meals on wheels service: knowledge and perceptions of health professionals and older adults

ORIGINAL RESEARCH

Meals on wheels service: Knowledge and perceptionsof health professionals and older adultsndi_1522 155..160

Amanda WILSON1 and Kaye DENNISON2

1Otago University, Dunedin, and 2Counties Manukau District Health Board, Auckland, New Zealand

AbstractAim: To investigate health professionals’ and older adults’ knowledge and perceptions of the meals on wheelsservice in Auckland, New Zealand.Methods: Thirty-eight health professionals participated in a survey on their knowledge and perceptions of themeals on wheels service. Sixty-one older adults, with the majority between 66 and 75 participated in a questionnaireand 42 of those also completed focus groups to discuss their knowledge, perceptions and barriers to utilisation.Results: Health professionals’ knowledge of the service and their interpretation and information to clients variedwidely. The majority of health professionals stated the current menu did not meet the cultural needs of older adultsin South Auckland. Twenty-one per cent of the older adults had never heard of meals on wheels. Poor knowledgeassociated strongly with non-New Zealand Europeans. Thirty-three per cent of older adults were familiar with theservice and 45% reported they first heard about it from friends. Positive perceptions were the social contact withdelivery and high nutritional value. Negative perceptions were the repetitive menu cycle and the similarity tounattractive hospital meals. The main barriers to using the service were lack of knowledge, feelings of embarrass-ment and loss of independence. Confusion over eligibility and having no choice available on the menu was a barrierespecially for ethnic and religious groups.Conclusion: Further research is needed to review if the New Zealand meals on wheels service is meeting the needsof the older adult population.

Key words: health professional, knowledge, meals on wheels, nutrition, older adult, perception.

Introduction

Meals on wheels (MOW) is a community support servicethat supports the nutritional needs of its clients, assistingthem to live independently for as long as possible1 andcontributes to the New Zealand (NZ) Government’s Healthof Older People Strategy.2 It is an increasingly importantservice for those with a medical condition or disability affect-ing their ability to prepare meals and maintain nutritionalstatus.

Since its inception in NZ in 1951, the MOW service hasbeen producing and delivering hot meals to people living athome, who because of their age, illness or disability areunable to prepare meals. The NZ MOW service offers a hotmeal (or a frozen meal in certain circumstances) and dessertat midday from one to five days per week, depending on the

client’s eligibility criteria and requests. Referrals can be madefrom an assessment team, general practitioners (GPs) orself-referrals.1 Access criteria include those that are unable toprepare a meal because of a medical condition or disabilityand have no family (whanau) or caregiver assistance readilyavailable.1 In 2007, the NZ Red Cross reported its volunteersdelivered over 15 000 meals per week nationwide.3 In NZ, ameal is required to provide one-third of an older person’sdaily energy (2520 kJ/600 kcal) and protein (18 g) require-ments.4 Similarly, the Commonwealth Department of HealthNutrition Guidelines for MOW meals state that an MOWmeal should aim to provide greater than or equal to one-third of the dietary requirement for energy, and one-half thedietary requirement for protein.5

By supporting the nutritional status of its clients, the NZMOW service aims to maximise independence to promoteself-supporting living, thus reducing government-fundednursing home health-care costs.1

One previous audit identified a lack of knowledge ofthe service by Maori and Pacific Peoples over the age of 55living in South Auckland, NZ (Kaye Dennison, unpublisheddata, 2007). This is of concern, as these minority groupshave a lower health status than the general population.6

A. Wilson, DipDiet, NZRD, Clinical DietitianK. Dennison, DipHomeScience, NZRD, Professional Leader for Dieti-tians Waitemata District Health BoardCorrespondence: A. Wilson, 8a Hampstead Road, Sandringham,Auckland 1025, New Zealand. Email: [email protected]

Accepted December 2010

Nutrition & Dietetics 2011; 68: 155–160 DOI: 10.1111/j.1747-0080.2011.01522.x

© 2011 The AuthorsNutrition & Dietetics © 2011 Dietitians Association of Australia

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Currently the population size of Maori (16.5%), Pacific(22.7%) and Asian (17.9%) peoples living in CountiesManukau are higher than the general NZ population.7 Theethnic minorities in Counties Manukau are expected to risein the future. Seventeen per cent of the Maori population willbe over 50 in 2016, 16.3% of the Pacific population in 2016will be over 50 and 25.7% of the Asian population will beover 50.8

There has been limited research on older adults’ knowl-edge, perceptions and barriers to referral for the MOWservice in NZ. Knowledge, perceptions and referral practicesof health professionals to the service are also unknown.

