Introduction

Background

Vision and hearing declines are problems frequently occurring in older adults, and people with vision and hearing declines are reported to respectively take up around 29% and 18% of the global population [1]. In Korea, the prevalence rates of partial or total vision impairment and partial or total hearing loss among older adults are estimated to be 32.6% and 22.8%, respectively [2]. Vision and hearing declines can occur simultaneously, and the incidence rates of vision and hearing declines are gradually increasing worldwide with population aging [3]. Dual sensory impairments refer to the simultaneous occurrence of both total vision and hearing losses, but this term is often confusingly used to refer to the functional decline or loss of vision and hearing [3,4]. However, while dual sensory impairments mean the loss of both vision and hearing, the concept of dual sensory declines includes cases where individuals only have partial functional declines, not total vision and hearing losses, so dual sensory declines can be used as a more inclusive term [2,5]. In other words, while persons with dual sensory impairments are classified as those with disabilities according to the objective criteria of vision and hearing, dual sensory declines refer to functional declines in vision and hearing irrespective of whether the conditions of vision and hearing are diagnosed as disabilities. The prevalence rates of dual sensory declines reported in Korea and abroad are widely different, ranging from 2.9% to 28.6% [2,5,6]. Dual sensory declines were found to be associated with an increased risk of limited communication, the lack of social participation and social support, mental health problems such as depression and anxiety, and low quality of life [4,7,8], and older adults with dual sensory declines were shown to have lower quality of life compared to those without dual sensory declines [4].

Malnutrition is associated especially with negative health outcomes such as falling, disability, and death in older adults [9]. The rate of malnutrition in older adults is reported to be higher in those living in long-term care facilities, but since the rate of malnutrition is increasing even in community-dwelling older adults, malnutrition is a health problem occurring even in community-dwelling older adults [10]. Systematic review studies on the risk factors for malnutrition in older adults reported that low socioeconomic status, living alone, old age, constipation, subjective health status, cognitive decline, chronic diseases, and depression were identified as risk factors for malnutrition in older adults [11,12]. As described above, malnutrition is influenced by various factors in a complex manner, and as a systematic approach to this question, analysis through social determinants of health has been proposed [13].

Social determinants of health are factors affecting overall health outcomes, and include age, gender, behavior patterns, social network, living and working conditions, socioeconomic factors, and environmental factors [14]. In 2010, the World Health Organization proposed the subfactors and conceptual framework of social determinants of health [15]. Social determinants of health are divided into structural determinants and intermediary determinants. The intermediary determinants are composed of material circumstances, psychosocial factors, and behavioral and biological factors. These factors affect health and well-being, and their importance in reducing health inequalities has been increasingly emphasized. In Healthy People 2030 of the U.S., it has been adopted as a basic strategy for public health promotion and set as an objective to identify the social determinants of health and establish health policies focused on them [16]. In Korea and abroad, research has been carried out to reduce health inequalities based on the conceptual framework of social determinants of health [17,18].

In particular, older adults with dual sensory declines may experience health inequalities due to limitations in mobility and communication, low socioeconomic status, and social stigma and discrimination [19]. These problems may lead to difficulty in preparing meals, poor access to nutrition information, and consumption of low-quality foods, and thus increase the risk of malnutrition in older adults with dual sensory declines [20-22]. As the number of older adults with dual sensory declines is rapidly increasing, in order to prevent and manage malnutrition risk, it is necessary as a prerequisite step to investigate the factors associated with malnutrition risk in older adults with dual sensory declines. Research on social determinants of health is a task that needs to be carried out especially for people exposed to health inequalities, so it is considered an appropriate analysis in studying a health problem in older adults with dual sensory declines [23,24]. However, in Korea, sufficient research has not been conducted so far to investigate malnutrition risk in older adults with dual sensory declines or analyze them with a focus on social determinants of health. Therefore, this study aimed to analyze malnutrition risk in older adults with dual sensory declines in terms of social determinants of health.

