The senior gardening and nutrition project: Development and transport of a dietary behavior change and health promotion program

Programs for Older Adults in Nutrition and Health Education RESEARCH ARTICLE

I

The Senior Gardening and Nutrition Project: Development and Transport of a Dietary Behavior Change and Health Promotion Program ROBERT 1

M.

HACKMAN, 1, 2 AND ELIZABETH

L. W AGNER 2

College of Human Development and Performance, University of Oregon, Eugene, Oregon 97405; and 2 Health Promotion Associates, Inc., Portland, Oregon 97202

ABSTRACT

A nutrition education-through-gardening program was conducted to encourage dietary behavior change and to promote psychological well-being among seniors. The model is based on psychosocial theories of perception of control and social support. The five-month intervention consisted ofweekly contact with the participants, with one bimonthly group meeting on nutrition, one bimonthly group meeting on gardening, and two individual visits at participants' homes each month. A raised garden box was provided for growing vegetables. The intake of food in targeted categories was encouraged through lectures, discussions, behavior self-monitoring cards, goal setting, and social interactions. Pre- and post-test measures of dietary behaviors and attitudes related to nutrition and to gardening were collected. The project was conducted at an initial location and then replicated in the second year at two other sites. Significant changes in the intake of food in targeted categories were noted at all locations and scores on attitudinal measures also improved among seniors at all sites. Similar changes in dietary behavior and attitudinal scores across the three programs suggest the appropriateness of this program for a variety of settings. aNE 22:262-270, 1990)

cessful, leaving educators and health profeSSionals with the great challenge of designing and implementing effective dietary behavior change interventions with seniors (1). One avenue for developing effective nutrition education programs for seniors may be to recognize the value of the context and the process by which information is communicated. Like the rest of us, most seniors already possess a great deal of nutrition information that they don't put into practice. Simply conveying more facts without giving attention to the motivational process often overloads an older learner. Emerging health-promotion models stress the importance of the educational process in communicating nutrition information and suggest a direction for designing effective interventions (2). Older people pursue their daily lives in a context related to their own past life experiences, as well as to their current situation. Achterberg notes that "meaningful learning is more likely to occur in an interactive context that fosters positive feelings" (3, p. 180), and that "learning in one context can affect learning in another context, especially if these contexts generate the same kind of feelings" (3, p. 180). She suggests that more emphasis be placed on holistic and qualitative research designs and on evaluations that recognize context, and that future research be conducted in "ecologically valid or natural" settings (3). Gerontologists have suggested for some time that the durability of cognitive and health behavior changes are proportional to the degree of active, rather than passive participation of the older learner (1). These elements suggest the use of an educational framework that involves participants in contributing their knowledge, life experiences and wisdom, enlisting them in the change process, and creating a dynamic and positive context in which to learn good nutrition. While most psychosocial research on older people has

INTRODUCTION Educational programs that encourage older people to choose health-promoting diets and enhance their psychological well-being may represent one of the next major advances in health care. Previous nutrition education programs for seniors have involved didactic education, distribution of pamphlets and brochures, the provision of meals, or authoritative counseling from a doctor or dietitian. These attempts at helping older people make lasting dietary changes have generally proved unsucAddress for correspondence: Robert M. Hackman, Ph. D., Associate Professor of Nutrition, 250 Esslinger Hall, University of Oregon, Eugene, OR 97403-1273; (503) 346-5706. 0022-3182/90/2206-0262$02.00/0 © 1990 SOCIETY FOR NUTRITION EDUCATION 262

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focused on morbidity and mortality, some models have examined aspects of function and well-being among disease-free seniors. Two dimensions that have been proposed as fundamental for successful aging are perception of control and social support (7). Perception of control. A sense of control may be one of the most important elements influencing an older person's health choices and health status (5). Perception of control, or the belief that one can exercise personal choice (6), creates a sense of competence, usefulness and purpose. Many seniors learn to feel and act helpless as a result of repeated experiences in situations in which the outcomes are independent of their behavior (7). Life events often affect perceived competence and control. Examples include the loss of role as parent and provider, the loss of self-identification through work, the disappearance of friends and reference groups through death, the experience of having a limited income, and developing physical limitations. This feeling of helplessness, which is learned from experiencing a real inability to control certain situations, often generalizes to other situations where control is possible, as with food choices (8). Learned helplessness and the lack of a perception of control have been found to correlate with the incidence of illness among older persons (9). For example, nursing home residents given even limited control over the care of a houseplant in their rooms, showed improvement on physical and mental health indices, compared with those who were also given a houseplant but were not allowed to make decisions about its care (10). Social support. Social support has been defined as "the set of personal contacts through which the individual maintains his [sic] social identity, and receives emotional support, material aids, services, information, and new social contacts" (11, p. 35). Social support appears to be an essential component of methods that produce lasting changes in health behaviors, and also seems to affect health indirectly by improving psychological well-being and by buffering the physiological effects of life stress (12). While the family plays an important role in the social support of older persons, peer networks also make a critically important contribution to social support and to health maintenance (13). Health-focused workshops that involve active participation furnish social support in addition to the more concrete objective of providing health education. Evaluation of the federally-funded congregate meal programs for seniors has shown that social, psychological, and physical activity improvements may be their main benefits, overshadowing the directly targeted nutritional benefits (14). Social support may also be a key factor in attracting older people to group programs and in minimizing attrition.

