EAL

FNOA: Aging Programs (2012)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To determine if a program providing fruit and vegetable baskets to homebound Seattle Senior Farmer's Market participants increased fruit and vegetable intake.

Inclusion Criteria:

Homebound adults older than 60 years of age
Resided in a specific catchment area in the city of Seattle
Those who met income guidelines to participate in Seattle Senior Farmer's Market program
Those with access to a phone
Those who were able to hear adequately
Those who were able to comprehend the survey questions.

Exclusion Criteria:

Those who could not hear adequately
Those who could not comprehend survey questions.

Description of Study Protocol:

Recruitment

Participants were recruited from among 480 homebound seniors who were eligible for the Senior Farmers' Market program in a specific area of Seattle. Subjects were recruited via flyers that were delivered by Meals on Wheels drivers. Those who wanted to participate responded by phone or postage-paid postcard.
Controls were recruited from an area outside the project service area. Method of recruitment was not described.

Design

Non-randomized trial. One group of seniors received baskets containing fruits and vegetables every two weeks, while another received no baskets. Both basket recipients and control group were interviewed before basket delivery started and at the end of the market season after basket delivery ceased. The interview was a modified version of the six fruits and vegetables questions in the Behavior Risk Factor Surveillance System.

Intervention

Baskets containing and average of 1.6 servings of vegetables and 0.67 servings of fruits delivered every two weeks by Meals on Wheels drivers. A newsletter that described the produce, provided recipes and promoted eating fruits and vegetables accompanied each basket.

Statistical Analysis

Sample T-test was used to compare differences between means, and paired sample T-tests were used to compare changes in means
ANOVA analyses were used to measure relationships between demographic variables and fruit and vegetable intake.

Data Collection Summary:

Timing of Measurements

Initial surveys took place in June, 2001. Intervention occurred from June to October, 2001. Final surveys were completed at the end of the market season.

Dependent Variables

Fruit and vegetable intake as measured by a telephone survey of intake of fruits and vegetables.

Independent Variables

Recipient of fruit and vegetable basket.

Control Variables

Gender
Age
Ethnic group
Race
Living situation.

Description of Actual Data Sample:

Initial N

100 market basket recipients and 52 control recipients. The intervention group were 71% females (N=62) and 28% males (N=25). The control group was composed of 75% females (N=33) and 25% males (N=11).

Attrition (final N)

At the end of the market season, 87 basket recipients (out of the original 100) and 44 control recipients (out of the original 52) responded to the survey. Three intervention and two control respondents died during the intervention. Three intervention and four control respondents could not be reached. Three intervention and two control respondents either refused or were unable to answer the questions due to impaired cognition. Six of the initial intervention respondents were screened out as ineligible after investigation of demographic data.

Age

In the intervention group, 38% (N=33) were 60 to 69 years old, 33% (N=29) were 70 to 79 years old, 22% (N=19) were 80 to 90 years old, and 7% (N=6) were more than 90 years old.

In the control group, 32% were 60 to 69 years old (N=14), 25% were 70 to 79 years old (N=11), 38% were 80 to 89 years old (N=17) and 5% (N=2) were more than 90 years old.

Ethnicity

In the Intervention group, 64% (N=56) were white, non-Hispanic; 28% (N=24) were African American, non-Hispanic; 3% (N=3) were Hispanic. There were no Asian-Pacific Islander or Native-American Alaskan Native in the intervention group. The ethnicity of 5% of the intervention group (N=4) was unknown.

In the Control group, 78% (N=34) were white, non-Hispanic; 13% were African American, non-Hispanic (N=13); 0% were Hispanic; 5% (N=5) were Asian-Pacific Islander; 2% (N=2) were Native American Alaskan Native; and 2% (N=1) were of unknown ethnicity.

Other Relevant Demographics

75% of the intervention group lived alone, as did 70% of the controls. 9% of the intervention group lived with a spouse and 11% with adult children or other relatives. 14% percent of the control group lived with a spouse and 9% lived with adult children or other relatives. 5% of the intervention group and 7% of the control group lived with another adult such as a caregiver.

64% of the intervention group and 70% of the control group were white, while 31% of the intervention group and 21% of the control group were non-white.

Location

Intervention and control groups resided in a specific catchment area in the city of Seattle, Washington.

Summary of Results:

The proportion of program participants who consumed five or more servings of fruits and vegetables increased from 22% to 39% while the proportion of seniors in the control group who consumed recommended levels fell from 30% to 23%.

Race, gender and living situation were not significantly associated with fruit and vegetable intake at baseline or with the magnitude of increased intake in the intervention group.

Mean Intake of Fruits and Vegetables at Baseline and Change at Follow-up for Basket Participants by Demographic Characteristics

Variables	N	Baseline Mean Daily Intake for All Seniors N=131 (SD)	Change Between Baseline and Follow-up for Seniors Who Received Market Baskets (N=87) (SD)	Statistical Significance of Group Difference
Age (years) 60 to 69 70 to 79 80 to 89 90+	47 40 36 8	3.39 (1.78) 3.50 (1.81 4.19 (1.74) 4.05 (2.19)	+ 1.02 (1.97) +0.91 (1.63) +1.04 (1.88) +1.81 (1.38)	P<0.05
Race White Non-white	95 36	3.74 (1.86) 3.65 (1.80)	+1.07 (1.74) +0.91 (1.94)	P value not specified
Gender Female Male	95 36	3.73 (1.93) 3.55 (1.80)	+1.18 (1.74) +0.70 (1.59)	P value not specified
Living situation Living alone	96	3.70 (1.83)	+1.01 (1.78)	P value not specified
Living with adult children	9	3.25 (1.90)	+0.70 (2.60)
Living with spouse or partner	14	3.76 (1.69)	+1.43 (1.76)
Living with other relatives	5	3.91 (2.20)	+1.81 (1.41)
Living with adult caregiver	7	3.73 (1.96)	+0.41 (1.67)

SD=Standard deviation.

Author Conclusion:

Home delivery of fruits and vegetables is an effective way to increase fruit and vegetable intake in homebound seniors.

Funding Source:

Government:

Grant U48/CCU009654 from the CDC to the University of Washington Health Promotion Research Center

Reviewer Comments:

The reviewer noted differences in demographics including age, ethnicity, living situation and race, between the intervention and control group that might have confounded results
The intervention included a newsletter and recipe that may have affected the participants' use of the produce and skewed the results. Providing a basket without any written information may have resulted in participants using less of the produce provided.
The authors provided no information that could affect intake of fruit and vegetables, such as dental status, functional status (ability to prepare food, for example) and food allergies or intolerance to fruit and vegetables
The authors did not specify if the interviewers were blinded at the beginning or end of the intervention
The only measure of increase in fruit and vegetable intake was a survey. No other data were collected to help validate changes in fruit and vegetable intake.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		No
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	No
	2.2.	Were criteria applied equally to all study groups?	N/A
	2.3.	Were health, demographics, and other characteristics of subjects described?	No
	2.4.	Were the subjects/patients a representative sample of the relevant population?	???
3.	Were study groups comparable?		No
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	No
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	No
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	Yes
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		No
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	No
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	No
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	Yes
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		???
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	N/A
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	No
	7.5.	Was the measurement of effect at an appropriate level of precision?	???
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	???
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		???
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	???
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	???
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	Yes
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes