LYNDON B. JOHNSON SCHOOL OF PUBLIC AFFAIRS POLICY RESEARCH PROJECT REPORT Number 16 MEAL SYSTEM FOR THE ELDERLY: CONVENTIONAL FOOD IN NOVEL FORM A Report by The Meal System for the Elderly Policy Research Project Lyndon B. Johnson School ofPublic Affairs The University of Texas at Austin 1977 Library of Congress Card Number: 76-620081 © 1977 The Board of Regents The University of Texas Price: $3.50 FOREWORD The Lyndon B. Johnson School of Public Affairs conducts interdisciplinary research on policy problems as an integral part of its educational program. In the Policy Research Project, 3 faculty members and about IS graduate students, all with diverse backgrounds, research a policy issue, analyze and write up their results, and formulate policy recommendations. The Policy Research Project brings the student face-to-face with administrators, legisla­tors, and other officials in the policy process; it is intended to develop the special talents which are needed for the conduct of research in a policy environment. The Policy Research Project is a year-long effort which involves students in a range of related activities, such as preparation of research plans; preparation of grant propo­sals; evaluation of programs, legislation, and proposals; organizing conferences and briefings; testifying before legislative committees; and reporting on research findings. During 1975-76 one of the LBJ School's Policy Research Projects was a cooperative venture with the National Aeronautics and Space Administration, Lyndon B. Johnson Space Center in Houston, Meals for the Elderly: Conven­tional Food in Novel Form. The LBJ School's part of the project was financed under a grant from the Texas Depart­ment of Public Welfare. Funds were also made available under a Ford Foundation grant to the School. The report presented here deals with the development of the meal system and evaluates the results obtained from two field tests. Based on this project, additional work is currently underway at the LBJ School to explore potential uses of the NASA meals system for other populations and purposes. The LBJ School seeks to develop men and women with the capacity to perform effectively in public service and to produce research that will enlighten and assist those actively engaged in the policy process. The project which produced this report has helped to accomplish the former; it is our hope and expectation that the report itself will contribute to the latter. Jurgen Schmandt Acting Dean PREFACE This document is the product of a cooperative venture involving several public agencies. It started when Anne Kohler, Director of the Texas Governor's Committee on Aging Research Utilization Program (now a part of the Texas Department of Public Welfare) made a request of NASA: could the space agency help to improve nutritional services for the elderly, particularly those in areas not reached by meals-on-wheels programs? As it turned out, NASA's experience in developing a shelf-stable, nutritious, easily transportable meals system for its manned space pro­grams provided the foundation for design and development of a meals system intended to meet the special needs of the elderly. A joint project was launched to develop the system, conduct technical and user taste tests, develop new delivery systems, conduct field tests, undertake medical assessments, and evaluate the results of these various activities. The participating institutions included the following: National Aeronautics and Space Administration LBJ School of Public Affairs United Action for the Elderly Texas Research Institute of Mental Sciences The University of Texas Medical Branch at Galveston Funding was obtained separately by each participating organization. The Texas Department of Public Welfare provided funds for the participation of the LBJ School and United Action for the Elderly. The LBJ School made funds from a Ford Foundation grant available to finance the medical component of the project. The LBJ School had been involved previously in a number of policy research projects concerned with social services, particularly for the aged. In many respects, however, the Meal System for the Elderly project was dif­ferent: here was an opportunity not only to research what had been done, but to take part in planning, implementing, and evaluating a social experiment. All student members of the LBJ team spent a significant amount of time in direct contact with the "clients" -elderly individuals, most of them poor, with many suffering from numerous ailments. Thus, ethical issues of social experimentation were directly experienced: what were the rights of the clients? Would they really understand what we told them about their rights? What would happen to them after the demonstra­tion was over? Would it be "right" to use a control group? How would we make sure that the medical condition of applicants allowed for their participation in the project? Was it possible to dissociate the elderly