Explaining the Nutritional Behaviors of Elderly Individuals Based on the PEN-3 Cultural Model: A Qualitative Study

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Considering the cultural and social aspects of this group's nutrition, it is essential to conduct qualitative research and select an appropriate approach. The PEN-3 model offers a cultural perspective for examining various dimensions of nutritional behaviors in elderly individuals. Objectives: The aim of this study is to explain the nutritional behaviors of the elderly based on the PEN-3 model. Methods: This qualitative study was conducted over six months in various areas of Tehran, Iran, in 2024. Data were collected through in-depth semi structured interviews using three interview guides, involving 13 elderly people (main participants), 4 caregivers, and 2 dietitians. Data analysis was conducted concurrently with data collection using the directed content analysis method based on Hsieh and Shannon's pattern, focusing on key influences on health behaviors: Perceptions, Enablers, and Nurturers. Results: Among the 169 extracted codes, the majority were assigned to perceptions and their subcategories, which include knowledge, beliefs, and attitudes. There were also fewer codes across all subcategories of enablers. However, regarding the nurtures, the codes were limited to the following subcategories: extended family and health personnel. Conclusions: The results of this study include positive and negative experiences of the elderly in the field of nutrition, as challenges and assets of the target population, which are effective in developing interventions that are more likely to be successful and reviewed. Integrating experiences in the perception domain with nutritional behavior facilitates the creation of educational content. Additionally, insights from the domains of nurturers and enablers contribute to the development of community policies. Elderly Nutritional Behaviors PEN-3 Model Qualitative Study Figures Figure 1 1. Background Today, while average life expectancy has increased, health span—the period during which individuals are in good health—has not followed suit (1). Healthy life expectancy is still lagging behind (2). Multiple modifiable risk factors are associated with an increased risk of disability and disease in older adults, one of the most important of which is poor diet quality (3). Nutrition and its improvement are regarded as key components of health promotion (4)(5) in primary prevention (6) and effective interventions for enhancing the quality of life of the elderly (7)(8). In fact, nutrition is a fundamental need for elderly individuals, supporting their life and well-being (9). While the benefits of healthy nutrition play a crucial role in maintaining the independence and quality of life of older adults (10), the percentage of elders consuming healthy diets remains significantly below the 50% target established by Healthy People 2020 (5). Numerous age-related changes, often subtle and gradual, progressively compromise older adults' ability to maintain an acceptable nutritional status (4). According to the WHO, elderly individuals in developing countries are defined as individuals over 60 years of age (11)(12). They are at risk of malnutrition and dehydration, regardless of whether they have pathological conditions (9). Protein-energy malnutrition is particularly common among those aged 65 and older (13). Numerous quantitative studies have examined and confirmed this problem. A systematic review of 98 studies encompassing a total sample size of 79,976 people revealed that the prevalence of malnutrition among elderly individuals worldwide is 18.6% (95% confidence interval: 16.4.21.1%) (14). Several recent studies conducted in various cities of Iran, either at the community level or in health centers, have indicated that at least one-fifth and up to more than half of the elderly individuals studied are at risk of malnutrition (15)(16)(17)(18)(19)(20). In these studies, the impact of various factors on the nutritional status of elderly individuals was also examined (15)(21)(22). Importantly, for elderly individuals, social and cultural aspects of nutrition must be considered alongside physiological factors (4). Food is just one aspect of the eating experience. (10); it has cultural significance for most people (23). Thus, food not only serves as a source of sustenance but also plays various roles in human societies and is closely linked to culture(24). While the nutritional content of food is important in diet planning, individual preferences and eating habits often have a greater impact on actual food intake. These habits are shaped by various influences, including developmental factors, gender, ethnicity, culture, beliefs about food, personal preferences, religious practices, lifestyle, economic conditions, medications and treatments, health status, alcohol consumption, advertising, and psychological factors (25). In fact, cultural models of eating dictate how, when, and where individuals should eat, as well as what constitutes a "proper" meal. These models significantly influence food choices and availability, shaping mealtimes and eating patterns (24). To address these factors, it is essential to conduct qualitative research in the field of nutrition in elderly individuals. The primary strength of qualitative research lies in its ability to infer values, beliefs, practices, and norms from the perspectives of the subjects being studied (26). This approach (qualitative research) enables researchers to focus on questions related to social experiences, how these experiences are constructed, and the meanings they impart to human life (27). The factors contributing to unhealthy dietary patterns are complex and necessitate an interdisciplinary approach that considers the social context of health (28). Qualitative findings provide a rich context for interpreting results and offer a flexible method for understanding subjective experiences (29). Therefore, they can be instrumental in examining eating habits, which are among the most intricate human behaviors (23). Different research objectives require different research designs and analysis techniques, and it is important for health researchers to determine their specific approach to the study before beginning data analysis (30). Since eating habits are among the oldest and most deeply rooted aspects of many cultures (23) and culture affects people's access to food through food distribution within households (24), we use the PEN-3 model as a cultural lens to better understand the individual, family, and societal impacts on health outcomes (31). 1.1 Theoretical framework The cultural model PEN-3, written by Dr. Collins Airhihenbuwa, focuses on putting culture at the forefront of health promotion (32). This model examines health promotion in three domains. Each domain includes three different dimensions, abbreviated as the PEN, each of which plays an important role in health decision-making. These three areas include, respectively (33): (1) key influence on health behaviors (Perceptions, Enablers, Nurturers), (2) impact of behavior on health (Positive, Existential, Negative), (3) focus on interventions (Person, Extended Family, Neighborhood) (33)(34) (Figure 1). This model encourages an in-depth exploration of individuals' cultural environments and how these contexts influence their health beliefs and practices (35), using culture as a framework for identifying health problems and organizing their components (36). Since its introduction in 1989, the model has guided efforts to address various issues, including food choices (37)(38)(39) and other challenges that require an understanding of both behavior and the associated cultural contexts (37). One application of this model is the cultural assessment of communities facing health issues by examining the key factors that affect health (40). Given that nutrition is crucial for promoting healthy aging in the elderly population (41) and that the increasing elderly population worldwide necessitates attention and planning for fostering healthy aging in the near future, the research group decided to conduct the present study to explain the nutritional behaviors of the elderly population based on the PEN-3 Model. 2. Method The present study is the first part of a mixed-method research project designed qualitatively using a directed content analysis approach based on the PEN-3 Model. 2.1 Setting and Participants The present study was conducted in Tehran, a large metropolis comprising 22 municipal districts, each comparable in size to a city and spread across four geographical regions: north, south, east, and west. Efforts were made to include samples from all four regions (with a breakdown of participants as follows: east 4, west and center 7, north 4, and south 4 people). The participants were divided into two groups. The first group consisted of elderly individuals aged 60 years and older (key participants), selected through convenience sampling. This was achieved by visiting health centers in various regions and utilizing their lists of elderly individuals, as well as by visiting community gathering places such as parks and events and through referrals from other participants. An emphasis was placed on selecting samples from all areas of Tehran with diverse characteristics (sampling for maximum diversity). The second group included caregivers of the elderly (both formal and informal) and dietitians from health centers (nonkey participants). The inclusion criterion for all included men and women were interested in participating in the study. Elderly participants were required to be aged 60 years and above, without psychological disorders or diseases, and not experience complex complications that would render them immobile in bed. The caregivers included both formal and informal, direct and indirect caregivers, and dietitians were required to have at least five years of professional experience. 2.2 Data collection A semi structured, in depth, face‒to-face interview method was employed to collect the data. In a directed content analysis approach, if data are collected primarily through interviews, an open-ended question can be posed first, followed by targeted questions about predetermined categories (30). In this study, the research team developed an interview guide that incorporated the key concepts, characteristics, and definitions from the PEN-3 Model. Three versions of the guide were created, each tailored for interviews with elderly individuals, caregivers, and dietitians (boxes in Appendices 2, 3, and 4). All interviews were recorded, and the researcher transcribed each recorded interview verbatim into written text as soon as possible. In the initial meeting with the elderly participants, the study's objectives were explained in detail. Consent was then obtained to conduct and record the interviews, with assurances that their information and recorded interviews would remain confidential. The interview location was chosen according to the participants' preferences, ensuring that they felt comfortable. The interviews were conducted at health centers (in the training room), a park near the participants' residences, their workplaces, and a coffee shop. At this stage, the demographic characteristics of the elderly participants, such as age, education level, and underlying health conditions, were collected. The interviews began with a brief interaction to express gratitude for their participation, followed by questions from the interview guide based on Boxes 2, 3, and 4. Then, on the basis of the participants' responses, probing continued with questions such as "Can you explain further?" or "What do you mean?" The interviews lasted between 35 and 60 minutes. All interviews were conducted in person and completed in one session, except for two caregivers, who were interviewed in two stages due to their busy schedules. A total of 13 elderly individuals, 2 formal caregivers, 1 caregiver who was both formal and informal (caring for a mother and other elderly individuals), 1 informal caregiver, and 2 dietitians participated in the study (Tables 1 and 2). Data saturation was reached after the 16th interview, indicating that no new codes emerged and that no additional information was obtained. To ensure certainty, three more interviews were conducted. Tables 1 and 2 present the general characteristics of the participants. Table 1 Demographics of the Elderly (Key Participants) Gender Age (years) Education Occupation status Situation de vie. Having a Chronic disease Female 61 Illiterate Housewives Married (Lives with her family) ü Female 78 Highschool Retired Married (Lives with son) û Female 60 Illiterate Housewives Married (Lives with sons) ü Male 72 Highschool Retired Married (Lives with his wife) ü Female 66 Illiterate Housewives Widow (Alone) ü Male 74 Primary Education Retired Married (Lives with his wife) ü Female 68 Highschool Housewives Married (Lives with her family) ü Female 83 Primary Education Retired Divorced (Alone) ü Male 82 Highschool Retired Married (Lives with his wife) ü Female 70 University Retired Married (Lives with her h usband) ü Female 69 Primary Education Housewives Widow (Alone) ü Female 69 Primary Education Housewives Married (Lives with her family) ü Female 7 0 University Retired Married (Lives with her h usband) û Table 2 Demographics of the Care Givers and Dietitians Gender Age (years) Education Occupation status Work experience (years) Caring Role Male 41 University Nursing Assistant 6 Formal Female 55 Highschool Housewives 13 Informal Female 46 University - 5 Formal Female 53 Highschool - 15 Formal Female 34 Master Working in a health center 8 Nutritionist Female 42 Bachelor Working in a health center 12 Nutritionist 2.3 Data analysis The data were analyzed using the directed content analysis method of the Hsieh and Shannon (2005) model. After the PEN-3 model was selected, its main concepts were studied and extracted by reviewing the theory. These concepts include key factors that influence health behavior (Perceptions, Enablers, Nurturers). Consequently, a coding matrix was created to illustrate these concepts and their subcategories (Table 3). Table 3: Coding Matrix for the Concepts of the PEN-3 Model Codes Subcategory Category knowledge Perceptions Beliefs Attitudes Values resources Enablers Accessibility Referrals service Extended Family Nurturers Peers Employers Health Personnel Religious Leaders Government Officials After the data were collected, semantic units and codes were extracted on the basis of the main research question and the concepts outlined in the coding matrix. Researcher 1 read and reread the interview transcripts and occasionally listened to the recorded interviews to develop a comprehensive understanding of the content. First, semantic units were identified from each transcript, and initial coding was conducted using the participants' expressions, which were aligned with the main research question and the concepts defined in the theory. Each code that was appropriate and consistent with the concepts and subcategory of the matrix was subsequently placed within it. This initial coding process was conducted by Researchers 