Multi-level Meals on Wheels insights: a qualitative study

Abstract

Purpose

Meals on Wheels (MOW) support older people to live in their own homes and communities. The purpose of this paper is to explore MOW experiences from a multi-stakeholder level to inform and better equip this valuable service.

Design/methodology/approach

A qualitative approach was undertaken utilising semi-structured interviews and focus groups with current, former and potential MOW service users and MOW stakeholders.

Findings

Qualitative analysis explored MOW perspectives and experiences, highlighting a lack of MOW information and awareness, the importance of a client-centred approach the multiple roles of MOW and service transition.

Originality/value

This research explores MOW from the perspective of different groups directly involved in this community service, offering unique multi-stakeholder insights to understand and guide the future of this service.

Citation

FitzGerald, C. (2024), "Multi-level Meals on Wheels insights: a qualitative study", Working with Older People, Vol. 28 No. 1, pp. 41-48. https://doi.org/10.1108/WWOP-12-2022-0063

Introduction

Traditionally, community services have tended to focus on a top-down service approach, a recent shift, however, has emerged towards an inclusive service approach which engages with all levels of service stakeholders. This shift adopts a multi-level lens, recognising the diverse range of MOW service users and service stakeholders. This state of transition is apparent across community services for older people which provide health and social care supports and services in the community and home of older people, with the overall goal of supporting ageing in place and minimising residential and acute care (Thomas et al., 2016). Community services comprise of a range of health and social supports, including respite care, home help, day centres, homecare packages and meals on wheels (MOW) (HSE, 2022). MOW is a community service that provides meals to older and vulnerable people who may be unable to or prefer not to prepare their own meals (Winterton et al., 2013). MOW plays a key role in enhancing and maintaining quality of life for older people. The primary role of MOW is to support the nutritional needs of older people and to assist older people to live in their own home for as long as possible (Wilson and Dennison, 2011; Krassie, Smart and Roberts, 2000).

Benefits of MOW have been well documented, particularly from a nutritional perspective. Community-dwelling older people who avail of MOW have shown improved nutritional status (Vilar-Compte et al., 2017; Wright et al., 2015; Volkert et al., 2019; O'Dwyer et al., 2009). In recent years, recognition has grown focusing on the social role of MOW, providing social contact while assisting older people to remain living in their own homes (Winterton et al., 2013). A notable randomised controlled trial in the USA found that MOW reduced loneliness for service users, with greater reductions in loneliness for services users who received meals daily as opposed to weekly meal recipients (Shan et al., 2019; Thomas et al., 2016) providing an opportunity for increased engagement and social interaction (Thomas et al., 2016). Overall quality of life and care needs have also been positively associated with MOW with recent studies illustrating reduced falls and mobility risks for MOW service users (Bonagurio et al., 2021; Thomas et al., 2020). Reduced rates of hospitalisation and long-stay admissions have also been shown to be positively correlated with MOW utilisation (Wright et al., 2015; Thomas et al., 2020), with evidence indicating that MOW offers a preventative care role in terms of admission to residential care (Thomas and Mor, 2013). Recent literature has studied the role MOW play in supporting a monitoring aspect for MOW service (Bonagurio et al., 2021), an emerging area which had previously been highlighted as a gap in the service (Zhu and An, 2013; Timonen and O'Dwyer, 2010), particularly in light of COVID-19 (Dickinson and Wills, 2022).

Although MOW provides significant benefits for older people, it currently faces significant challenges that require exploration and understanding to continue to effectively support a growing user base. The ageing and diverse profile of MOW service users in terms of culture, ethnicity and personal preferences further requires a greater degree of diversity to be reflected within the MOW service.

The COVID-19 pandemic acutely demonstrated the value of MOW. At a time when the traditional nutritional and social supports of the MOW users were severely constrained, MOW provided critical nutritional and social contributions (Henning-Smith et al., 2022) which drove an increased demand for MOW amongst services providers (Henning-Smith et al., 2022; Papadaki et al., 2022).

The aim of this paper is to explore MOW experiences from a multi-level perspective to inform and equip MOW services to meet the needs of a growing and increasingly diverse older population. This paper outlines a multi-stakeholder approach to explore MOW, representing the need for a more inclusive service approach towards engaging with all levels of service stakeholders. This shift adopts a multi-level lens, recognising the diverse range of service users and service stakeholders.