participants' reaction to the social contact from their reaction to the meals as such? On a different level, interaction with various administra­tive and policy environments provided a source of instant learning which could not be matched by classroom exper­ience: what approach would NASA officials, used to dealing with issues in the clear cut language of engineering, take in dealing with poor, old, frail individuals? How would the Administration on Aging of the Department of Health, Education, and Welfare , react to a project of this kind? Would there be interest at the Congressional level? Out of these varied experiences one lesson emerged with suggestive force: social experimentation of the kind tried here needs careful planning, deep respect for those intended to be helped, a blending of many professional skills, a willingness to work with others, and a commitment to social improvement which does not end with the publica­tion of research results. We submit that these factors carry sufficient weight to justify the fact that our team was involved in all stages of the project. Traditionally, respon­sibility for project development and program evaluation is entrusted to different groups, in order to ensure greater objectivity in evaluating results. Under ideal circumstances this may well be the case. But working with the kind of client population as we did-many had infrequent social contacts, and were not used to meeting with strangers or being interviewed-we felt justified in serving both func­tions simultaneously. However, within the group we did establish a division of labor among those principally responsible for field work and others in charge of evalua­tion. The experiment described in the report was a small one. We are gratified to find that the project led to national legislation proposing a larger and longer demonstration. We also see possible uses of the meal system for other social services, for disaster relief and emergency aid, and, perhaps, there is even potential for wide commercial utilization. At the same time, we realize that these developments can only occur if and when government agencies and industry determine on their own that there is real potential in the concept and that the system can be used, however refined and changed, to meet a variety of human and social needs. There are many individuals and organizations who made it possible for us to undertake the project. We greatly appreciate their help and encouragement. Our greatest appreciation is due to those 200 volunteers who agreed to participate in the project. Their lots need to be improved. We hope that our work will make a small contribution to this task. Jurgen Schmandt Project Director POLICY RESEARCH PROJECT PARTICIPANTS Deborah Beckett, B.A. (Government), University of Texas at Austin Dan Casey, B.A. (Political Science), University ofMichigan Barbara Dydek, B.A. (Government), University ofTexas at Austin Hannah Eisner, B.A. (Anthropology), Lawrence University Al Giles, B.A. (Zoology), University of Texas at Austin John Hunt, B.A. (American Studies), University of Texas at Austin Stan Kaplan, A.B. (History), Rutgers College Thomas Martin, B.A. (Zoology), University of Texas at Austin Joe Motter, B.A. (Political Science), University of Toledo Francine Pegues, B.A. (Government), University of Texas at Austin Rita Seymour, B.A. (Economics), Washington University Julius Whittier, B.A. (Philosophy), University ofTexas at Austin Peggy Wilson, B.A. (Politics}, Ithaca College Lodis Rhodes, Assistant Professor ofPublic Affairs Ruth Roth, Social Science Research Associate Jurgen Schmandt, Project Director, Professor ofPublic Affairs David Warner, Associate Professor ofPublic Affairs SUMMARY OF FINDINGS Sample Characteristics: 1) Almost half of the elderly were 71 to 80 years of age. Women comprised 72 percent of the sample. All but five participants had incomes which made them eligible to receive Title XX Social Service benefits. 2) While two-thirds of the elderly lived alone, most reported relatively frequent contact with friends and relatives. In addition, 60 percent had regular contact with social service providers with trans­portation being the most frequently received ser­vice. 3) Only 37 percent of the elderly owned and drove their own vehicles. The rest were dependent upon others for transportation assistance for shopping, errands, doctor's visits, church, etc. 4) Three-quarters of the group reported eating a daily hot meal before participating in the NASA meals program. However the limited budgets of almost all restricted the types and quantities of foods that could be regularly eaten. 5) About 30 percent of the group was essentially homebound due to extreme poor health. In addi­tion, about a quarter of the sample reported having difficulty getting around their home, and performing basic household tasks, including cooking. Evaluation Summary: 1) Over three-quarters of the participants liked the NASA meals "very much" and wanted to continue receiving them, although not necessarily on a daily basis. Ninety percent found it convenient to have a complete meal in one box. The two most attractive features of the system, according to the participants, were the food itself, and the ease of food preparation. 