2 and 3 for a few interviews. If there was agreement among all three researchers, the code was accepted. The coding of the remaining interviews was then reviewed and approved by them, along with the two main project reviewers. Table 4 illustrates how the raw data were utilized to code and assign them to the main substructures and constructs of the theory. Finally, on the basis of the codes and findings obtained from comparisons and matches with the theoretical definitions in the matrix, an operational definition was provided for each of the main concepts of the theory(30). Table 4 Examples of how the raw data were utilized to code and assign it to the main substructures and constructs Row data Codes Subcategory Category I eat one boiled egg every day, and I have noticed significant improvements in my health due to their high protein content. I made this change because I needed extra protein after I was sick and had surgery. (P:15) Understanding protein sources and their importance knowledge Perceptions I try to eat very little red meat. Instead, I consume a lot of turkey and chicken, having red meat only once or twice a week at most. Additionally, there is one day each week when I don’t eat any meat at all… (P: 19) Consume more white meat rather than red meat . Beliefs (Beliefs, Attitudes, Values) For example, if you search for diabetes or blood pressure on Google or follow Instagram, you may find that Instagram presents a mix of truths and misinformation, while Google offers medical information. A search yields a wealth of information. (P: 11) Obtaining nutritional information online resources Enablers Access to basic food is good in this area, with essential ingredients readily available. They are easy to obtain, typically taking only a quarter to half an hour to gather and return home (P: 9) Easy access to essential food supplies Accessibility Because the centers are constantly moving, this health center is sometimes located in Dardasht, sometimes 30 meters away, and at other times in different locations. I'm not in the mood to go out. My legs hurt as well, and I can't walk far. (P:12) Avoid visiting health centers due to various restrictions. Referrals Many of them also receive support from the relief committee, but the amount is insufficient. ) p:13) Inadequate services provided by the Imam Khomeini Relief Committee. service If it's a party, then no. If it's a guest, however, then yes, just like before—greasy, spicy, and very... (P:17) Not adhering to the diet at parties. Extended Family Nurturers No, it hasn't happened yet. For example, they told him to eat a low-protein diet. It doesn't have protein, but, for example, a food group that doesn't have protein or, for example, something that I can safely make and give to my elderly person to eat—no, they didn't tell me the details. (P:10) General nutritional education provided by a doctor. Health Personnel 2.4 Consideration of Rigor Long-term contact with the data subject (immersion) and data collection from July to December 2024 were among the methods used to validate the present study. To ensure that the analysis accurately reflected the experiences of the elderly individuals , caregivers, and dietitians, participant reviews were conducted for the extracted codes, and changes were made as necessary. The interviews and analysis results, including the initial codes, subcategories, and categories of the PEN-3 model, were reviewed by three experts and discussed among the research team to verify the reliability and consistency of the data. Sampling strategies that maximize diversity and consider a wide range of experiences from primary and secondary contributors have ensured the transferability of findings for readers and reviewers. 3. Results A total of 169 merged and refined codes were derived from the analysis of the interviews. The findings indicate that a greater number of codes were assigned to the category of Perceptions. Owing to the close relationships among beliefs, attitudes, and values, codes related to these concepts were grouped into a single subcategory (beliefs). Additionally, there were fewer codes across all subcategories of Enablers. However, regarding Nurturers, the codes were limited to the subcategories of extended family and health personnel. Below, the three main constructs or categories of the matrix based on the PEN-3 are described and explained, along with their subcategories, using data from the participants' experiences. 3.1 Perceptions influencing nutritional behavior Perceptions based on the PEN-3 model encompass knowledge, beliefs, attitudes, and values that can either facilitate or hinder motivation to change behavior (34). Nutritional behaviors are defined as "the sum of all planned, spontaneous, and intentional actions (functions) or the habits of individuals or social groups related to the procuring, preparation, and consumption of food. "(42) Analysis of data from participants' perceptions revealed that the nutritional behaviors of the elderly include three functional domains: procuring, preparation, and consumption. Experiences not directly related to these three behavioral domains but derived from the knowledge and beliefs of the elderly regarding nutritional behaviors were expressed as general knowledge and general beliefs. 3.1.1 Knowledge about Procuring Food: The experiences of the elderly in this area highlighted several important issues, such as preparing basic food ingredients in small quantities, ensuring the quality of ingredients, sourcing from reliable suppliers, and incorporating more white meat into their diets. P (15), 80-year-old man : “For example, about meat, I tell the butcher to give me some meat, to give me brick-colored meat; they know me too. They charge more but give me better quality. Or when I want to buy chicken, I look to see if it's fresh. Or when I want to buy fish. I say, "Are the trout fresh? " They say, "If it's not fresh, we won't give it to you. We know you. "” P (19), 70-year-old woman: “ I try to eat very little red meat. Instead, I consume a lot of turkey and chicken, having red meat only once or twice a week at most. Additionally, there is one day each week when I don’t eat any meat.” 3.1.2 Knowledge about Preparation Food: Despite being less busy in old age, most participants continued to prepare more food and several meals out of habit or based on circumstances, a point confirmed by dietitians. P (2), 78-year-old woman: “ Sometimes I cook at noon, and that meal is also for dinner. For example, I often cook at night. When I was an employee, I would prepare dinner at night so that I could have lunch ready when I got home the next day. Now, as a housewife, I still sometimes cook for dinner at noon ." They also mentioned the importance of spending adequate time preparing food, using less salt and oil, employing healthier frying methods, and maintaining hygiene during preparation. P (16), 70-year-old woman: " I t should be low in fat, which means minimizing fried foods. At the end, you put a bit of butter on top for flavor, and that's my approach ." 3.1.3 Knowledge about Consumption Food: Seniors mentioned experiences such as eating dinner early, snacking, and choosing home-cooked or traditional foods over dining out. A large number of participants skipped one of the main meals for various reasons, including feelings of adequacy, doctor advice, and concerns about weight gain. P (1), 61-year-old woman: “ Yes, the doctor said to eat dinner instead. He advised eating breakfast and dinner properly, but not lunch, because you're overweight and your legs hurt .” 3.1.4 General knowledge about nutritional behavior: Elderly individuals and their caregivers generally had a limited understanding of harmful substances related to chronic diseases and the consequences of their consumption. P (4), 74-year-old man: “ I believe that rice contains starch and bread has starch, which increases blood sugar. For example, I truly enjoy halva; I know it raises my blood sugar .” Despite this awareness, many elderly participants reported not adhering to the recommended diets for their chronic conditions, a point confirmed by caregivers and dietitians. P (12), 68-year-old woman: “ I pay attention to all the medical advice. I listen to health programs that discuss diseases and such. I hear it all, but... I don’t follow it .” 3.1.5 Beliefs about Procuring Food: Despite the restrictions, many elderly individuals preferred to prepare basic food ingredients on their own and believed this preparation should be performed in advance. P (19), 70-year-old woman: “ No, I try to do my shopping myself; for example, I don’t take a car, which makes me walk a bit. Yes, I do that. I usually do most of the shopping myself .” Some also felt it was important to keep a reserve of food. P (14), 83-year-old woman: “ However, I make predictions. For example, now I’ll buy one or two dry loaves of bread that won’t spoil. I’ll leave them at home and use those dry loaves when I need to. ” 3.1.6 Beliefs about Preparation Food: The experiences of the elderly indicate that they often strive to maintain their independence in this area by employing various strategies, and for some, this process is enjoyable. P (6), 70-year-old woman: “First, dealing with food is very pleasant for me. I never approach this task out of boredom or aversion; rather, I do it with joy .” Additionally, they emphasized the importance of personal interests and the use of seasonings and spices to enhance their meals. P (9), a 55-year-old caregiver: “ tells me, ‘Put cinnamon in my tea, add cardamom, include rose petals.’ For example, one day I put cardamom and rose petals in my tea, another day cloves, and another day cardamom and cinnamon .” 3.1.7 Beliefs about Consumption Food: Beliefs such as avoiding unpleasant foods, not consuming food under poor conditions, emphasizing breakfast, the desire for sweet foods in the morning and considering the cold and hot nature of foods significantly influenced the dietary choices of elderly. Dietitians also confirmed that elderly people pay attention to the cold and hot nature of foods. P (16), 70-year-old woman: “ Yes, the cold and hot nature must be observed. Yes, that means I shouldn't eat yogurt with fish if the food is fish. Or cucumber and watermelon shouldn't be eaten together at all. Or, for example, milk, which is very important, I should eat milk in a way that it is truly far away from food and fruit because they don't go together. Milk has a cold nature .” 3.1.8 General beliefs about nutritional behavior: This domain encompassed the attitudes and feelings of the elderly regarding nutrition (positive and negative), the belief that there was no need to change their nutritional habits, and the emphasis on quality over quantity. For some individuals, nutrition was considered a top priority in their lives. P (15), 83-year-old man: " It's very important; let's eat something. No, I eat something that benefits me. I eat well. I eat little, but I eat well. Quality has a big impact." For some, food was merely a prerequisite for taking medication. P (5), 66-year-old woman: " Yes, breakfast is also small. Not like that. For instance, I eat two or three bites of walnuts and diet cheese. I also eat that so I can take the pills after breakfast." In this study, in accordance with the experiences of elderly individuals, perceptions of nutritional behaviors across all subcategories—knowledge, belief, attitudes, and values—were expressed with multiple instances. These perceptions were directly related to three areas of nutritional behavior: food procuring, food preparation, and food consumption. Although some perceptions were not directly linked to these areas, they still reflected the overall structure of perceptions, all of which influences or obstructs the nutritional behaviors of elderly individuals. 3.2 Enablers influencing nutritional behavior According to the PEN-3 Model, enablers are social or systemic forces that can either enhance health behavior or create barriers that hinder it. These enablers include available resources, accessibility, referrals, and types of services (34). 3.2.1 Available resources: Two important sources related to nutritional behaviors—information to enhance nutritional knowledge and financial resources to obtain food—were identified in the experiences of the elderly in this area. They utilized various sources, including public media, books, and the internet (accessed by themselves or by family members), to improve their nutritional knowledge. P (3), 60-year-old woman: "... Yes, for nutrition, they say that dairy products are good for elderly individuals, and eggs are good as well. For example, I look at it like this (TV); I see that for my age, it speaks to me." P)19(, 70-year-old woman: " I visit the internet more frequently , and then I look to see what certificate the expert who wrote the article possesses. Then , I have some experience ; however , I visit the internet more frequently to see what is going on there". Given the symmetry of retirement and old age, income inadequacy was experienced by the elderly unless they had another source of income in addition to retirement income. P (6), 74-year-old man: " Why don't we buy expensive things anymore? For example, let's say cherries and sour cherries were once 150 tomans; we never bought them. Now they're going down; now they're 100 tomans. Maybe we'll buy half a kilo to take home; that's how it is ." However, P (14), 84-year-old women: "I rented that house to help with my salary... Yes, but my salary is low, not much. Along with the rent, I also have more money than food and groceries." 3.2.2 Accessibility: Most elderly individuals and caregivers in the present study experienced easy access to food, with a few exceptions related to the geographical location of their residences. P (16), 70-year-old female: " Yes, there are two markets of municipality within walking distance of us. There is a fruit shop in the alley, a supermarket, and a bakery, all close to us. We are truly..." Most of them, along with dietitians, acknowledged that access to prepared foods suitable for the elderly is limited. P (10), 46-year-old female as caregiver: " It's very rare to find places where you can order diet and healthy food specifically for elderly individuals. Unless you can find healthy, ready-made options, you likely won't come across a diet-friendly vegetable dish. Such offerings are quite uncommon. " 3.2.3 Referrals: Most elderly people indicated that they did not visit health centers as an important source of referrals due to various limitations. P (1) 61-year-old woman: " I don't come here often. I used to come here for a visit; then, for example, they sent me somewhere else to get a test, and I got a visit here too. Therefore, what is the difference? I'll just go there, get a visit, and get my test done there. " The key point here is follow-up by centers for elderly individuals to encourage visits. P (9), 55-year-old female caregiver: "They even called me from the health center. I visited several times to inform them that I had a senior citizen at home, and they provided me with guidance." 