Conceptual framework

The conceptual framework of the present study was developed based on the conceptual frame work of social determinants of health presented by Solar & Irwin [15]. According to Solar & Irwin [15], social determinants of health are comprised of structural determinants, social capital, and intermediary determinants. Structural determinants are social determinants of health inequalities, and they may include socioeconomic status and political context. Socioeconomic status includes factors such as income, education level, occupation, gender, and race. Social capital is a mediator between structural and intermediary determinants, and it may include community integration and the social network among members. Intermediary determinants are factors for the alleviation of health inequalities at the community level, and they are composed of material circumstances, psychosocial factors, and behavioral and biological factors. Material circumstances include the living environment and working environment, and psychosocial factors may include situations related to high levels of psychological stress, such as the presence or absence of household debt or job satisfaction. Behavioral and biological factors include health behaviors such as smoking and physical activity.

In this study, structural determinants and intermediary determinants, which are subdomains of social determinants of health, were set as shown in Figure 1, and these factors were set as factors affecting malnutrition risk in older adults with dual sensory declines. Specifically, variables related to socioeconomic status were included in the domain of structural determinants, and social participation and social network size were included in the domain of social capital. Finally, the design of the conceptual framework was completed by including material circumstances (living status (living alone), living satisfaction, and environmental satisfaction), psychosocial factors (household debt), and behavioral and biological factors (smoking, physical activity, and comorbidity) in the domain of intermediary factors.

Objectives

The objectives of this study are as follows: 1) To compare social determinants of health according to the level of malnutrition risk among community-dwelling older adults with dual sensory declines; 2) to analyze the relationship between social determinants of health and malnutrition risk among older adults with dual sensory declines.

Methods

Study design

This study is a secondary analysis research to evaluate malnutrition risk according to social determinants of health among older adults aged 65 or older by using the raw data of the 2020 National Survey of Older Koreans (NSOK). This article was written according to the STROBE reporting guidelines [25].

Participants and data collection

This study used data from the 2020 NSOK. The NSOK has been conducted since 2007 in order to examine the status of various areas of the life of older adults, such as health, economic conditions, social participation, and leisure activity, and present basic data for exploring ways to support healthy life in old age [26]. Based on the 2018 Population and Housing Census data, older adults aged 65 or older were used as the population, and the sample was extracted by the probability proportional to size systematic sampling method. In the first stage of stratification, the population was divided into 17 cities and provinces in the country, and in the second stage, the subpopulations were divided into neighborhoods (dongs) and townships (eups and myeons). In the third stage, the subpopulations were divided into general survey districts and apartment survey districts according to the type of survey district. Finally, a geographically representative sample was extracted from each survey district by the proportional allocation method. As a result, 10,097 people finally participated in the survey.

The inclusion criteria of this study were as follows: older adults aged 65 or older with dual sensory declines who were found to have both vision and hearing declines based on the responses to 2 questions for screening for vision declines and 2 questions for screening for hearing declines. The questions used for screening for dual sensory declines were as follows. Regarding vision decline, people with vision declines were the respondents who answered ‘Have difficulty’ or ‘Have great difficulty’ in response to the question about whether they have difficulty in daily life due to vision decline or vision impairment. People using vision aids (eyeglasses, contact lenses, a magnifier, etc.) were asked to respond about difficulty in daily life experienced while wearing vision aids. As for hearing decline, people with hearing declines were the respondents who answered ‘Have difficulty’ or ‘Have great difficulty’ in response to the question about whether they have difficulty in daily life due to hearing decline or impairment. People using hearing aids were asked to respond about difficulty in daily life experienced while wearing hearing aids. In this study, people with dual sensory declines correspond to the respondents who answered ‘Have difficulty’ or ‘Have great difficulty’ in both the questions about visual decline and the questions about hearing decline. The processes of screening for visual and hearing declines by self-report questionnaires have also been previously conducted by other studies [2,5].

The exclusion criterion was people who did not respond themselves but responded by proxy. This study included variables that involve subjective evaluations, such as living satisfaction and environmental satisfaction. Since a previous study [27] reported discrepancies between the responses of older adults themselves and those of proxy respondents in the subjective evaluation items, the participants who responded by proxy were excluded from analysis in this study.

