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"Outings to Your Taste": A Nutrition Program for the Elderly

^a Faculty of Nursing and Groupe de Recherche Interdisciplinaire en Santé, Université de Montréal, Canada
^b Public Health Directorate, Régie de la santé et des services sociaux de Montréal-Centre, Canada
^c Centre de recherche, Institut universitaire de gériatrie de Sherbrooke, Canada
^d Faculty of Medicine, Université de Sherbrooke, Canada

Correspondence: Lucie Richard, PhD, Associate Professor, Faculty of Nursing, Université de Montréal, P.O. Box 6128, Station Centre-Ville, Montréal, Québec H3C 3J7, Canada. E-mail: Lucie.Richard{at}Umontreal.ca.

Decision Editor: Nancy Morrow-Howell, ACSW, PhD

	Abstract

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"Outings to Your Taste" is an innovative program that aims to improve the nutritional status and social network of elderly people who receive home-delivered meals. This article examines participation in one of the program's components, outings to community restaurants. Participation data were collected on-site and information about client characteristics was collected in at-home interview surveys of targeted clients (n 144). While about half of the clients had tried at least one outing, more than 25% of them participated in at least one third of the outings offered to them. Results indicate that the program attracted a variety of clients in terms of sociodemo-graphic, health, and social isolation characteristics.

Key Words: Nutrition • Social isolation • Health promotion • Community services

Homebound elderly people and those who need help to remain living in their homes appear to be particularly vulnerable to nutritional problems (Coulston, Craig, and Voss 1996; Herndon 1995; MacLelland 1997; Payette, Gray-Donald, Boutier, and Cyr 1995; Richard, Gosselin, Trickey, and Maltais 1994; Webber and Splett 1995; Weddle, Wellman, and Bates 1997). Because of their association with a host of health problems as well as with decreased longevity (Rosenberg 1994), nutritional deficiencies definitely need to be addressed by prevention programs. The first objective of this article is to present such a program, designed for elderly people receiving home-delivered meals (through Meals-on-Wheels). A second objective is to establish how successfully the program reached the target clientele by examining participation rates, with a particular focus on people whose characteristics place them at high risk for nutritional problems.

	Conceptual Basis

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Many studies have attempted to identify risk factors for malnutrition in the elderly population in general, and in functionally dependent elderly people, in particular. Factors most often identified involve physical (e.g., vision, poor appetite) and mental (e.g. cognitive impairment, stress) health as well as socioeconomic conditions (Casper 1995; Herndon 1995; Payette et al. 1995; Posner, Smigelski, Miller, and Mitchell 1994; Webber and Splett 1995). Social factors also emerge as playing a significant role. Indeed, it appears that living and/or eating with others and having broader social support are linked to better nutritional outcomes, at least in the general elderly population (Learner and Kivett 1981; McIntosh and Shifflett 1984; Walker and Beauchesne 1991). As outlined by McIntosh, Shifflet, and Picou (1989), "people often rely on others for transportation to the market, prepared meals, companionship to make meals more palatable, and information regarding recipes, diets, or healthfulness of food in general" (p. 141). This is particularly true for seniors, who are more likely to have fewer resources and to face disabilities that may act as barriers in terms of access to food, its preparation, and its consumption. Clients of home-care services are certainly vulnerable in this respect, given the high prevalence of loneliness and weak social relationships in this group (Payette et al. 1995; Smith, Mullins, Mushel, Roorda, and Colquitt 1994; Weddle et al. 1997).

Given the above-mentioned findings, it has been suggested that socialization opportunities or companionship programs be incorporated into home-delivered meal programs (Locher, Burgio, Yoels, and Ritchie 1997; Smith et al. 1994; Weddle et al. 1997). Congregate meals in the community have already demonstrated their capacity to promote socialization for seniors (Neyman, Zidenberg-Cheer, and McDonald 1996; Smith et al. 1994). However, because travel is required, such activities may be more readily accessible to healthy elderly people who are living independently. Facilitating the participation of functionally dependent homebound seniors may still pose a significant challenge.