3.2.4 Services: Two services were offered to address the nutritional needs of elderly individuals: the Imam Khomeini Relief Committee and the distribution of food baskets at community centers. However, the elderly participants were completely unaware of the latter, and the dietitians indicated that these services were inadequate. P (13), 42-year-old female as dietitians: “We provide food baskets, but there is a need for a daily or regular monthly supply that can be counted on. Although many receive support from the relief committee, the amount is insufficient." In this study, according to the experiences of elderly individuals, the enabling factors of nutritional behaviors in all subcategories—resources, access, referrals, and services—were expressed with various instances. Each factor plays a role in either promoting or hindering these behaviors. 3.3 Nurturers influencing nutritional behavior According to the PEN-3 model, individuals may receive reinforcements from significant others, which can include extended family members, peers, employers, healthcare personnel, religious leaders, or government officials (34). 3.3.1 Extended family: In accordance with the experiences of elderly people, as well as input from dietitians and caregivers, family members played a crucial role in supporting elderly people by helping to compensate for decreased income and meet nutritional needs. They focused on the nutritional status of their loved ones and assisted in food preparation and awareness of their preferences. P (14), 83-year-old woman: " My eldest son said, 'I'm at your disposal one day a week from morning to noon. I’ll go wherever you want, buy whatever you need, and bring whatever you ask for.' We have been living in Jordan for thirteen years now. You might not believe it, but during this time, he hasn't broken his promise even once, even once." Family significantly influences the food choices of elderly individuals. This impact is evident when elderly individuals deviate from their diets in parties or follow the dietary preferences of their children. P (17), 69-year-old woman: " For example, my daughter-in-law sometimes called me when they got fast food. The distance is close. Occasionally, the grandchildren would say, "We have fast food; come here. I go, or I won't buy it myself." 3.3.2 Healthcare personnel: Given the frequent doctor visits by the elderly for chronic conditions, the provision or lack of nutrition education from the attending physician was a significant experience reported in this study. P (4), 72-year-old man: " No, I went to the doctor yesterday and waited for two hours to be examined. They didn’t provide any explanations; they just looked at me. Mr., "I’ll give you your medicine." They enter it into the monitor, and we'll proceed as usual . " Considering the limitations of elderly individuals, one issue mentioned was the use of educational strategies by dietitians to help them understand and retain educational materials, as well as to validate information with them . P (13), 43-year-old woman as dietitians: " Many of them are illiterate or have poor memories, that is a challenge as well. I often tell them to record my voice or to bring someone along next time. We're asking someone to help them pay closer attention . Or, for example, I'll say it in very simple ways. Eat at least this many pieces of bread at each meal (indicating the size with her hand), and remember that, to some extent … " In this study, according to the experiences of elderly individuals, the nurturing factors of nutritional behaviors in only two subcategories—extended family and healthcare personnel—were expressed with various instances that can either enhance health behavior or create barriers that hinder it. 4. Discussion This study aimed to explain the nutritional behaviors of elderly individuals in Tehran using the PEN3 model, which was employed to analyze the findings. The research team examines the nutritional behaviors of the elderly by focusing on one of the three domains of this model: factors influencing health, which include perceptions, enablers, and nurturers. An analysis of the findings of this study indicates that this domain of the model encompasses all dimensions of the nutritional behavior experiences of elderly people. Despite searching various databases, no studies utilizing this model in the field of nutrition for the elderly population were found. However, several qualitative studies have been conducted on the nutritional status of elderly individuals(43)(44)(45)(46)(47)(48)(49). Some of their findings support the present study, whereas others contradict it. Most elderly individuals' experiences fall within the first domain, which includes perceptions—such as knowledge, beliefs, attitudes, and values—related to nutritional behavior. Most of them were aware of and emphasized many things, such as reducing salt and oil consumption and healthy cooking methods. However, in response to the question about which foods they consider beneficial, some individuals mentioned the foods they typically consume, stating that they do not focus on the impact of these foods on their health. Additionally, in the study by Terp et al. (45), when participants were asked about their eating habits and their relationship with health, their narratives emphasized the social and sensory aspects of eating, with no mention of health. Despite the awareness and attention of most participants in the present study to food health, only a small number raised important issues, such as increasing protein and micronutrient intake, avoiding the elimination of specific food groups (dairy and vegetables) (50), and fortification of familiar foods (51). Issues such as salt consumption, which has been emphasized more in training, appear to have become ingrained in the behavior of elderly individuals. Therefore, it is essential to revise the educational content to address problems such as protein malnutrition. In the study by Vanderpool et al. (47), elderly individuals identified their physical condition as a barrier to cooking. However, in this study, participants endeavored to maintain their independence in food preparation despite these physical limitations by utilizing measures such as periodic rest, assistive devices, and extra caution. This is due to both cultural differences—since culture can influence the value placed on achievement, independence, and work (52)—and the fact that people age differently. While some older individuals require care, many influence their experiences of aging (5). This same item—participation in preparation and cooking—was the foundation of the education of Wallace and Devine (53), which had significant and lasting effects on food knowledge and behaviors. Nutrition not only impacts the health of elderly individuals but also plays a crucial role in managing chronic diseases (54). Most older adults experience one or more chronic conditions (4). In the study by Terp et al. (45), individuals with chronic diseases not only confirmed their knowledge and experience of the impact of diet on health but also recognized the importance of adhering to dietary recommendations. In contrast, this study revealed that elderly individuals with chronic diseases, despite being aware of dietary recommendations and experiencing complications, did not adhere to the suggested diet and believed that it had no impact on their health. However, dietitians confirmed that in cases of acute issues, the diet led to visible and short-term results, making these individuals more cooperative in accepting and implementing the education provided. This refers to a sense of control, which is an individual's perception of their ability to influence their environment and achieve desired outcomes (55). This feeling is less pronounced in chronic issues, as they do not provide objective and immediate results. Lin et al. (44), who reported results similar to those of the present study, expressed self-control, i.e., the ability of an individual to resist temptation and control behavior. If it is weak, it will maintain the wrong behavior and create a separation between knowledge and action. These two issues should be taken into account in nutritional interventions for chronic diseases. In the enablers and subcategory—resources—participants reported that retirement income (as a financial resource) alone was insufficient to meet their nutritional needs, which impacted their choices. In Chalermsri et al.'s study (48), participants who relied on government pensions reported that the cost of food significantly influenced their food choices, leading them to prepare low-quality meals. Declining income and retirement savings, combined with rising healthcare and living costs, have adversely affected many older individuals. These issues are significant challenges associated with aging (5) and demand the attention of society's policymakers. On the other hand, health care providers should not blame older individuals for preventable health problems, as these individuals may lack the financial resources or support—both past and present—necessary to make healthy lifestyle changes (5). The definition of resources also includes the sources of information (56). Sources of nutritional information were included in the subcategory of resources, similar to a previous study (38). This included mass media, books, and even the internet) both search engines and social networks. In the study by Chen et al. (43), elderly individuals also identified similar sources for obtaining nutritional information. Receiving conflicting information was a common finding in both studies, as confirmed by dietitians in the present study. Therefore, in addition to obtaining information, it seems necessary to validate it with dietitians. Access to nutrition focuses on supply and refers to the amount of food resources that are physically available through local production and trade (24). In the present study, with a few exceptions, most of the elderly participants were satisfied with their access to basic food sources. The participants in this study, as well as those in the study by Van Der Pols et al.(47), raised concerns about the lack of access to ready-to-eat food. In the present study, dietary health was considered more important in terms of hygiene and diet, whereas in the above study, poor quality and poor taste of food were considered. One interpretation pertains to cultural differences, whereas the other addresses differences in the perceptions of elderly individuals. Health centers and dietitians are examples of referrals within the enabler’s subcategory in the field of nutrition. The implementation of the Health System Transformation Plan in Iran emphasized a healthy diet as a key national program, aligning the presence of dietitians in centers with this objective. However, the study's results indicated that the elderly faced barriers to accessing these centers and dietitians due to various restrictions. In the study by Chen et al. (43), most of the participating elderly individuals had not received professional nutrition counseling and were unaware of the existence of a nutrition-related department. According to a study by Mawardi et al. (57), general practitioners require greater support from dietitians and community nurses in identifying patients at risk of malnutrition and assisting them in managing this condition. The study revealed that malnutrition screening was conducted more frequently by nurses than through referrals to dietitians. In the study by Avgerinou et al. (49), participants expressed varying preferences regarding the professional backgrounds of service providers. Some felt that a doctor or nurse would be appropriate, whereas others believed that dietitians had the necessary time and expertise to deliver this type of intervention. On the basis of these results and the findings of the present study, the nutritional issues faced by elderly individuals will continue to be overlooked until they visit medical centers. To prevent malnutrition and its complications, proactive measures and planning for counseling by dietitians are necessary. The extended family, as a subcategory of nurture, plays a crucial role in the experience of health and illness and in shaping health decisions, as demonstrated by Iwelunmor et al. in their applications of the PEN3 model (40). This study describes the supportive role of the family in meeting the nutritional needs of elderly individuals, both directly and indirectly, through financial and nonfinancial means. Additionally, it explains the effects of family on the food choices and dietary compliance of elderly individuals. Spending time with family members was also valued by the elderly as a tradition that is declining. This encouraged the elderly person to cook and eat. The study by Terp et al. (45) reported that older adults valued both cooking for or with others and eating together, which encouraged them to eat. Additionally, the anticipation of sharing a meal with others motivated individuals to take the time to prepare good food. In the study by Chalermsri et al. (48), companionship during meals was identified as a significant factor influencing positive eating habits, serving as a valuable experience and an incentive for cooking among elderly individuals. However, a significant finding of this study is that the elderly reported that this gathering caused them to disregard their diets. In the Terp et al. (45) study, relatives provided practical support by finding nutritional information and offering mental encouragement to promote healthy food intake. This case highlights the social and ceremonial roles that food plays in various cultures (23). In general, when family members pay closer attention to and become more knowledgeable about the elderly's diet, they can offer positive guidance that supports the implementation and maintenance of healthy eating behaviors (44). Therefore, involving this group in nutritional interventions for the elderly is essential. Among health personnel, physicians play a crucial role as gatekeepers of the health care system in encouraging healthy eating and lifestyles. They can assist individuals by providing nutritional counseling, conducting nutritional assessments, and recommending that patients seek professional nutritional care, all of which fall under the umbrella of nutritional care (58). Elderly individuals frequently visit this group because of chronic diseases and pain. However, participants' experiences indicate that nutrition education provided by doctors is neither objective nor acceptable. In the study by Lin et al. (44), participants anticipated more detailed and specific dietary recommendations; however, the actual recommendations were quite abstract, resulting in misinterpretations of the information. The participants in the present study noted that physicians' roles were focused primarily on prescribing medication. Dietitians corroborated this by citing time constraints during their visits as a reason for the lack of nutrition education. The participants in the study by Avgerinou et al. (49) confirmed that doctors are busy, but they also noted that certain communication skills are more important than professional skills. Mawardi et al. (57) noted that despite the significance of malnutrition in elderly individuals, general practitioners reported that they do not systematically screen for it and view it as a "secondary concern." As the study by Lin et al. (44) indicated that participants had high trust in the information provided by medical staff, it is essential for physicians to receive training in nutritional care. Given that visit times are limited, elderly patients should be referred to dietitians. This study is the first part of a larger effort to develop an intervention. Nutrition interventions that do not account for social, cultural, and emotional aspects of eating are unlikely to be effective because few people eat to live Most of us "live to eat."