Variables

1. Social determinants of health

In this study, social determinants of health were set based on the conceptual framework proposed by Solar & Irwin [15], and the factors of the subdomains were organized based on previous foreign studies [18,28]. Among social determinants of health, structural determinants included age, gender (men, women), presence of economic activity (Yes, No), education level (≤elementary school, middle school, ≥high school), national basic livelihood security system (NBLSS) recipient status (Yes, No), housing (living in a self-owned home) (Yes, No), and presence of the spouse (Yes, No).

As for the variables of social capital, social participation (Yes, No), and social network size were included in the analysis. The status of social participation (Yes, No) was examined using the question ‘Have you ever participated in social clubs, volunteer work, entertainment, learning, or religious activities in the past year?’ The respondents were asked to answer ‘No’ when they have not participated in any of the activities in the past year, the status of social participation, and they were asked to answer ‘Yes’ when they have participated in one or more of the activities in the past year [2]. Social network size was measured as the number of people close to the individual, including close relatives, friends, neighors, and acquaintances, and a larger number of people close to the individual indicates a larger social network size [29].

Among intermediary determinants, material circumstances included living status (with someone, living alone), living satisfaction, and environmental satisfaction. Living satisfaction was assessed using the question ‘How satisfied are you with the residence where you currently live?’, and the degree of living satisfaction was divided into satisfaction (Very satisfied, Satisfied) and dissatisfaction (Neutral (Neither satisfied nor dissatisfied), Dissatisfied, Very dissatisfied). Environmental satisfaction was measured by 6 items. Specifically, the 6 items are questions about the distance to convenience facilities and medical institutions, frequencies and routes of public transit services, sufficiency of green space or the distance to green space, public security and traffic safety, the distance to the residences of children or relatives, and opportunities for interaction with neighbors. Each item is rated on a 5-point Likert scale, and total scores range from 6 to 30 points. Higher total scores indicate higher levels of environmental satisfaction.

Regarding psychosocial factors, household debt was included in the analysis, and currently having a debt and currently having no debt were categorized as ‘Yes’, and ‘No’, respectively. Lastly, behavioral and biological factors included current smoking status (Yes, No), physical activity (Yes, No), and comorbidity (Yes, No). Current smoking status was examined by the question ‘Are you currently a smoker?’ The performance of physical activity was examined by the question ‘Do you usually perform exercise?’ Regarding the presence or absence of comorbidity, based on the number of medically diagnosed chronic diseases, the presence of 3 or more chronic diseases was categorized as ‘Yes’, and the presence of less than 3 chronic diseases was categorized as ‘No.’

2. Malnutrition risk

Malnutrition risk was examined using a Korean version of the DETERMINE of Your Nutritional Health Checklist, which was jointly developed by the American Society for Nutrition, the American Academy of Family Physicians, and the National Council on Aging in the United States [30,31]. The Korean version was developed by Jung & Kim [32] through the translation and modification of the original version. In this tool, the scores assigned to each item vary from 1 to 4 points depending on the items, and the specific items of the tool and the score for each item are as follows. The tool consists of 10 items on financial problems in food preparation (4 points), eating less than two meals a day (3 points), changes in diet due to health problems (2 points), insufficient intakes of vegetables and fruits (2 points), consumption of 3 or more glasses of alcohol a day (2 points), oral health problems (2 points), unintentional weight loss (2 points), physical burden in food preparation (2 points), eating alone (1 point), and taking three or more medications a day (1 point). Total scores range from 0 to 21 points, and higher scores indicate poorer nutritional status. As presented in the study by Jung & Kim [32], 0~2 points were categorized as ‘low risk’, 3~5 points as ‘moderate risk’, and 6 points or higher as ‘high risk.’ The Cronbach’s α value was reported as 0.86 in Jung & Kim [32], and the Cronbach’s α value was 0.71 in this study.

