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Volume 1: No. 1, January 2004
ORIGINAL RESEARCH
Qualitative Assessment of
Participant Utilization and Satisfaction With the Seattle Senior Farmers’
Market Nutrition Pilot Program
Lynne T. Smith, RD, PhD, MPH, Donna B. Johnson, RD, PhD, Sharon Beaudoin,
MPH, RD, CD, Elaine R. Monsen,
RD, PhD, James P. LoGerfo, MD, MPH
Suggested citation for this article: Smith LT, Johnson
DB, Beaudoin S, Monsen ER, LoGerfo JP. Qualitative assessment of participant
utilization and satisfaction with the Seattle Senior Farmers' Market
Nutrition Pilot Program. Prev Chronic Dis [serial online] 2004
Jan [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
jan/03_0010b.htm
PEER REVIEWED
Abstract
Introduction
The Seattle Senior Farmers' Market Nutrition Pilot Program delivered fresh
fruits and vegetables to homebound seniors in King County, Washington, from
June through October 2001. A primary objective of the program was to
increase participants' intake of fruits and vegetables. A qualitative study
was conducted to examine the impact of the program on participating
homebound seniors.
Methods
Semi-structured interviews were performed with 27 participants in their
homes to identify benefits and barriers they encountered and to measure
their use and sense of satisfaction with the program.
Results
Analysis of the transcribed interviews revealed several common themes:
- Participants appreciated the variety and quality of the fresh fruits
and vegetables.
- Some participants would not have had access to fresh fruits and
vegetables without the program.
- Home-delivered baskets of fresh fruits and vegetables brought
participants joy, stimulated interest in healthy foods, and improved
quality of life.
- The program newsletter supported consumption of fresh produce.
Conclusion
Program success was rooted in the multiple ways the program addressed
potential barriers and reinforced behavioral intent.
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Introduction
Older adults, compared to younger adults, tend to eat more servings of
fruits and vegetables, yet many older adults do not consume the recommended
5 or more daily servings (1). Approximately 65% of older adults in
Washington State consume less than the recommended 5 servings of fruits and
vegetables per day (1).
There are several potential barriers to adequate consumption of fruits
and vegetables among older adults (2,3). Physical and cognitive disabilities
may prevent shopping and cooking. Dental problems and difficulty chewing and
swallowing interfere with eating many foods, especially raw vegetables and
fruits. Also, sense of taste can change with aging so that some foods are
less appealing or even distasteful. Additionally, the use of medications
escalates with aging, and many medications can alter taste, depress
appetite, and interfere with digestion (4). Although preference for eating
fruit is more prevalent among older compared to younger adults, especially
among women (5), lack of financial resources is a significant barrier to
healthy eating habits for many older adults (6,7).
From a public health perspective, good nutrition is a significant factor
in promoting health and quality of life (8). The outcomes of community-based
interventions to increase fruit and vegetable intake have varied
considerably (9). More successful interventions have observed increases
ranging from 0.5 to 3.7 servings per day. Successful interventions have the
following qualities: they are flexible, they are based on a theoretical
model, they incorporate feedback from the target audience, they include
multiple tactics to communicate and reinforce messages, and their messages
specifically address increasing fruit and vegetable intake.
The Food and Nutrition Services of the United States Department of
Agriculture (USDA) funded the Senior Farmers' Market Nutrition Pilot Program
(SFMNPP) in Washington State in 2001. The purpose of SFMNPP is two-fold: to
provide fresh, locally grown fruits, vegetables, and herbs from
community-supported agriculture programs to low-income seniors and aid
expansion of domestic farmers' markets and community-supported agriculture
(10).
Many state Senior Farmers' Market Nutrition projects use voucher systems
for qualifying seniors to purchase fresh produce at farmers' markets (11). In
Washington State, a unique program was developed to target homebound
seniors. From June through October 2001, bags of fresh fruits and vegetables
were delivered every other week to homebound seniors who also received their
home-delivered (frozen) meals through Seattle Senior Services in Seattle and
other locations in King County. The program lasted 20 weeks for a total of
10 deliveries per participant. Each basket contained locally grown, fresh
produce including fruits, vegetables, and herbs. Each delivery included a
program newsletter that listed items in the bag and described recipes and
simple methods of preparation. Newsletters provided information about
nutrition, local farmers who grew the produce, SFMNPP collaborating
agencies, and volunteer involvement.