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Gardening and nutrition education. One way to incorporate perception of control and social support into a nutrition education program for older people is through gardening. Since older people rank gardening as their second most popular activity, behind "socializing with friends" (15), a gardening program can provide the type of supportive atmosphere and context in which a variety of health and psychosocial concerns can be directly and indirectly addressed (16). A gardening program that emphasizes a health-promoting diet can foster personal growth and optimism about the future. While gardening for seniors has been proposed as a means of improving the availability of nutritious foods for this group (17, 18), most information available on gardening does not specifically address its use as a potential tool for improving dietary behaviors. Therapeutic horticulture typically has been used with special institutional and non-institutional populations to influence the health and psychological well-being of participants (19, 20). If horticulture is an effective therapy for helping people with illness and disability, the approach also may aid relatively healthy persons to achieve an optimal state of health. This paper summarizes the demonstration and assessment of a nutrition education-through-gardening program with seniors, measuring pre- to post-test changes of dietary behaviors and psychological well-being. After a year of pilot work, the program was conducted over two gardening seasons in three different locations, a medium-sized metropolitan area in Oregon, a small Pennsylvania town economically depressed since the closure of its main industry ten years ago, and a large urban senior center in Pennsylvania. METHODS YEAR 1: Fifty-Six subjects in Oregon were selected from volunteers identified through referrals made by people familiar with the project and by senior services personnel. Admission criteria included owning one's own home, being over 62 years of age, not having grown a vegetable garden for at least the previous three years, and being able to make a commitment to attend ten bimonthly group meetings and to participate in ten bimonthly home visits over a five month period. These criteria identified seniors most likely to be affected by a gardening and nutrition intervention, and who would be likely to continue to use the garden box in future years. Thirty-four single people and eleven couples participated in the program, which was supported by grant funds and was, therefore, free to participants (21). Forty-five "benchboxes" were built in the yards of the participants. Because many older people experience difficulty bending, twisting, reaching, squatting, kneeling or standing for extended periods of time, the wooden-

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framed box was specially designed to allow seniors to sit on the bench seat and still be able to reach all parts of their garden easily. The benchbox had interior dimensions of 10 feet by 3 feet and was 17 inches in height, with a 6-inch wide bench top around the entire perimeter. The box was filled with a rich planting mixture. Beginning in early May, and extending through the end of September, 9O-minute meetings were held every other week at a local senior center. The first meeting each month covered nutrition topics and the second covered gardening topics. Separate meetings were used to conduct nutrition interventions without potential educational confusion arising from overlapping gardening topics. The nutrition meetings were led by the principal investigator, a University nutrition professor. The gardening classes were taught by a Master Gardener from the county Cooperative Extension Service. Home visitors were university students majoring in either health education or gerontology. Staff salaries were supported by grant funds. Intervention design. The nutrition classes were conducted in a facilitative manner, based on the principles of enhancing perception of control and social support. The content of the nutrition education component targeted seven nutritional areas for improvement: dairy products, Vitamin C-rich foods, iron-rich foods, dark green leafy vegetables, water, fiber from fruits and vegetables, and fiber from whole grains and dried beans. Only the minimum amount of information considered to be prerequisite for behavior change was presented for each nutrient. The information for each target nutrient category addressed two questions: 1) "Why is this nutrient important to my health?", and 2) "What are some practical changes I could make to include enough of this nutrient in my diet?" The format of the nutrition meetings allotted 30 minutes each to three key elements of the educational intervention: a) providing nutrition information, b) developing an action plan to implement dietary improvements, and c) sharing successes and brainstorming ways to help each other eat well. Group discussion and partner dyads were utilized in each class. A large-print nutrition workbook contained the information covered in the lectures and included motivational activities, such as goal setting sheets developed in our laboratory (22) and recipes emphasizing foods from the targeted categories. A series of four "Nutrition Bingo" cards, graphically depicting food categories and the suggested number of daily servings for each ofthe target nutrient groups (23), was distributed at each monthly nutrition meeting. Participants used the cards as a daily checklist to monitor the number of servings from the target nutrient categories. A recipe from the workbook was prepared for each of the first four nutrition meetings, which concluded with a tasting of the food. The final meeting was highlighted by a garden