Data analysis

The sample of the NSOK used in this study was extracted using a complex sampling design. In data analysis, weights were applied to match the regional structures of the elderly population in Korea to address the potential bias and ensure the accuracy of estimation in analysis. Thus, since it was necessary to use a statistical program for performing analysis applying a weight, all analyses were performed using IBM SPSS Complex Samples 28.0 [33]. The level of significance was set at p<.05.

In this study, data analysis was conducted in the following steps. First, for all the variables, descriptive statistical analysis was conducted, and the unweighted frequency and the weighted percentage, mean, and standard deviation were presented. Second, in analyzing the levels of social determinants according to the level of malnutrition risk, continuous variables were analyzed using one-way analysis of variance and the Bonferroni post-hoc test, and categorial variables were comparatively analyzed using the Rao-Scott test. Third, to analyze the association between malnutrition risk (moderate or high malnutrition risk) and social determinants of health, hierarchical logistic regression analysis was conducted by using low malnutrition risk as the reference category. A total of 5 regression models were presented according to the order of entering variables as follows. In Model 1, only structural determinants were included in the analysis. In Model 2, social capital variables were entered along with structural determinants. In Model 3, the variables of material circumstances among intermediary determinants were additionally entered, and in Model 4, a psychosocial factor among intermediary determinants was additionally entered. In Model 5, all the independent variables including the behavioral and biological factors among intermediary determinants were entered to analyze the relationships between the variables and malnutrition risk. The Hosmer–Lemeshow test (p>.05) was used to test the goodness of fit of the regression model, and the explanatory power of each regression model was examined using Nagelkerke R².

Ethical considerations

The raw data of the NSOK was collected after obtaining written informed consent about survey participation and data utilization from the participants. This study received an exemption determination from the Institutional Review Board of Konyang University (IRB No. KYU IRB 2024-05-022). Then, after submitting an informant security pledge, a personal information collection and usage agreement, and a research plan to Health and Welfare Data Portal, this study received approval for data use through an internal review. After receiving approval from the portal, raw data was received through remote access, and research was conducted.

Results

Participant selection

The final participants were selected through a two-step process according to the inclusion and exclusion criteria, as shown in Figure 2. Out of 10,097 people of the raw data, 177 proxy respondents were excluded. Additionally, 8,149 people who did not have any sensory declines or did not have both vision and hearing declines were excluded, and thus, a total of 1,771 people were finally included in the analysis.

Comparison of social determinants of health according to the level of malnutrition risk in the participants

Among older adults with dual sensory declines, 6 participants (0.6%) were diagnosed with a visual disability and 35 participants (2.2%) were diagnosed with a hearing disability according to the Act on Welfare of Persons with Disabilities, but the majority of the participants (97.2%) were not diagnosed with visual or hearing disability. In terms of the level of malnutrition risk, 937 participants (52.9%) were at low risk for malnutrition, 496 participants (28.0%) were at moderate risk for malnutrition, and 338 participants (19.1%) were at high risk for malnutrition. The analysis results of statistically significant differences in structural determinants and intermediary factors according to the level of malnutrition risk are shown in Table 1. With respect to structural determinants, old age (t=3.25, p=.039), women (F=11.77, p<.001), NBLSS recipient status (F=6.39, p=.012), low education level (F=8.02, p<.001), no housing (the absence of a self-owned home) (F=3.74, p=.024), and the absence of the spouse (F=19.25, p<.001) were associated with higher malnutrition risk. Regarding social capital, a lower level of social network size was associated with higher malnutrition risk (t=8.53, p<.001). In terms of intermediary determinants, living alone (F=20.61, p<.001), lower environmental satisfaction (t=10.41, p<.001), the presence of household debt (F=11.17, p=.021), and the presence of comorbidity (F=71.92, p<.001) were linked to higher malnutrition risk.