The use of both quantitative and qualitative approaches to evaluate the
same health promotion program can overcome limitations of either method
alone (12). Qualitative evaluation can derive insights directly from the
subjects that a program is intended to benefit, and adherence to established
standards of qualitative research methodology supports credibility of the
research findings (13). Qualitative research is considered to be valid to
the extent that the study findings correspond to reality (14). Triangulation
is an analytical method used to validate study findings. Through
triangulation, qualitative research findings are compared with outcomes
obtained by a different method (12), or the qualitative study findings are
applied to an existing model that was based on outcomes from a similar but
different study. The extent to which the study outcomes fit the existing
model lends validity to the study findings.
Brug and colleagues (15) developed a model of fruit and vegetable intake
based on qualitative research of adults aged 17 to 45 years who lived in
Holland. In this model, behavioral intent strongly correlates with
self-efficacy and attitude that, in turn, overcome barriers to fruit and
vegetable intake (Figure 1). The model of attitudes, social influence, and
self-efficacy (ASE) illustrates how an intervention can address multiple
factors that contribute to a person's intention and, in turn, overcome
barriers to the target behavior.
Figure 1.
Model of Psychosocial Determinants of Fruit and Vegetable Consumption.
Adapted from Brug et al (15). Reprinted with permission from Elsevier.
We used certain criteria in determining the quantity of information and
the number of interview subjects needed for appropriate and adequate data
(16):
- Adequacy of the data is recognized when data become repetitive and new
data do not provide new insight.
- For homogeneous samples, 6 to 8 sources are usually adequate.
- For maximally variable (i.e., non-homogeneous) samples, 12 to 20
interviews may be needed.
In our study, we assumed that SFMNPP participants represented a
non-homogeneous sample and thus we would need up to 20 interviews.
The purpose of our study was to interview homebound seniors and identify
themes and significant issues regarding participants' experiences with the
program. Validity of the study findings was supported by triangulation with
the quantitative evaluation of participants' fruit and vegetable intake and
by comparison with the ASE model.
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Methods
The overall study design and methodology were based on the principles of
qualitative research and previously published examples of qualitative
research applied to health and nutrition studies (14). The procedures of
this study are diagrammed in Figure 2. Human subjects approval was obtained
from the Internal Review Board of the University of Washington.
Figure 2.
Procedures for Qualitative Assessment of Seattle Senior Farmers' Market
Nutrition Pilot Program, 2001.
In qualitative research, a directed approach to sampling targets subjects
who will be optimally informative and yield rich data (17). In our study,
subjects were self-selected. We placed recruitment flyers in produce bags
during the fifth cycle of deliveries. A $10 incentive was offered.
Volunteers replied by mailing in a preaddressed, postage-paid card or by
leaving a telephone voice mail message. We conducted interviews during the
sixth through the ninth delivery cycles.
After the first week of recruitment, it became apparent that more
individuals volunteered than could be interviewed. We halted further
recruitment and selected subjects from the existing list. We based interview
subject selections on geographic location so we could include the different
areas served in Seattle and King County. We could not base selection on race
or age, because that information was not available prior to the interview.
We continued program enrollment so that we would have enough subjects to
represent the racial, ethnic, and age diversity of homebound participants.
One of the 28 volunteers cancelled the interview. We conducted 27
in-person interviews in subjects' homes. Two subjects declined to have the
interview audiotaped, and one session was not taped due to equipment
failure.
SFMNPP stakeholders provided input on the design of the interview
questionnaire (Appendix). Stakeholders included Senior Services of King
County, Public Health-Seattle & King County, King County Area Agency on
Aging, Pike Place Market Community Supported Agriculture, and the University
of Washington Health Promotion Research Center. The focus was to identify
and understand behavior that sustained and/or improved consumption of fresh
fruits and vegetables. The questionnaire was pre-tested by mock interview
with a nutritionist. The interviews with program participants lasted 20 to
45 minutes. The interview questions were both directed and open-ended so
that we could address certain issues and also encourage subjects to bring to
mind whatever was important to them (18). Although not specifically asked,
many subjects provided information about their health, physical or cognitive
disability, and financial ability to purchase fresh fruits and vegetables.