harvest potluck meal to which the senor gardeners brought food prepared with ingredients from their gardens. Staff monitoring showed that 90% of the food brought to the potluck reflected one or more of the nutrition principles taught in the program. The nutrition meetings were designed to encourage participants to eat a health-promoting diet while also building a sense of confidence and competence as well as a future commitment to eating well and staying healthy. The interventions in this program were conducted predominantly in a facilitative manner. Content information was imparted by the nutritionist, who also led discussions in a way that helped the senior gardeners draw their own conclusions and enhanced their feelings of responsibility, competence, knowledge and experience. Seniors designed personal dietary goals, then voiced a commitment to their goal, assessed their chances of reaching that goal, and identified whom they would ask to help them. Monthly gardening classes provided technical information for the appropriate stage of the season, and were taught primarily in a didactic manner. Topics included planning and planting the bench box, watering, fertilizing, pest control, composting, fall/winter gardening, and future planning and soil maintenance. Seeds and seedlings, donated by local merchants, were distributed free of charge at the end of each meeting. From May to early October, a staff member visited each gardener's home twice a month. The home visit was an integral component of the intervention and was designed from the same model as the nutrition meetings to provide seniors with social support and encouragement to eat foods from the seven targeted categories, and to assist and advise on the progress of the gardens. The home visitors were university students who received extensive training in implementing the intervention model, and who met weekly with the principal investigator to review and maintain standardization of the home visit procedure. Measurements. Data collection involved demographic information and pre- and post-intervention measurements of dietary behavior and psychosocial attitudes related to nutrition and to gardening. Body weight and blood pressure measurements were taken at rest by a registered nurse. Each person was interviewed extensively by a trained staff member regarding a typical weekly dietary intake, with information recorded on a food frequency questionnaire. The interview and food frequency instrument obtained specific information regarding foods consumed in the seven target nutrient categories. Psychological and attitudinal parameters were assessed for both nutrition and gardening, using scales adapted from activity and psychosocial attributes measures (24, 25). The published instruments had been tested for validity in previous settings, and were pretested on a sample group of non-participating seniors prior to use

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Table 1. Changes in dietary intakes among seniors at Site A (n = 55).

Recommended # of servings (ADA exchanges)

6 4 4

2 2 1

Mean

Food Category

(ADA exchanges) (pre-test)

Mean # of servings (ADA exchanges) (post-test)

Water Dairy products Whole grains & starchy vegetables Vegetables & fruits' Iron-rich foods Vitamin C-rich vegetables/fruits Folic acid-rich vegetables

4.45 3.35 2.60

5.20 3.73 2.98

0.75** 0.38 0.38**

1.96

2.40

# of servings

Mean Difference

1.38 1.60

1.91

2.33

0.44** 0.53** 0.73**

1.22

1.47

0.25

** P ~ .01; differences between testing periods (paired Hest) , Not including vitamin C and folic acid-rich vegetables and fruits

in this study. The instruments were interviewer-administered to avoid reading and interpretation errors. Responses were scored using a 7-point Likert scale for each of four areas proposed by Ryan (24) as global factors suggestive of perception of control in numerous physical activities: 1) Perceived competence (e. g., "I think my eating habits are pretty good" or "I think I am pretty good at gardening"). 2) Interest and enjoyment (e. g., "I enjoy eating healthy food very much" or "I think gardening is enjoyable"). 3) Future orientation (e. g., "Will you try other types of healthy foods and activities when this project is over" or "Will you continue gardening when this project is over"). 4) Success attribution (e. g., "How important is good nutrition in your daily life" or "How important is gardening in your daily life"). YEAR 2: A process evaluation of Year 1 was the basis for some minor modifications in the design of the Year 2 intervention. The modified program was then implemented at two locations in a major metropolitan area of Pennsylvania. Site B was an economically depressed community whose main industry had closed ten years previously. Site C was a large, urban senior center. The authors trained staff members at each location regarding all aspects of the program developed in Year 1, and wrote a staff manual detailing the theoretical model and the nutrition education methods. Modeling, observation and feedback by the authors were used at the site visits as examples for practical implementation. Eligibility requirements were similar to those at site A, except that people over 60 years of age were admitted at site B and over 55 years of age at site C. Each month from May to September, one nutrition meeting, one gardening meeting and two home visits were conducted in a manner similar to that described above for site A. In addition, the meetings were followed by a meal in conjunction with the local senior lunch program at both sites Band C. Registered dieticians led the nutrition