Relationships between social determinants of health and malnutrition risk (moderate or high malnutrition risk)

The results of logistic regression analysis of the relationship between malnutrition risk (moderate or high malnutrition risk) and social determinants of health are shown in Table 2. In Model 1, only structural determinants were included in the analysis. For Model 1, Nagelkerke R² was .03, and the model fit was acceptable (χ²=4.56, p=.803). The odds ratio for women was 1.75 (95% CI=1.19~2.57, p=.005), and the odds ratio for NBLSS recipients was 1.82 (95% CI=1.10~3.01, p=.015). Also, the odds ratio for older adults without the spouse was 1.81 (95% CI=1. 27~2.58, p=.001). In other words, among older adults with dual sensory declines, women were found to be 1.75 times more likely to belong to the malnutrition risk group than men. Also, NBLSS recipients were shown to be 1.82 times more likely to belong to the malnutrition risk group, compared to those who were not NBLSS recipients. In addition, older adults without the spouse were 1.81 times more likely to belong to the malnutrition risk group, compared to those with the spouse.

In the case of Model 2, where social capital variables were additionally entered, Nagelkerke R² was .87, and the model fit was acceptable (χ²=5.46, p=.707). As in Model 1, in Model 2, women, NBLSS recipients, and older adults without the spouse were found to have a statistically significantly higher likelihood for malnutrition risk (moderate or high malnutrition risk). In addition, the odds ratio for no social participation was 1.33 (95% CI=1.03~1.73, p=.03). In other words, older adults without social participation were 1.33 times more likely to belong to the malnutrition risk group, compared to those with social participation. Also, the odds ratio for social network size was 0.95 (95% CI=0.92~0.99, p=.022). In other words, as social network size increased by one person, the likelihood of belonging to the malnutrition risk group at moderate or high malnutrition risk was decreased by 5%.

In Model 3, where the variables of material circumstances among intermediary determinants were additionally included in analysis, Nagelkerke R² was .09, and the model fit was acceptable (χ²=7.05, p=.531). The odds ratio for living dissatisfaction was 1.61 (95% CI=1.16~2.23, p=.004). In other words, the living dissatisfaction group was found to be 1.61 times more likely to belong to the malnutrition risk group than the living satisfaction group. The odds ratio for environmental satisfaction was 0.95 (95% CI=0.92~0.99, p=.006), and this means that as the score for living satisfaction was increased by 1 point, the likelihood of belonging to the malnutrition risk group was decreased by 5%. Among the variables of material circumstances, living status did not have a significant relationship with malnutrition risk.

In Model 4, where psychosocial factors were additionally entered, Nagelkerke R² was .12, and the model fit was acceptable (χ²=7.28, p=.507). In this model, the odds ratio for the presence of household debt compared to the absence of household debt was 1.59 (95% CI=1.02~2.49, p=.043), and this means that older adults with household debt were 1.59 times more likely to belong to the malnutrition risk group than those without household debt. As in Model 3, living dissatisfaction and environmental satisfaction among material circumstances were statistically significant factors, but living status did not have a significant relationship with malnutrition risk.

Lastly, in Model 5, where the behavioral and biological factors among intermediary determinants were additionally included in the analysis, Nagelkerke R² was .20, and the model fit was acceptable (χ²=3.84, p=.871). Among the material circumstances of intermediary determinants, living dissatisfaction and environmental satisfaction were statistically significant factors, and among psychosocial factors, household debt was also a statistically significant factor. The odds ratio for the presence of comorbidity among behavioral and biological factors was 3.85 (95% CI=2.98~4.97, p<.001), and this means that older adults with comorbidity are 3.85 times more likely to be at malnutrition risk than those without comorbidity.