The researchers were interested in the verbal and writteninformation health professionals gave to their clients, theirknowledge of eligibility criteria, nutrition, benefits and costof the service and whether they saw MOW as a long-termform of passive support, or a short-term restorative nutritionintervention.

The aims of this study were twofold: first, to investigateNZ health professionals’ knowledge and perceptions of theMOW service and the verbal and written information givento clients; second, to explore older New Zealanders’ knowl-edge and perceptions of the MOW service, and barriers tousing the service.

Methods

The study was part of a practicum submitted for the Post-graduate Diploma in Dietetics in NZ. This study used amixed-methods design including qualitative and quantita-tive questionnaires for both study groups and six qualitative-based focus groups for the older adults group. Ethicsapproval was granted from both the hospital and the Uni-versity of Otago, Dunedin, NZ.

Two groups of respondents (health professionals andolder adults) were required for this study. Health profession-als were invited to participate in a survey; the majority wererecruited as a convenience sample through professional andcommunity networks. GPs and practice nurses wererecruited from the eight largest practices in the South Auck-land region, as identified in the telephone directory. Thesurvey was sent to 153 health-care professionals at two largepublic hospitals in Auckland, GPs and practice nurses in theSouth Auckland community. Respondents were surveyed onbasic knowledge and perceptions of MOW including cost,nutritional value, eligibility criteria and information given toclients.

The older adult group was invited to complete a ques-tionnaire and some of those adults were also invited toparticipate in focus groups. The older adult group wasrecruited via community organisations in South Auckland,e.g. Age Concern and The Stroke Foundation and from twoolder adult rehabilitation wards at a large hospital in Auck-land. Participants were recruited by contacting the commu-nity organisation’s group coordinators, but the number ofolder adults invited to participate was unknown. There wasa mix of residential and community-dwelling older adults.Sixty-one participants were given a plain language state-

ment of the study and invited by the researcher to completean anonymous questionnaire, which was filled out by themor by the researcher if they could not read or write. Inclu-sion criteria were either receiving or not receiving MOW inthe present or past and adults over the age of 65 (or over55 years for Maori and Pacific Island because of their lowerlife expectancy).6 Ethnicity was classified through level onecategory as defined by statistics NZ, which includes eightethnicity choices plus ‘other’ based on subjective self-identification.9 The exclusion criteria were adults less thanthe age of 65 (or under 55 years for Maori and PacificIsland, even if they had a disability and were able to accessMOW).

A total of 61 older adults from community organisationscompleted a questionnaire for their opinion of MOW, anynegative or positive feelings associated with it, barriers tousing it, previous experiences, preferences for community orfamily help, and what they thought of the name. Forty-twoolder adults from community organisations also participatedin six audio recorded focus groups with the numbersattending for focus groups as follows: 3, 3, 7, 8, 10 and 11older adults. Data saturation was reached in five out ofsix groups and in the other group a time limit of 90 minuteswas reached. Older adults with Chinese or Indian ethnicitywere oversampled (25 and 18% of the older adults group,respectively) to obtain sufficient information to represent thepopulation demographics.7 Maori and Pacific Island peoplewere not oversampled as there had been previous studiesconducted regarding MOW knowledge and perceptions(Kaye Dennison, unpublished data, 2007). Informed,written consent was gained from each respondent in thestudy.

The focus groups were transcribed and systematicallycoded by the main issues discussed. The codes were collatedand potential themes were gathered; they were then checkedand refined, and extracts were then selected to give examplesof each theme.10,11 Quantitative data were analysed throughinputting data into Microsoft Office Excel 2007. Statisticalanalyses were performed by using a chi-square with Yatescorrelation (two-tailed) contingency table, with a P-value �0.05 as a significance limit. All questions were optional andall questions testing knowledge had a not applicable/I do notknow option.

Results

Table 1 shows the demographics of the health professionalsand the older adults. Thirty-eight health professionals com-pleted the survey (25% response rate), 89% (n = 34) werefemale and 68% (n = 26) were NZ European. Table 2 showsthat 53% (n = 20) of the health professionals have receivedformal information about the service. Sixty-three per cent (n= 26) have seen a meal from MOW and 65% (n = 17) ofthose thought it looked appetising.

Table 3 shows responses to questions about knowledge ofMOW. Fifty-eight per cent (n = 22) of the health profession-als knew the number of meals a client could receive per weekand 53% (n = 20) knew the weekly cost of MOW. In terms

A. Wilson and K. Dennison


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of nutrition, 40% (n = 15) of the health professionals knewthe energy contribution of a MOW meal.