	The Outings to Your Taste Program

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Outings to Your Taste is a two-component program addressing two objectives: to improve nutrient intake among Meals-on-Wheels (MOW) elderly clients and to strengthen their social network, especially with peers. The first component entailed stepping up home-delivered meal services by offering elderly individuals the option of receiving two additional meals, with a maximum of seven meals per week. The second component enabled clients to eat out in a restaurant in the company of peers once every two weeks. This article deals only with the second component of the program, which was implemented as a pilot project in two Montreal-area districts during a 12-month period. Districts were selected according to their large elderly population (18% and 17%, respectively) and their linguistic and cultural characteristics. District 1 was largely French-speaking, and District 2 was largely English-speaking. In each district, a senior's center helped develop and carry out the project initiated by the Montréal-Centre Public Health Directorate.

The eligibility criteria for the participation in outings included receiving MOW and the ability to speak French or English. Persons displaying signs of confusion or physical impairment severe enough to interfere with the activity were discouraged from participating and referred to other activities. Eligibility was assessed by the project coordinator based on information provided by potential clients themselves and/or by the MOW coordinator. Potential clients were informed of the existence of the project through a program brochure given out by the MOW delivery person. Restaurant outings took place once every two weeks. Given the characteristics of the target clientele, various means for reducing physical, psychological, and financial obstacles to participation were employed. First, to be selected, restaurants had to be located in the two targeted districts. They also had to be easily accessible to mobility-impaired persons and offer a choice of at least two affordable meals. Second, volunteers transported and accompanied elderly individuals on the outings. In most cases, volunteers' personal cars were used; a few wheelchair users were referred to the Public Transportation System's Adapted Services, as volunteers were not authorized by senior's centers to provide transportation to those clients. Once on the premises, volunteers encouraged participants to interact and establish social contacts. Seating all the participants at the same table also served this end. Throughout the project, reminders were sent to keep clients informed of future outings and encourage them to participate.

A total of 22 outings took place in District 1. Several district restaurants were visited throughout the project. During the same period, 26 outings took place in District 2, all of them to the same restaurant, with the exception of one that was held at a community center.

Due to a growing number of programs relying on limited volunteer resources, the number of volunteers required to run the program was an important issue to District 1's sponsoring agency. Data collected at this site showed that for a majority of the outings, a ratio of one volunteer per three participants was required for a smooth delivery of the program. Such a ratio was judged to be very close to the one targeted by the agency for the usual conduct of its activities (one volunteer per four participants).

	Methods

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Respondents
All elderly people eligible for the program were asked to participate in a clientele survey. The present analysis is of clients who were offered at least four outings. Approximately 10% of the target population had access to three or fewer outings, most often because they were new MOW clients who enrolled just a few weeks before the end of the data collection period. During the project, 185 persons were invited to participate in at least four restaurant outings. (92 from District 1, 93 from District 2). Of these, 76 clients from District 1 and 68 clients from District 2 agreed to participate in the survey, for response rates of 83% and 73%, respectively.

Measures and Procedure
Data on participation in outings were compiled from cards filled out by program staff after each outing. Other variables were measured at the beginning of the project by means of a questionnaire administered in clients' homes by interviewers. The first section of the questionnaire included general and specific questions about health. Functional autonomy was assessed by nine questions derived from the OARS (Fillenbaum and Smyer 1981), including items related to mobility, activities of daily living (ADLs) and instrumental activities of daily living (IADLs; Cronbach's .81). The second section of the questionnaire included the Revised UCLA Loneliness Scale minus one item (Russell, Peplan, and Cutrona 1980; Cronbach's 0.87).