Discussion

This study attempted to investigate the relationship between malnutrition risk and social determinants of health among Korean older adults with dual sensory declines. Analysis results showed that the moderate malnutrition risk group accounted for 29.0% of the participants, and the high malnutrition risk group took up 18.5%, so 47.5% of the participants were found to have malnutrition risk. A previous study in China [6] reported that the proportions of the moderate malnutrition risk group and the high malnutrition risk group were 43.2% and 2.5%, respectively, and the total proportion of the malnutrition risk group was 45.7%. In comparison with the above results, although the rate of malnutrition risk was similar, the proportion of the high malnutrition risk group was higher in the present study. This difference in the research results may be attributed to the differences in the participants. In this study, the mean age of the participants was 76.8 years, and women accounted for 61.3% of them, but in the study by Zhao et al. [6], the mean age of the participants was 70 years, and the proportion of women was 58.9%. In Model 1 of the present study, although there was not a statistically significant correlation between age and malnutrition risk, there was a significant association between women and malnutrition risk. These results are consistent with the results of a systematic review study by Bardon et al. [11] reporting that women are at higher risk for malnutrition than men. In addition, it has been reported that older women with sensory declines may be at higher risk of malnutrition due to a reduction in nutrient intake and daily calorie intake, compared to older women without sensory declines [34] and older men with sensory declines [35]. Considering that the proportion of women is higher among older adults with dual sensory declines, and women are at higher malnutrition risk than men among older adults with dual sensory declines, there is a need to conduct in-depth research to assess the nutritional status of older women with dual sensory declines in order to manage their nutritional status.

With respect to material circumstances, NBLSS recipients were found to be at higher malnutrition risk. A previous study reported that the proportion of NBLSS recipients among older adults without sensory declines was 5.6% [2]. In the present study, among older adults with dual sensory declines, the proportion of NBLSS recipients was 9.2%, and especially in the high malnutrition risk group, the proportion of NBLSS recipients was as high as 14.5%. The proportion of older adults in the lowest income group was found to be higher among older adults with dual sensory declines than among those without dual sensory declines [36,37]. Compared to older adults without dual sensory declines, those with dual sensory declines may have greater difficulty in participating in economic activities, and may not be able to fully utilize economic opportunities provided by the national government or the community due to poorer access to information [20,21]. These problems may cause difficulty in purchasing or preparing healthy foods, such as fresh vegetables and fruits and foods rich in protein, and thus may lead older adults with dual sensory declines to rely on convenience foods or delivery foods, thereby causing malnutrition [20,21]. Therefore, it may be necessary to provide financial support to older adults with dual sensory declines to ensure that they can consume nutritionally adequate foods. In a future study, there is a need to analyze the nutrients and foods whose intake levels are inadequate in older adults with dual sensory declines, and provide support for them by prioritizing types of foods that they urgently need to consume.

In this study, among the material circumstances of intermediary determinants, living dissatisfaction and a high level of environmental satisfaction were identified as factors related to malnutrition. Living satisfaction may influence the processes of preparing and cooking healthy foods. More specifically, older adults with sensory declines may have greater trouble and are at higher risk for safety accidents in the process of preparing or cooking foods due to the inconvenient arrangement of a countertop or pantries or difficulty in using electronic appliances, compared to those without sensory declines, so it is difficult for older adults with sensory declines to maintain healthy dietary patterns [38,39]. Environmental satisfaction may act as an important factor in purchasing health foods. For example, there may be limitations in purchasing fresh fruits, vegetables, or dairy products in areas with poor access to public transportation such as buses or subways [40]. In particular, for older adults with sensory declines that have difficulty in using public transportation, the presence or absence of convenient facilities such as grocery stores within a walking distance may be an important factor [22]. To address these problems, housing models for adults with disabilities are being developed in Korea as well, but the actual utilization rate is currently markedly low [41,42]. Especially, older adults with dual sensory declines that are not diagnosed with disabilities are excluded from accessing support for the improvement of the living environment. The role of nurses is likely to be limited in the improvement of the residential environments of individuals, but as case managers, nurses perform the roles of assessing the residential environments of service recipients and providing them with information on how to receive support for improving their residential environment [43]. The results of this study showed the necessity of the assessment and improvement of the residential environment of older adults with dual sensory declines, and confirmed the association between the residential environment and malnutrition risk among older adults with dual sensory declines.

