interventions in older adults. For the purpose of this chapter, we will focus on those that have been most commonly utilized in nutrition interventions in geriatric populations.
2.3.1 Social Ecologic Theory or the Ecological Perspective
The Ecological Perspective highlights the interaction between, and interrela- tionship between, factors within and across all levels of a health problem. It is discussed in greater detail in Chapter 1. The key tenet of the Ecological Perspective is that behavior both affects and is affected by multiple levels of influence. McLeroy and colleagues (1) identified five levels of influence: (1) intrapersonal or individual factors, (2) interpersonal factors, (3) institutional or organizational factors, (4) community factors, and (5) public policy factors. At the individual level, characteristics such as knowledge, attitudes, beliefs, and personality traits all influence, for example, an older person’s eating patterns and preferences. At the interpersonal level, family, friends, and peers may have an equally important impact on dietary intake, especially if the older adult depends on others for food preparation or procurement. Institutional or orga- nizational factors may include rules, regulations, policies, and informal struc- tures that support or impede adequate or health-promoting dietary intake. At the community level, social norms or standards often influence an older adult’s ability to adhere to a particular dietary strategy, especially if that strategy runs counter to prevailing social norms. Many public policy factors at the local, state, and federal level affect nutritional issues in older adults. For example, state and federal pressures to prevent weight loss in nursing home settings have both increased positive attention to nutritional issues in this setting and, at times, contributed to potentially excessively aggressive interventions (such as enteral nutrition in residents with advanced illness).
Many health behavior theories focus on intrapersonal (individual) and interper- sonal factors in behavior change. Examples of theories that focus primarily on these intrapersonal factors include theHealth Belief Model,theStages of Change (Trans- theoretical) Model, theTheory of Planned Behavior (TPB),theTheory of Mean- ingful Learning,and theInformation Processing Model.
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2.3.2 The Health Belief Model
The Health Belief Model (HBM) focuses on perceptions individuals have of the threat posed by a health problem (susceptibility, severity), the potential benefits of avoiding the threat, and factors influencing the decision to act (barriers, cues to action, and self-efficacy). The tenet of this model is that for individuals to adopt a new health behavior or change their current health behavior, they have to (1) believe they are susceptible to the condition, (2) believe the condition will have serious consequences, (3) believe that changing their behavior will reduce their susceptibil- ity to the condition or its severity, and (4) believe costs of taking action (perceived barriers) are outweighed by the benefits. Health behavior change in this model is also facilitated by specific factors that prompt action such as a reminder from one’s provider (also called a ‘‘cue to action’’) or when the individual is confident in their ability to successfully perform an action (also called ‘‘self-efficacy’’)(2).
2.3.3 Stages of Change
The Stages of Change Model (3) posits that behavior change is a process, not an event. This model asserts that as people attempt to change their be- havior, they move through five stages: precontemplation, contemplation, pre- paration, action, and maintenance. In the precontemplation stage, the individual has no intention of taking action (some definitions include a time period; e.g., no intention to take action within the next 6 months). In the contemplation stage, the individual intends to take action in foreseeable future. In the prepara- tion stage, the individual plans to take action within the next 30 days and is taking some steps in this direction. In the action stage, the individual has successfully changed behavior for a short period of time, whereas in the main- tenance stage, the individual has changed behavior for a longer period of time or at least 6 months. The Stages of Change Model, in addition to emphasizing the process of behavior change, recommends stage-specific interventional strate- gies tailored to where the person is in their transition from one behavior to another more health-promoting behavior (see Table 2.1).
2.3.4 The Theory of Meaningful Learning
The Theory of Meaningful Learning posits that each individual must construct his or her own understanding of concepts and relationships. While health care providers and others can assist an older adult in learning, the construction of mean- ings and understandings, and ultimately learning and behavior change, is a unique process that only each person can achieve on their own(4).
2.3.5 The Information Processing Model
The Consumer Information Processing Model states that individuals must be exposed to, comprehend, retain, and retrieve pertinent information in order to make a decision and engage in behavior change (5). In another words, health information is important but not sufficient for people to adopt healthful behaviors.
Central assumptions of this model are that (1) individuals have limitations in how Chapter 2/ Behavioral Theories Applied to Nutritional Therapies 21
much information they can process at one time and (2) information is more useable if combined into manageable ‘‘chunks.’’ Individuals are more likely to use informa- tion if it is perceived as relevant to their situation, useful, new, and easy to use(6).
Table 2.1
Stage-based dietary counseling strategies
Stage Patient needs Counseling messages
Not interested in dietary change (Precontemplation)
Motivation to engage in dietary change
Ask what patient/caregiver likes/dislikes about recommended dietary changes
Discuss pros and cons along with perceived barriers Reinforce and build on
patient/caregiver’s personal reasons for making dietary change
Discuss positive effects of dietary change on health, lifestyle, and quality of life Restate desire to support the
patient and assist with change
Follow up with patient and let them know you will
Interested in dietary change in the next 6 months but not in the next 30 days
(Contemplation)
Motivation to engage in dietary change sooner than later
Strengthen the benefits for dietary change and weaken the cons
Interested in making a dietary change in the next 30 days (Preparation)
Skill building Support specific
planning strategies
Encourage patient/caregiver to make a specific plan using small, achievable steps Address expected obstacles In process of making a dietary
change – has consistently made this change in the past 6 months (Action)
Relapse prevention Congratulate on success Review concerns If brief relapse (e.g.,
consumption of too much sodium during a holiday), encourage to cycle back to recommended diet right away and use experience as an opportunity for learning rather than discouragement Has engaged in dietary change
for more than 6 months (Maintenance)
Relapse prevention Support, encourage, and review plans for relapse prevention
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2.3.6 Social Cognitive Theory
Social Cognitive Theory (SCT) posits that whether a person will change a health behavior depends on (1) self-efficacy, (2) goals, and (3) outcome expectancies. If individuals have a high level of confidence, they can change even when they are faced with many obstacles. If they are not confident about the behavior in ques- tion, they will be less motivated to act or to persevere through obstacles or challenges as they arise. Important elements of SCT include reciprocal determin- ism (the interaction of the person, behavior, and the environment), behavioral capability (knowledge and skills needed to perform a particular behavior), expec- tations (the individual’s anticipated outcome of the behavior), self-efficacy (con- fidence in one’s ability to overcome the barriers encountered during behavior change), observational learning (watching the actions and outcomes of others’
behavior), and reinforcements (factors that increase or decrease the likelihood of the desired behavior)(7).
2.4 EXAMPLES OF NUTRITION INTERVENTIONS GROUNDED