Participants were asked about the following areas:
- General thoughts about the program.
- Utilization of fruit and vegetable items.
- Ability to prepare fresh fruits and vegetables.
- Quality of fruit and vegetable items.
- Usefulness of the newsletter.
- Interest in participating in the program in the future.
Probing was used to help subjects recall their use of the produce,
problems experienced, whether or not they had help with preparing the
produce items, other sources of fresh produce for comparing the quality of
the produce, and their experiences with the newsletter.
We systematically reviewed written transcripts to identify and
substantiate themes relating to participant utilization of the fruits and
vegetables and participant satisfaction with the program. The 4 major steps
used in data analysis were as follows (19):
- Evaluate transcribed interviews and notes; organize topics and
subgroups.
- Identify basic themes.
- Substantiate themes with quotes.
- Triangulate: compare findings with quantitative study and apply
findings to model.
As indicated by the flow diagram (Figure 2), the process was iterative.
We repeated the same steps with each transcript and for each theme and
subcategory, and then we discussed, revised, and applied the findings to the
model. The process continued until themes were stabilized and no new themes
were generated.
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Results
The interview subjects represented the range of gender, age, and race of
Seattle Meals On Wheels participants (Table). The diversity of ethnic
minorities was less represented. For example, there were no Asian or Pacific
Island participants among the interviewees. It is likely that the limited
diversity represented by the interview subjects was due in part to the small
sample size. In addition, cultural differences may have influenced
participants' responses to recruitment.
The interviewer noted the type of housing and whether the person lived
alone or with one or more people at the time of the interview. Most of the
subjects lived alone (20 out of 27), and the majority lived in public housing,
senior housing, or other rental units (15 out of 27).
We taped 24 of the 27 completed interviews. To minimize transcription
errors, the tapes were played, transcribed, replayed, corrected, and then
replayed to check the corrected transcription. We created headings to
capture the variety of topics introduced by the interview responses. In
addition, we extracted quotes from the transcripts and organized them
according to the following headings:
- Thoughts about the program in general.
- Suggestions to improve the program.
- SFMNPP has health benefits.
- Disability affects ability to prepare and eat fruits and/or vegetables.
- Financial need impacts acquisition of fruits and vegetables.
- SFMNPP affects knowledge of nutrition.
Analysis led to the identification of themes that we then substantiated
by quotes and/or observations from the interview. Four major themes emerged
and are presented below.
Theme 1: Utilization of fresh fruits and vegetables
Participants indicated whether they used everything, used everything except
for only one or 2 items, or regularly did not use 3 or more items. All
participants who we interviewed for this study reported that they used most
or all of the fruit items. A 79-year-old female said: "I used it all. I
love vegetables and fruit. I find my health is better when I eat as much as
I can of it."
Since the fruit items could be eaten without cooking, seniors who needed
help with chopping and cooking could wash and eat the fruit without
assistance. Most of the fruit items (peaches, cherries, apples, Bartlett
pears, strawberries, blackberries, and blueberries) were familiar to all the participants.
Later in the program, less common varieties such as black pears and Asian
pears required identification. Some seniors said that because fruit is
expensive, they would not have been able to buy the amount or variety of
fruit that they received through the program.
"I love it. I hope it never ends. I know it will, but I just love
it. I tell you I couldn't afford to get all of the fruits, like what they
put in the basket, I couldn't afford it," said a 65-year-old female.
"I don't think I'd eat that much food if I had to pay for it, it's
so expensive. The fruit is so high this year," commented another female, 75
years of age.
Vegetable use varied more than fruit use. Participants who followed
special diets or had one or more food restrictions involving fruits or
vegetables still used most of the produce they received. For example, one
senior who could not eat corn ate everything else and gave the corn to
another senior in her building.
We also explored the relationship between utilization of produce and
needing help to prepare food. All the participants who had a caregiver
reported using all of the produce. A few seniors said that they needed more
help and could not manage to prepare some of the produce, especially
vegetables that required cooking. However, other participants with physical
disabilities found ways to prepare things themselves or get help. It was
clear that attitude as well as physical ability affected the outcome of
utilizing most or all of the produce items. For example, one senior, a
65-year-old male, was
confined to a wheelchair and could not readily use the kitchen. He offered this comment: "I can't cook too well, so I
have a neighbor, I share my vegetables with her. She cooks them and shares
them with me. That has worked real good."
