N09015: Design and evaluation of peer-led community based food clubs. A means to improve the diet of older people from deprived social backgrounds

Study Duration: July 2002 to October 2005

Contractor: University of Newcastle upon Tyne

There is evidence from the literature that peer-led education has been used successfully in a number of settings such as drugs or smoking cessation amongst young people. The limited published evidence of the use of peer-led educators in promoting healthy eating is mainly from international sources, but indicates that it can be effective, particularly with hard-to-reach groups such as adults on low incomes and ethnic minority communities. This is an intervention for elderly people living in the community.

The study aims to:

• develop and evaluate a community based, peer-led dietary intervention (in the form of Food Clubs) for improving the diet of older people from socially deprived backgrounds; and
• evaluate the effectiveness of peer educators.

The project objectives are:

1. To develop and pre-test a dietary intervention package.
2. To train peer educators.
3. To deliver the intervention.
4. To measure the effectiveness of the intervention by measuring:

• diet and nutrient intake and status
• attitudes and beliefs
• nutritional knowledge
• qualitative analyses (peer educators and subjects)
• cost-effectiveness

The approach is a randomised controlled trial (RCT) using, as subjects, 32 groups of nine persons (16 test and 16 controls) aged between 65 and 85 years, living in sheltered accommodation in Tyne and Wear.

The intervention design is:

• Review of existing literature – a follow-up to the HEA report and the grey areas informed the review.
• Formative, qualitative research – in-depth interviews with health development officers from Age Concern and with community dieticians and peer educators.
• 20 week food club plan – hands-on approach rather than by demonstration.
• Pilot testing.

Control groups are to have non-dietary activities such as manicures, bingo and so on.

The main criteria for the recruitment of peer educators are:

• an interest in cooking/food preparation
• an interest in food and health
• good communication/interpersonal skills
• car driver
• over 60 years of age

A total of 23 peer educators have been recruited through a press release, club notices and advertisements in local papers (43 applications were received and 36 invited for interview). They will be paid an hourly rate and split into four groups for training.

Training of peer educators involves:

• 13 weeks training
• 5 hours per week – 2 to 3 hours of taught time and 2 to 3 hours of self-taught time.
• Weekly homework provided with feedback.
• Accredited training course, modified to suit the intervention package.
• All registered for open college qualification – at the end of the training they will become nutrition education assistants.

A sociologist interviewing each peer educator before training, during training and after training carried out a qualitative evaluation of the peer educators' experience.

The aims of this project were to: (1) design a Food Club that was based on practical food preparation and healthier eating that could be delivered by ‘peer leaders’ to older adults living in sheltered housing accommodation; (2) recruit and train ‘peer leaders’ to deliver the Food Clubs and; (3) test the effect of this Food Club on dietary knowledge, attitude and practice.

Key results obtained

The mean age of the 97 subjects who received a Food Club was 76 years (range from 71 to 80), with approximately 14% being men. The mean age of the 104 subjects in the control group was also 76 years, (range 71 to 84), with approximately 15% being men. Three Sheltered Housing Schemes withdrew from the study before the Food Clubs commenced; however the 13 Sheltered Housing Schemes that started a Food Club saw it through to completion.

Diet, body fatness and blood vitamin status: Information on diet was collected from 201 subjects at baseline. This showed that the diet of older adults living in sheltered accommodation in socially deprived areas was high in saturated fat, low in fibre and fruits and vegetables and low in vitamin D. Encouragingly, the diet was not too high in sugars.

Information on diet was collected from 94 subjects (49 Food Club, 45 Control) immediately following the intervention and 72 subjects (36 Food Club, 40 Control) at one year following the intervention. Immediately following the intervention no changes in diet were observed. At one year following the Food Club the change in the amount of energy from carbohydrate was significantly greater (and positive) in the Food Club group. There was a trend towards higher consumption of sugars (but not added sugars) in the Food Club group. The average change in fruit intake was 25g higher in the Food Club group compared with the control group but this did not reach statistical significance. At one year following the Food Club the intake of vitamin D intake had fallen in the intervention group and had increased in the control group.

At baseline 76% of subjects were overweight or obese and only 0.5 % of subjects were underweight. Following the Food Club there were no significant changes in measurements of body fatness.