There were variations in assessment criteria used whenassessing eligibility for MOW. Twenty per cent (n = 12)used weight parameters, 20% (n = 12) used other medical/nursing staff’s professional opinions and 11% (n = 7) hada standardised questionnaire. Written information given toclients about the service included no written information(24%, n = 9), Ministry of Health, District Health Boardspecific resource (16%, n = 6) and other booklets such as

‘Ageing Well’ or information on easily prepared meals(26%, n = 10).

Only 39% (n = 15) of the health professionals were awarethat the MOW service was available as long-term supportand a temporary intervention. Forty-seven per cent (n = 18)thought it was just for long-term and 11% (n = 4) thought itwas just for short-term use.

Opinion was sought on aspects of the MOW service. Themajority of health professionals thought that the menu didnot cater to the various cultures in NZ, and some suggestedthat this may be too difficult or costly.

‘Probably not, I feel it would be difficult to provide tradi-tional foods.’

‘But that is undesirable—costs would rise with too muchchoice.’

Health professionals gave many suggestions on how toimprove use of the MOW service.

‘(1) 7 days a week service is recommended. (2) Menuchoices via e-mail (Family could action this). (3) Snackfood provision also for extra cost. (4) Ethnic food choices.(5) Trial of a different caterer to contest menu choices plusprices for comparison, to improve?’

‘A more pro-active information service about what theyprovide would be useful for our team and also plans thatthey may have to expand the range of meals to meet thediverse cultural needs.’

In a multi-choice questionnaire, respondents were askedto select the answer that best matched their understandingof the MOW service. Table 1 shows 61 older adultsresponded, 52% (n = 32) were female, 40% (n = 26) wereNZ European, 25% (n = 16) were Chinese and 18% (n = 12)were Indian. Forty-three per cent (n = 26) were living inde-pendently with their spouse, 25% (n = 15) with family orfriends and 16% (n = 10) were living alone. Table 4 shows33% (n = 21) of respondents understood the role of theMOW service. NZ Europeans had a significantly greaterunderstanding of the service, compared with non-NZ Euro-peans. Of those respondents that had heard of the MOWservice, 45% (n = 25) heard about it from friends, 22% (n =12) from family and 20% (n = 11) from a health profes-sional. Sixty-three per cent (n = 37) of older adults had noidea how much MOW cost, with 22% (n = 13) of respon-dents correctly choosing $4.50 per meal. Forty-nine percent (n = 30) had no idea how many meals older adultswere able to receive each week, with 16% (n = 10) ofrespondents correctly choosing one to five meals per week.Fifty-two per cent (n = 30) had no idea about how muchMOW should contribute to older adults’ daily energyrequirements, while 26% (n = 15) of respondents correctlychose one-third of daily energy requirements.

Forty-two of the respondents who completed the ques-tionnaire were involved in the six focus group discussions.There was no significant difference in demographicsbetween those that completed the questionnaire and thosethat attended the focus groups. Almost half (48%, n = 22)

Table 1 Demographics of older adults and health profes-sionals

Older adults Health professionals

n = 61 n = 38

SexMale 29 4Female 3 34

EthnicityNZ European 24 26Maori 1 0Samoan 1 1Cook Island Maori 0 1Tongan 0 1Niuean 0 1Chinese 15 1Indian 12 1Other 8 6

Age (years)46–55 556–65 966–75 2576–85 1485+ 8

Table 2 Closed answer results in the health professionals’questionnaire

Question Yes No

Have you received formal information on theMOW service? n = 38

20 18

Have you seen a sample of MOW? n = 38 26 12If you have seen a MOW meal, did it look

appetising? n = 2617 9

Does the current MOW service meet theneeds of the various cultures in NZ? n = 29

6 23

Do you ask about food preferences whentalking to a client about MOW? n = 38

21 17

Do you ask for dietary requirements whentalking to a client about MOW? n = 38

31 7

Do you weigh the client when assessing needfor MOW? n = 37

6 31

Do you think MOW is an appropriate namefor the service? n = 37

33 4

MOW, meals on wheels.

Qualitative and quantitative survey results


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were NZ European, 24% (n = 11) Indian, 9% (n = 4) Chineseand 15% (n = 7) other.

In regards to what the MOW service was, most thought itwas for those incapable of cooking but several thought it wasa charity.

‘I always thought it was for someone who was sick andwas incapable of doing it and they carried on until theywere well again, back on deck.’

‘I actually thought it was a charity supplying people, whocould no longer supply their own food.’