(59). According to the PEN-3 model, sustainable interventions for changing health behaviors must be rooted in culture. They are founded on (a) an understanding of the health-related cultural context for a specific population and (b) an appreciation of the community's strengths and challenges (32). This study explores the experiences of elderly individuals within the cultural context of nutritional behaviors, highlighting both their strengths and weaknesses. 5. Limitations The primary limitation of this study was the reluctance of elderly participants to be interviewed. Most of them viewed this work as useless because of their negative attitude toward aging; however, some agreed to cooperate after the research objectives were explained. Additionally, elderly individuals who lived with their families and were unable to make independent decisions, as well as employed elderly individuals, lost the opportunity to participate in the study, which should be considered in future research. 6. Conclusion The results of this study, in addition to showing that factors beyond elderly people's perceptions (including knowledge and beliefs) determine their nutritional behaviors by integrating these factors with the areas of nutritional behavior (food preparation, procuring, and consumption), distinguished the stages of nutrition as well as the cultural and contextual causes that influence them, which can be used in developing educational content to improve nutrition for elderly people. According to the results of this study, traditional methods are insufficient for examining and evaluating the nutritional behaviors of elderly individuals with life experience, particularly in the areas of nurturers and enablers. Considering family and social factors is essential for effectively shaping overall community policies. On the other hand, this study encompasses both the positive and negative experiences of the elderly regarding nutritional behaviors. By viewing these experiences as assets and challenges within the target community, interventions can be designed for greater success, and the steps taken can be effectively reviewed. Declarations Acknowledgments This study was part of the PhD thesis of the first author and was supported by Tarbiat Modares University. The authors would like to thank all the participants who made this study possible, the officials at Tarbiat Modares University for their coordination, the health centers, and especially elderly individuals. Author contributions TS was the main investigator and contributed to the development of the research protocol, implementation of the research, and drafted the manuscript. SH and GF supervised the study and scientific integrity of the data collection and revision of the manuscript ME was an advisor for the study, contributed to the interpretation of the data and revised the manuscript. HA was an advisor for the study and participated in the design of the study. All the authors have read and approved the final manuscript. Funding This study was financially supported by Tarbiat Modares University (TMU). The funder had no involvement in the study design, data collection, analysis, interpretation and composition of the manuscript. Data availability The data utilized for analysis are available from the corresponding author upon reasonable request. Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and was approved by Research Ethics Committee of Tarbiat Modares University (ID: Approved IR.MODARES.REC.1403.006). Written informed consent was obtained from all participants before the interview. 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07:07:19","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":152801,"visible":true,"origin":"","legend":"","description":"","filename":"bf6c48545f2f4159b4ede1af5ef7b3d21structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8131774/v1/16010bf9e98d218c14ac2b37.xml"},{"id":100866210,"identity":"394ef23a-f988-4162-a9d7-5a116f5e0df6","added_by":"auto","created_at":"2026-01-22 08:32:18","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":171971,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8131774/v1/05d9b28015ae7120d026c4a2.html"},{"id":100866205,"identity":"6b2f42bb-2625-47a0-bce4-4db0b0789dde","added_by":"auto","created_at":"2026-01-22 08:32:17","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":9725,"visible":true,"origin":"","legend":"\u003cp\u003eDimensions of the PEN3 Model\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8131774/v1/abc1a09c805922778fc931f3.jpg"},{"id":100952634,"identity":"b9521e80-a932-4246-bf68-068c2117d370","added_by":"auto","created_at":"2026-01-23 07:17:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2130513,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8131774/v1/363646b8-ca29-4f5c-8b2a-7ccbf1666e94.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Explaining the Nutritional Behaviors of Elderly Individuals Based on the PEN-3 Cultural Model: A Qualitative Study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eToday, while average life expectancy has increased, health span\u0026mdash;the period during which individuals are in good health\u0026mdash;has not followed suit (1). Healthy life expectancy is still lagging behind (2). Multiple modifiable risk factors are associated with an increased risk of disability and disease in older adults, one of the most important of which is poor diet quality (3).\u003c/p\u003e\n\u003cp\u003eNutrition and its improvement are regarded as key components of health promotion (4)(5) in primary prevention (6) and effective interventions for enhancing the quality of life of the elderly (7)(8). In fact, nutrition is a fundamental need for elderly individuals, supporting their life and well-being (9). While the benefits of healthy nutrition play a crucial role in maintaining the independence and quality of life of older adults (10), the percentage of elders consuming healthy diets remains significantly below the 50% target established by Healthy People 2020 (5).\u003c/p\u003e\n\u003cp\u003eNumerous age-related changes, often subtle and gradual, progressively compromise older adults\u0026apos; ability to maintain an acceptable nutritional status (4). According to the WHO, elderly\u0026nbsp;individuals\u0026nbsp;in developing countries are defined as individuals over 60 years of age\u0026nbsp;(11)(12). They are at risk of malnutrition and dehydration, regardless of whether they have pathological conditions\u0026nbsp;(9). Protein-energy malnutrition is particularly common among those aged 65 and older\u0026nbsp;(13). Numerous quantitative studies have examined and confirmed this problem. A systematic review of 98 studies encompassing a total sample size of 79,976 people revealed that the prevalence of malnutrition among elderly individuals worldwide is 18.6% (95% confidence interval: 16.4.21.1%)\u0026nbsp;(14). Several recent studies conducted in various cities of Iran, either at the community level or in health centers,\u0026nbsp;have indicated\u0026nbsp;that at least one-fifth and up to more than half of the elderly\u0026nbsp;individuals\u0026nbsp;studied are at risk of malnutrition\u0026nbsp;(15)(16)(17)(18)(19)(20). In these studies, the impact of various factors on the nutritional status of elderly\u0026nbsp;individuals was\u0026nbsp;also examined\u0026nbsp;(15)(21)(22).\u003c/p\u003e\n\u003cp\u003eImportantly, for elderly individuals, social and cultural aspects of nutrition must be considered alongside physiological factors (4). Food is just one aspect of the eating experience. (10); it\u0026nbsp;has\u0026nbsp;cultural significance for most people\u0026nbsp;(23). Thus, food not only\u0026nbsp;serves\u0026nbsp;as a source of sustenance but also plays various roles in human societies and is closely linked to culture(24). While the nutritional content of food is important in diet planning, individual preferences and eating habits often have a greater impact on actual food intake. These habits are shaped by various influences, including developmental factors, gender, ethnicity, culture, beliefs about food, personal preferences, religious practices, lifestyle, economic conditions, medications and treatments, health status, alcohol consumption, advertising, and psychological factors\u0026nbsp;(25). In fact, cultural models of eating dictate how, when, and where individuals should eat, as well as what constitutes a \u0026quot;proper\u0026quot; meal. These models significantly influence food choices and availability, shaping mealtimes and eating patterns\u0026nbsp;(24). To address these factors, it is essential to conduct qualitative research in the field of\u0026nbsp;nutrition in\u0026nbsp;elderly\u0026nbsp;individuals. The primary strength of qualitative research lies in its ability to infer values, beliefs, practices, and norms from the perspectives of the subjects being studied\u0026nbsp;(26).\u003c/p\u003e\n\u003cp\u003eThis approach (qualitative\u0026nbsp;research) enables researchers to focus on questions related to social experiences, how these experiences are constructed, and the meanings they impart to human life\u0026nbsp;(27). The factors contributing to unhealthy dietary patterns are complex and necessitate an interdisciplinary approach that considers the social context of health (28). Qualitative findings provide a rich context for interpreting results and offer a flexible method for understanding subjective experiences (29). Therefore, they can be instrumental in examining eating habits, which are among the most intricate human behaviors (23).\u003c/p\u003e\n\u003cp\u003eDifferent research objectives require different research designs and analysis techniques, and it is important for health researchers to determine their specific approach to the study before beginning data analysis (30). Since eating habits are among the oldest and most deeply rooted aspects of many cultures (23) and culture affects people\u0026apos;s access to food through food distribution within households (24), we use the PEN-3 model as a cultural lens to better understand the individual, family, and societal impacts on health outcomes (31).\u003c/p\u003e\n\u003ch2\u003e1.1 Theoretical framework\u003c/h2\u003e\n\u003cp\u003eThe cultural model PEN-3, written by Dr. Collins Airhihenbuwa, focuses on putting culture at the forefront of health promotion (32). This model examines health promotion in three domains. Each domain includes three different dimensions, abbreviated as the PEN, each of which plays an important role in health decision-making. These three areas include, respectively (33): (1) key influence on health behaviors (Perceptions, Enablers, Nurturers), (2) impact of behavior on health (Positive, Existential, Negative), (3) focus on interventions (Person, Extended Family, Neighborhood) (33)(34) (Figure 1).\u003c/p\u003e\n\u003cp\u003eThis model encourages an in-depth exploration of individuals\u0026apos; cultural environments and how these contexts influence their health beliefs and practices (35), using culture as a framework for identifying health problems and organizing their components (36). Since its introduction in 1989, the model has guided efforts to address various issues, including food choices (37)(38)(39) and other challenges that require an understanding of both behavior and the associated cultural contexts (37).\u003c/p\u003e\n\u003cp\u003eOne application of this model is the cultural assessment of communities facing health issues by examining the key factors that affect health (40). \u003cstrong\u003eGiven that nutrition is crucial for promoting healthy aging in the elderly population\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(41)\u003c/strong\u003e and that the increasing elderly population worldwide necessitates attention and planning for fostering healthy aging in the near future, the research group decided to conduct the present study to explain the nutritional behaviors of the elderly population based on the PEN-3 Model.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cp\u003eThe present study is the first part of a mixed-method research project designed qualitatively using a directed content analysis approach based on the PEN-3 Model.\u003c/p\u003e\n\u003ch2\u003e2.1 Setting and Participants\u003c/h2\u003e\n\u003cp\u003eThe present study was conducted in Tehran, a large metropolis comprising 22 municipal districts, each comparable in size to a city and spread across four geographical regions: north, south, east, and west. Efforts were made to include samples from all four regions (with a breakdown of participants as follows: east 4, west and center 7, north 4, and south 4 people). The participants were divided into two groups. The first group consisted of elderly individuals aged 60\u0026nbsp;years\u0026nbsp;and older (key participants), selected through convenience sampling. This was achieved by visiting health centers in various regions and utilizing their lists of elderly individuals, as well as by visiting community gathering places such as parks and events and through referrals from other participants. An emphasis was placed on selecting samples from all areas of Tehran with diverse characteristics (sampling for maximum diversity). The second group included caregivers of the elderly (both formal and informal) and dietitians from health centers (nonkey\u0026nbsp;participants).\u0026nbsp;The inclusion criterion\u0026nbsp;for all included men and women were interested in participating in the study.\u0026nbsp;Elderly\u0026nbsp;participants were required to be aged 60\u0026nbsp;years\u0026nbsp;and above, without psychological disorders or diseases, and not\u0026nbsp;experience\u0026nbsp;complex complications that would render them immobile in bed.\u0026nbsp;The\u0026nbsp;caregivers included both formal and informal, direct and indirect caregivers, and dietitians were required to have at least five years of professional experience.\u003c/p\u003e\n\u003ch2\u003e2.2 Data collection\u003c/h2\u003e\n\u003cp\u003eA\u0026nbsp;semi structured, in depth,\u0026nbsp;face‒to-face interview method was employed to collect\u0026nbsp;the\u0026nbsp;data. In a directed content analysis approach, if data\u0026nbsp;are\u0026nbsp;collected primarily through interviews, an open-ended question can be posed first, followed by targeted questions about predetermined categories (30). In this study, the research team developed an interview guide that incorporated the key concepts, characteristics, and definitions from the PEN-3 Model. Three versions of the guide were created, each tailored for interviews with elderly individuals, caregivers, and dietitians (boxes in Appendices 2, 3, and 4). All interviews were recorded, and the researcher transcribed each recorded interview verbatim into written text as soon as possible.