INT'L. J. AGING AND HUMAN DEVELOPMENT, Vol.

47(4) 299-327,1998

SOCIAL COGNITIVE PREDICTORS OF NUTRITIONAL

RkSK IN RURAL ELDERLY ADULTS*

HELEN M. HENDY, PH.D.

GORDON K. NELSON, PH.D.
Penn State University
MARGARET E. GRECO, A. A.
Integrated Medical Group, Pottsville, Pennsylvania

ABSTRACT
According to Social Cognitive Theory (Bandura, 1997). nutritional risk
would be predicted by perceptions of nutrition efficacy, which in turn would
be predicted from four sources: modeling, verbal support, physiological con-
ditions, and nutrition habits. In telephone interviews with 154 rural elderly
adults (44 men, 110 women; mean age = 74.4 years), nutritional risk was
measured with Nutritional Risk Index (NRI), Nutritional Screening Initiative
(NSI), and seven-high-risk-nutrients consumed less than 50 percent of RDA
(Diet Plus Analysis). Nutritionefficacy was measured with a new twenty-
five-item scale of Perceived Nutrition Barriers (PNB). Sources of nutrition-
efficacy included mealtime modeling-shared meals, household size; verbal
suppofi-people talk to each day, hours talked, number of confidants;
physiological conditions that may affect nutrition-age, body mass, medica-
tions, disability, negative affect, and nutrition h a b i t s d a i l y food variety, use
of meal services. Path analysis was performed with each measure of nutri-
tional risk (NRI, NSI, 7-high-risk-nutrients) as a criterion variable, nutrition-
efficacy (PNB) as a possible mediating variable, and sources of nutrition-
efficacy as predictor variables. Social Cognitive variables accounted for
58 percent of variance in NRI, 49 percent of variance in NSI, and 29 percent
of variance in seven-high-risk-nutrients. Nutritional risk was directly

*The present study was supported in part by a Research Development Grant from Penn State
University, and by Small Grants, the Research Assistant Program, and the Research and Scholarship
Award from the Schuylkill Campus of Penn State University.

299
Q 1998, Baywood Publishing Co., Inc.

doi: 10.2190/F770-RNBD-GFMT-RQGV
http://baywood.com
300 / HENDY. NELSON AND GRECO

predicted by large households, few shared meals, few confidants, high body
mass, many medications, and few daily foods; it was indirectly predicted
(via PNB) by high levels of negative affect. Perceived Nutrition Barriers
(PNB) most ofkn mentioned were food cost, eating alone, food tastelessness,
transportation to the store, and chewing difficulty.

Poor nutrition in elderly adults is associated with more doctor visits, more emer-
gency room visits, more hospitalizations, more nursing home placement, more
health costs, reduced survival rates, and reduced perceptions of health and well-
being (Delhey, Anderson, & Laramee, 1989; NRC, 1989; Ryan, 1990; Silver,
1993; USDHHS, 1988; USDHHS, 1991). Elderly people who live in a rural
environment may be at particular risk because of high rates of poverty, isolation,
and difficulty getting to health services (Buckwalter, Smith, & Caston, 1994;
Clayton, Dudley, Patterson, Lawhorn, Poon, Johnson, & Martin, 1994; Coward,
Bull, Kukulka, & Galliher, 1994; Glasgow, 1993; McCulloch & Lynch, 1993;
Peterson & Maiden, 1991). Past research on predictors of nutritional risk in
elderly people has identified demographic and medical variables predictive of
increased nutritional risk: being Hispanic or African American, being a woman,
living in poverty, being unmarried, having little education, being a smoker,
losing the sense of smell or vision, having dental problems, and taking many
medications (Burt, 1993; Davis, Randall, Forthofer, Lee, & Margen, 1985; Ferris
& Duffy, 1989; Gordon, Kelley, Sybyl, Mills, Kramer, & Jahnigen, 1985;
Holcomb, 1995; Mahajan & Schafer, 1993; Parker, 1992; Payette, 1995;
Peterson & Maiden, 1991; Posner, Ohls, & Morgan, 1987; Rikans, 1986; Schafer
& Keith, 1982; Zipp, 1992). However, many of these demographic and medical
predictors are difficult to change, have unknown relevance for the nutrition
concerns of elderly people themselves, and therefore provide few intervention
ideas for health service agencies (Office for Senior Services, Meals-on-Wheels).
Past research has also considered cognitive variables predictive of nutritional
risk in elderly adults (e.g., perceived control, social support), but the selection of
the predictors has been primarily atheoretical (McIntosh, Shifflett, & Picou,
1989; Posner, Jette, Smigelski, Miller, & Mitchell, 1994; Smith, 1994; Speake,
Cowart, & Pellet, 1989; Toner & Moms, 1992; Walker & Beauchene, 1991).
The purpose of the present study was to use Social Cognitive Theory
(Bandura, 1986, 1997) as a guide to examine predictors of nutritional risk in
elderly adults, so that future nutrition intervention programs could be designed
to enhance nutrition confidence in rural elderly adults. The Social Cognitive
Theory concept of self-efficacy, or perception of mastery, has been found to be
a significant predictor for a wide variety of health-promoting behaviors, includ-
ing weight-loss, smoking cessation, exercise, contraception, wearing seat belts,
etc. (O’Leary, 1985; Stretcher, DeVellis. Becker, & Rosenstock, 1986; Welch &
West, 1995). According to Social Cognitive Theory, nutritional risk behavior
 NUTRITIONAL RISK IN RURAL ELDERLY / 301

would be predicted by perceptions of efficacy, either in general domains (health,

