Elderly population is at risk for malnutrition due to various factors. To address this issue, the elderly needs to be screened for malnutrition and received an appropriate care plan if necessary. The use of nutrition resource is useful as part of a care plan due to its ability to provide nutrition education for malnourished and at-risk elderly. Therefore, this thesis aimed to develop and evaluate a nutrition resource kit for nutrition intervention among malnourished and at-risk elderly in health clinic setting. This multiphase, action research study was conducted in four selected health clinics in Kuantan, Pahang. A mixed-method approach was taken to achieve the research objective: (Phase I: Plan) qualitatively assessed the types of nutrition resource kit needed by community living elderly; (Phase II: Act) development of nutrition resource kit and educational video for malnourished and at-risk elderly and (Phase III: Observe and Reflect) qualitatively explored the acceptability towards the newly developed nutrition resource kit and educational video and improvisation of it. Phase I aimed to demonstrate the types of nutrition resource kit needed by community living elderly in health clinic setting. Twenty-one elderly participants with a mean age of 67.24 ± 6.98 years were purposively recruited for individual in-depth interview. Thematic analysis of the interview identified five themes; 1) provision of nutrition resource kit, 2) preference needed to solve this issue (Webb et al., 2018). Favourable outcomes for printed version, 3) eye-friendly, 4) facilitate understanding with diagram and 5) support for technology-based materials. In phase II, a nutrition resource kit with incorporation of an educational video in a QR code were developed based on the integration of findings in phase I and the scoping review which had been performed to identify the suitable topics to be included. This newly developed kit and video then had undergone validation by experts and elderly. Six experts involved in content and face validation of the kit and video. Both resources achieved excellent content validity. Suggestions by experts were considered and revision was done accordingly. The revised kit and video was further assessed by twelve elderly for face validation. All elderly positively evaluated both resources. Amendment was done according to the elderly’s suggestions for further improvement. Then, assessment on acceptability towards the developed kit and video among malnourished and at-risk elderly was conducted in phase III. Twenty-two elderly participants (mean age = 68.82 ± 5.33 years) were purposively selected for individual in-depth interview and triangulation was performed using a questionnaire. Interviews were thematically analysed and descriptive statistic was used for data triangulation. Four themes emerged; 1) positive acceptance, 2) elderly-friendly, 3) valuable and 4) individual preference. Additional suggestions given by elderly were reviewed and revised accordingly. To conclude, this newly developed nutrition resource kit both in the printed format and electronically was well-accepted by the malnourished and at-risk elderly. Provision of nutrition resource kit tailored to the need of elderly could help to deliver nutritional guidance effectively and serve as an important reference for them to prevent and overcome malnutrition.

Elderly population are susceptible to malnutrition. However, malnutrition identification among community-living elderly through nutrition screening is not routinely performed in Malaysia health clinics; although it is recommended to be performed routinely in all healthcare setting. Major issue to this is due to no specific nutrition screening guideline and validated tool in this setting. Due to this gap, development of nutrition screening guideline is essential for use among healthcare staff. The aimed of this study are to develop a nutrition screening guideline for use by healthcare staff in health clinic setting and assess its feasibility. This study has taken a mixed-method approach and action research to address the research objectives. This study was divided into three phases; Phase 1: Identification of barriers and opportunities of nutrition screening in elderly patients in the health clinic setting; Phase 2: Development of nutrition screening guideline by using Mini Nutritional Assessment Short-Form (MNA® -SF) for healthcare staff in health clinic setting; and Phase 3: To assess the feasibility of newly developed nutrition screening guideline for health clinic setting among healthcare staff. Four health clinics from urban and rural areas in Kuantan, Pahang involved in this study. In Phase 1, in-depth interviews were conducted among twenty healthcare staff. Non-participant observations that acted as triangulation were conducted among twenty-one elderly patients. Both data from interviews and observations were analysed thematically using NVivo software version 12. Four themes emerged for barriers and opportunities were Theme 1: Time; Theme 2: Patient factors; Theme 3: Organization factors and; Theme 4: Nutrition screening knowledge. Findings from Phase 1 has become guidance in content development of the nutrition screening