\u003c/p\u003e\n\u003cp\u003eIn the initial meeting with the elderly participants, the study\u0026apos;s objectives were explained in detail. Consent was then obtained to conduct and record the interviews, with assurances that their information and recorded interviews would remain confidential. The interview location was chosen according to the participants\u0026apos; preferences, ensuring that they felt comfortable. The interviews were conducted at health centers (in the training room), a park near the participants\u0026apos; residences, their workplaces, and a coffee shop. At this stage, the demographic characteristics of the elderly participants, such as age, education level, and underlying health conditions, were collected. The interviews began with a brief interaction to express gratitude for their participation, followed by questions from the interview guide based on Boxes 2, 3, and 4. Then, on the basis of the participants\u0026apos; responses, probing continued with questions such as \u0026quot;Can you explain further?\u0026quot; or \u0026quot;What do you mean?\u0026quot; The interviews lasted between 35 and 60 minutes. All interviews were conducted in person and completed in one session, except for two caregivers, who were interviewed in two stages due to their busy schedules. A total of 13 elderly individuals, 2 formal caregivers, 1 caregiver who was both formal and informal (caring for a mother and other elderly individuals), 1 informal caregiver, and 2 dietitians participated in the study (Tables 1 and 2). Data saturation was reached after the 16th interview, indicating that no new codes emerged and that no additional information was obtained. To ensure certainty, three more interviews were conducted. Tables 1 and 2 present the general characteristics of the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDemographics of the Elderly (Key Participants)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSituation de vie.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaving a Chronic disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e61\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIlliterate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousewives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with her family)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e78\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighschool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetired\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with son)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ucirc;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIlliterate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousewives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with sons)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e72\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighschool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetired\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with his wife)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e66\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIlliterate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousewives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWidow\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Alone)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e74\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetired\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with his wife)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e68\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighschool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousewives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with her family)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e83\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetired\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDivorced\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Alone)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e82\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighschool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetired\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with his wife)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e70\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUniversity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetired\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with her\u003c/strong\u003e \u003cstrong\u003eh\u003cstrong\u003eusband)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousewives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWidow\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Alone)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousewives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with her family)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026uuml;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.19176%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.2472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUniversity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.2139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetired\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.7829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Lives with her\u003c/strong\u003e \u003cstrong\u003eh\u003cstrong\u003eusband)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4105%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ucirc;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDemographics of the Care Givers and Dietitians\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1746%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.20635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.6825%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork experience\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.0794%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaring Role\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1746%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.20635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e41\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUniversity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNursing Assistant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.6825%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.0794%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFormal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1746%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.20635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e55\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighschool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousewives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.6825%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.0794%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInformal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1746%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.20635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e46\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUniversity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.6825%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.0794%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFormal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1746%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.20635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e53\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighschool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.6825%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.0794%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFormal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1746%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.20635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e34\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaster\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorking in a health center\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.6825%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.0794%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNutritionist\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.1746%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.20635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e42\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBachelor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.4286%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorking in a health center\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.6825%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.0794%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNutritionist\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e2.3 Data analysis\u003c/h2\u003e\n\u003cp\u003eThe data were analyzed using the directed content analysis method of the Hsieh and Shannon (2005) model. After the PEN-3\u0026nbsp;model was selected, its main concepts were studied and extracted by reviewing the theory.\u0026nbsp;These concepts include key factors that influence health behavior (Perceptions, Enablers, Nurturers). Consequently, a coding matrix was created to illustrate these concepts and their subcategories (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003eCoding Matrix for the Concepts of the PEN-3 Model\u003c/p\u003e\n\u003ctable dir=\"rtl\" border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eCodes\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSubcategory\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eCategory\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eknowledge\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003ePerceptions\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eBeliefs\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eAttitudes\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eValues\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eresources\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eEnablers\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eAccessibility\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eReferrals\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eservice\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eExtended Family\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" style=\"width: 200px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eNurturers\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003ePeers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eEmployers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eHealth Personnel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eReligious Leaders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eGovernment Officials\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAfter the data were collected, semantic units and codes were extracted on the basis of the main research question and the concepts outlined in the coding matrix. Researcher 1 read and reread the interview transcripts and occasionally listened to the recorded interviews to develop a comprehensive understanding of the content. First, semantic units were identified from each transcript, and initial coding was conducted using the participants\u0026apos; expressions, which were aligned with the main research question and the concepts defined in the theory. Each code that was appropriate and consistent with the concepts and subcategory of the matrix was subsequently placed within it.\u003c/p\u003e\n\u003cp\u003eThis initial coding process was conducted by Researchers 2 and 3 for a few interviews. If there was agreement among all three researchers, the code was accepted. The coding of the remaining interviews was then reviewed and approved by them, along with the two main project reviewers. Table 4 illustrates how the raw data were utilized to code and assign them\u0026nbsp;to the main substructures and constructs of the theory. Finally, on the\u0026nbsp;basis of the\u0026nbsp;codes and findings obtained from comparisons and matches with the theoretical definitions in the matrix, an operational definition was provided for each of the main concepts of the theory(30).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003eExamples of how the raw data were utilized to code and assign it to the main substructures and constructs\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable dir=\"rtl\" border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eRow data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eSubcategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eI eat one boiled egg every day, and I have noticed significant improvements in my health due to their high protein content. I made this change because I needed extra protein after I was sick and had surgery. (P:15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eUnderstanding protein sources and their importance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eknowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 88px;\"\u003e\n \u003cp dir=\"LTR\"\u003ePerceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eI try to eat very little red meat. Instead, I consume a lot of turkey and chicken, having red meat only once or twice a week at most. Additionally, there is one day each week when I don\u0026rsquo;t eat any meat\u0026nbsp;at all\u0026hellip; (P: 19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eConsume more white meat rather than red meat\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eBeliefs\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e(Beliefs, Attitudes, Values)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFor example, if you search for diabetes or blood pressure on Google or follow Instagram, you may find that Instagram presents a mix of truths and misinformation, while Google offers medical information. A search yields a wealth of information. (P: 11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eObtaining nutritional information online\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eresources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 88px;\"\u003e\n \u003cp dir=\"LTR\"\u003eEnablers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAccess to basic food is good in this area, with essential ingredients readily available. They are easy to obtain, typically taking only a quarter to half an hour to gather and return home\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e(P: 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eEasy access to essential food supplies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAccessibility\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eBecause the centers are constantly moving, this health center is sometimes located in Dardasht, sometimes 30 meters away, and at other times in different locations. I\u0026apos;m not in the mood to go out. My legs hurt as well, and I can\u0026apos;t walk far. (P:12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAvoid visiting health centers due to various restrictions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eReferrals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMany of them also receive support from the relief committee, but the amount is insufficient.\u003cspan dir=\"RTL\"\u003e)\u003c/span\u003e p:13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eInadequate services provided by the Imam Khomeini Relief Committee.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eservice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eIf it\u0026apos;s a party, then no. If it\u0026apos;s a guest, however, then yes, just like before\u0026mdash;greasy, spicy, and very...\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e(P:17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eNot adhering to the diet at parties.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eExtended Family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 88px;\"\u003e\n \u003cp dir=\"LTR\"\u003eNurturers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp dir=\"LTR\"\u003eNo, it hasn\u0026apos;t happened yet. For example, they told him to eat a low-protein diet. It doesn\u0026apos;t have protein, but, for example, a food group that doesn\u0026apos;t have protein or, for example, something that I can safely make and give to my elderly person to eat\u0026mdash;no, they didn\u0026apos;t tell me the details.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e(P:10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp dir=\"LTR\"\u003eGeneral nutritional education provided by a doctor.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHealth Personnel\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch2\u003e2.4 Consideration of Rigor\u003c/h2\u003e\n\u003cp\u003eLong-term contact with the data subject (immersion) and data collection from July to December\u0026nbsp;2024\u0026nbsp;were among the methods used to validate the present study. \u003cstrong\u003eTo ensure that the analysis accurately\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ereflected\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;the experiences of the elderly\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eindividuals\u003c/strong\u003e\u003cstrong\u003e, caregivers, and dietitians, participant reviews were conducted for the extracted codes, and changes were made as\u0026nbsp;\u003c/strong\u003enecessary. The interviews and analysis results, including the initial codes, subcategories, and categories of the PEN-3 model, were reviewed by three experts and discussed among the research team to verify the reliability and consistency of the data. Sampling strategies that maximize diversity and consider a wide range of experiences from primary and secondary contributors have ensured the transferability of findings for readers and reviewers.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 169 merged and refined codes were derived from the analysis of the interviews. The findings indicate that a greater number of codes were assigned to the category of Perceptions. Owing to the close relationships among beliefs, attitudes, and values, codes related to these concepts were grouped into a single subcategory (beliefs). Additionally, there were fewer codes across all subcategories of Enablers. However, regarding Nurturers, the codes were limited to the subcategories of extended family and health personnel. Below, the three main constructs or categories of the matrix based on the PEN-3 are described and explained, along with their subcategories, using data from the participants\u0026apos; experiences.\u003c/p\u003e\n\u003ch2\u003e3.1 Perceptions influencing nutritional behavior\u003c/h2\u003e\n\u003cp\u003ePerceptions based on the PEN-3 model encompass knowledge, beliefs, attitudes, and values that can either facilitate or hinder motivation to change behavior (34). Nutritional behaviors are defined as \u0026quot;the sum of all planned, spontaneous, and intentional actions (functions) or the habits of individuals or social groups related to the procuring, preparation, and consumption of food.\u0026nbsp;\u0026quot;(42)\u0026nbsp;Analysis of data from participants\u0026apos; perceptions\u0026nbsp;revealed\u0026nbsp;that the nutritional behaviors of the elderly include three functional domains: procuring, preparation, and consumption. Experiences not directly related to these three behavioral domains but derived from the knowledge and beliefs of the elderly regarding nutritional behaviors were expressed as general knowledge and general beliefs.\u003c/p\u003e\n\u003ch3\u003e3.1.1 Knowledge about Procuring Food:\u003c/h3\u003e\n\u003cp\u003eThe experiences of the elderly in this area highlighted several important issues, such as preparing basic food ingredients in small quantities, ensuring the quality of ingredients, sourcing from reliable suppliers, and incorporating more white meat into their diets. P (15), 80-year-old man\u003cem\u003e: \u0026ldquo;For example, about meat, I tell the butcher to give me some meat, to give me brick-colored meat; they know me too. They charge more but give me better quality. Or when I want to buy chicken, I look to see if it\u0026apos;s fresh. Or when I want to buy fish. I say, \u0026quot;Are the trout fresh?\u0026nbsp;\u0026quot; They say, \u0026quot;If it\u0026apos;s not fresh, we won\u0026apos;t give it to you. We know you. \u0026quot;\u0026rdquo;\u0026nbsp;\u003c/em\u003eP (19), 70-year-old woman: \u0026ldquo;\u003cem\u003eI try to eat very little red meat. Instead, I consume a lot of turkey and chicken, having red meat only once or twice a week at most. Additionally, there is one day each week when I don\u0026rsquo;t eat any meat.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003e3.1.2 Knowledge about Preparation Food:\u003c/h3\u003e\n\u003cp\u003eDespite being less busy in old age, most participants continued to prepare more food and several meals out of habit or based on circumstances, a point confirmed by\u0026nbsp;dietitians. P (2), 78-year-old woman: \u0026ldquo;\u003cem\u003eSometimes I cook at noon, and that meal is also for dinner. For example, I often cook at night. When I was an employee, I would prepare dinner at night so that I could have lunch ready when I got home the next day. Now, as a housewife, I still sometimes cook for dinner at noon\u003c/em\u003e.\u0026quot; They also mentioned the importance of spending adequate time preparing food, using less salt and oil, employing healthier frying methods, and maintaining hygiene during preparation. P (16), 70-year-old woman: \u0026quot;\u003cem\u003eI\u003c/em\u003e\u003cem\u003et should be low in fat, which means minimizing fried foods. At the end, you put a bit of butter on top for flavor, and that\u0026apos;s my\u0026nbsp;\u003c/em\u003e\u003cem\u003eapproach\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003ch3\u003e3.1.3 Knowledge about Consumption Food:\u003c/h3\u003e\n\u003cp\u003eSeniors mentioned experiences such as eating dinner early, snacking, and choosing home-cooked or traditional foods over dining out.\u0026nbsp;A large number of participants skipped one of the main meals for various reasons, including feelings of adequacy,\u0026nbsp;doctor\u0026nbsp;advice, and concerns about weight gain. P (1), 61-year-old woman: \u0026ldquo;\u003cem\u003eYes, the doctor said to eat dinner instead. He advised eating breakfast and dinner properly, but not lunch, because you\u0026apos;re overweight and your legs hurt\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003e3.1.4 General knowledge about nutritional behavior:\u003c/h3\u003e\n\u003cp\u003eElderly individuals and their caregivers generally had a limited understanding of harmful substances related to chronic diseases and the consequences of their consumption. P (4), 74-year-old man: \u0026ldquo;\u003cem\u003eI believe that rice contains starch and bread has starch, which increases blood sugar. For example, I truly enjoy halva; I know it raises my blood sugar\u003c/em\u003e.\u0026rdquo; Despite this awareness, many elderly participants reported not adhering to the recommended diets for their chronic conditions, a point confirmed by caregivers and dietitians. P (12), 68-year-old woman: \u0026ldquo;\u003cem\u003eI pay attention to all the medical advice. I listen to health programs that discuss diseases and such. I hear it all, but... I don\u0026rsquo;t follow it\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003e3.1.5 Beliefs about Procuring Food:\u003c/h3\u003e\n\u003cp\u003eDespite the restrictions, many elderly individuals preferred to prepare basic food ingredients on their own and believed this preparation should be\u0026nbsp;performed\u0026nbsp;in advance. P (19), 70-year-old woman: \u0026ldquo;\u003cem\u003eNo, I try to do my shopping myself; for example, I don\u0026rsquo;t take a car, which makes me walk a bit. Yes, I do that. I usually do most of the shopping myself\u003c/em\u003e.\u0026rdquo; Some also felt it was important to keep a reserve of food. P (14), 83-year-old woman: \u0026ldquo;\u003cem\u003eHowever, I make predictions. For example, now I\u0026rsquo;ll buy one or two dry loaves of bread that won\u0026rsquo;t spoil. I\u0026rsquo;ll leave them at home and use those dry loaves when I need to.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003e3.1.6 Beliefs about Preparation Food:\u003c/h3\u003e\n\u003cp\u003eThe experiences of the elderly indicate that they often strive to maintain their independence in this area by employing various strategies, and for some, this process is enjoyable. P (6), 70-year-old woman: \u003cem\u003e\u0026ldquo;First, dealing with food is very pleasant for me. I never approach this task out of boredom or aversion; rather, I do it with joy\u003c/em\u003e.\u0026rdquo; Additionally, they emphasized the importance of personal interests and the use of seasonings and spices to enhance their meals. P (9), a 55-year-old caregiver: \u0026ldquo;\u003cem\u003etells me, \u0026lsquo;Put cinnamon in my tea, add cardamom, include rose petals.\u0026rsquo; For example, one day I put cardamom and rose petals in my tea, another day cloves, and another day cardamom and cinnamon\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003e3.1.7 Beliefs about Consumption Food:\u003c/h3\u003e\n\u003cp\u003eBeliefs such as avoiding unpleasant foods, not consuming food under poor conditions, emphasizing breakfast, the desire for sweet foods in the morning and considering the cold and hot nature of foods significantly influenced the dietary choices of elderly. Dietitians also confirmed that elderly people pay attention to the cold and hot nature of foods. P (16), 70-year-old woman: \u0026ldquo;\u003cem\u003eYes, the cold and hot nature must be observed. Yes, that means I shouldn\u0026apos;t eat yogurt with fish if the food is fish. Or cucumber and watermelon shouldn\u0026apos;t be eaten together at all. Or, for example, milk, which is very important, I should eat milk in a way that it is truly far away from food and fruit because they don\u0026apos;t go together. Milk has a cold nature\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003e3.1.8 General beliefs about nutritional behavior:\u003c/h3\u003e\n\u003cp\u003eThis domain encompassed the attitudes and feelings of the elderly regarding nutrition (positive and negative), the belief that there was no need to change their nutritional habits, and the emphasis on quality over quantity. For some individuals, nutrition was considered a top priority in their lives. P (15), 83-year-old man: \u0026quot;\u003cem\u003eIt\u0026apos;s very important; let\u0026apos;s eat something. No, I eat something that benefits me. I eat well. I eat little, but I eat well. Quality has a big impact.\u0026quot;\u003c/em\u003e For some, food was merely a prerequisite for taking medication. P (5), 66-year-old woman: \u0026quot;\u003cem\u003eYes, breakfast is also small. Not like that. For instance, I eat two or three bites of walnuts and diet cheese.\u003c/em\u003e \u003cem\u003eI also eat that so I can take the pills after breakfast.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, in accordance with the experiences of elderly individuals, perceptions of nutritional behaviors across all subcategories\u0026mdash;knowledge, belief, attitudes, and values\u0026mdash;were expressed with multiple instances. These perceptions were directly related to three areas of nutritional behavior: food procuring, food preparation, and food consumption. Although some perceptions were not directly linked to these areas, they still reflected the overall structure of perceptions, all of which influences or obstructs the nutritional behaviors of elderly individuals.\u003c/p\u003e\n\u003ch2\u003e3.2 Enablers influencing nutritional behavior\u003c/h2\u003e\n\u003cp\u003eAccording to the PEN-3 Model, enablers are social or systemic forces that can either enhance health behavior or create barriers that hinder it. These enablers include available resources, accessibility, referrals, and types of services (34).\u003c/p\u003e\n\u003ch3\u003e3.2.1 Available resources:\u003c/h3\u003e\n\u003cp\u003eTwo important sources related to nutritional behaviors\u0026mdash;information to enhance nutritional knowledge and financial resources to obtain food\u0026mdash;were identified in the experiences of the elderly in this area. They utilized various sources, including public media, books, and the internet (accessed by themselves or by family members), to improve their nutritional knowledge. P (3),\u0026nbsp;60-year-old woman: \u0026quot;... \u003cem\u003eYes, for nutrition, they say that dairy products are good for elderly individuals, and eggs are good as well. For example, I look at it like this (TV); I see that for my age, it speaks to me.\u0026quot;\u003c/em\u003e P)19(, 70-year-old woman: \u003cem\u003e\u0026quot;\u003c/em\u003e\u003cem\u003eI visit the internet more frequently\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e\u0026nbsp;and\u0026nbsp;\u003c/em\u003e\u003cem\u003ethen I\u003c/em\u003e\u003cem\u003e\u0026nbsp;look to see what certificate the expert who wrote the article possesses.\u003c/em\u003e \u003cem\u003eThen\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e\u0026nbsp;I have some experience\u003c/em\u003e\u003cem\u003e; however\u003c/em\u003e\u003cem\u003e, I visit the internet more frequently\u003c/em\u003e \u003cem\u003eto see what is going on there\u0026quot;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGiven the symmetry of retirement and old age, income inadequacy was experienced by the elderly unless they had another source of income in addition to retirement income. P (6), 74-year-old man: \u0026quot;\u003cem\u003eWhy don\u0026apos;t we buy expensive things anymore? For example, let\u0026apos;s say cherries and sour cherries were once 150 tomans; we never bought them. Now they\u0026apos;re going down; now they\u0026apos;re 100 tomans. Maybe we\u0026apos;ll buy half a kilo to take home; that\u0026apos;s how it is\u003c/em\u003e.\u0026quot; However, P (14), 84-year-old women: \u003cem\u003e\u0026quot;I rented that house to help with my salary... Yes, but my salary is low, not much. Along with the rent, I also have more money than food and groceries.