social, cognitive) or in more nutrition-specific domains. Nutrition-efficacy would,
in turn, be predicted by four sources of efficacy: mealtime modeling, verbal
support, physiological conditions that may affect nutrition, and nutrition habits.
Measures of nutritional risk have been developed by panels of professional
dietitians and usually include questions about demographic and medical corre-
lates of malnourishment. For example, the Nutritional Risk Index (NRI, 1989;
Prendergast, Coe, Chavez, Romeis, Miller, & Wolinsky, 1989; Wolinsky,
Prendergast, Miller, Coe, & Chavez, 1985) is a sixteen-item scale focusing on
medical conditions that can influence nutrition ( e g , abdominal pain, trouble
swallowing, vomiting, constipation, diarrhea, anemia, dentures). The Nutritional
Screening Initiative (NSI; Abdellah & Moore, 1988; Posner, Jette, Smith, &
Miller, 1993; White, Ham, Lipachitz, Dwyer, & Wellman, 1991) is a ten-item
scale developed by a panel of diet professionals to be a quick screen of nutri-
tion risk. It includes questions about both medical and environmental conditions
that may increase nutritional risk (e.g., skipping meals, having three or more
alcoholic drinks daily, eating alone, not having enough money to buy food).
However, in addition to nutritional risk measures developed by diet profes-
sionals, the present study sought to develop a measure of nutrition-efficacy that
considered nutrition bamers perceived as important by elderly adults themselves.
Unfortunately, measures of nutrition-efficacy available at the time of the present
study focused on weight loss concerns and the perceived control of dieters to
resist tempting situations (Clark, Abrams, Niaura, Eaton. & Rossi, 1991; Glynn
& Ruderman, 1986; Rossi, Rossi, Velicer, & Prochaska, 1995; Schlundt, 1995;
Schlundt & Zimering, 1988; Stanton, Garcia, & Green, 1990; Stotland, Zuroff,
& Roy, 1991), rather than focusing on the person’s perceived control for eating
a nutritious variety of foods each day. Therefore, a new twenty-five-item scale
of Perceived Nutrition Bamers was developed for the present study to measure
nutrition-efficacy relevant to elderly adults themselves to guide the development
of future nutrition intervention programs.

METHODS
Telephone interviews were conducted with 154 elderly adults who were sixty
years or older and living independently (not in a nursing home) in a low income,
rural county of eastern Pennsylvania (44 men, 110 women). Their mean age was
74.4 years (SD = 7.3, range = 60 to 96), their mean education was 11.7 years
(SD = 2.6, range = 4 to 18), 99.3 percent of them were white Americans, 20.8
percent were mamed, and 68.2 percent of them lived alone. The study was
approved by the Office for Regulatory Compliance of Penn State University. To
include elderly adults who varied in functional health status and independent
living skills, participants were recruited from a number of county-wide programs
for elderly participants. Participants from some of these programs are required
302 I HENDY. NELSON AND GRECO

to be “homebound” or “disabled” (such as the Meals-on-Wheels and Center

for Independent Living, n = 46). Participants in other programs have no such
restrictions (such as the local Senior Centers, n = 41, Housing Authority apart-
ment buildings, n = 13, and the very active Retired Senior Volunteer Program of
the Oftice for Senior Services, n = 48).
Recruitment materials were distributed to people sixty years or older by
the Executive Directors of the local county’s Office for Senior Services,
Housing Authority, Meals-on-Wheels program, and Center for Independent
Living. The study was described as a telephone interview concerning “eating
habits and how they are related to aspects of everyday life.” If interested in
participating, the elderly adult used a stamped envelope that was provided to
return a signed informed consent form, a phone number, and convenient times
to call.
Of the 154 participants in the present study, the forty-six participants from
Meals-on-Wheels and Center for Independent Living programs also served as
participants in another study of 122 participants (Hendy & Nagle, 1998). The
second study examined similar predictors of nutritional risk, but for rural adults
with disability. and it included adults of all ages (16 to 96 years of age). Separate
studies were conducted for elderly adults and for adults with disability in order
to avoid the stereotypical assumption that elderly people and people with dis-
abilities are one and the same.
Telephone interviews were made by a team of adult students who received
approximately ten hours of training, including a study description, a written
protocol, and update meetings every two weeks to emphasize consistency, cour-
tesy, and confidentiality in recording information from the telephone interviews.
The mean time to complete an interview was 37.0 minutes (SD = 10.6, range =
13 to 75).

MEASURES OF NUTRITIONAL RISK

Three measures of nutritional risk were gathered during the telephone
interviews:

1. Nutritional Screening Initiative

The Nutritional Screening Initiative (NSI; Abdellah & Moore, 1988; Posner
et al., 1993; White et al., 1991) is a ten-item scale developed by a panel of diet
professionals as a quick screen of nutritional risk that could be self-administered
by a wide variety of populations (Babbitt, Edlen-Nezin, Manikam, Summers, &
Murphy, 1995). Participants answer true or false to each question, answers of
“true” are assigned from 1 to 4 points according to how much they increase
nutritional risk, then points are added to give the NSI score that ranges from 0
to 21. The NSI was originally tested with 449 mostly white, non-institutionalized
 NUTRITIONAL RISK IN RURAL ELDERLY / 303

elderly adults in New England (Posner et al., 1993). The points assigned to each
item in the scale were originally determined by a panel of gerontologists and
nutritionalists from beta weights shown in multiple regression analyses of
predictofs for consumption of essential nutrients reported in twenty-four-hour
recalls. Although reliability coefficients are not available for the NSI, its validity
was reviewed by finding it to be correlated with the intake of protein, vitamin
A, vitamin C, thiamine, and calcium (Babbitt et al., 1995; Posner et al., 1993;
Reuben, Greendale, & Harrison, 1995; Rush, 1993). The NSI has been criticized
for including items that are difficult to alter in order to directly produce nutri-
tional changes (Rush, 1993). Examples of NSI items and points assigned to them
include: “I have three or more drinks of beer, liquor, or wine almost every day”
(2 points), “I eat fewer than two meals a day” (3 points), “I do not always have
enough money to buy the food I need” (4 points), “Without wanting to, I have
lost or gained ten pounds in the last six months” (2 points).