The third section of the questionnaire included several questions about respondents' social network. The measures employed were based on the work of Rook 1987 and Thompson and Heller 1990 who distinguish between social networks of family and friends. A list of social and leisure activities (e.g., outings to restaurants or the community center, receiving or making visits) and instrumental activities (e.g., shopping) was read to respondents. For each activity, the respondent had to specify (a) whether he or she had participated in such an activity in the previous month and how often; (b) in whose company; and (c) his or her relationship (friend or relative) to that person or those persons. Using this information, three indicators related to the companionship function of the social network (Rook 1987) were developed: (a) number of persons (relatives and nonrelatives) with whom respondents had participated in all the proposed activities; (b) number of persons with whom respondents had participated in the subset of activities identified as leisure or social activities; and (c) number of nonrelatives with whom respondents had participated in the subset of activities identified as leisure or social activities. Previous results obtained for these measures support their construct validity, showing associations between scores obtained and indicators of health and well-being (Rook 1987, Rook 1995). The last section of the questionnaire included questions on sociodemographic characteristics.

Analysis
A binary index reflecting participation in the program was constructed. The value 1 ("participants") was assigned to persons who took part in at least one third of the outings to which they were invited. Value 0 ("nonparticipants") was assigned to persons who participated in fewer than one third of the outings offered, along with those who never responded to the invitation.

Client participation was analyzed by means of descriptive statistics. Characteristics of clients more likely to participate in outings were identified through bivariate and multivariate logistic regression analyses. In view of the sample size, the respondents from Districts 1 and 2 were grouped together for the logistic regression analysis. All variables showing a statistical association with participation (p < .20) were selected for the regression model. Interaction terms involving the district variable were incorporated into the regression model.

	Results

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Characteristics of the Respondents
Table 1 shows the profile of the population targeted by the program. The population primarily includes people aged 75 and older who live alone, the majority of whom were women. The health and functional profile of the target population shows clearly that this is a vulnerable group.

Factors Associated With Participation
Bivariate analysis revealed that few of the study variables were significantly associated (p < .05) with participation. Functional limitations emerged as being related but the direction of the relationship varied with the district. In District 2, clients who had difficulty getting around outside the home (39%) or doing shopping (38%) participated in greater proportion than clients having no such difficulties (11% and 14%, respectively). Consistent with this pattern, clients with vision problems, as compared to those without such problems, were better represented among the program participants in District 2 (62% vs 20%). In District 1, respondents declaring functional limitations in term of getting around outside the home (17% vs 40%), using transportation (17% vs 38%), and shopping (19% vs 39%) were less likely to participate than clients not declaring these limitations. Participation in the program was not significantly related to the perception of solitude or to any of the dimensions pertaining to social network. Although they were not significantly related to participation, four additional variables whose bivariate test had a p value <.20 were retained for inclusion in the multivariate model: gender, difficulty getting around in the home, difficulty preparing meals, and satisfaction with social relationships.

Three variables emerged as independent predictors of participation: vision problems, satisfaction with social relationships, and the interaction between site and functional autonomy (see Table 2 ). As shown by the odds ratios, elderly people with poor vision were more than four times more likely to participate in the program. Dissatisfaction with social relationships increased participation by a factor of almost 3. The predictive role of functional autonomy varied between the two sites. In District 1, persons who scored higher on the functional autonomy scale were six times more likely to participate. However, this variable did not appear to play a significant role in participation in District 2.

	Discussion

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A major result of this study is that the target clientele responded favorably to the invitation to participate in restaurant outings in their community. This finding is important because, given their social and health characteristics, one might expect that these clients would be reluctant to take part in this sort of activity. Moreover, the concurrent offer of home-delivered meals could have served to discourage people from participating in nutritional support activities in the community. It does not appear that this was the case, at least not for a large proportion of the target clientele. The data collected show that about half of the targeted clients participated in at least one outing, and more than one quarter participated to a greater extent, taking part in at least one third of the outings offered to them. As far as clients with reduced autonomy and weak social ties are concerned, anecdotal data provided by one of the sponsoring agencies show that this level of participation is comparable to participation in a similar activity (e.g., group shopping) offered on the same basis (once every two weeks) to a comparable clientele.

Another interesting finding is that participation in the program did not appear to be associated with the sociodemographic characteristics of the clients. The program thus reached a varied clientele in terms of gender, age, and marital and socioeconomic status. In addition, very few social and health variables were predictive of participation, confirming that the program attracted a variety of people from the standpoint of perceived health status, hearing health, size of social network, and feelings of loneliness. Only three of the study variables emerged as independent predictors of participation: vision, satisfaction with social relationships, and functional autonomy.

With regard to vision and social relationships, a pattern of greater participation among more vulnerable clients was clearly identified in the data. As vision deteriorates, the number of activities accessible to elderly people decreases. Because diminished eyesight is not incompatible with sharing a meal, outings in restaurants may constitute an especially inviting activity for people suffering from vision problems. This is even more likely if participants are being offered companionship and transportation services by volunteers, as was the case here. As for social relationships, results indicated that people who were less satisfied with their relationships participated more in restaurant outings. It may be that such dissatisfaction, stemming from the perception that one's social network is either too limited or generates conflict, encouraged elderly people to seek opportunities to create new ties. Given the important role that social relationships play in the health of elders, the program has considerable potential for health promotion because it reaches a population segment that is socially isolated.

Finally, with regard to functional autonomy, the results showed a differential pattern of participation. Although a positive association between the clients' functional autonomy and participation was observed in District 1, no association of this kind was detected in District 2. Many factors could explain such a differential profile, but one contextual factor could offer a preliminary explanation. To meet the demands of seniors, the program staff in District 1 offered a variety of restaurants, some of which were not completely accessible to functionally dependent persons. In District 2, the outings always took place in the same restaurant, which fully satisfied the criteria related to physical accessibility. It is also possible that the use of a single restaurant attenuated the stress associated with going out, thus facilitating the participation of people with reduced mobility.

On the whole, the differential profile of participation found in the two study districts suggests that the program has the potential to attract clients with various levels of autonomy, provided that contextual adjustments are made to fit the target clientele's needs. More generally, its success in the two study districts provides evidence that the program can be implemented in various organizational contexts and that it can attract seniors from diverse cultural and ethnic backgrounds. Given the results of this pilot experience, it is reasonable to conclude that the program has good potential for replicability.

This study is limited in that information on clients' characteristics was collected on only one occasion at the beginning of the project. Therefore, changes in functional status and other variables are not accounted for in the design. Second, although some nutritional data were collected from a limited subsample of participants (data not presented here), the resulting data set precludes any analysis aimed at showing the difference between participants and nonparticipants in terms of nutritional status. Future work should seek to determine to what extent the program has the potential to attract seniors in need of nutritional support. Finally, this project was designed as a pilot experiment, so the sample size may have been too small to conduct a detailed analysis within certain subgroups of the population (e.g., men, low-socioeconomic status).

Despite its limitations, the present study is important in that it shows the potential of an innovative nutrition intervention for homebound elders, a group that is particularly susceptible to nutritional problems. The clientele's response to the program represents an especially interesting result. Moreover, although the analysis revealed few factors associated with participation, a pattern of greater participation among more vulnerable clients was identified for a few important variables. The next study of this type should evaluate the effect of the outings on nutritional as well as social and psychological variables.

	Acknowledgments

 
This research was supported by grants from Health Canada (Seniors Independence Research Program; Grant 4687-05-93-00500) and from the Régie régionale de la santé et des services sociaux de Montréal-Centre (Grant 0074). Lucie Richard is a Canadian Medical Research Council Scholar (Grant H4-33565-AP007366). Hélène Payette is a National Health Research Scholar, Health Canada (Grant R6605-4131-48). The authors gratefully acknowledge the contributions of Micheline Bouvier, Marjorie Northrup and Rachelle Sigouin.

Received for publication October 14, 1999. Accepted for publication March 6, 2000.

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