Ask the Experts: Creative Solutions for Local Providers by Local Providers

Increasing Participation at Older Americans Act Title III Funded Congregate Meal Sites

Why is participation in the congregate meals programs important?

Participation in the congregate meals programs enhances the daily nutrient intake, nutritional status, social interactions and functionality of older adults. Improvements in these key factors for good health and quality of life generates the necessary environment for older adults to age successfully (1). The 1995 National Evaluation of the Elderly Nutrition Program (ENP) (2) showed that participation in Title III congregate meals has a very important role in the dietary intake of older adults. Each congregate meal supplies a minimum of one-third of the daily RDAs.
For many nutrients consumed, congregate meals contribute 40 to 50 percent of the RDAs. Congregate participants have significantly higher daily intakes (than non-participants) of the nutrients that are usually low in the diets of older adults including: calories, calcium, vitamin B6 and zinc. In addition, 12 percent of congregate participants take either a full meal or a snack home from the congregate site, which further increases their overall daily nutrient intake. Many congregate programs also provide a variety of nutrition-related services such as nutrition education, nutrition screening and nutrition counseling that are otherwise not available to non-institutionalized older adults.

Along with the nutritional benefits of consuming a congregate lunch, ENP participants have increased opportunities for social interaction (2). In March, 2000 the Chicago Suburban Area Agency on Aging (SAAA) held focus groups at seven congregate sites conducted by Madelyn Iris, PhD, from the Buehler Center on Aging, at Northwestern University. Participants in the focus groups felt that they receive substantial social and recreational benefits from the congregate program. Attending a meal site allows them social interaction with other older adults promoting conversation, camaraderie, support and friendship. The opportunity to connect with other older adults provides relief from loneliness, social isolation and feelings of depression. Participants spoke of having a reason to "get up and get going." Participants also recognized their own need for cognitive stimulation - they spoke of being "kept young and mentally active." Another benefit these participants derive from social interaction at the congregate site is through the opportunity to volunteer in the program. Volunteering was seen as important in the success of the program as it gave participants the feeling that they are "a part of the place." The third most important benefit reported by SAAA congregate participants was access to a variety of activities and social services. The National Evaluation2 showed that 70 percent of congregate participants engage in recreational activities offered at congregate sites. In addition to improving nutrition and social well being, these activities promote overall health and functionality for older adults.

Who are the older adults that are being served at congregate meal sites?

Congregate meal programs serve people who are at greater health and nutritional risk than their peers in the general older adult population. Participants are older, poorer, more likely to be members of racial and ethnic minorities, and more likely to be socially isolated and food insecure.
Although available to everyone age 60 and over, the average congregate meal participant is 76 years old. About two-thirds (69%) of participants are female. Overall racial and ethnic minorities constitute 27% of congregate participants with 12% African-American and 12% Hispanic. One-third of participants have incomes at or below the federal poverty level and participants are more likely to be older adults who live alone. A significant number of congregate participants have health problems and functional impairments. The average participant has two to three diagnosed chronic health conditions. About 1/4 have had a hospital or nursing home stay within a one-year period and about 1/4 have functional difficulty doing everyday tasks. There is also evidence that many participants are at nutrition risk, with 18-32% having lost (or gained) 10 pounds within a six-month period prior to participation in the ENP (2).

What is the evidence that participation at congregate meal sites is declining?

Both the number of congregate participants and meals served has been steadily declining nationwide for the past 12 years (4). In fiscal year (FY) 1988, 147.2 million meals were served under Title III-C at congregate meal sites. By the close of FY 1998, the number of congregate meals served had dropped to 114 million meals -- a 23% decrease. In FY 1998, there were about 511,000 less congregate participants than those attending congregate meal sites in FY 1995.
In contrast, the number of meals being provided to older adults participating in the Title III home-delivered meal programs has continually increased. In FY 1988 there was 94.7 million home delivered meals served compared to 130 million home delivered meals in FY 1998 -- a 27.2% increase. As a result, home delivered meals now (1998 data) comprise 32% of total ENP participation.

Why is participation declining at congregate meal sites?

Eligible older adults cite many reasons that they stop or do not participate in congregate meals programs. Reasons for non-participation include: not recognizing that they have a need for services, inadequate transportation, impaired health, social discomfort with attending or applying for assistance, dissatisfaction with foods served and lack of awareness that the program exists.
In the SAAA focus groups (3) several barriers to attendance were identified. The most common problem encountered by older adults who wished to attend congregate lunch was lack of transportation. Getting to congregate sites by public transportation was difficult, especially in bad weather. Several participants who drive to sites complained about inadequate parking close to the site. The biggest complaint was related to reliability and scheduling of special transportation services - participants often arrive late for meals or are too frail to wait for long periods of time to be picked up.
As in studies conducted in the 1980's of non-participation (5-7), lack of awareness about the existence of the congregate meal program was another reason cited for poor attendance. Participants in the SAAA focus groups suggested increasing advertising in community newspapers, not only with news announcements, but also by highlighting personal anecdotes from site events. Other suggestions that were made were: develop an information brochure describing the program, activities offered and benefits, and ask banks and other community institutions to insert it in their mailings; post flyers in churches, synagogues and other local gathering places; and conduct door-to-door campaigns that target senior neighborhoods.
Lack of flexibility in choosing food items and serving times is another obstacle for many older adults. The SAAA congregate program has piloted a restaurant dining alternative where participants are offered the option of either a combined restaurant dine-out plus congregate meal or a dine-out only program. Participants contribute $3.00 to receive a coupon that covers the cost of a meal in a local (cooperating) restaurant.
One of the key reasons SAAA participants enjoy the dine-out option is the ability to make food choices, particularly of fruits, vegetables, desserts and beverages. This issue is an extra concern for older adults who are on restricted diets. Although 49% of congregate sites make meals modified in sodium, fat and calories available2, a survey of 438 congregate participants conducted by Moran in 19938 showed that the 30% of clients who were on "special diets" (most commonly low sodium, low cholesterol or low fat) attended congregate sites less frequently than those who did not have dietary restrictions.
Many of the SAAA participants who chose the dine-out option also explained that choice is important to them because lunch is not their main meal of the day, and some said they would prefer not to eat at noontime at all. Additionally, SAAA participants commented that the variety and number of activities offered at congregate sites needs to expand. For example, at several sites participants stated their need for participating in a regular exercise program. Other participants expressed the desire for group activities that originate from the congregate site and go out to area attractions, like visiting a museum or zoo.
While the dine-out alternative is able to address some of the concerns that older adults have in regard to congregate meal participation (i.e., flexibility and choices), the program has not met other needs of older adults targeted by the Older Americans Act. Because the dine-out program has limited funds, requires participants to stand in line to obtain vouchers and transport themselves to restaurants, and does not provide similar opportunities for socialization and volunteering as the congregate sites do, it has primarily served older adults who are least frail, and most economically and socially advantaged.

What can our program do to increase participation?

The 1999 Nutrition 2030 Grassroots Survey (9) of 478 Elderly Nutrition Programs (ENP), Area Agencies on Aging (AAA) and State Units on Aging (SUA) identified the need for expanding outreach and improving marketing as key components of attracting participants to congregate sites. Other avenues to increase participation seen as important by these survey respondents were: providing transportation to sites, improving the variety of activities at sites and providing linkages to other nutrition and social services for older adults.
One final lesson to be learned for increasing congregate meal participation from the SAAA focus groups is that dining in a restaurant removed the stigmas of "charity" and "aging" often associated with congregate site participation and made dine-out participants feel "more valued", i.e. equal to other restaurant consumers. Dining in an environment of people of mixed ages and the opportunity to see their neighbors and friends made participants feel more socially acceptable.

Components of a Successful Program (3)