2. Nutritional Risk Index

The Nutritional Risk Index (NRI; Prendergast et al., 1989; Wolinsky et al.,
1985) is a sixteen-item scale that asks primarily about medical conditions related
to nutrition. Participants answer yes or no to each question on the scale, then
the number of yes answers is the NRI score. The NRI was originally designed
as a quick, easy to understand, telephone screen of nutritional risk that could be
used by relatively unskilled examiners (Babbitt et al., 1995). It was originally
tested with 401 non-insitutionalized elderly adults in St. Louis, Missouri, with
Cronbach’s reliability coefficient of .60, and a test-retest re€iability of .65. As a
consideration of validity, NRI scores for the original study group were found to
be correlated with number of physician visits, trips to emergency rooms, and
hospital admissions (Wolinsky et al., 1985). The NRI has been criticized for
failing to distinguish whether the medical conditions it includes are causes or
effects of poor nutrition (Reuben, Greendale, & Harrison, 1995). Examples of
items from the NRI include: “Do you have troublc biting or chewing any
kind of food?” “During the past month, did you have any trouble swallowing
for three days or more?’ “During the past month, did you have any vomiting that
lasted three days or more?’ “Do you have any trouble with your bowels that
makes you constipated or gives you diarrhea?“ “Have you ever had an operation
on your abdomen?” “Do you smoke cigarettes regularly now?’ (Note: The
NRI was added to the study after 74 randomly selected participants had
already completed their telephone interviews, so it is available for statistical
analyses only for 80 participants. Also, one item of the original NRI-“Are‘there
any kinds of foods that you don’t eat because they disagree with you?’-
was omitted due to a clerical error, so NRI scores in the present study could
range from 0 to 15.)
304 I HENDY. NELSON AND GRECO

3. Seven High-Risk-Nutrients Consumed Less than

50 Percent of RDA
Nutritionists have identified seven essential nutrients for which elderly adults
often have inadequate daily consumption: vitamin E, thiamin, riboflavin, folacin,
calcium, iron, and zinc (Guthrie & Picciano, 1995). The number of these seven-
high-risk-nutrients consumed at less than 50 percent of the Recommended
Dietary Allowance (RDA; USDHHS, 1988, 1991) was determined from a com-
puter diet analysis program that used the participant’s twenty-four-hour food
recall, body mass index (kg/m*), age, and gender (Diet Plus Analysis, West
Publishing Company, No. 0-3 14-04192-3).A registered dietitian was consulted
to provide standard serving sizes if the participant failed to give adequate infor-
mation about food amounts. In addition, only participants who reported that their
twenty-four-hour food recall was “typical” were included in statistical analyses
considering this measure of nutritional risk (89.5%). In a review of diet assess-
ment methods, twenty-four-hour food recalls obtained from seventy-six elderly
adults were found to produce no significant differences in diet assessment com-
pared to direct observation of food consumption, food weighings, or longer
periods of food recall, except that fewer total calories were recalled with the
twenty-four-hour food recall method (Block, 1982; Gersovitz, Madden, &
Smiciklas-Wright, 1978;Reuben, Greendale, & Harrison, 1995;Wolper, Heshka,
& Heymsfield, 1995). Advantages of twenty-four-hour food recalls are that they
are quick and simple to use, and they can be conducted over the telephone (as
they were used in the present study). They are considered best if gathered for an
unannounced day, and if used in comparison to other nutritional risk measures
(as they were used in the present study).
To consider how the three measures of nutritional risk used in the present
study might overlap, Pearson correlation coefficients were examined between
each pair of scores. It was found that the NRI and the NSI were significantly
correlated (r = .56, n = 80,p < .Ol), but that neither were significantly related
to seven-high-risk-nutrientsconsumed at less than 50 percent RDA.

MEASUREMENT OF GENERAL EFFICACY

To measure perceived efficacy in general domains of life, the twenty-nine-item
Perceived Control Scale (PCS; Nelson, 1993) was used. It includes perceived
control in three areas: Health-eg., “I can pretty much stay healthy by taking
good care of myself,” “If I get sick, I can help myself get well,” “No matter what
I do, if there is a flu going around, I will probably get it,” “Whether or not I stay
healthy is just not up to me.” Social--e.g., “Going to visit friends is easy for me
to do,” “If I want my family to visit me they come,” “I cannot find people who
will really listen to what I have to say,” “No matter how hard I try, people
generally do not allow me to help them.” Cognitive-“I can understand difficult
 NUTRITIONAL RISK IN RURAL ELDERLY I 305

instructions if I want to,” “If I want to, I can solve problems that involve
numbers,” “When it comes to reimbursements or claims to an insurance com-
pany, it is beyond me to figure them out,” “I cannot remember certain things no
matter what I do.” The Perceived Control Scale (Nelson, 1993) was originally
developed with 205 adults in New England. Participants in the present study
responded whether each item was true or false, appropriate items were reversed,
then a total was calculated for items of perceived control considered true. Scores
could range from 0 to 29 (Cronbach’s alpha = .82).

MEASUREMENT OF NUTRITION-EFFICACY

To measure nutrition-specific efficacy, a new twenty-five-item scale of

Perceived Nutrition Barriers was developed (PNB, Cronbach’s alpha = .76).
Items for the Perceived Nutrition Bamers scale were gathered from past research
on dimensions of adult food perception in adults (Birch, 1989; Burt, 1993;
Gordon et al., 1985; Rappoport & Peters, 1988; Soltesz, Price, Johnson, &
Telljohann, 1994), and from consultation with staff from the Meals-on-Wheels
Program and Center for Independent Living. The number of the barriers rated
true by each participant was hisher score for the Perceived Nutrition Bamers
scale. Items in the Perceived Nutrition Barriers scale included problems of
appetite, equipments food cost, eating alone, transportation, time, food prefer-
ences, chewing ability, special diets, and social cooperation.

SOURCES OF NUTRITION-EFFICACY

Information was also gathered about four sources of nutrition-efficacy as sug-

gested by Social Cognitive Theory (Bandura, 1986, 1997):

Mealtime Modeling

Number of Shared Meals Each Day

Past research has found that people tend to eat more food when with others
(Clendenen, Herman, & Polivy, 1994).

Household Size

Especially for rural adults, proximity to family members has been found to be
related to the type and amount of support available (McCulloch, 1995; Mercier,
Paulson, & Moms, 1988).
306 I HENDY, NELSON AND GRECO

Verbal Support
Number of People to Whom Talk Each Day
Hours Talk Each Day
Number of Confidants
Participants were asked to give the “number of people in your life with whom
you can talk about absolutely anything on your mind.” It was added to the more
quantitative measures above (number of people to whom talk, number of hours
talk) because past research has often found that the quality of social support,
rather than its quantity, is the better predictor of health outcomes (Antonucci &
Johnson, 1994; Cohen & Wills, 1985; Delongis, Folkman, & Lazarus, 1988;
Gibson, 1986; Sarason & Sarason, 1994; Seeman & Berkman, 1988).