meetings as outlined in the staff manual, and seniors received the nutrition workbook and Nutrition Bingo cards described above. Expert gardeners taught the gardening classes. At site B, the home visitors were paraprofessionals with experience in social work. The home visitors at site C were undergraduate nutrition students from a local university. The home visitors conducted interventions as described in Year 1, and received training from the authors and from project supervisors. In addition to the food frequency and psychological assessment described for site A, three pre- and three post-test impromptu 24-hour dietary recalls were obtained by the home visitors using a standardized interview method. The 24-hour diet recalls were added to the assessment in Year 2 in an attempt to more accurately determine food intake relative to food frequency data. No clinical measurements were taken. The 24-hour diet recalls were coded into the number of daily servings of seventeen different food categOlies using a system adapted from the American Dietetic Association/American Diabetic Association food exchange system (26). The coding system and food categories were developed by the authors (22). RESULTS AND DISCUSSION Demographics. For site A, all 55 seniors were Caucasian, with 14 males and 41 females participating. Twelve participants were couples (i.e., six married couples). The mean age of the subjects was 68.2 years, ranging from 62 to 81. The mean income was $14,200, ranging from $4,700 to $38,300. The 50 seniors from site B included 17 men and 33 women, all of whom participated individually. The sample was 60% black and 40% white, and had a mean age of 68. 9 years, ranging from 61 to 84. The mean income was $8,840, with a range from $980 to $20,000. Among the 36 seniors from site C were 10 men and 26 women, all enrolled in the program as individuals. The sample was 31% black and 69% white, with a mean

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Table 2. Changes in dietary intakes among seniors at Site B (n = 43). Recommended # of servings (ADA exchanges)

6 4 4 2 2 1

Food Category Water Dairy products Whole grains & starchy vegetables Vegetables & fruits' Iron-rich foods Vitamin C-rich vegetables/fruits Folic acid-rich vegetables

Mean # of servings (ADA exchanges) (pre-test)

Mean # of servings (ADA exchanges) (post-test)

Mean Difference

3.79 0.62 1.12

6.11 0.85 2.26

2.32** .23* 1.14**

2.66

1.41 1.38

3.05 1.50 1.51

.39 .09 .13

0.40

0.48

.08

* p s .05, ** P s .01; differences between testing periods (paired Hest) 1 Not including vitamin C and folic acid-rich vegetables and fruits

age of 64.8 years and a range from 56 to 80. The mean income was $11,960 and ranged from $4,200 to $40,000. Dietary behavior changes. Site A: At site A, the preto post-program changes in the self-reported dietary intake in the seven nutritionally targeted food categories showed a number of statistically significant changes in the desired direction based upon paired t-tests (Table 1). The intake of dairy products rose from an average of 3.35 to an average 3.73 servings per day. The intake of vitamin C-rich foods rose from 1.6 to 2.33 daily servings (p :5 .01). Folic-acid rich food intake increased from 1.2 to 1.47 average servings daily (p :5 .01), and iron-rich food consumption increased from 1.38 to 1. 91 daily servings (p :5 .01). Water intake increased from 4.45 to 5.2 servings per day (p :5 .01). Fiber intake from fruits and vegetables rose from 1. 96 to 2.4 daily servings (p :5 .01), and fiber intake from whole grains and beans increased from 2.6 to 2.98 average daily servings (p :5 .01). The reported pre-test intakes reflected a fairly well-balanced diet, and yet increases were still noted. While the increases in folic-acid rich foods may be related to the abundance of produce at the end of a gardening season, the other reported dietary changes are more general and are more likely to reflect the effects of the nutritional intervention. Site B: Pre- to post-program dietary changes for seniors at site B are shown in Table 2. A significant (p :5 .01) increase in the consumption of water was noted, rising from 3.79 to 6.11 servings per day. Increased water intake was the most common monthly goal set by participants. This change may have been aided by the summertime temperatures. Water quality in this community was poor, and many seniors chose to purchase bottled water as a means of supplying their needs. A significant (p:5 .05) increase in dairy products was also noted, rising from 0.62 to 0.85 portions per day. While statistically significant, the higher mean intake is still well below the four servings per day suggested in the program. The