The dominant theme around positive feedback for theMOW service was that it provided social contact with thedelivery people. Smaller themes were the nutritional valueand that it was a greatly appreciated service for some people.

‘. . . having a person calling in once a day, at least duringthe week is sometimes their only visitor, so they lookforward to it, more as a social thing.’

‘I think that the meals are quite nutritious, is very good,because it’s decided by professional dietitian.’

The three most dominant themes for negative feedbackwas how unattractive the meals are, how there is no choiceon the menu and the short, repetitive cycle.

‘. . . as I understand basically no choice and you basicallyget what’s given.’

‘Well I’ve always had the opinion that they are not veryattractive.’

In response to the question why the respondents thoughtolder adults would not access MOW, the most dominanttheme was the lack of knowledge of the service. Also loss ofpride and independence and the stigma around MOW werestrong. Respondents saw MOW as appropriate for only lowincome or disabled adults. Other minor themes were a lackof choice for older adults with certain medical conditions orethnic groups. Some respondents mentioned that in someethnic minorities, the family acts as a caregiver for itsmembers and provides meals.

‘Simply because I know nothing about it and if you don’tknow anything about it why buy it?’

‘Well if somebody sees the Meals on Wheels coming nextdoor, then they will say there’s a poor person living there,or something like that, or that they’re disabled’

‘Well if they are diabetic or something, or religious reasonsor something that would stop a lot of people’

Table 3 Knowledge of MOW from health professionals’ survey—multiple choice questions

Needsassessors(n = 12)

Districtnurse

(n = 7)OT

(n = 4)

Practicenurse

(n = 3)

Socialworker(n = 3)

GP(n = 2)

SLT(n = 2)

Dietitian(n = 1)

Other(n = 4)

Total (%)(n = 38)

C NC C NC C NC C NC C NC C NC C NC C NC C NC C NC

Meals per week 7 5 4 3 2 2 2 1 2 1 2 2 1 3 1 58 42Cost per meal 11 1 1 6 1 3 3 2 1 2 1 1 1 1 3 53 47Energy contributionof MOW

7 5 4 3 4 3 1 2 2 2 1 1 3 40 60

C, correct; GP, general practitioner; MOW, meals on wheels; NC, not correct; OT, occupational therapist; SLT, speech and language therapist.

Table 4 Knowledge of MOW from older adults’questionnaire—multiple choice questions

QuestionNo. of

participants

Have you heard of the meals on wheelsservice?

(n = 63)

Not at all 13Yes, but don’t know anything 13Yes, but know little 11Yes, understand service 21Have used myself 4Other 1

Where did you first hear about the MOWservice?

(n = 55)

Family 12Friends 25Health professional 11Other 7

How much does a meal from MOW cost? (n = 59)Free for those malnourished 2$4.50 per meal 13$6.50 per meal 7No idea 37

How many meals a client can receive perweek?

(n = 61)

7 meals per week 75 meals per week 13Between 1–5 10No idea 30Other 1

How much energy does a meal provide perday?

(n = 58)

All daily requirements 53/4 daily requirements 21/2 daily requirements 61/3 daily requirements 15No idea 30

MOW, meals on wheels.



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‘. . . here, you have so many ethnic groups, now a lot ofpeople don’t want to eat food I eat, but then I don’t wantto eat the kind of food they eat’

‘. . . from what I gather the Maori and Pacific Islanderswould be being looked after in their own house by theirown family’

In terms of preference to use community support servicessuch as MOW or rely on family and friends, those of ethnicminority predominantly answered family (Chinese andIndian) and the other focus groups indicated there weremixed opinions.

‘The problem of course is these days family members areall involved in their own life . . . they have hardly got timeto cook a meal’

‘No I think your children should help out, especiallybecause my husband likes his Island food and they wouldunderstand how to cook it’

All of the participants in the focus groups respondedpositively to the name Meals on Wheels.

‘A lot of international recognition, even in the UK . . .’

‘. . . if they try and change the name the money would befar better spent improving the meals rather than wastingmoney on trying to promote the service . . .’

Discussion

There was a lack of education and standard informationavailable to this sample of health professionals. Their poorknowledge of the MOW service cost, nutritional value andthe number of meals clients were able to receive, could resultin eligible older adults not being referred to the service. Thisresult cannot be extrapolated to all health professionalsbecause of the small convenience sample.

Results indicate that the use of standardised assessmentcriteria is limited. The Ministry of Health MOW specifica-tions provide a ‘risk assessment framework’ to determinewhether clients are at high, medium or low risk of need forMOW.1 It is recommended that this framework be used toassist health professionals assess clients for referral to theMOW service.