Physiological Conditionsthat May Affect Nutrition

Age
Body Mass Index (kg/d)
Medicationsper Day
Many commonly used medications may affect appetite, taste perception, and
digestion (Blumberg & Suter, 1991; Rikans, 1986).
Disability
Functional disability in activities of daily living has been found to be predic-
tive of many health outcomes for elderly adults (Johnson & Wolinsky, 1993).
Therefore, as a simple measure of “disability,” elderly adults in the present study
who were participants in Meals-on-Wheels or Center for Independent Living
programs were considered “disabled” (and given a value of 1 for the disability
score). Elderly adults in the present study recruited from the other community
organizations (Office for Senior Services community volunteer program, Senior
Centers, Housing Authority) were considered “not disabled” (and were given a
value of 0 for the disability score). In addition, a brief measure of functional
health status (Johnson & Wolinsky, 1993) was added to the interview late in the
study for the last randomly selected seventy-one participants. Participants were
asked whether they needed assistance for each of nine activities of daily living
(ADLs): bathing, dressing, grooming, toileting, walking, shopping, meal
preparation, eating, traveling outside home. The mean number of ADLs needing
assistance was 1.8 (sd = 2.1, range = 0 to 7). However, because of the small
number of participants for whom the measure was available, this measure was
not included in the analysis for predictors of nutritional risk. However, it was
used as a brief validity check that study participants from the “disabled” and “not
disabled” groups who completed this measure (n = 27 and n = 44,respectively)
did show significant differences in their reported functional disability (t = 7.24,
df= 69, p < .001).
 NUTRITIONAL RISK IN RURAL ELDERLY I 307

Negative Affect
Negative affect has consistently been found to be related to poor nutrition
(APA, 1994; Christensen, 1993; Cools, Schotte, & McNally, 1992; Greeno &
Wing, 1994; Heatherton, Herman, & Polivy, 1992; Lingswiler, Crowther, &
Stephens, 1989; Lyman, 1989; Schotte, 1992; Somer, 1995; Spillman, 1990;
Steinberg, Tobin, & Johnson, 1990; Wurtman, 1987). Negative affect was
measured here with the ten-item negative affect portion of the Positive and
Negative Affect Scale (PANAS; Watson, Clark, & Tellegen, 1988). Participants
were asked how much they felt each of the following moods during the last
day or two: nervous, upset, scared, ashamed, guilty, distressed, irritable, hostile,
afraid, jittery. They responded with no = 1, sometimes = 2, often = 3, and then
responses were summed over the ten items. Scores for Negative Affect Scale as
used here could range from 0 to 30 (Cronbach’s alpha = .85). The Negative
Affect portion of the PANAS Scale was originally tested with over one thousand
adults in Texas, showing a Cronbach’s reliability coefficient of .86, and as a
check of its construct validity it was found to be correlated with the Beck
Depression Inventory ( r = .56) and the Hopkins Symptom Schedule (r = .65)
(Watson, Clark, & Tellegen, 1988).

Nutrition Habits
Daily Food Variety
Variety of foods eaten each day was measured as the number of different foods
reported in a twenty-four-hour food recall, but only for participants who reported
it as a “typical” day (89.5%). Duplicate and similar items were eliminated from
the count (e.g.. milk in the morning and milk in the evening were counted only
once; skim milk and lowfat milk were counted only once). When a food mixture
was reported (e.g., salad, sandwich, stew, pizza), the participant was asked to list
foods included in the mixture. No minimum portion size was required for a food
to be counted in the number of foods consumed in the twenty-four-hour recall.
As used in the present study, therefore, the measure recorded habits of daily food
variety as perceived and recalled by the elderly participant. For participants
reporting that they could not remember foods eaten during the past twenty-four
hours, the variable was considered as missing data.
Use of Meal Services
Participants were asked to give the number of days each week they usually
used meal services such as Meals-on-Wheels or meals provided at the local
Senior Center (Peterson & Maiden, 1991; Posner, Ohls, & Morgan, 1987; Smith,
1994). Although such formal meal services provide meab that are nutritionally
balanced and supervised by dietitians, the elderly adults who receive these meals
may not necessarily consume all foods offered.
308 / HENDY, NELSON AND GRECO

DATA ANALYSIS

Descriptive statistics were calculated for all variables (Table 1). Also, the
percent of participants reporting each of the twenty-five Perceived Nutrition
Barriers was determined (Table 2).
Then, stepwise multiple regression analyses were used to examine which of
the sources of nutrition-efficacy (mealtime modeling, verbal support, physio-
logical conditions that affect nutrition, nutrition habits) were the best direct
predictors for each measure of nutritional risk (NSI, NRI,7-high-risk-nutrient).
Sources of nutrition-efficacy considered as predictors included: shared meals,
household size, number of people to whom talk,hours talk, confidants, age, body
mass, medications, disability, negative affect, daily food variety, use of meal
services. Pairwise deletion of missing values was used. After the stepwise mul-
tiple regression analysis had identified significant predictor variables for each
measure of nutritional risk, the analysis was repeated using only the significant
predictors so that no degrees of freedom would be lost because of missing values
for insignificant variables (Pedhazur, 1982).
Next, simultaneous multiple regression analysis was used to determine
whether variation in each of the three measures of nutritional risk (NSI, NRI,
seven-high-risk-nutrients) was better accounted for by general efficacy
(measured with the Perceived Control Scale; Nelson, 1993) or by nutrition-
specific efficacy (measured with the new Perceived Nutrition Bamers
scale). From past research, it was expected that nutrition-efficacy would be
the better predictor, because health outcomes are usually more related to
health-specific efficacy than to general efficacy (Ajzen & Timko, 1988; Bausell,
1986; Berry & West, 1993; Duncan, Duncan, & McAuley, 1993; Gistand &
Mitchell, 1992; Kaplan, Atkins, & Reinsch, 1984; Lee, 1992; Lust, Celuch, &
Showers, 1993).
Finally, if nutrition-efficacy (Perceived Nutrition Barriers) was confirmed
to be the better predictor of nutritional risk, it was used as a possible mediating
variable in the following path analysis suggested by Social Cognitive Theory
(Bandura, 1986, 1997): Simultaneous multiple regression analyses examined
each measure of nutritional risk as the criterion variable ( M I , NSI, 7-high-
risk-nutrients), with nutrition-efficacy as a possible mediating variable (Per-
ceived Nutrition Barriers), and sources of nutrition-efficacy as predictor
variables (using only those found significant in the above stepwise mul-
tiple regression analyses for each measure of nutritional risk). From each
regression analysis, it was noted which of the predictor variables remained
significant when Perceived Nutrition Barriers was entered first into the
regression equation, indicating a direct relationship with nutritional risk, and
which of the predictor variables lost significance with Perceived Nutrition
Barriers entered first, indicating an indirect relationship with nutritional risk (see
Figure 1.)
 NUTRITIONALRISK IN RURAL ELDERLY I 309