An initial concern among the stakeholders of SFMNPP in Seattle and King
County had been the potential for adverse health effects from the produce.
Possible problems included food allergies, food borne illness from eating
unwashed or spoiled produce, and drug interactions — for example, the
anticoagulant warfarin (also known by the trade name of Coumadin®) may
react with vitamin K in dark, green-leaf vegetables. However, participants
did not report having any problems. Three seniors reported that they used
Coumadin®, but they knew what items they needed to avoid and passed those
items on to someone else. Only one person reported possible problems
associated with the produce: this individual had a complex medical condition
that included immune suppression, intermittent hospital stays, the use of
Coumadin®, and the inability to prepare produce that required chopping or
peeling. This participant suggested that having half of the produce
delivered once a week (instead of a full allotment every 2 weeks) would have
allowed her to utilize more of it. Nonetheless, this person knew how to
manage her condition and appreciated receiving the fresh produce, none of
which she could afford to buy.
Theme 2: Participants' perceived benefits from SFMNPP
Seniors frequently made statements about how they appreciated the variety
and quality of the home-delivered fresh produce. Many of the seniors related
that through SFMNPP they had gained access to fresh fruits and vegetables
that they otherwise would not have had. Some sample comments included:
- "Well, it's a marvelous program and I hope they have it next year.
The vegetables, as you saw, are fantastic, and you always get a good variety
of them." (80-year-old female)
- "I think it's wonderful — it's the only fresh fruit and vegetables
that I ever get, really." (64-year-old female)
- "It saves a lot of time and by being diabetic I really can use the
vegetables and fruit…the produce that they bring helps a lot. It really
does." (61-year-old male)
Participants expressed that by participating in SFMNPP they experienced
improved quality of life in terms of psychological as well as physical
health. Several participants spoke of the home-delivered produce as being a
surprise or a gift, and they indicated that the gift of fresh fruits and
vegetables brought them joy. An 87-year-old female said, "I am
extremely satisfied with the whole procedure. It's like getting a Christmas
gift every other week. A nutritious one."
Theme 3: Newsletter-supported SFMNPP objectives
The newsletter was intended to support participant utilization of fresh
produce by providing nutrition education, food safety information, food
preparation hints and recipes, as well as information about SFMNPP and local
participating farmers. Almost all those interviewed indicated that they used
the newsletter to refer to the list of items in the bag. Only 3 of the 27
who were interviewed said that they did not regularly read the newsletter.
One person, who was legally blind, said that she could not read the
newsletter. Most of the participants said that they enjoyed reading the
newsletter and that it was useful and informative about the program and the
local farmers that grew the produce.
Theme 4: Participant satisfaction with SFMNPP
All of the subjects in this study stated that they wanted the program to
continue and they would sign up again if it were offered next year. When
asked for suggestions to improve the program, most of them said they liked
it the way it was. When pressed, they added suggestions about increasing or
adding items they liked, such as peaches, collard greens, potatoes, or
onions. A 73-year-old male said, "They've done all right by me. I don't
have any complaints about it. A little more would be nice, but I ain't gonna
be greedy." An 84-year-old female offered this: "I think it's very
good, if they want the elderly to stay in their homes."
Triangulation
Triangulation with other studies was carried out in 2 parts to validate data
and theme interpretation. First, we compared the findings of the SFMNPP
qualitative study with the results of the quantitative study (20). Second, we compared the
findings of the qualitative study with the ASE model (15).
The quantitative study results showed that participants in the SFMNPP
increased their intake of fruits and vegetables during the 20 weeks of the
program. The daily intake of fruits and vegetables increased 1.04 servings
compared to a decrease of 0.27 servings for controls (95% CI, 0.68-1.95, P
< .001). The overall positive attitude toward SFMNPP, the participants'
utilization and enjoyment of the fresh produce baskets, and the measured
outcomes of the increased number of servings of fruits and vegetables were
consistent with the findings of the semi-structured interviews.
We applied SFMNPP findings to the ASE model (Figure 3). Issues mentioned by
participants and identified by data analysis as relating to utilization of
produce and satisfaction with SFMNPP fit into the scheme of the model shown.