In this study, social participation and social network size, which belong to social capital, were found to be preventive factors for malnutrition risk and these results are similar to the findings of previous studies [21,44]. In relation to the maintenance of nutritional balance, individuals may be influenced by the eating habits of people close to them, including the family members [40]. This is due to the fact that foods, meal plans, and information can be shared within social networks, and meals can be provided at community organizations [40]. In addition, since older adults with dual sensory declines have reduced access to information due to difficulty in reading materials written in small letters and acquiring nutritional information, they obtain information mainly through social networks, so their social network size may be an important factor in obtaining nutritional information [21,45]. However, dual sensory declines may reduce social participation and social network size due to problems such as limitations in mobility, communication problems, and social discrimination [46,47]. Therefore, as older adults with dual sensory declines are likely to have lower levels of social participation and social network size compared to those without dual sensory declines, they are likely to be at increased risk for malnutrition. The results of this study suggest that social participation and social network size, which are social capital factors, may be related to each other in older adults with dual sensory declines.

In this study, comorbidity was the most significant factor affecting malnutrition risk in older adults with dual sensory declines. Older adults with dual sensory declines have been shown to have a higher level of comorbidity than those without dual sensory declines [2,48]. Moreover, they may have difficulty in the management of chronic diseases because vision and hearing declines may result in decreased physical activity, and act as a barrier to communication with medical staff, thus preventing them from receiving proper treatment [20,47]. Previous studies have pointed out the problem of health inequalities that occur as older adults with dual sensory declines do not receive proper medical care [19]. In addition to these problems, taking multiple medications due to multimorbidity may lead to malnutrition risk because the regular use of multiple medicines may cause problems such as changes in taste and smell, dry mouth, decreased appetite due to nausea and vomiting, and interference with nutrient absorption due to drug absorption [49]. The above results of this study suggest that an in-depth research should be conducted to examine and improve the status of the management of chronic diseases as well as nutritional management in older adults with dual sensory declines.

Although this study investigated factors affecting malnutrition risk in older adults with dual sensory declines with a focus on social determinants of health by using a large-scale sample data, this research has the following limitations. First, although this study used the DETERMINE checklist regarding malnutrition, the dependent variable, there were limitations in accurately examining the state of malnutrition in the participants due to a lack of concrete survey data such as food intake survey data. Second, regarding social capital, although social participation and social network size, which were quantitative factors, were measured, qualitative factors were not considered in the process. Also, in terms of psychosocial factors among intermediary factors, only household debt was included in the analysis, and other situations related to a high level of psychological stress were not considered. Third, the results of objective vision and hearing tests were not included in the information showing the states of sensory declines of the participants. Fourth, since the design of this study was a cross-sectional study, there was a limitation in presenting clear causal relationships between social determinants of health and malnutrition risk.

Conclusions

This study attempted to identify social determinants of health associated with malnutrition risk in community-dwelling older adults with dual sensory declines. In this study, 47% of the participants were found to be at moderate or high malnutrition risk. Women and NBLSS recipient status, which are structural determinants, were found to be factors affecting malnutrition risk. In addition, regarding social capital factors, social participation and social network size were found to act as significant factors, and living and environmental satisfaction, household debt, and comorbidity were shown to act as intermediary determinants. The majority of older adults with dual sensory declines were not medically diagnosed as persons with disabilities, but were at high malnutrition risk. Among older adults with dual sensory declines, the overall social determinants of health were found to be in a vulnerable state, and this situation resulted in health inequalities.

Based on the above research results, the following suggestions on research and nursing practice are presented. First, it is necessary to conduct an in-depth analysis of foods whose intake levels are inadequate in older adults with dual sensory declines, considering their financial difficulty. To this end, research should be conducted to perform an in-depth analysis using food consumption surveys and qualitative methods to identify types of foods for which support is urgently needed, and develop an economic support policy based on the research results. Second, it is necessary to develop community-level programs to promote and support the social participation of older adults with dual sensory declines. Third, it is also required to conduct an in-depth analysis including qualitative analysis to investigate nutritional status and the status of self-care in older adults with both dual sensory declines and multimorbidity, and develop customized programs for the management of chronic diseases and nutritional balance. Lastly, in the practice of community nursing, it is necessary to provide programs to improve nutritional health, and it is also required to provide information on receiving social support and link them with relevant organizations to help them receive appropriate economic support in consideration of health inequalities due to differences in social determinants of health among older adults with dual sensory declines.

Figure 1.

Conceptual framework of this study

Figure 2.

Flowchart of selecting participants

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