Table 1. Descriptive Statistics for 154 Rural Elderly Participants

(44Men, 110 Women; 99.3% White; Including46 Participants
in Meals-on-Wheelsor Center for Independent Living
Programs for People with Disability)
Variable Mean SD Range

NUTRITIONAL RISK
Nutritional Risk Index 4.5 2.1 (0-9)
(NRI, Wolinsky et al., 1985)
Nutritional Screening Initiative 5.2 3.7 (0-15)
(NSI; White et al., 1991)
Seven-high-risk-nutrients 2.3 1.3 (1-7)
(number less than 50% RDA)

PERCEIVED EFFICACY
General efficacy 23.4 4.4 (14-29)
(Perceived Control Scale;
Nelson, 1993)
Nutrition-efficacy 4.8 3.5 (0-15)
(Perceived Nutrition Barriers;
Cronbach’s alpha = .76)

SOURCES OF NUTRITION-EFFICACY
Mealtime modeling
Shared meals per day 0.8 1.1 (0-5)
Others in household 0.4 0.7 (0-5)

Verbal support
Number of people to whom talk 6.4 7.2 (0-50)
each day
Hours talk each day 2.8 2.4 (0-12)
Number of confidants 4.2 7.2 (0-80)

Physiological factors
Age 74.4 7.3 (60-96)
Body mass index (kg/m2) 27.1 5.3 (15-43)
Medications each day 3.4 2.5 (0-10)
Negative affect (Watson et al., 1988) 3.1 3.5 (0-15)

Nutrition habits
Number of foods in 24 hour recall 10.1 3.4 (4-18 )
Use of meal service (daysheek) 1.3 2.2 (0-5)
Note: The seven-high-risk-nutrients include zinc, iron, calcium, folic acid, riboflavin,
thiamin, vitamin E. The range of possible scores included: zero to 15 for NRI, zero to 21 for
NSI, zero to 29 for general efficacy, zero to 25 for Perceived Nutrition Barriers, and zero to
30 for negative affect.
310 / HENDY, NELSON AND GRECO

Table 2. Perceived Nutrition Barriers Scale (Cronbach’s Alpha = -76)

Showing Percent of Rural Elderly Adults (n= 154) Who Agree With Each Barrier
Percent
PerceivedNutrition Barrier Who Agree
Some foods cost too much. 64.9
I do not like preparing foods just for myself. 48.9
Foods do not taste as good as they used to. 45.8
I have difficulty getting to the store to buy foods. 32.1
I have difficulty chewing some foods. 27.5
I like the taste of junk foods more than nutritiousfoods. 27.5
I have difficulty digesting some foods. 26.7
Food is just not that important to me. 18.3
I forget to eat sometimes. 16.8
I do not like the taste of many nutritious foods. 16.8
Lately Ido not have much of an appetite. 16.0
I have equipment to prepare foods, but I cannot work it. 14.5
My medical problems make it difficult for me to prepare foods. 13.0
Some foods react with my medication. 13.0
I have difficulty getting other people to buy or prepare foods for me. 12.2
The people who prepare my foods make things I do not like. 12.2
I am on a special diet, but I do not always like what I am supposed
to eat. 11.5
I do not have enough choice in the foods I eat. 9.9
I am on a special diet, but I do not always know what I am
supposed to eat. 9.2
I do not have time to prepare foods. 8.4
The people who prepare my foods make things I am not supposed
to eat. 8.4
Ifeel nauseated. 8.4
I run out of food. 6.1
I am too busy to worry about the foods I eat. 5.3
I do not have all the equipment I need to prepare foods. 3.8

RESULTS

The five most frequently mentioned Perceived Nutrition Barriers were food
costs (64.9%),dislike eating alone (48.9%). foods seem tasteless (45.8%). dif-
ficulty getting to the store (32.1%).and like taste of junkfooddifficulty chewing
(tied at 27.5%)(see Table 2).
From stepwise multiple regression analyses, it was found that the sources of
nutrition-efficacy variables accounted for 50 percent of the variance in nutri-
tional risk as measured by NRI, 36 percent of the variance in nutritional risk as
0

SOURCES OF NUTRITION-EFFICAC‘

Mealtime rncdelinq

Shared meals each day

Household sue

I Nutritional Risk Index

Verbal s u ~ w r l
r (Wolinsky et al., 1985)
NUTRITION-EFFICACY
People to whom talk each day
Hours talk each day
Confidants Perceived Nutrition Barriers
(Cronbach’s alpha = .76) Nutritional Screening Initiative
(White et al , 1991)
Phvsiolwical factors

Age
Body mass index (kglm’)
Medications each day Seven-high-risk-nutrients
Disability program participation consumed less than 50% RDA
Negative affect
zinc
iron
calcium
Nutrition habits
folic acid
riboflavin
Number of daily foods
lhiamin
Use of meal services
vitamin E