Reception to SFMNPP and belief in the health benefits of eating fruits and
vegetables affected attitude. Delivery staff and SFMNPP newsletters affected
social influence. Participants' belief in their ability to obtain and eat
fruits and vegetables supported self-efficacy expectations. Encouragement,
involvement of support systems, and increased knowledge about nutrition and
local farming reduced barriers and promoted abilities. Thus, according to
this model, barriers were minimized and abilities were reinforced to support
intention to eat more fruits and vegetables.
Figure 3.
Triangulation of Seattle Senior Farmers' Market Nutrition Pilot
Program Study Findings, 2001, with Attitude, Social Influence and
Self-Efficacy (ASE) Model. MOW = Meals on Wheels, ADL = Activities of
daily living. ASE model adapted from Brug et al (15). Reprinted with
permission from Elsevier.
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Discussion
Although we did not specifically ask study subjects about their health,
they often volunteered personal health information that related to their
motivation and ability to use the produce provided by SFMNPP. Thus, we
identified health status and physical and cognitive disability as key
factors influencing homebound seniors' intake of fruits and vegetables.
The participants' feedback regarding the program indicated their strong
support for SFMNPP and the benefits that they felt they experienced because
of the program. Seniors reported that they were healthier because they
participated in the program. They said they were less constipated, felt
better, and had better control of their diabetes. It would be difficult, if
even possible, to measure joy and the program's positive effect on mental
health, but these also were experiences that the participants related in the
interviews. In the ASE model (Figure 1), the individual's attitude is
important in determining the strength of his or her intention. In this
model, strong intention can overcome barriers to the target behavior. While
all of the interviewees said they ate most or all of the produce, probing
revealed that the actual amount that they ate varied. Although disability
appeared to be a significant factor preventing some seniors from fully
utilizing the produce, physical disability was often overcome by those who
were motivated. Thus, applying the findings to the model substantiated the
importance of attitude. In the present study, many seniors made statements
indicating they believed that eating fresh fruits and vegetables was good
for their health. According to the model, having this belief or attitude
would strengthen their intention to follow through with the target behavior
and overcome potential barriers including physical disabilities.
The ASE model also helps to identify how participants overcame potential
barriers to utilizing the fresh produce they received through SFMNPP.
Participants with disabilities utilized more of the produce when they had
assistance from an aide, a caretaker, family, or friends. Interactions with
family and friends also could affect the seniors' motivation to overcome
disabilities. Reading the newsletter or talking to the delivery person often
overcame lack of knowledge about how to prepare items for eating. Finally,
the behavior itself — eating more fruits and vegetables — reinforced the
behavior by making seniors feel better.
It is likely that SFMNPP in Seattle and King County succeeded in
increasing fruit and vegetable consumption among participants because it
used a multi-pronged approach and addressed several components identified in
the ASE model. While the homebound seniors were enjoying the fresh produce,
they were also improving their health, reinforcing positive eating habits,
strengthening their belief in the benefits of good nutrition, and extending
their social network by getting help and sharing their SFMNPP experiences
with others. By delivering the produce to homes, the program design
eliminated 2 of the major barriers faced by many homebound seniors, namely
their inability to go shopping and their lack of money to buy fresh fruits
and vegetables. Thus, perceived self-efficacy increased with direct delivery
of produce.
Another factor was the quality and variety of the produce. The homebound
seniors who were interviewed were a diverse group representing different
ages, races, ethnicities, social and economic backgrounds, and certainly
different personalities and interests. While many considered themselves to
be vegetable and especially fruit eaters, their taste preferences varied
considerably. The freshness and variety of the produce was openly
appreciated by a number of those interviewed. There was variety within each
basket, the produce changed with the season, and participants received items
they enjoyed. It was also stimulating for many of the seniors to receive
more unusual items — mizuma, black pears, and fingerling potatoes — that they
had never before eaten.
It is important to keep in mind some of the limitations of the present study
and the use of qualitative methodology. Ideally, in a qualitative study the
subjects would be individually selected to maximize representation of the
diversity of the population under study. Our subjects volunteered to be
interviewed. It is not known if and how these seniors differed from others
who did not volunteer. For example, this study did not reveal themes
regarding not wanting to continue with the program or general
dissatisfaction with the program.