Methodology

This qualitative study comprised of a three-phased qualitative approach. The first phase consisted of semi-structured interviews with current (n = 11) and former (n = 2) MOW service users; older people who at the time of the study were either currently using the MOW service or were former MOW service users. Semi-structured interviews with current and former MOW users were conducted face-to-face in the home of the service user/former services user. The second phase consisted of three focus groups with potential MOW services users (n = 7, n = 4 and n = 6); older people who had not previously used MOW. Focus groups were conducted face-to-face in a central local community space. The third phase comprised of semi-structured interviews with MOW key stakeholders (n = 12) including public health nurses, home care package coordinators, community social workers, general practitioners (GPs), community development officers, managers of older people services and MOW providers. Key stakeholder semi-structured interviews were conducted face-to-face in the workplace of each key stakeholder.

Each of the three phases was pilot tested and revised accordingly. No interview/focus group guide was shared with participants ahead of data collection.

The researcher initials (CF) conducted all data collection, with extensive qualitative research experience. The researcher did not have a previous relationship with participants and had no prior involvement in their service experience. Data collection continued until data saturation was reached.

Sampling

A purposive sampling strategy, with clear identification of inclusion and exclusion criteria, was the most effective approach to participant recruitment for all three data collection phases. Inclusion and exclusion criteria were developed to provide diverse representation.

Ethical approval

Ethical approval was obtained for the study from the University Research Ethics Committee. Written informed consent was sought prior to participation for all participants. Prior to consent for data collection, all participants received study information sheets, an overview of the study and an opportunity for questions. There was no basis for researcher bias.

Data analysis

All interviews and focus groups were fully transcribed by the researcher (CF). Data analysis followed a reflexive thematic approach (Braun and Clarke, 2021). Braun and Clarke’s six steps of thematic analysis were adhered to for the analysis process: data familiarisation, generating initial codes, identification of similar item codes and preliminary themes, review of themes and manuscript development using quotes to support themes. NVivo software was used to manage the data analysis.

Findings

Four key themes were derived from the data: lack of MOW information and awareness, client-centred approach, multiple MOW roles and service transition.

Lack of Meals on Wheels information and awareness

The first key theme relates to the existence of an MOW information and awareness deficit, which was evident across all groups. Current, former and potential MOW users, as well as MOW stakeholders, identified a lack of information on MOW services as an issue. This lack of information was experienced from current MOW users in terms of a lack of clarity about eligibility criteria for availing of the service and who can use the service:

I live on my own, because I think the meal is only available for people living on their own (Current Service User – U5).

Older people who had not used MOW previously, who could be viewed as potential MOW users also showed a lack of understanding of the service in terms of who the service is aimed at:

Well I think it’s for old people, I’m just thinking you know, but I hadn’t heard of them giving it to young people, maybe there is some young people that need it (Potential Service User – FG3 2).

A lack of clarity on the client base for MOW was also evident amongst key stakeholders. From this stakeholder’s perspective, there was a lack of clarity in relation to how to refer an older person to MOW, which was seen to be linked to a lack of awareness of the service amongst older people:

They’re [older people] not aware of it. They are certainly not. I mean, we think they are but they are not. Not alone that, it’s difficult to get the information of who to contact. I’d say if you went into a GP and asked where’s the nearest MOW and how would I go about getting it, I don’t think they’d know. And the other thing is, the older person would never instigate it, I’ve a feeling they’d do without it rather than instigate it (Key Stakeholder – KS 4).

A gap in how key stakeholders perceived navigation of the service by older people was evident, despite the visibility of the service within some communities:

It’s possible that they mightn’t know how to start using MOW alright, now having said that if any of them saw the van coming you’d think would a neighbour tell them or maybe a son or daughter (Key Stakeholder – KI 12).

As well as limited knowledge on eligibility, there was also a lack of awareness amongst older people about payment for the meals and if any financial support was available to those who used MOW:

They have to pay for the meals though don’t they, it’s subsided though isn’t it? (Potential Service User – FG2 1).