Figure 1. Path analysis model used for each of three measures of nutritional risk (NRI, NSI, seven-high-risk-nutrients),
with Social Cognitive Theory sources of nutrition-efficacy sewing as predictor variables, and nutrition-efficacy
sewing as a mediating variable (measured by Perceived Nutrition Barriers).
312 / HENDY, NELSON AND GRECO

measured by NSI, and 28 percent of the variance in nutritional risk as measured

by seven-high-risk-nutrients. When measured with NRI, greater nutritional risk
was associated with greater household size, fewer meals shared, fewer con-
fidants, more medication, more negative affect, and less daily food variety
(Table 3). When measured with NSI, greater nutritional risk was associated with
more medication, more negative affect, and less daily food variety (Table 4).
When measured with seven-high-risk-nutrients, greater nutritional risk was asso-
ciated with more body mass and less daily food variety (Table 5).
From the simultaneous multiple regression analyses to compare general effi-
cacy (Perceived Control Scale) or nutrition-efficacy (Perceived Nutrition Bar-
riers) as predictors of nutritional risk, it was found that only nutrition-efficacy
significantly accounted for variance in the Nutritional Risk Index (beta = .38,
t(ss) = 2.67, p c .02).Similarly, only nutrition-efficacy significantly accounted for
variance in the Nutritional Screening Index (beta = .61, t(93)= 6.04, p c .OOOl).
However, neither nutrition-specific efficacy nor general efficacy accounted for a
significant portion of the variance in nutritional risk when measured as the
number of seven-high-risk nutrients eaten with less than 50 percent of the
Recommended Daily Allowance. As in the present results, past research also
finds that health outcomes are usually more related to health-specific efficacy
than to general efficacy (Ajzen & Timko, 1986; Bausell, 1986; Beny & West,
1993; Duncan et al., 1993; Gistand & Mitchell, 1992; Kaplan, Atkins, Reinsch,
1984; Lee, 1992; Lust, Celuch, & Showers, 1993).
In the path analysis for nutritional risk measured with NRI (Table 3), it was
found that household size, shared meals, confidants, medications, and daily food
variety all remained significant direct predictors of NRI even with nutrition-
efficacy (PNB) entered first as a possible mediating variable. Negative affect,
however, was no longer a significant predictor when nutrition-efficacy (PNB)
was entered first into the regression equation, indicating that negative affect has
only an indirect relationship to nutritional risk (via PNB). With both nutrition-
efficacy (PNB) and the set of significant sources of nutrition-efficacy in the
regression equation, 58 percent of total variance was explained for nutritional
risk measured by NRI.
In the path analysis for NSI (Table 4), medications and daily food variety both
remained significant direct predictors of NSI even with nutrition-efficacy (PNB)
entered first as a possible mediating variable. As with NRI, negative affect lost
significance as a predictor of NSI when nutrition-efficacy (PNB) was entered
first into the regression equation, indicating that negative affect has only an
indirect relationship to nutritional risk (via PNB). With both nutrition-efficacy
(PNB) and the set of significant sources of nutrition-efficacy in the regression
equation, 49 percent of total variance was explained for nutritional risk measured
by NSI.
In the path analysis for nutritional risk measured as the number of seven-high-
risk-nutrients consumed less than 50 percent RDA (Table 5 ) , body mass index
 NUTRITIONALRISK IN RURAL ELDERLY I 313

Table 3. Multiple Regression Results for Social Cognitive Theory

(Bandura, 1986,1997)Predictors of Nutritional Risk Measured
by NutritionalRisk Index (NRI, Wolinsky et al., 1985)”b
(Directly)’ (Via Nutrition-Efficacy)b
Variable beta t p beta t P
NUTRITION-EFFICACY
Perceived Nutrition Barriers .48 4.80 .0001

SOURCES OF
NUTRITION-EFFICACY

Mealtime modeling
Shared meals each day -.36 3.59 .0007 -.39 4.21 .0002
Household size .22 2.22 .03 .23 2.49 .02

Verbal support
People to whom talk
each day
Hours talk each day -.28 3.22 .003 -.31 3.78 -0004
Confidants

Physiological factors
Age
Body mass index (kg/m2) .36 3.88 .0003 .27 3.13 .003
Medications each day
Disability program
participation .23 2.58 .02 (ns)
Negative affect

Nutritionhabits -.20 2.34 .03 -.18 2.17 .04

Number of daily foods
Use of meal services

total ?t = 5 0 total $-= 58

66.67) = 11.12 67.66) = 13.02
p < .0001 p < .0001
’Results of stepwise multiple regression considering sources of nutrition-efficacyas direct
predictorsof NRI.
bResults of simultaneous multiple regression considering significant sources of nutrition-
efficacy (from ? as indirect predictorsof NRI when mediated by nutrition-efficacy(Perceived
Nutrition Barriers), entered first into the equation.
314 / HENDY, NELSON AND GRECO

Table 4. Multiple Regression Results for Social Cognitive Theory

(Bandura, 1986, 1997) Predictors of Nutritional Risk Measured by
Nutritional Screening Index (NSI, White et al., 1991)”’
(Directly)’ (Via Nutrition-Efficacy)’

Variable beta t p beta t P

NUTRITION-EFFICACY
Perceived Nutrition Barriers 59 8.21 .0001

SOURCES OF
NUTRITION-EFFICACY

Mealtime modeling
Shared meals each day
Household size

Verbal support
People to whom talk
each day
Hours talk each day
Confidants

Physiological factors
Age
Body mass index (kg/m2)
Medications each day .45 6.06 .0001 .35 4.78 .0001
Disability program
participation
Negative affect .22 2.93 .005 (ns)

Nutrition habits
Number of daily foods -.23 3.21 .002 -.19 2.79 .007
Use of meal services
total /? = 3 6 total R2 = .49
63.127) = 23.68 64.110)= 26-86
p c .0001 p c .0001
‘Results of stepwise multiple regression considering sources of nutrition-efficacyas direct
predictorsof NSI.
*Results of simultaneous multiple regression considering significant sources of nutrition-
7
efficacy (from as indirect predictors of NSI when mediated by nutrition-efficacy(Perceived
Nutrition Barriers). entered first into the equation.
 NUTRITIONAL RISK IN RURAL ELDERLY I 315

Table 5. Multiple Regression Results for Social Cognitive Theory

(Bandura, 1986, 1997) Predictors of Nutritional Risk Measured by Number of
Seven-High-Risk-Nutirents Consumed at Less than 50% RDAaPb
(Directly)a (Via Nutrition-Efficacy)b

Variable beta t p beta t P

NUTRITION-EFFICACY
Perceived Nutrition Barriers

SOURCES OF
NUTRITION-EFFICACY

Mealtime modeling
Shared meals each day
Household size

Verbal support
People to whom talk
each day
Hours talk each day
Confidants

Physiological factors
Age
Body mass index (kg/m2) .21 2.51 .02 .21 2.44 .02
Medications each day
Disability program
participation
Negative affect

Nutrition habits
Number of daily foods -.44 5.29 .0001 -.44 5.21 .0001
Use of meal services
~ ~~

total $ = .28 total = .29

R2.107) = 212 3 f(3.106) = 14.17
p < .0001 p < .0001
'Results of stepwise multiple regression considering sources of nutrition-efficacy as direct
predictors.
bResultsof simultaneous multiple regression considering significant sources of nutrition-
efficacy (from 4 as indirect predictors of seven-high-risk-nutrientsmediated by nutrition-
efficacy (Perceived NutritionBarriers), entered first.
316 / HENDY, NELSON AND GRECO

and daily food variety both remained significant direct predictors of nutri-
tional risk even with nutritionefficacy (PNB) entered first as a possible
mediating variable. With both nutrition-efficacy (PNB) and the set of significant
sources of nutrition-efficacy in the regression equation, 29 percent of the
variance was explained for nutritional risk measured by seven-high-risk-
nutrients.