A limitation of the study design is inherent in the use of semi-structured
interviews. The questions were both structured and open-ended in order to
direct the focus of the interview and at the same time allow each subject to
reveal issues that mattered to them. The semi-structured format with guided
questions prevented the interviews from becoming too long, but it may have
inhibited subjects from revealing themes that this study did not identify.
Our study identified several areas for future evaluations of Senior Farmers'
Market programs.
- What are the roles of family, caregivers, and chore persons (who provide
help with meal preparation and light housekeeping) in facilitating food
preparation and increasing consumption of fresh fruits and vegetables by
homebound seniors? For seniors who lack support and need it, how can
programs address this need?
- What are the issues for participants who are dissatisfied with Senior
Farmers' Market programs and why do some drop out of the programs?
- Are there problems for seniors using certain medications and/or on
restricted diets? Are there special problems for those who are
immune-suppressed? How do these seniors relate to the program?
- How does the effectiveness of home-delivered produce compare with giving
participants coupons to purchase produce at farmers' markets?
- Following the program, does the increase in fruit and vegetable
consumption continue after the home deliveries stop, or does the number of
servings per day drop back to the preprogram levels?
Our qualitative study provides insight into why SFMNPP was successful in
increasing fruit and vegetable intake among homebound seniors. Home delivery
overcame the barriers of being homebound and having limited resources. In
addition, the gift of locally grown fresh fruits and vegetables was a
stimulating source of interest and encouragement to be healthy that was
received by participants with anticipation and pleasure. The impact of this
experience on the health of homebound seniors would be difficult to quantify
but is nonetheless worthy of support.
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Acknowledgments
This study was supported by Grant U48/CCU009654 from the Centers for
Disease Control and Prevention to the University of Washington Health
Promotion Research Center. We thank Sheryl Schwartz, Monica Jarrett and Adam
Drewnowski for helpful discussions. We thank the seniors who participated in
this study and our collaborators from Senior Services of King County, Pike
Place Market Community Supported Agriculture, King County Area Agency on
Aging, Public Health-Seattle & King County, and Washington State Aging
and Adult Services Administration, Aging and Disability Services.
Author Information
Corresponding Author: Donna B. Johnson, RD, PhD, Interdisciplinary
Program in Nutritional Sciences & Center for Public Health Nutrition,
Nutritional Sciences, University of Washington, Box 353410, Seattle, WA
98195. Phone 206-685-1068. E-mail: djohn@u.washington.edu
Author Affiliations: Lynne T. Smith, RD, PhD, MPH, Centers for Disease
Control and Prevention, Community Guide Branch, Washington State Department
of Health, Olympia, Wash. Work was done at Prevention Research Center and
Nutritional Sciences Program, University of Washington, Seattle, Wash. Sharon Beaudoin,
MPH, RD, CD, Healthy Mothers, Healthy Babies Coalition of Washington,
Seattle, Wash; Elaine R. Monsen, RD, PhD, Interdisciplinary Program in
Nutritional Sciences, University of Washington, Seattle, Wash; James P. LoGerfo, MD, MPH, Health Promotion Research Center, University of
Washington, Seattle, WA.
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References
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Tables
Table.
Comparison of Demographic Characteristics of Participants in Seattle Meals
on Wheels Program and Interview Subjects in Seattle Senior Farmers' Market
Nutrition Pilot Program, 2001
|
|
Meals on Wheels Participants
N=557
|
Interview Subjects for Qualitative Evaluation
N=28
|
|
|
n
|
%
|
n
|
%
|
| Gender |
| Male |
167 |
30 |
7 |
25 |
| Female |
390 |
70 |
21 |
75 |
| Age (y) |
| <60 |
6 |
1 |
0 |
0 |
| 60-69 |
139 |
25 |
9 |
32 |
| 70-79 |
200 |
36 |
12 |
43 |
| 80-89 |
167 |
30 |
4 |
14 |
| 90+ |
45 |
8 |
1 |
4 |
| Unknown |
0 |
0 |
2 |
7 |
| Race/Ethnicity |
| White
and non-Hispanic |
368 |
66 |
19 |
66 |
| Nonwhite
or Hispanic |
167 |
30 |
7* |
26 |
| Unknown |
22 |
4 |
2 |
7 |
|
*Nonwhite subjects included 5 African Americans, 1 Native
American, and 1 Puerto Rican.
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|