Key stakeholders who were health-care professionals working in the area of community services also highlighted the lack of MOW information and the impact it has for their work, ultimately presenting a barrier to service access, referrals and use:

It would be very useful for me to know what MOW services were in an area immediately, and how do we access the service. I know as a professional working in the area that would be very useful for me, because it could take me five phone calls before I can track down who does MOW. I’d also be interested to see where the gaps are, I’d love to see that, so at least when I am looking I can see what services are available in each area. And it would also highlight the areas where there are gaps in the service (Key Stakeholder – KS 8).

Similar challenges were reported from a service user perspective, expressing difficulties around not knowing how to start using MOW was also evident:

One thing I remember was that somebody mentioned it, and they said that the GP would have it, but I went in and asked in the GP’s office and they didn’t have any contact for it, and I was surprised (Current Service User – U6).

A lack of knowledge of practical elements associated with using MOW services were also evident. Potential MOW service users spoke strongly on reheating meals provided by MOW, with health concerns expressed in relation to having to reheat meals using microwave ovens. This illustrates how a combination of different perspectives and lack of dissemination of accurate information can create a barrier to service use. This barrier to MOW services offers new insights into perceptions and potential changes required to ensure older people’s health concerns are acknowledged:

A lot of people don’t like to use the microwave, oh a lot of people don’t want to use the microwave, no they don’t, I don’t like using it either (Potential Service User – FG1).

I don’t have a microwave and I even don’t like to heat something in the microwave, so am. so ya, I had a bit of a thing with that (Potential Service User – FG1 1).

I used have to put it in the microwave. She showed me, I didn’t know how to use the microwave (Potential Service User – FG2 4).

Sources of MOW information and how this information was communicated was highlighted as a challenge for older people and stakeholders. In one such example, a Health and Social Care MOW stakeholder highlighted the use of internet as a source of MOW information for older people. This pointed to a gap with experiences shared from older people, where most older people involved did not have access to, or proficiency in, using the internet, with local media the dominant source of information:

Well you used to hear about it on the wireless. One time there used be a man who’d write about food in the local newspaper, so he went out and visited it (the MOW provider) at that time and he had a great report about them (Current Service User – U2).

Client-centred approach

The second research theme to emerge focuses on the client-centred approach of MOW. Due to the multi-level perspectives applied in this study, the findings contributed to the area of client-centred approach area by comparing the perspectives of MOW users (current, former and potential) and a range of MOW stakeholders. Interestingly, while the issue of a more client-centred service featured strongly from the perspective of MOW users, it was largely absent from the perspective of stakeholders.

For service users, opportunities for consultation on the service, such as providing feedback on meal preference was an important component of the service. A recent shift in the service towards the option of having meals available as either hot or chilled was a topic that participants spoke about, this option of chilled meals emerged as both a barrier and facilitator to service use:

Well we used to get a hot dinner, and you can get used to anything, you can fit it in, we thought, well at least I thought it was hard in that I wouldn’t like it, but it’s better now (Current Service User – U3).

In the beginning I was using them every day, and after a while I used them three times a week. I did that for a long time, for at least two years, then they changed it, you got a chilled meal then instead of a hot meal, and that didn’t appeal to me (Former Service User – F1).

Consultation around MOW payment was highlighted, with inadequate information and a lack of clarity evident amongst potential users and stakeholders involved in delivering the service. Payment for meals emerged as a factor that appeared to reduce stigma associated with using MOW services:

You see people have this feeling that you were begging, whereas now that you have to pay for it, it’s not begging anymore (Current Service User – R3).

Multiple Meals on Wheels roles

Insights highlighted the multiple roles of MOW, whereas some service users spoke of the nutritional elements, the social role of the service strongly resonated amongst service users and is cited as being of key importance to users:

Having people knock on the door everyday if you are living alone, it’s that human contact during the day (Current Service User – U6).

Service users spoke about using the service as a “lifestyle” choice, with MOW being seen as a convenient healthy food option that fits in with the lifestyle of the service user:

It’s very handy like, you know, because sometimes if I rang them at ten or half ten in the morning and say “I am stuck for a dinner today, would you be able to send me a dinner?” that would be fine (Current Service User – U7).

The reassurance provided by using MOW, where service users have a sense of reassurance knowing that the MOW service provides a monitoring aspect was common amongst participants. Service users valued the sense of reassurance associated with having a meal delivered to their homes, seeing this as a source of security and social contact associated with using the service:

Getting the Meals on Wheels you know there is somebody coming everyday (Current Service User – U3).