DISCUSSION
Social Cognitive Theory (Bandura, 1986, 1997) appears to be a useful model
to explain nutritional risk in rural elderly adults. Sources of nutrition-efficacy
accounted for between 29 percent and 58 percent of the variance in three
measures of nutritional risk, either directly or indirectly via nutrition-efficacy,
measured by the new scale of Perceived Nutrition Barriers. (See summary of
path analyses in Figure 2.) In addition, all of the four sources of nutrition-
efficacy predicted by Social Cognitive Theory were represented among signifi-
cant predictors of nutritional risk.

MealtimeModeling
The number of shared meals each day was a significant predictor of nutritional
risk, measured with the Nutritional Risk Index, a finding similar to that of past
research with elderly adults (Mahajan & Schafer, 1993; McIntoch, Shifflet, &
Picou, 1989; Smith, 1994; Walker & Beauchene, 1991). A surprising finding was
that the larger the household size, the greater the nutritional risk when measured
with the Nutritional Risk Index. However, past research has shown that poor
nutritional models may worsen nutrition and other health care behaviors (Burg
& Seeman, 1990; Rook, 1992; Smith, Holcroft, & Marien, 1994). Future
research could examine the nutrient quality of foods being purchased, prepared,
shared, and modeled by all household members.

Verbal Support
The number of confidants was a significant predictor of the Nutritional Risk
Index. Furthermore, the quality of verbal support (number of confidants) was a
better predictor of nutritional risk than was the quantity of verbal support (num-
ber of people to whom talk, hours talked). Past research has also found that the
perceived quality rather than quantity of social support is the better predictor of
a variety of health outcomes (Antonucci & Johnson, 1994; Cohen & Wills, 1985;
Delongis. Folkman. & Lazarus, 1988; Sarason & Sarason, 1994; Seeman &
Berkman, 1988). Future research might consider more nutrition-focused verbal
interactions, such as recommendations to try certain foods, warnings to avoid
other foods, and from what sources these persuasions about food come (family,
friends, magazines, television, health care professionals, etc.).
 NUTRITIONAL RISK IN RURAL ELDERLY I 317

NUTRITION
SOURCES
OF

EFFICACY
I NUTRITION
EFFICACY 'R
.58

.50
>

1 35
SOURCES
I
I I
NUTRITION
OF
EFFICACY
NUTRITION NSI

-U
EFFICACY

.36

SOURCES

OF
EFFICACY
NUTRITION HIGH-RISK

-I
EFFICACY NUTRIENTS

.28
318 / HENDY, NELSON AND GRECO

Physiological ConditionsThat May Affect Nutrition

Body mass index was a significant predictor of seven-high-risk-nutrients, and
daily medications and negative affect were significant predictors for both the
Nutritional Risk Index and the Nutrition Screening Initiative. In past research
with elderly adults, reduced diet quality has also been found associated with the
use of many medications (McIntosh, Shifflet, & Picou, 1989). Future research
might examine how type of medication, especially medication for negative
affect, can influence diet quality and perceived nutritional barriers of rural
elderly adults. For example, would elderly adults who receive counseling for
negative affect show better diet quality and fewer perceived nutrition barriers
than elderly adults whose negative affect was treated only with medication?
Future research could also examine functional health status more precisely than
in the present study (Johnson & Wolinsky, 1993), to discover the particular
ADLs most closely associated with nutritional risk in rural elderly adults, and to
design effective nutrition intervention programs.

NutritionHabits
Number of foods eaten in a typical day was a significant predictor for all three
measures of nutritional risk used in the present study: Nutritional Risk Index,
Nutritional Screening Initiative, and seven-high-risk-nutrients. Surprisingly, use
of formal meal services was not significantly related to nutritional risk as
measured in the present study. Perhaps meal service programs as presently
offered by human service agencies (food stamps, Meals-on-Wheels, Senior
Center meals) could be redesigned to provide greater opportunities for shared
meals and confidants, factors which were predictive of nutritional risk. For
example, Meals-on-Wheels volunteers could offer to stay and share a meal with
an isolated elderly adult, rather than dropping off food and leaving the elderly
adult to eat it alone. Future research could examine characteristics of elderly
adults who benefit most from such formally provided social support, including
age, gender, ethnic group, and especially perceived health status (Johnson &
Wolinsky, 1993).
The new nutrition-efficacy measure of Perceived Nutrition Barriers accounted
for 35 percent of the variance risk as measured by the Nutritional Screening
Initiative (R2= .35; F(1.126)= 67.45; p < .OO01), and 23 percent of the variance
for nutritional risk as measured by the Nutritional Risk Index (R2= .23; F(i.78) =
23.00, p c .OO01). It is not known why the Perceived Nutritional Barriers
measure was not significantly related to nutritional risk measured by seven-high-
risk-nutrients consumed at less than 50 percent RDA (R2 = .01; F(1,120) = 1.61;
p < .21). The measure was based on a twenty-four-hour food recall, for which
most of the elderly participants in the present study appeared to have a clear
memory. (Only 10 participants, 1 man and 9 women, reported that they could not
recall all foods and beverages consumed in the past 24 hours.) In addition, the
 NUTRITIONAL RISK IN RURAL ELDERLY I 319

seven-high-risk-nutrients measure was only calculated if the participant reported