findings might be explained by a significant incidence of lactose intolerance among blacks, which is higher than that of the general population. Interventionists, in subjective reports, have noted that a large number of blacks report that they do not tolerate dairy products. At the direction of the principal investigator, the curriculum and home visitors suggested alternative sources of calcium when dairy product intake was low. Alternative sources included dark green leafy vegetables and calcium supplements. Calcium was the only nutrient for which a supplement was suggested in the intervention. However, only two participants took calcium supplements, and the total calcium consumption remained lower than recommended. The findings suggest that project planners must be sensitive to the dietary practices of different ethnic groups. The consumption of whole grains and starchy vegetables showed a significant (p :5 .01) increase over the course of the project, rising from 1.12 to 2.26 servings per day. When refined and unrefined carbohydrates (i.e., all breads, cereals and starchy vegetables) were combined into a single group, a slight but nonsignificant increase in intake was noted, indicating a change from refined to whole grain foods. Other food categories, including vegetables and fruits, dark green leafy vegetables, legumes, and vitamin C-rich vegetables and fruits, showed slight increases in intake, but these changes were not statistically significant. Approximately 70% of the seniors in this group grew collard greens, which were not harvested until after post-test data collection. Thus, it is possible that the intake of dark green leafy vegetables might have been greater had the evaluation period been delayed. The food records showed that only one senior took vitamin supplements. The number of seniors taking nutritional supplements did not change over the course of the program. The relatively low number of people using supplements appeared to be due to a lack of perceived need, to limited financial resources to purchase such products, and to the emphasis on food sources of

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Table 3. Changes in dietary intakes among seniors at Site C (n = 17). Recommended # of servings (ADA exchanges)

6 4 4 2 2 1

Mean

# of servings

Mean

# of servings

Food Category

(ADA exchanges) (pre-test)

(ADA exchanges) (post-test)

Mean Difference

Water Dairy products Whole grains & starchy vegetables Vegetables & fruits' Iron-rich foods Vitamin C-rich vegetables/fruits Folic acid-rich vegetables

2.55 0.63 1.48

4.01 1.13 0.67

1.46" .50" - .82""

3.83 1.21 2.14

3.78 1.44 2.45

-.05 .23 .31

0.21

0.36

.15

"" p ~ .01; differences between testing periods (paired t-test) Not including vitamin C and folic acid-vegetables and fruits

1

nutrients in our intervention. A mean daily intake of 0.05 ounces of alcohol was found in the pre-test measures, and no one reported consuming alcohol at the post-test. Site C: Among seniors at site C, 17 completed threeday food records were obtained for the dietary analysis (Table 3). The absence of one of the three pre- or three post-program diet recalls was a criterion for exclusion of the records from the analysis. Problems in coordinating the data collection by staff members resulted in a number of incomplete records. A significant (p :5 .05) increase in water intake was noted, rising from a mean of 2.55 to a mean of 4.01 servings per day. Considerations for explaining this change are similar to those noted above. Dairy intake also rose, from 0.63 to 1.13 servings per day, which was statistically significant (p :5 .05). As with site B, the intake of dairy products and calcium supplements among this group was still well below the suggested intake. There was a statistically significant (p :5 .05) decrease in the intake of all breads, cereals, and starchy vegetables, from 5.39 to 4.57 servings per day. Since the program recommended four servings of whole grains, dried beans and starchy vegetables, the decline noted here is consistent with the suggestions. However, the intake of whole grains and starchy vegetables also dropped, from 1.48 to 0.67 servings per day (p :5 .01), with no apparent explanation. No statistically significant changes were reported for the remaining food categories. The reported intake of all vegetables and fruits, and of vitamin C-rich vegetables and fruit, was high at the pre-test, and this intake was maintained for the duration of the study. No one reported taking vitamin or mineral supplements before or after the program. A mean daily alcohol intake of 0.15 ounces was reported for the pre-test. No alcohol intake was reported for the post-test.

Attitudinal changes. Pre- to post-program changes in nutritional attitudes and in gardening attitudes were analyzed using paired t-tests, assessed from responses to a

7-point Lickert scale, with 7 being strongly positive. At site A, the mean nutritional attitude score rose from 5.11 to 5.86 (p :5 .01; Table 4), and the mean gardening attitude score rose from 4.68 to 5.72 (p :5 .01; Table 5). Analysis of variance with repeated measures was also conducted for each subscale for the pre- and post-test values. The tests showed statistically significant improvements in attitudes and perceptions related to both the nutritional and gardening dimensions of interest and enjoyment, future orientation, perceived competence, and success attribution. The psychological outcome measures closely followed the qualitative evaluations obtained from a consistent interview process by the home visitors, and from anecdotal observations. Among seniors at site B, statistically significant improvements were noted from the nutrition attitude inventories, with the mean score rising from 5.29 to 5.99 (p :5 .01; Table 4). Seven post-program records were unavailable for the final analysis due to incomplete collection procedures. Qualitatively, participants generally reported more confidence in their ability to structure a health-promoting diet, and that they were looking forward to eating well in the future. No significant changes were noted in gardening attitudes from this group (Table 5). Post-project interviews suggested that most seniors perceived that their ability to garden remained the same throughout the program, and that the benchbox simply allowed them to take action with their existing skills. Among seniors at site C, an improvement in nutritionrelated attitudes was noted, with the mean score rising from 5.08 to 5.50, which was statistically significant (p :5 .01; Table 4). A statistically significant improvement in gardening-related attitudes was also found, with the mean score increasing from 4.60 to 5.61 (p :5 .01; Table 5). For the seniors at site A, no significant change in mean body weight from the beginning to the end of the project was found. No significant changes in either systolic or diastolic blood pressure in the group were detected. Pre-

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Table 4. Changes in nutrition attitudes among senior gardeners at three testing sites.'