guideline. In Phase 2, twenty-three documents have been included from conducted scoping review for the content development of the guideline. Following this, A4-sized guideline has been developed. The guideline has been validated among six experts by using Item-Content Validity Index (I-CVI). Items that have achieved ≥0.83 were remained. Meanwhile, items with a score <0.83 were revised accordingly. Next, face validity among twelve healthcare staff has been conducted and all participants showed positive responses. Amendment has been made based on provided suggestions. For Phase 3, 22 healthcare staff from similar health clinics participated and had screened five elderly patients each (total=110, mean age= 68.7±6.1 years). After completing nutrition screening, individual in-depth interviews were conducted with the healthcare staff. All data were analysed thematically. The themes obtained were Theme 1: Ease of use; Theme 2: Identification and management of malnutrition; Theme 3: Acceptability; and Theme 4: Implementation of nutrition screening. In summary, this multiphase study has identified appropriate approaches in implementing nutrition screening among elderly patients in health clinic setting. Provision of a comprehensive newly developed nutrition screening guideline tailored to this setting was well-accepted among healthcare staff and feasible in health clinic setting. This nutrition screening guideline is recommended to be adopted nationwide in Ministry of Health’s health clinics towards optimum nutritional status of elderly population and achieving healthy ageing; whilst policy related to nutrition screening implementation in health clinics can be further enforced.

Malnutrition is a concern around the globe including in Malaysia due to its negative effects to the health of elderly. Nutrition screening can help to identify malnutrition and subsequent interventions can be provided to overcome health deterioration related to malnutrition. This study aimed to identify the prevalence of malnutrition and associated factors, dietary intake and effectiveness of nutrition intervention among elderly living in the community. In Phase I of the study, a total of 413 participants aged 60 years and above in several agricultural settlements around Kuantan, Pahang was recruited (n= 134 men, n= 279 women). Malnutrition risk was evaluated using the Mini Nutritional Assessment Short Form (MNA-SF), whilst functional status was determined using Instrumental Activities of Daily Living (IADL). Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS) were used to identify cognitive impairment and depressive symptom of participants respectively. Dietary intake data were collected with the use of diet history method and analyses were performed using Nutritionist Pro Software. Adequacy of participants’ dietary intake was assessed against Recommended Nutrient Intakes for Malaysia (RNI) 2017. Phase II of the study evaluated the effectiveness of nutrition intervention on nutritional status and dietary intake of the elderly after three months. The elderly who were at malnutrition risk were grouped into intervention (n=30) and control groups (n=30). The intervention group received intensive nutrition intervention while the control group received individual dietary consultation only. Statistically significant value was set at p<0.05. This study revealed that 5.1% of elderly participants were malnourished, whilst 20.6% of them were at risk of malnutrition. Age, smoking status, income level, living status and depression were significantly associated with malnutrition risk. This study found that mean energy, protein and fiber intake were significantly lower than recommendation in both genders except for fat and carbohydrate. Micronutrients intake including calcium, vitamin A, vitamin C, vitamin D, riboflavin, thiamine, iron and folate did not meet the requirement outlined in RNI with statistically significant differences. In addition, energy, carbohydrate, protein, fat, folate and iron intake were significantly higher in male than female participants. Meanwhile, calcium and vitamin A intake were significantly higher in female than male participants. Phase II of the study demonstrated that nutrition intervention could help to improve nutritional status of the elderly living in the community. Mean MNA-SF score, body weight, energy, carbohydrate and fiber intake of intervention and control groups improved significantly after three-month follow-up. Mean MNA-SF score of intervention group was identified in well-nourished category after three months which indicated greater impact of intensive nutrition intervention. In conclusion, this study showed malnutrition was prevalent among elderly living in the community while inadequate dietary intake was also an issue in this population. The findings contribute to the body of evidence that nutrition screening is an important initial step to identify malnutrition risk among community living elderly and appropriate intervention is vital to improve their nutritional status. Multidisciplinary healthcare professional collaboration is warranted in future research to identify malnutrition problems and provide effective measures for nutritional care of the elderly.