that foods were typical for them. However, future research to examine Perceived
Nutrition Bamers as a predictor of daily food intake might consider more than
one twenty-four-hour recall and include collaborative evidence (from household
members, refrigerator and cupboard samples, etc.).
Future research might also consider gender differences in nutritional risk
among rural elderly adults. Among young adults, women are consistently found
to be at greater risk than men for developing eating disorders (Dolan &
Gitzinger, 1994; Fallon, Katzman, & Wooley. 1994; Garner, Garfinkel, Schwartz,
& Thompson, 1980; Hsu, 1989; Rolls, Fedoroff, & Guthrie, 1991). Similarly,
past research has found elderly women to be at greater nutritional risk than men
(Mahajan & Schafer, 1993; Posner et al., 1994). In the present study, the only
measure of nutritional risk to show a gender difference was the Nutritional
Screening Initiative (t = 2.30, df = 147, p < .03), with the elderly women show-
ing greater nutritional risk than the elderly men (mean = 5.6; SD = 3.8; mean =
4.1, SD = 3.0; respectively). Future research might examine larger samples of
elderly adults than that of the present study in order to conduct separate multiple
regression analyses for men and women and compare them for Social Cognitive
predictors of nutritional risk. Besides physiological differences between men and
women that could have an impact on their nutritional risk (medications, body
mass, negative affect, etc.), gender differences are likely in social cognitions
associated with food. For example, women often perceive themselves as the
“nutritional gatekeepers” of their households, especially older women and
women in rural areas with more traditional gender role expectations (Brannen,
Dodd, Oakley, & Storey, 1994; McIntosh & Zey, 1989; Stoller & Lee, 1994), so
they may be more troubled by any drop in their perceived nutrition-efficacy to
provide nutritious meals for themselves and their households.
Another limitation of the present sample is that it includes primarily white,
low-income, rural participants with little formal education beyond high school.
Past research has shown all of these variables to be related to nutritional risk.
For example, African-American and Hispanic elderly adults may be at greater
nutritional risk than white elderly adults (Burt, 1993; Parker, 1992), low-income
elderly adults are usually at greater nutritional risk (McIntosh, Shifflett, & Picou,
1989), rural elderly adults may be at greater nutritional risk than urban or sub-
urban elderly adults (Coward, Bull, Kukulka, & Galliher, 1994), and elderly
adults with the least education are often at greatest nutritional risk (Holcomb,
1995). Although these variables are not suggested as predictors of nutritional risk
by the Social Cognitive model used to guide the present study (Bandura, 1986,
1997), future research should consider whether the present results generalize to
larger samples of elderly adults with increased ethnic, income, regional, and
educational diversity.
Although the variables examined with multiple regression in the present study
are referred to as “predictor variables” for the nutritional risk measures, the
320 I HENDY, NELSON AND GRECO

present interview approach can only determine correlations among variables, not
causdeffect directions. For example, it remains unclear from present results
whether many medications, large body mass, few shared meals, few confidants,
and little daily food variety caused an increase in nutritional risk for the elderly
participants of the present study, or whether their nutritional problems caused
changes in these variables. A more experimental approach would be needed to
determine the causdeffect direction of these variable relationships and to answer
the question of whether the significant “predictors” of nutritional risk found in
the present study cause changes in nutritional risk for rural elderly adults.
Future research could begin nutrition intervention programs for rural elderly
adults based on significant Social Cognitive Theory sources of nutrition-efficacy,
and from Perceived Nutrition Barriers mentioned most frequently. From the
significant Social Cognitive predictors of nutritional risk found in the present
study, nutrition intervention programs for rural elderly adults should encourage
opportunities for food variety each day, shared meals, opportunities to develop
close confidants, reduction of obesity and negative affect, and close monitoring
for detrimental effects of medications on nutrition (e.g., changes in appetite, taste
sensitivity, digestion). From the top five Perceived Nutrition Barriers found in
the present study, nutrition intervention programs for rural elderly adults should
include opportunities for shared meals, transportation to the store, reduced food
costs, regular dental checkups, and enhanced food flavor.
Thus, preliminary suggestions for nutrition intervention programs for rural
elderly adults include:
1. Regular medication reviews, dental checkups, and counseling options
discussed by the elderly adult and hisher health care professionals to closely
monitor and plan for the effects that daily medications, obesity, chewing diffi-
culty, and negative affect may have on appetite, taste perception, ability to
prepare meals, or digestion;
2. Two-person pot luck dinner clubs, held in the homes of elderly adults and
designed to encourage shared transportation, food costs, meal preparation, food
variety, and opportunities for confiding in one another. Menus for pot luck club
meals could be chosen by participants, with encouragement that they include
at least one item from each basic food group (grains, milk products, fruits or
vegetables, meat or meat substitutes), that each participant contribute something
to the shared meal, and that each participant agree to try at least one new food
during each pot luck meal.
To build nutrition confidence in rural elderly adults, it is recommended that
health care professionals encourage empowerment, choice, and co-management
of their own health care (Baker & Pallett-Hehn, 1995; Beckingham & Watt,
1995). In addition, pot luck clubs or other efforts to share meals should
emphasize the reciprocity of benefits so that rural elderly adults do not perceive
themselves as passive recipients of care (Field, Minkler, Falk, & Leino, 1993;
Roberto, 1989; Stoller & Lee, 1994). Such nutrition intervention efforts could
 NUTRITIONAL RISK IN RURAL ELDERLY I 321

be compared to waiting-list control groups for their long-term effectiveness in

improving diet, nutrition-efficacy, health care costs, and quality of life for rural
elderly adults.

ACKNOWLEDGMENTS
For participant recruitment, we wish to thank Marie Beauchamp and Carol
Bowen of the Schuylkill County Office for Senior Services, Teddi Cunningham
of Schuylkill County Meals on Wheels Program, Marie Wanchick of the
Schuylkill County Housing Authority, and Timothy Nagle of the Anthracite
Center for Independent Living, Pennsylvania. We also thank Diane Woznicki,
R.D. and Lauren Hartle for nutritional consultation. In addition, Allen Hendy,
M.D., Margaret Hendy, M.D., and Bryan Raudenbush, Ph.D. gave helpful
comments during preliminary studies. Finally, thanks are given to Kimberly
Kopko, Patricia Blakeslee, Julie Pritiskutch, Elmer Lazar, and Connie Heffner
for serving as interviewers.

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