This study showed that the older adults surveyed, espe-cially those of non-NZ European ethnicity, had a poorknowledge of the MOW service. Recent audits of sevenMaori and 10 Pacific people in NZ showed similar results oflow awareness and knowledge of the MOW service (KayeDennison, unpublished data, 2007). An overseas study byAhmad and Walker reported that 65% (from 104) Asianpeople over 55 years and living in Britain had never heard ofthe MOW service.12 Boneham et al. found that 11% (from71) of people from ethnic minorities in Liverpool, England,had no knowledge of MOW.13

Lack of choice on the menu was identified in most focusgroups in the current study as a major barrier to usingMOW, especially for people with a medical condition such

as diabetes, or of certain religious or ethnic groups. Thisperception further confirmed that information about theservice was poor, as in fact, there were 12 ‘special’ dietoptions on the MOW menu. The diets offered cater forthose with a medical condition such as the diet for diabetes,modified texture and those with an intolerance or personalpreferences such as vegetarian/vegan or dairy free.1 ManyMOW services in NZ cater for a variety of special diets onrequest.

Ahmad and Walker found that only 18% of peoplethought that MOW would be of some help after the servicewas explained to them.12 Boneham et al. found that 32% ofethnic minorities in Liverpool thought the service and foodwould not be suitable for them.13 Dennison found similarresults with Maori and Pacific peoples, where they statedtheir need for a traditional culturally appropriate menu(Kaye Dennison, unpublished data, 2007).

Many MOW production kitchens in Australia now have amulticultural MOW menu serving Chinese, Italian, Hungar-ian, Vietnamese, Greek and Eastern European meals.14 Asimilar development in NZ would cater to the increasinglydiverse cultural population, but costs associated withresearch, staff training, resource development and marketinghave not been ascertained.

In most focus groups, the first barrier to accepting MOWwas lack of knowledge of the service. The need for healthprofessionals to market the service was also noted by somerespondents. Lack of knowledge was the main barrier toaccepting MOW in recent audits with Maori and Pacificpeople. This group suggested increasing awareness throughadvertising in their language using appropriate mediathrough GPs and Maori service providers (Kaye Dennison,unpublished data, 2007).

There were many negative perceptions around using theMOW service. These related to loss of independence andpride, and some people said they would be embarrassed iftheir neighbours saw MOW being delivered to them. Theyfeared people would think that they were poor or disabled.Dennison found that Kaumatua and Kuia (Older Maori) feltMaori people had not accessed MOW because of the shamethat people would find out and some are too shy, stubborn orproud to ask for the service. If knowledge increased aroundthe MOW service, and negative stereotypes removed, moreeligible people might use the service (Kaye Dennison,unpublished data, 2007).

The majority of respondents stated they would prefer acommunity service such as MOW over family support if theydid need help with cooking in the future. The exceptions tothis were the Indian and Chinese groups who preferredfamily support. The reasons behind this were that theseethnic minorities preferred family members to cook to their‘traditional’ tastes. Stommel et al. found caregivers lookingafter older adults with Alzheimer’s disease living in Michi-gan, USA had a strong preference for family over communityservices as caregivers. However, older adults were moreaccepting of government services than younger adults.15

Miller and Mukherjee found some caregivers in the USA,including White people and African Americans had a pref-

Qualitative and quantitative survey results


159

erence for family assistance compared to community servicesbecause of issues of trust, independence and pride.16

The limitations of the study included the older adultsgroup recruited from community organizations and residen-tial care and may have had more knowledge and awarenessof community services. Also no information was collectedfrom adults with a disability who are younger than 65 andeligible for MOW. There was also a low response rate fromhealth professionals, and therefore extrapolating the data toother health professionals would require a larger study.

The misinformation held by older adults’ health profes-sionals suggests that further research is required on howthese knowledge gaps affect service utilisation and to makerecommendations for improvement. Further research with alarger sample size to determine level of knowledge and per-ceptions of the NZ MOW service is recommended withregular audits to review if the MOW service is meeting theneeds of the communities in NZ.

For almost 60 years, MOW in NZ has provided an impor-tant support system for people who meet the criteria forMOW. This study showed varied knowledge and assessmentcriteria used for the MOW service from health professionalsquestioned.

Low knowledge and perceptions of the MOW service inthe older adults questioned was also found. The main bar-riers to using the service were lack of knowledge, feelings ofembarrassment and loss of independence. Confusion overeligibility and limited available menu choice were barriers,especially for ethnic and religious groups.

Acknowledgements

The authors would like to thank all those who participatedin this study and contributed to the manuscript.

References

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