Site A Site B Site C

n

Mean Pre

SEM.

Mean Post

55 43 29

5.11 5.29 5.08

0.11 0.10 0.12

5.86 5.99 5.50

SEM. 0.10

0.06

0.12

Mean Difference 0.75** 0.70** 0.42**

, Responses based on a 7-point Likert scale, with a score of 7 being strongly positive. The mean scores represent attitudes related to perceived competence, interest and enjoyment, future orientation and success attribution. ** p s .01; differences between testing periods (paired Hest)

test measures showed only seven people with clinically elevated systolic values, and none with clinically elevated diastolic values. These parameters were not assessed among seniors at sites Band C due to a lack of trained personnel and reliable equipment. The seasonality of the intervention may account for some of the changes noted here. With a garden harvest available in late summer, seniors may eat better then than in the early spring. Heating bills are generally lower in late summer than in early spring, which could result in more money being available for the purchase of groceries. However, some changes in dietary behaviors found in both years seem independent of seasons, such as the increase in the intake of dairy products noted in all three interventions. The reported attitude changes related to healthy eating practices and future gardening actions may also be seasonal since a season of gardening activity might influence one's motivation toward food choices. At site A, it was found that of the sixteen senior gardeners interviewed a year after their involvement in the project, fourteen continued to garden and to maintain at least one of the improvements in their diet that they began during the project. Replicability of the program is suggested by the consistency of the dietary and attitudinal changes across all three sites. The intervention and evaluation also varied among sites, owing to the challenges of training different staff and monitoring their progress from a distance. For example, staff problems made the evaluation of seniors at site C more difficult than expected, and resulted in a lower number of completed records than the number of seniors enrolled in the program. With additional training and monitoring, and a lessened need to quantitatively evaluate program outcomes, future staffing difficulties may be alleviated. By developing strategies to help older people move beyond their real or perceived limitations through community participation and by sharing their own insights and wisdom, seniors may begin to develop new beliefs in their ability to make personal changes. Once they feel empowered with a renewed ability to prevent recurring problems, they may go on to experience an improved quality of life, community connectedness, and self-development. Friere has developed an empowerment model as a basis for behavior change (27). His major construct holds that education is an active and dynamic process

that takes place in the context of people's lives, and that true learning requires action. In this sense, knowledge does not come from listening to expert professionals expound upon the information they possess, but rather derives from group members sharing their experiences and from the positive effect of such social influences on their lives. Friere's approach has been applied to nutrition education efforts with notable success (28, 29), and is further illustrated here. The symbolic aspects of a nutrition education-throughgardening program are suited for incorporating the theoretical components of perception of control and social support. In gardening, participants can view their achievements as a result of their own efforts and capabilities. Opportunities to experience choice and control are numerous, such as in the selection of plants to be grown and in the design of the garden. The frequent rewards of gardening, both immediate and delayed, enhance a perception of control as participants see their actions yield desired and predictable consequences. Quickly maturing plants, such as radishes, assure the excitement of something happening immediately. The anticipation of an abundant harvest creates joy and a sense of responsibility and accomplishment. Gardening can rekindle the older person's interest in the future through anticipating the germination of a seed or the taste of a vine-ripened tomato at harvest (30). With an interest in the future, one's commitment to eating well may become substantially enhanced. The multifaceted nature of the intervention is useful for demonstrating the feasibility of programs affecting dietary and attitudinal changes among seniors. More rigorously controlled studies may further explain the relative influence of the various components of the program by separately testing the impact of facilitative nutrition meetings, gardening, and home visits, and comparing the outcomes with a control group. This would enable the most cost-effective intervention to be designed for future use. Extensive dietary and psychological evaluations, both quantitative and qualitative (31), may add further insight to the findings reported here.

CONCLUSIONS Experiences that provide a perception of choice, control,

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Table 5. Changes in gardening attitudes among senior gardeners at three testing sites.'

Site A Site B Site C

n

Mean Pre

S.E.M.

Mean Post

S.E.M.