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003e3.2.2\u0026nbsp;\u003cstrong\u003eAccessibility:\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMost elderly individuals and caregivers in the present study experienced easy access to food, with a few exceptions related to the geographical location of their residences. P (16), 70-year-old female: \u0026quot;\u003cem\u003eYes, there are two markets of municipality within walking distance of us. There is a fruit shop in the alley, a supermarket, and a bakery, all close to us. We are truly...\u0026quot;\u003c/em\u003e Most of them, along with dietitians, acknowledged that access to prepared foods suitable for the elderly is limited. P (10), 46-year-old female as caregiver: \u0026quot;\u003cem\u003eIt\u0026apos;s very rare to find places where you can order diet and healthy food specifically for elderly individuals. Unless you can find healthy, ready-made options, you likely won\u0026apos;t come across a diet-friendly vegetable dish. Such offerings are quite uncommon.\u003c/em\u003e\u0026quot;\u003c/p\u003e\n\u003ch3\u003e3.2.3\u0026nbsp;\u003cstrong\u003eReferrals:\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMost elderly people indicated that they did not visit health centers as an important source of referrals due to various limitations. P (1)\u0026nbsp;61-year-old woman:\u0026nbsp;\u0026quot;\u003cstrong\u003e\u003cem\u003eI don\u0026apos;t come here often. I used to come here for a visit; then, for example, they sent me somewhere else to get a test, and I got a visit here too. Therefore, what is the difference? I\u0026apos;ll just go there, get a visit, and get\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;my \u003cem\u003etest done\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003ethere.\u0026nbsp;\u003c/em\u003e\u0026quot; The key point here is follow-up by centers for elderly individuals to encourage visits. P (9), 55-year-old female caregiver: \u003cem\u003e\u0026quot;They even called me from the health center. I visited several times to inform them that I had a senior citizen at home, and they provided me with guidance.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003e3.2.4 Services:\u003c/h3\u003e\n\u003cp\u003eTwo services were offered to address the nutritional needs of elderly individuals: the Imam Khomeini Relief Committee and the distribution of food baskets at community centers. However, the elderly participants were completely unaware of the latter, and the dietitians indicated that these services were inadequate. P (13), 42-year-old female as dietitians:\u003cem\u003e\u0026nbsp;\u0026ldquo;We provide food baskets, but there is a need for a daily or regular monthly supply that can be counted on. Although many receive support from the relief committee, the amount is insufficient.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, according to the experiences of elderly individuals, the enabling factors of nutritional behaviors in all subcategories\u0026mdash;resources, access, referrals, and services\u0026mdash;were expressed with various instances. Each factor plays a role in either promoting or hindering these behaviors.\u003c/p\u003e\n\u003ch2\u003e3.3 Nurturers influencing nutritional behavior\u003c/h2\u003e\n\u003cp\u003eAccording to the PEN-3\u0026nbsp;model, individuals may receive reinforcements from significant others, which can include extended family members, peers, employers, healthcare personnel, religious leaders, or government officials (34).\u003c/p\u003e\n\u003ch3\u003e3.3.1 Extended family:\u003c/h3\u003e\n\u003cp\u003eIn accordance with the experiences of elderly people, as well as input from dietitians and caregivers, family members played a crucial role in supporting elderly people by helping to compensate for decreased income and meet nutritional needs. They focused on the nutritional status of their loved ones and assisted in food preparation and awareness of their preferences. P (14), 83-year-old woman: \u0026quot;\u003cem\u003eMy eldest son said, \u0026apos;I\u0026apos;m at your disposal one day a week from morning to noon. I\u0026rsquo;ll go wherever you want, buy whatever you need, and bring whatever you ask for.\u0026apos; We have been living in Jordan for thirteen years now. You might not believe it, but during this time, he hasn\u0026apos;t broken his promise even once, even once.\u0026quot;\u003c/em\u003e \u003cstrong\u003eFamily significantly influences the food choices of elderly individuals. This impact is evident when elderly individuals deviate from their diets in parties or follow the dietary preferences of their children. P (17), 69-year-old woman:\u003c/strong\u003e \u0026quot;\u003cstrong\u003e\u003cem\u003eFor example, my daughter-in-law sometimes called me when they got fast food. The distance is close. Occasionally, the grandchildren would say, \u0026quot;We have fast food; come here. I go, or I won\u0026apos;t buy it myself.\u0026quot;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e3.3.2 Healthcare personnel:\u003c/h3\u003e\n\u003cp\u003eGiven the frequent doctor visits by the elderly for chronic conditions, the provision or lack of nutrition education from the attending physician was a significant experience reported in this study. P (4), 72-year-old man:\u0026nbsp;\u003cstrong\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eNo, I went to the doctor yesterday and waited for two hours to be examined. They didn\u0026rsquo;t provide any explanations; they just looked at me. Mr., \u0026quot;I\u0026rsquo;ll give you your medicine.\u0026quot; They enter it into the monitor, and we\u0026apos;ll proceed as usual\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e\u003c/strong\u003e \u003cstrong\u003eConsidering the limitations of elderly individuals, one issue mentioned was the use of educational strategies by dietitians to help them understand and retain educational materials, as well as to validate information with\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethem\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e P (13), 43-year-old woman as dietitians:\u0026nbsp;\u003cstrong\u003e\u0026quot;\u003c/strong\u003e\u003cem\u003eMany of them are illiterate or have poor memories,\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003ethat is a challenge as well. I often tell them to record my voice or to bring someone along next time. We\u0026apos;re asking someone to help them pay closer attention\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e.\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;Or, for example, I\u0026apos;ll say it in very simple ways.\u003c/em\u003e\u003c/strong\u003e \u003cstrong\u003e\u003cem\u003eEat at least this many pieces of bread at each meal (indicating the size with her hand), and remember that, to some extent \u0026hellip;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026quot;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, according to the experiences of elderly individuals, the nurturing factors of nutritional behaviors in only two subcategories\u0026mdash;extended family and healthcare personnel\u0026mdash;were expressed with various instances that can either enhance health behavior or create barriers that hinder it.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study aimed to explain the nutritional behaviors of elderly individuals in Tehran using the PEN3 model, which was employed to analyze the findings. The research team examines the nutritional behaviors of the elderly by focusing on one of the three domains of this model: factors influencing health, which include perceptions, enablers, and nurturers. An analysis of the findings of this study indicates that this domain of the model encompasses all dimensions of the nutritional behavior experiences of elderly people.\u003c/p\u003e\n\u003cp\u003eDespite searching various databases, no studies utilizing this model in the field of nutrition for the elderly population were found. However, several qualitative studies have been conducted on the nutritional status of elderly individuals(43)(44)(45)(46)(47)(48)(49). Some of their findings support the present study, whereas others contradict it.\u003c/p\u003e\n\u003cp\u003eMost elderly individuals\u0026apos; experiences fall within the first domain, which includes perceptions\u0026mdash;such as knowledge, beliefs, attitudes, and values\u0026mdash;related to nutritional behavior.\u0026nbsp;Most of them were aware of and emphasized many things, such as reducing salt and oil consumption and healthy cooking methods. However, in response to the question about which foods they consider beneficial, some individuals mentioned the foods they typically consume, stating that they do not focus on the impact of these foods on their health. Additionally, in\u0026nbsp;the study by Terp et al.\u0026nbsp;(45), when participants were asked about their eating habits and their relationship\u0026nbsp;with\u0026nbsp;health, their narratives emphasized the social and sensory aspects of eating, with no mention of health.\u0026nbsp;Despite the awareness and attention of most participants in the present study to food health, only a small number raised important issues,\u0026nbsp;such as increasing protein and micronutrient intake, avoiding the elimination of specific food groups (dairy and vegetables)\u0026nbsp;(50), and fortification of familiar foods\u0026nbsp;(51). Issues such as salt consumption, which\u0026nbsp;has\u0026nbsp;been emphasized more in training, appear to have become ingrained in the behavior of elderly individuals. Therefore, it is essential to revise the educational content to address problems\u0026nbsp;such as\u0026nbsp;protein malnutrition.\u003c/p\u003e\n\u003cp\u003eIn the study by Vanderpool et al. (47), elderly individuals identified their physical condition as a barrier to cooking. However, in this study, participants endeavored to maintain their independence in food preparation despite these physical limitations by utilizing measures such as periodic rest, assistive devices, and extra caution.\u0026nbsp;This is due to both cultural differences\u0026mdash;since culture can influence the value placed on achievement, independence, and work\u0026nbsp;(52)\u0026mdash;and the fact that people age differently. While some older individuals require care, many influence their experiences of aging (5).\u0026nbsp;This same item\u0026mdash;participation in preparation and cooking\u0026mdash;was the foundation of the education\u0026nbsp;of\u0026nbsp;Wallace and Devine\u0026nbsp;(53), which had significant and lasting effects on food knowledge and behaviors.\u003c/p\u003e\n\u003cp\u003eNutrition not only impacts the health of elderly individuals but also plays a crucial role in managing chronic diseases (54). Most older adults experience one or more chronic conditions (4). In the study by Terp et al. (45), individuals with chronic diseases not only confirmed their knowledge and experience\u0026nbsp;of\u0026nbsp;the impact of diet on health but also recognized the importance of adhering to dietary recommendations. In contrast, this study\u0026nbsp;revealed\u0026nbsp;that elderly individuals with chronic diseases, despite being aware of dietary recommendations and experiencing complications, did not adhere to the suggested diet and believed\u0026nbsp;that\u0026nbsp;it had no impact on their health. However, dietitians confirmed that in cases of acute issues, the diet led to visible and short-term results, making these individuals more cooperative in accepting and implementing the education provided. This refers to a sense of control, which is an individual\u0026apos;s perception of their ability to influence their environment and achieve desired outcomes\u0026nbsp;(55). This feeling is less pronounced in chronic issues, as they do not provide objective and immediate results. Lin et al.\u0026nbsp;(44),\u0026nbsp;who reported\u0026nbsp;results\u0026nbsp;similar\u0026nbsp;to\u0026nbsp;those of\u0026nbsp;the present study, expressed self-control, i.e., the ability of an individual to resist\u0026nbsp;temptation\u0026nbsp;and control behavior. If it is weak, it will maintain\u0026nbsp;the\u0026nbsp;wrong behavior and create a separation between knowledge and action. These two issues should be taken into account in nutritional interventions for chronic diseases.\u003c/p\u003e\n\u003cp\u003eIn the enablers and subcategory\u0026mdash;resources\u0026mdash;participants reported that retirement income (as a financial resource) alone was insufficient to meet their nutritional needs, which impacted their choices. In Chalermsri et al.\u0026apos;s study (48), participants who relied on government pensions reported that the cost of food significantly influenced their food choices, leading them to prepare low-quality meals. Declining income and retirement savings, combined with rising healthcare and living costs, have adversely affected many older individuals. These issues are significant challenges associated with aging\u0026nbsp;(5)\u0026nbsp;and demand the attention of society\u0026apos;s policymakers. On the other hand, health care providers should not blame older individuals for preventable health problems, as these individuals may lack the financial resources or support\u0026mdash;both past and present\u0026mdash;necessary to make healthy lifestyle changes\u0026nbsp;(5).\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;definition of resources also includes the sources of information (56). Sources of nutritional information were included in the subcategory of resources, similar to a previous study\u0026nbsp;(38). This included mass media, books, and even the internet)\u0026nbsp;both search engines and social networks. In the study by Chen et al.\u0026nbsp;(43), elderly individuals also identified similar sources for obtaining nutritional information. Receiving conflicting information was a common finding in both studies, as confirmed by dietitians in the present study. Therefore, in addition to obtaining information, it seems necessary to validate it with dietitians.\u003c/p\u003e\n\u003cp\u003eAccess to nutrition focuses on supply and refers to the amount of food resources that are physically available through local production and trade (24). In the present study,\u0026nbsp;with a few exceptions,\u0026nbsp;most of the elderly participants were satisfied with their access to basic food sources. The participants\u0026nbsp;in this study, as well as those in the study by Van Der Pols et al.(47), raised concerns about the lack of access to ready-to-eat food. In the present study, dietary health was considered more\u0026nbsp;important\u0026nbsp;in terms of hygiene and diet, whereas in the above study, poor quality and poor taste of food were considered. One interpretation pertains to cultural differences,\u0026nbsp;whereas\u0026nbsp;the other addresses differences in\u0026nbsp;the\u0026nbsp;perceptions of elderly individuals.