Blood levels of fat soluble vitamins A and beta-carotene did not change as a result of the Food Club, and were not different throughout the period of the study. Plasma vitamin E levels fell during the study in both groups but the magnitude of decrease was not different between those who had had a food club and the control group.

Nutrition and food safely knowledge: Information on nutrition knowledge was collected using a questionnaire from 177 subjects at baseline. Knowledge of sources of fibre and lower fat options was poor and there was low awareness of the links between a poor diet and chronic diseases such as cancer, stroke and tooth decay. At baseline, information was obtained from 163 subjects on knowledge of food safety. This showed that for all but one question, less than 50% of subjects answered the questions correctly and less than 1/3 of respondents knew the correct meaning of the terms ‘use by’ and ‘best before’, meaning that they could potentially be consuming foods that were unsafe to eat. The Food Club did not result in any changes in the knowledge of nutrition or food safety.

Attitudes towards and barriers to healthier eating: The baseline responses to the questions on dietary attitudes (collected from 160 subjects) showed a positive attitude towards healthier eating and a perceived need to eat more healthily. The subjects viewed their diet as more healthy that it actually was; a perception referred to as ‘optimistic bias’ which itself is a barrier to eating more healthily. Immediately following the Food Club 88 subjects (49 in the Food Club group and 39 in the control group) answered the questionnaire on dietary attitudes and behaviour. One year after the Food Clubs 64 subjects (32 in the Food Club group and 32 in the control group) answered the questionnaire again. One year following the intervention those who attended a Food Club more strongly believed that a healthy diet would help control their weight. An interesting finding that was relevant to an aim of the Food Clubs to encourage food preparation, was that preparing and cooking foods was perceived to be less of a barrier towards healthier eating for subjects who had attended a Food Club. However, evidence of optimistic bias remained and was greater in those that had attended a Food Club.

Interviews with the Sociologist

Views of the Food Club participants: The interviews with the Food Club participants did suggest that some small positive dietary changes had been made by some. Many claimed to have regained interest in cooking for themselves and there was evidence that participants enjoyed new ways of cooking small portions. Perceived barriers to change included access to supermarkets – inability to shop for ones self may act as a constraint on the possibility of change. Wasting food was an issue and the inability to obtain small quantities when cooking for one was identified as a potential barrier to consuming more fruits and vegetables. Age was also a perceived barrier to change, many stating they were too old to change. The participants’ views on the concept of a Food Club and its delivery by peer leaders were overall very positive.

Views of the peer leaders: Most peer leaders enjoyed the training and expressed themselves as content with it as preparation for their subsequent work with a Food Club. Three commented that more direct preparation for their specific role was required, but overall the leaders were very positive about their experience of running the clubs and the responsiveness of the participants to the social experience offered.

The cost of the Food Club: As the Food Club did not result in any measurable benefit in terms of diet, a full cost benefit analysis could not be conducted. However the cost of training the peer leaders and running the clubs was determined and this showed that it cost approximately £700 to train one peer educator and that the average cost of running a Food Club was £130 per week. This cost would however be reduced if peer educators did more than one Food Club: for example if each peer leader did 5 Food Clubs the average cost/club/week would reduce to around £70.

Poster presentation & abstract on food shopping habits and the elderly. Shopping Habits of Older Adults from Low Income Areas in the North East of England. Presented at a workshop on Food, old people and quality of life, 26/10/05.

Learning from Peer Educators: Perceptions of Training for and Delivering a Community-Based Nutrition Intervention to Older Adults.
Robert M. Hyland PhD, Charlotte E. Wood, BSc, Ashley J. Adamson PhD, SRD, RPHNutr, John C. Mathers PhD RNutr, Moira Hill BSc, SRD, Chris J. Seal PhD RNutr, Paula J. Moynihan PhD, SRD, RPHNutr, J. Nutr. Elderly

Resources

Copies of the resources developed for the recruitment, training and support of volunteers and for the running of the food clubs are available on a CD which may be obtained from vivien.lund@foodstandards.gsi.gov.uk.

The final report is available from the Agency’s Information Centre.
To obtain a copy, please contact the Enquiry Desk, Information Services, Food Standards Agency (tel: 020 7276 8181/8182 or email: infocentre@foodstandards.gsi.gov.uk)

For any enquiries concerning this research project, please contact the relevant Programme contact or email: science@foodstandards.gsi.gov.uk