Having people knock on the door everyday if you are living alone, it’s that human contact during the day (Current Service User – U6).

Service transition

Service transition elements including issues of stigma and changes in the health service were identified. A sense of stigma associated with using the MOW services from some service users and key stakeholders was identified. Contrary to existing research, these findings show that stigma remains an ongoing issue in relation to MOW services. Not only did older people display awareness of the issue of stigma, but the findings also extend the presence of stigma towards MOW services to other sources, such as families and neighbours:

There’s a lot of people that needs it, but they wouldn’t like to see the van coming to the house. But I don’t mind about that. Let them talk if they like (Current Service User – R2).

Challenges, particularly related to funding in the wider health service, were also seen to be significant. Reduced funding was seen to limit the role, availability and duties of Home Helps, significantly reducing the amount of time allocated to provide support to older people. The reduced role of Home Helps was seen to present particularly significant challenges for older people living in rural areas:

We have an issue as well at the moment around Home Helps and cooking in the home, and we are moving away from sort of a household duty the more personal care element of it, that again is because of resources, and while there is a lot of value in cooking a meal in a person’s home and in taking that away and suddenly having a meal just brought in (Key Stakeholder – KS 2).

This reduction in care hours has limited the scope of duties provided by Home Helps in Ireland to providing assistance with only the most essential tasks. Such tasks are predominantly focused on activities of daily living, such as assistance with personal hygiene, getting out of bed and getting dressed. As a result, the role of the Home Help in preparing food has changed, with many older people no longer having the option of having a meal prepared or receiving assistance in the preparation of a meal in their own home.

Discussion

Although previous research showed the central nutritional role of MOW (Wilson and Dennison, 2011; Krassie, Smart and Roberts, 2000; Vilar-Compte et al., 2017), this paper explored the broadened role of MOW; in particular, how MOW was recognised for its socialisation attributes, reflecting previous research which places greater importance on this element of the service (Winterton et al., 2013). New insight was provided into how MOW are perceived by some older people as a lifestyle choice as opposed to a source of nutrition or social outlet, MOW is seen not in the traditional sense of a meal being delivered, but as a food choice based around lifestyle and convenience.

From a broader health monitoring focus, MOW service users recognised this aspect of the service, mirroring emerging explorations around this potential role of MOW (Bonagurio et al., 2021). The monitoring role of the service, if harnessed, has the potential to assist in ensuring that older people have sufficient supports and to assess any changes in individual circumstances, thus helping older people to remain living in their own home independently.

Lack of information about MOW amongst older people, such as eligibility criteria, has previously been shown as a barrier which prevents older people from using MOW (Wilson and Dennison, 2011; CMDHB, 2006), with a lack of information also identified from MOW stakeholders including health-care professionals. The issue around a lack of knowledge from health professionals’ perspectives may also be seen to impact on the likelihood of referral of eligible older people to MOW.

Looking beyond individual level to incorporate a systematic multi-level perspective, this study adds to extend a broader base of international evidence on MOW knowledge and experiences, as well as providing a deeper understanding of MOW systems. The results from this study highlight the important role of a client-centred approach to MOW, focusing on engaging and including individual choice and needs within a growing and diverse older population. Consideration of such needs must be acknowledged and incorporated into MOW services to ensure that older people can continue to rely on MOW to support them to live in their own homes.

Given the lack of multi-level research in MOW, this study contributes valuable information to better understand the service from a multi-level perspective. Insights from this paper offer tangible learnings to inform MOW in terms of service implementation and evaluation.

Conclusion

To ensure that MOW services are ready to meet the needs of a growing and increasingly diverse older population, it is essential that the perceptions and experiences of service users and stakeholders are explored and understood. Understanding and equipping the MOW service to respond to these challenges is made more complex given a lack of research in MOW service user and stakeholder knowledge (CMDHB, 2006).

This multi-level qualitative study explored MOW experiences from a multi-stakeholder perspective to inform and better equip the service. This paper outlined a multi-stakeholder approach to explore MOW, representing the need for a more inclusive service approach to recognise and engage the diverse range of service users and service stakeholders.