\u003c/p\u003e\n\u003cp\u003eHealth centers and dietitians are examples of referrals within the enabler\u0026rsquo;s subcategory in the field of nutrition. The implementation of the Health System Transformation Plan in Iran emphasized a healthy diet as a key national program, aligning the presence of dietitians in centers with this objective. However, the study\u0026apos;s results indicated that the elderly faced barriers to accessing these centers and dietitians due to various restrictions. In the study by Chen et al. (43), most of the participating elderly\u0026nbsp;individuals\u0026nbsp;had not received professional nutrition counseling and were unaware of the existence of a nutrition-related department. According to a study by Mawardi et al.\u0026nbsp;(57), general practitioners require greater support from dietitians and community nurses in identifying patients at risk of malnutrition and assisting them in managing this condition. The study\u0026nbsp;revealed\u0026nbsp;that malnutrition screening was conducted more frequently by nurses than through referrals to dietitians. In the study by Avgerinou et al.\u0026nbsp;(49), participants expressed varying preferences regarding the professional backgrounds of service providers. Some felt that a doctor or nurse would be appropriate,\u0026nbsp;whereas\u0026nbsp;others believed that dietitians had the necessary time and expertise to deliver this type of intervention. On the basis of\u0026nbsp;these results and the\u0026nbsp;findings of the present\u0026nbsp;study, the nutritional issues faced by elderly\u0026nbsp;individuals\u0026nbsp;will continue to be overlooked until they visit medical centers. To prevent malnutrition and its complications, proactive measures and planning for counseling by dietitians are necessary.\u003c/p\u003e\n\u003cp\u003eThe extended family, as a subcategory of\u0026nbsp;nurture, plays a crucial role in the experience of health and illness and in shaping health decisions, as demonstrated by Iwelunmor et al. in their applications of the PEN3 model (40). This study describes the supportive role of the family in meeting the nutritional needs of elderly individuals, both directly and indirectly, through financial and nonfinancial means. Additionally, it explains the effects of family on the food choices and dietary compliance of elderly individuals.\u0026nbsp;Spending time with family members was also valued by the elderly as a tradition that is declining.\u0026nbsp;This encouraged the elderly person to cook and eat.\u0026nbsp;The study by Terp et al.\u0026nbsp;(45)\u0026nbsp;reported\u0026nbsp;that older adults valued both cooking for or with others and eating together, which encouraged them to eat. Additionally, the anticipation of sharing a meal with others motivated individuals to take the time to prepare good food. In the study by Chalermsri et al.\u0026nbsp;(48), companionship during meals was identified as a significant factor influencing positive eating habits, serving as a valuable experience and an incentive for cooking among elderly individuals. However, a significant finding of this study is that the elderly reported that this gathering caused them to disregard their diets. In the Terp et al.\u0026nbsp;(45)\u0026nbsp;study,\u0026nbsp;relatives\u0026nbsp;provided practical support by finding nutritional information and offering mental encouragement to promote healthy food intake. This case highlights the social and ceremonial roles that food plays in various cultures\u0026nbsp;(23). In general, when family members pay closer attention to and become more knowledgeable about the elderly\u0026apos;s diet, they can offer positive guidance that supports the implementation and maintenance of healthy eating behaviors\u0026nbsp;(44). Therefore, involving this group in nutritional interventions for the elderly is essential.\u003c/p\u003e\n\u003cp\u003eAmong health personnel, physicians play a crucial role as gatekeepers of the health care system in encouraging healthy eating and lifestyles. They can assist individuals by providing nutritional counseling, conducting nutritional assessments, and recommending that patients seek professional nutritional care, all of which fall under the umbrella of nutritional care\u0026nbsp;(58). Elderly individuals frequently visit this group\u0026nbsp;because of\u0026nbsp;chronic diseases and pain. However, participants\u0026apos; experiences indicate that nutrition education provided by doctors is neither objective nor acceptable. In the study by Lin et al.\u0026nbsp;(44), participants anticipated more detailed and specific dietary recommendations; however, the actual recommendations were quite abstract, resulting in misinterpretations of the information. The participants\u0026nbsp;in the present study noted that physicians\u0026apos; roles were focused\u0026nbsp;primarily\u0026nbsp;on prescribing medication. Dietitians corroborated this by citing time constraints during their visits as a reason for the lack of nutrition education. The participants\u0026nbsp;in the study by Avgerinou et al.\u0026nbsp;(49)\u0026nbsp;confirmed that doctors are busy, but they also noted that certain communication skills are more important than professional skills. Mawardi et al.\u0026nbsp;(57)\u0026nbsp;noted that despite the significance of malnutrition in elderly individuals, general practitioners reported that they do not systematically screen for it and view it as a \u0026quot;secondary concern.\u0026quot; As the study by Lin et al.\u0026nbsp;(44)\u0026nbsp;indicated that participants had high trust in the information provided by medical staff, it is essential for physicians to receive training in nutritional care. Given that visit\u0026nbsp;times are\u0026nbsp;limited,\u0026nbsp;elderly patients\u0026nbsp;should\u0026nbsp;be referred\u0026nbsp;to dietitians.\u003c/p\u003e\n\u003cp\u003eThis study is the first part of a larger effort to develop an intervention. Nutrition interventions that do not account for social, cultural, and emotional aspects of eating are unlikely to be effective because few people eat to live Most of us \u0026quot;live to eat.\u0026quot;(59). According to the PEN-3 model, sustainable interventions for changing health behaviors must be rooted in culture. They are founded on (a) an understanding of the health-related cultural context for a specific population and (b) an appreciation of the community\u0026apos;s strengths and challenges (32). This study explores the experiences of elderly individuals within the cultural context of nutritional behaviors, highlighting both their strengths and weaknesses.\u003c/p\u003e"},{"header":"5.\tLimitations","content":"\u003cp\u003eThe primary limitation of this study was the reluctance of elderly participants to be interviewed. Most of them viewed this work as useless because of their negative attitude toward aging; however, some agreed to cooperate after the research objectives were explained. Additionally, elderly individuals who lived with their families and were unable to make independent decisions, as well as employed elderly individuals, lost the opportunity to participate in the study, which should be considered in future research.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThe results of this study, in addition to showing that factors beyond elderly people's perceptions (including knowledge and beliefs) determine their nutritional behaviors by integrating these factors with the areas of nutritional behavior (food preparation, procuring, and consumption), distinguished the stages of nutrition as well as the cultural and contextual causes that influence them, which can be used in developing educational content to improve nutrition for elderly people. According to the results of this study, traditional methods are insufficient for examining and evaluating the nutritional behaviors of elderly individuals with life experience, particularly in the areas of nurturers and enablers. Considering family and social factors is essential for effectively shaping overall community policies. On the other hand, this study encompasses both the positive and negative experiences of the elderly regarding nutritional behaviors. By viewing these experiences as assets and challenges within the target community, interventions can be designed for greater success, and the steps taken can be effectively reviewed.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThis study was part of the PhD thesis of the first author and was supported by Tarbiat Modares University. The authors would like to thank all the participants who made this study possible, the officials at Tarbiat Modares University for their coordination, the health centers, and especially elderly individuals.\u003c/p\u003e\n\u003ch2\u003eAuthor contributions\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp;TS was the main investigator and contributed to the development of the research protocol, implementation of the research, and drafted the manuscript. SH and GF supervised the study and scientific integrity of the data collection and revision of the manuscript ME was an advisor for the study, contributed to the interpretation of the data and revised the manuscript. HA was an advisor for the study and participated in the design of the study. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis study was financially supported by\u0026nbsp;Tarbiat Modares University (TMU). The funder had no involvement in the study design, data collection, analysis, interpretation and composition of the manuscript.\u003c/p\u003e\n\u003ch3\u003eData availability\u003c/h3\u003e\n\u003cp\u003eThe data utilized for analysis are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and was approved by Research Ethics Committee of Tarbiat Modares University (ID: Approved IR.MODARES.REC.1403.006). Written informed consent was obtained from all participants before the interview. A consent form was provided, allowing participants the opportunity to consult with their families. Some signed the form immediately,\u0026nbsp;whereas\u0026nbsp;others did so after discussing it with their families. Once consent was secured, arrangements were made to schedule and conduct the interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChin S, Wong R, Hirani V, O\u0026rsquo;Leary F. Nutrition Knowledge Assessment Tools for Older Adults and their Carers: A Scoping Review. Nutr Res Rev. 2021;(15).\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eFakoya OA, McCorry NK, Donnelly M. Loneliness and social isolation interventions for older adults: a scoping review of reviews. BMC Public Health. 2020;20:1\u0026ndash;14.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eTeggart K, Ganann R, Sihota D, Moore C, Keller H, Senson C, et al. 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OED. 2025 [cited 2025 Aug 9]. resource (noun). Available from: https://www.oed.com/dictionary/resource_n?tl=true\u003c/li\u003e\n\u003cli\u003e Mawardi F, Lestari AS, Kusnanto H, Sasongko EPS, Hilmanto D. Malnutrition in older adults: How interprofessional teams see it? A systematic review of the qualitative research. Fam Pract. 2021;38(1):43\u0026ndash;8.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003e Mogre V, Amoore BY, Gaa PK. A scoping review of nutrition education interventions to improve competencies, lifestyle and dietary habits of medical students and residents. J Nutr Sci. 2023;12:1\u0026ndash;14.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003e Meiner SE. Gerontologic Nursing Fifth Edition. 5th ed. Mosby; 2014.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Elderly, Nutritional Behaviors, PEN-3 Model, Qualitative Study","lastPublishedDoi":"10.21203/rs.3.rs-8131774/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8131774/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Despite the crucial role of nutrition in the health promotion and quality of life of elderly individuals, many are at risk of malnutrition. Considering the cultural and social aspects of this group's nutrition, it is essential to conduct qualitative research and select an appropriate approach. The PEN-3 model offers a cultural perspective for examining various dimensions of nutritional behaviors in elderly individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThe aim of this study is to explain the nutritional behaviors of the elderly based on the PEN-3 model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis qualitative study was conducted over six months in various areas of Tehran, Iran, in 2024. Data were collected through in-depth semi structured interviews using three interview guides, involving 13 elderly people (main participants), 4 caregivers, and 2 dietitians. Data analysis was conducted concurrently with data collection using the directed content analysis method based on Hsieh and Shannon's pattern, focusing on key influences on health behaviors: Perceptions, Enablers, and Nurturers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong the 169 extracted codes, the majority were assigned to perceptions and their subcategories, which include knowledge, beliefs, and attitudes. There were also fewer codes across all subcategories of enablers. However, regarding the nurtures, the codes were limited to the following subcategories: extended family and health personnel.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The results of this study include positive and negative experiences of the elderly in the field of nutrition, as challenges and assets of the target population, which are effective in developing interventions that are more likely to be successful and reviewed. Integrating experiences in the perception domain with nutritional behavior facilitates the creation of educational content. Additionally, insights from the domains of nurturers and enablers contribute to the development of community policies.\u003c/p\u003e","manuscriptTitle":"Explaining the Nutritional Behaviors of Elderly Individuals Based on the PEN-3 Cultural Model: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 08:32:12","doi":"10.21203/rs.3.rs-8131774/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-24T05:57:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T15:13:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T11:21:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206751430623552469122349886115050314159","date":"2026-01-30T11:00:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226716386051013287052053842905455644938","date":"2026-01-29T21:49:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270887553698325813263773124331322157271","date":"2026-01-29T05:43:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9693414552138003111584306190898944221","date":"2026-01-20T14:23:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T14:06:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-02T05:46:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-27T06:02:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-27T06:02:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-17T06:24:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92a6fe29-c956-43fe-92b8-b9863b219a23","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-17T11:23:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 08:32:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8131774","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8131774","identity":"rs-8131774","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}