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The purpose of the study was to identify themes and significant issues regarding the experiences of participants in a program to provide fresh produce to homebound senior adults.

• Participants were homebound senior adults receiving home delivered meals through the Seattle (WA) Senior Services Meals-on-Wheels program
• Participants volunteered to be interviewed for the research study.

 

No specific exclusion criteria were identified. 

Recruitment

• A recruitment flyer, seeking volunteers for an interview, was included with the meals and food provided to the seniors in the Meals-on-Wheels program
• A $10 incentive was offered to those who volunteered for the interview
• The number of subjects who volunteered for the study exceeded the number that could be accommodated in the research project. Therefore, the final study participants were selected by the researchers on the basis of the volunteers' geographic location within the Seattle/King County, WA, area served by the Meals-on-Wheels program, and on racial, ethnic and age diversity of the homebound Meals-on-Wheels population. 

Design

Cross-sectional, descriptive study:

• All participants were receiving home-delivered Meals-on-Wheels. Throughout a 20-week period from June through October, 2001, a bag of fresh fruits and vegetables from local farmers' markets was included every other week with the regular meals, for a total of 10 fresh produce deliveries. The produce was provided through the U.S. Department of Agriculture (USDA) Senior Farmers' Market Nutrition Pilot Program (SFMNPP).
• A newsletter included with the produce listed the fruit and vegetable items and provided recipes, preparation methods and information on nutrition and about the local farmers
• The recruitment flyer was included in the 10^th week of the 20-week program, requesting participation in an interview regarding the produce
• Interviews lasting 20 to 45 minutes were conducted with the selected subjects in the their homes during the 12^th to 18^th week of the program. A semi-structured questionnaire with both direct and open-ended questions was developed to identify benefits and barriers to produce use, assess behaviors that sustained or increased fresh fruit and vegetable consumption and satisfaction with the produce program. Probing was used to help subjects recall their experiences in using the produce. The interviews were audio-recorded and transcribed to identify common themes in the following areas:
  • General thoughts about the fresh produce program
  • Utilization of the fresh produce items
  • Ability to prepare the fresh produce
  • Quality of the fruits and vegetables
  • Usefulness of the newsletter
  • Interest in future participation in the produce program
  • Quoted remarks of the participants were used to substantiate the themes.

Intervention

All individuals participated in the same program.

Statistical Analysis

• Data was validated by triangulation, comparing the qualitative data with the quantitative evaluation of participants' fruit and vegetable intake and by comparison of the qualitative data with the attitudes, social influence and self-efficacy (ASE) model
• Sample size was determined by methods for qualitative research data for non-homogeneous samples. These methods were described and referenced.

Timing of Measurements

One interview was held with each of the selected study participants between the 12th and 18th week of the 20-week program.

Dependent Variables

Interviews lasting 20 to 45 minutes were conducted with the selected subjects in the their homes during the 12th to 18th week of the program. A semi-structured questionnaire with both direct and open-ended questions was developed to identify benefits and barriers to produce use, assess behaviors that sustained or increased fresh fruit and vegetable consumption and satisfaction with the produce program. Probing was used to help subjects recall their experiences in using the produce. The interviews were audio-recorded and transcribed to identify common themes in the following areas: 

• General thoughts about the fresh produce program
• Utilization of the fresh produce items
• Ability to prepare the fresh produce
• Quality of the fruits and vegetables
• Usefulness of the newsletter
• Interest in future participation in the produce program
• Quoted remarks of the participants were used to substantiate the themes.

Independent Variables

• All participants were receiving home-delivered Meals-on-Wheels. Throughout a 20-week period from June through October, 2001, a bag of fresh fruits and vegetables from local farmers' markets was included every other week with the regular meals, for a total of 10 fresh produce deliveries. The produce was provided through the U.S. Department of Agriculture (USDA) Senior Farmers' Market Nutrition Pilot Program (SFMNPP).
• A newsletter included with the produce listed the fruit and vegetable items and provided recipes, preparation methods and information on nutrition and about the local farmers.

 

 

• Initial N: 28; (21 females, seven males)
• Attrition (final N): 27 (no data on the one withdrawal)
• Age: 60 to 90 or more; 60 to 79, N=21 (75%); 80 to 90+, N=5 (18%); Unknown, N=2 (7%)
• Ethnicity: White non-Hispanic, 66%; Non-white or Hispanic, 26%; Unknown, 7%.

Other Relevant Demographics

Most (74%) of participants lived alone; the majority lived in public housing, senior housing or other rental units.

Comparison of study participants to the Seattle area Meals-on-Wheels population as a whole:

• Gender proportion was similar
• Ethnic minority groups were under-represented
• Total age range (60 to 90 years or more) was similar, but within that range, the older (80 to 90 years or more) ages were under-represented.

Location

All participants lived within Seattle and King County in Washington state.

The interview data was organized into four major themes.

• Utilization of the fresh produce: Produce was well utilized, especially fruit, which required less preparation. Participants who had a caregiver helping with meals had higher utilization.
• Participants' perceived benefits from SFMNPP: Participants appreciated the fresh produce. Many believed that eating fresh produce was beneficial to their health
• Newsletter-supported SFMNPP objectives: The majority of the participants read the newsletter and found the information useful
• Participant satisfaction with SFMNPP: All participants liked the program and would participate in the future if the program continued. No themes regarding general dissatisfaction with the program were revealed by the participants. 

Other Findings

• Although the questionnaire did not specifically ask about financial or health status, some study subjects also included personal information that related to their motivation and ability to use the produce. Many stated that they would not be able to buy the produce for themselves. The authors identified health status and physical and cognitive disabilities as key factors influencing intake of fresh fruits and vegetables. 
• The qualitative findings reported in this article were consistent with quantitative data on fruit and vegetable intake of the same participants (reported elsewhere), which showed an increased intake.  

 

The study provides insight into factors that successfully increase fruit and vegetable intake among homebound seniors. The free, home-delivered produce eliminated two major barriers of many senior adults:

• The inability to go shopping
• Lack of money to purchase fresh produce.

The program influenced the three aspects of the ASE model, which include attitude, social influence, and self-efficacy. Enjoyment in receiving and eating the produce and belief in the health benefits affected attitude toward consumption. Delivery staff and the newsletter provided social influence. Nutrition information increased abilities to use the produce and supported self-efficacy. The positive attitude of the participants, utilization of the produce and increased number of produce servings were consistent. According to the ASE model, these factors would strengthen the intention to continue the target behavior and to overcome barriers that would prevent doing so. 

 

Government:

Centers for Disease Control and Prevention supported the study. Food and Nutrition Services of the USDA funded the Senior Farmers' Market Nutrition Pilot Program (SFMNPP) in Washington state

 

• Quotations of participants were used to substantiate the identified themes although there is no indication of the number of subjects who made similar comments supporting a particular theme. Some identified factors for fruit and vegetable intake, such as health status and physical and cognitive disabilities, can be age-related. Compared to the Seattle area Meals-on-Wheels population, a smaller proportion of the study participants, 18% versus 38%, were 80 years or older. It is not clear who conducted the interviews.
• Limitations of the study included the small sample size and the volunteer participation of the study subjects. It is not known how they may have differed from those who did not volunteer for the interview. For example, the interview participants were satisfied with the produce program; those who did not volunteer for the interview might have had other views and different themes might have emerged. Ethnic minorities were under-represented in study population compared to the Seattle area Meals-on-Wheels recipients. The use of a semi-structured questionnaire may have limited the comments, and therefore the themes, identified in the study.