Mean Difference

55 35 28

4.68 4.62 4.60

0.09 0.10 0.10

5.72 4.67 5.61

0.12 0.09 0.19

1.04** 0.05 1.01**

1 Responses based on a 7-point Likert scale, with a score of 7 being strongly positive. The mean scores represent attitudes related to perceived competence, interest and enjoyment, future orientation and success attribution. ** p ~ .01; differences between testing periods (paired t-test)

and social support may be among the most effective means of influencing dietary behavior changes among seniors. The nutrition-through-gardening program, employing a process-oriented educational intervention technique, has demonstrated that improvement in dietary intake and psychological well-being are possible. Emerging models of health promotion for older persons emphasize a holistic orientation, considering the relationship among the body, mind and spirit (32). For seniors, a balanced emphasis may be particularly valuable for a number of reasons. With a decline in body functions, the loss of skin elasticity, the need for eye glasses, hearing aids or dentures, and a history of medical concerns, the body develops an appearance and an ability to function which is different from that experienced in one's younger years. Helping older people value themselves for their wisdom, life experiences and interpersonal attributes de-emphasizes the orientation society places on the physical body and helps people regain a sense of value for who they are. When these feelings of value can be linked with a nutrition education message, it is possible that attitudes may be structured in a manner that promotes behavior changes. Experiences that encourage seniors to develop a heightened awareness of their skills and abilities may provide a renewed sense of hope, thereby influencing a variety of health behaviors, including dietary choices. A garden is one way that many people become reacquainted with their resourcefulness, and in the process, may also experience a perception of control and a competence for growing food that promotes their own health. Linking of the practical aspects of food production to the educational dynamics of nutrition education appears to be effective in helping seniors improve their attitudes and selections regarding food. The model presented here demonstrates a potential for replication, and suggests that innovative nutrition education programs for seniors are effective in a variety of settings.

ACKNOWLEDGMENTS This research was supported by grants from the AARP Andrus Foundation, Washington, D.C. and the Vira I. and Howard Heinz Endowments, Pittsburgh, PA. We wish to thank the many local and national gardening companies, and city and county agencies, for their generous donation of materials and

labor. Above all, we thank the senior gardeners who volunteered for this project. The advice and statistical support of Christopher Bolton, Ph. D., Associate Professor of Gerontology, University of Oregon, is gratefully acknowledged.

NOTES AND REFERENCES 1 Butler, R.N., D.L. Oberlander, J.S. Gertman, and L. Schindler. Self-care, self-help, and the elderly. International Journal, Aging and Human Develupment 10:95-117, 197~0. 2 Gillespie, A.H. and P. Yarbrough. A conceptual model for communicating nutrition. Juurnal ufNutrition Education 16:168-176, 1984. 3 Achterberg, C. Contexts in context. Journal ofNutrition Education 20:180-184, 1988. 4 Rowe, J.W. and R.L. Kahn. Human aging: Usual and successful. Science 237:143-149, 1987. 5 Lefcourt, H. The function of the illusion of control and freedom. American Psychologist 28:417-425, 1973. 6 Langer, E.J. and J. Rodin. The effects of choice and enhanced personal responsibility for the aged: A field experiment in an institutional setting. Journal of Personality and Social Psychology 34:191-198, 1976. 7 Seligman, M.E.P. Helplessness. San Francisco: Freeman, 1975. 8 Solomon, K. Social antecedents of learned helplessness in the health care setting. The Gerontulogist 22:282-287, 1982. 9 Rodin, J. Aging and health: Effects of a sense of control. Science 223:1271-1276, 1986. 10 Schulz, R. Long-term effects of control and predictability on the physical and psychological well-being of the institutionalized aged. Journal of Personality and Social Psychology 36:1194-1201, 1978. 11 Walker, K.N., A. McBride and M.L.S. Vachon. Social support networks and the crisis of bereavement. Social Science and Medicine 11:35-41, 1977. 12 Pilsuk, M. and M. Minkler. Supportive networks: Life ties for the elderly. Journal of Social Issues 36:95-116, 1980. 13 Kahn, R.L. and T.C. Antonucci. Convoys over the life course: Attachment, roles and social support. In: P.B. Baltus and O.G. Brum (eds.), Life span development and behavior. volume 3. New York: Academic Press, 1980, pp. 253-286. 14 Kohrs, M.B. Evaluation of nutrition programs for the elderly. The American Journal of Clinical Nutrition 36:735-736, 1982. 15 Harris, L. & Associates, for National Council on Aging, Inc. In: "Why a project to increase gardening opportunities for older Amercians?" Gardens for all. Burlington, VT, 1975. 16 Campbell, R. and B. Chenoweth. Health education as a basis for social support. The Gerontologist 21:619--627, 1981. 17 Skeist, R. Self-care and social change. Generations 11:18-19, 1980. 18 Held, S. Gardening stimulated nutrition lessons. Nutrition News 39:11, 1976. 19 University of British Columbia. Gardening as therapy. Botanical Garden Technical Bulletin No.5, Vancouver, British Columbia, Canada, 1978. 20 Hefley, P.D. Horticulture: A therapeutic tool. Journal of Rehabilitation 27-29, 1973. 21 Prior to its inception, this study was reviewed and approved by the University Committee for the Protection of Human Subjects.

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22 "Applied Nutrition: Choice and Control," Final report submitted to the Northwest Area Foundation, October 15, 1983, Robert Hackman, Principal Investigator. 23 Hackman, R.M. and E.L. Wagner. Nutrition bingo in the Senior Gardening and Nutrition Project. Journal of Nutrition Education 19:225A, 1987. 24 Ryan, R.M. Control and information in the intrapersonal sphere: An extension of cognitive evaluation theory. Journal of Personality and Social Psychology 43:450-461, 1982. 25 Ryan, R. M., V. Mims and R. Koestner. Relation of reward contingency and interpersonal context to intrinsic motivation. A review and test using cognitive evaluation theory. Journal of Personality and Social Psychology 45:736-750, 1983. 26 American Dietetic Association and American Diabetic Association. Exchange lists for meal planning. Chicago: American Dietetic Association and American Diabetic Association, 1986. 27 Friere, P. Education for critical consciousness. New York: Seabury Press, 1973. 28 Rody, N. Empowerment as organizational policy in nutrition intervention programs: A case study from the Pacific Islands. Journal of Nutritional Education 20:133-141, 1988. 29 Kent, G. Nutrition education as an instrument of empowerment. Journal of Nutrition Education 20:193-195, 1988. 30 Keough, C. Beat the clock. Organic Gardening 162--168, January 1980. 31 Achterberg, C. A perspective on nutrition education, research and practice. Journal of Nutrition Education 20:240-243, 1988. 32 Burdman, G.M. Healthful aging. Englewood Cliffs: Prentice-Hall, 1986, pp. 153-167.

RESUME Pour encourager une modification du comportement dietetique et pour developper Ie mieux-etre psychologique parmi les gens ages, un programme educatif d'alimentation et de jardinage a ete developpe, base sur les theories de perception du contr61e et d'assistance sociale. Le programme a dure 5 mois et a inclu plusieurs reunions avec les participants: une reunion bimensuelle sur la nutrition, une reunion bimensuelle sur Ie jardinage, et des reunions individuelles chez les participants deux fois par mois. Dne jardiniere etait fournie pour la culture des legumes. La consommation alimentaire etait encouragee par des conferences, des discus-

sions, des auto-evaluations, l'etablissement des objectifs, et des activites sociales. Les resultats d'une evaluation avant et apres Ie programme ont ete recueillis. Le projet a eM refait une deuxieme annee a deux autres endroits. Les changements de consommation dans les trois cas etaient significatifs, une mesure d'attitude a aussi souligne cette amelioration. Les resultats demontre la pertinence du programme dans les diverses circonstances. (jNE 22:262-270, 1990)

Translated by Carla Chamberlin

RESUMEN Se desarrollo un programa de nutricion con huertos para promover cambios en las practicas de alimentacion y asi contribuir a un mejoramiento sicol6gico de un grupo de ancianos. EI modelo se baso en las teorias sicol6gicas de percepcion y de control de apoyo social. La intervencion dur6 cinco meses, y consisti6 de una visita por semana con los participantes, el grupo de nutricion se reunia cada otro mes, un grupo se reunia cada otro mes para el huerto. Se efectuaron dos reuniones por mes con cada participante, en su domicilio. Se distribuyeron cajas elevadas para la produccion de verduras (vegetales). Se promovio un mejor consumo de alimentos por medio de charlas, platicas, discusiones en grupo, tarjetas de motivacion de conducta, determinacion de metas a alcanzar y a traves de la interacci6n social. Se efectuaron estudios de base, previos a la intervencion y de evaluacion posterior, para conocer el cambio en las practicas de aIimentacion y en las actitudes relacionadas con la nutricion y el huerto. EI proyecto se llevo a cabo primero en una localidad y se repiti6 el siguiente ano en otras dos localidades. En todas las localidades se observaron cambios significativos en la ingesta de alimentos de categorias specificas, y las puntuaciones en las medidas sobre actitudes tambien se mejoraron para los ancianos en todas las localidades. Los cambios en conductas dieteticas y las puntuaciones de actitudes en los tres proyectos sugieren que el program fue el apropriado para los diversos contextos sociales. (jNE 22:262-270, 1990)

Translated by Maria Teresa Cerqueira

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