2) Almost half of the group felt each meal provided more than enough to eat. Many participants could not eat a single meal at one sitting, and routinely stretched each meal over the course of the day to provide two meals, or one meal and several snacks. 3) Overall, participants did not become bored eating the NASA meals on a daily basis. Less than a third felt some food items had been repeated too fre­quently during the course of the program. Over a third missed eating certain favorite food items normally a part of their diet. 4) The vast majority of participants had no difficulty either opening the food packages or in preparing the food items. Ease of food preparation was one of the most attractive features of the meal system for these elderly. 5) The majority of participants expressed a preference for home delivery of meals by a volunteer. When asked if they could pick up the meals from a central location such as a church, over 50 percent said "no". Mail delivery of the food packages was acceptable to the 15 participants who received their meals by that method. 6) The majority of participants receiving the NASA meals as a weekend supplement found the meals of similar or better quality than the meals provided by their hot meals program during the week. All but one wanted to continue receiving the meals for weekend use. The fact that almost 20 percent of this group did not frequently eat a hot meal on the weekend prior to this program suggests there is a service gap on weekends which the NASA meal system worked well to fill. 7) The ease of preparation of the NASA meals allowed some alternate care participants to prepare the meals themselves. In addition, providers or home­makers who normally prepared meals and/or shop­ped for this group reported a savings of time by using the NASA meals. 8) The majority of participants who received the meals for 105 days reported no decrease in interest in the program over the additional two cycles. Addition­ally, most participants said that since they had been eating the NASA meals, they had more free time which they spent gardening, visiting friends, or doing household chores. Economic Summary: 1) The highest per meal cost was $5.58 while the lowest per meal cost was $2.33. The average cost per meal for food and primary packaging was $2 .88. The cost 2) Personal delivery costs ranged from $.87 to $1.55 of the special-run single serving sized cans was per seven-day package. The average cost was about considerable. The average cost of a meal, adjusted $1.20 per pack or $.17 per meal. Mailing costs for the high packaging cost, is approximately $1.60 were about $1 .20 per seven-day pack-a cost com­ per meal. parable to the average cost of personal delivery. TABLE OF CONTENTS FOREWORD PREFACE POLICY RESEARCH PROJECT PARTICIPANTS SUMMARY OF FINDINGS CHAPTER I: INTRODUCTION Project Responsibilities Program Approach CHAPTER II : SYSTEM DEVELOPMENT Food Preference and Attitude Survey Technical Taste Test User Taste Test Technical Requirements Summary CHAPTER III : PRELIMINARY FIELD DEMONSTRATION Site Selection Participant Selection Meal Delivery Method Participants Findings Design Changes · Changes Recommended Summary CHAPTER IV: PLANNING AND IMPLEMENTATION OF THE MAJOR FIELD DEMONSTRATION Site Selection Participant Characteristics Evaluation Instruments Summary CHAPTER V: DEMONSTRATION RESULTS Sample Characteristics Evaluation Results Technical Results Medical Findings iii iv vi vii 3 7 17 23 CHAPTER VI : THE ECONOMICS OF THE NASA MEAL SYSTEM Evaluation of the Meal System Costs Other Considerations Policy Implications Summary CHAPTER VII: THE POLICY IMPLICATIONS OF THE MEAL SYSTEM 45 Social Services Disaster Relief and Emergency Aid Institutional Use Recreational and Personal Use Industry The Next Steps Conclusion APPENDIX I: NASA MEAL SYSTEM FOR THE ELDERLY-PROJECT SCHEDULE 48 APPENDIX II : MENU LISTING AND NUTRITIONAL DATA 52 APPENDIX III: PARTICIPANT APPLICATION AND AGREEMENT FORMS 61 APPENDIX IV: MEAL EVALUATION FORM, 2 WEEK DEMONSTRATION 63 APPENDIX V: POST-DEMONSTRATION QUESTIONNAIRE, 2 WEEK DEMONSTRATION 66 APPENDIX VI: PARTICIPANT APPLICATION FORM, 63 DAY DEMONSTRATION 71 APPENDIX VII : FIELD NETWORK 72 APPENDIX VIII: MEDICAL COMPONENT 74 APPENDIX IX: DROPOUT QUESTIONNAIRE 76 APPENDIX X: MEAL EVALUATION CARDS 82 APPENDIX XI: POST-DEMONSTRATION QUESTIONNAIRE 84 APPENDIX XII: EXTENDED SERVICE QUESTIONNAIRE 89 APPENDIX XIII: CASE STUDIES OF ALTERNATE CARE PARTICIPANTS 90 APPENDIX XIV: LIST OF BRIEFINGS AND TESTIMONY ON THE NASA MEAL PROJECT 94 APPENDIX XV: PROPOSED NATIONAL MEALS-ON-WHEELS ACT OF 1976 (S.3585, H.14450) 95 CHAPTER I INTRODUCTION Information presented at hearin~ on the Older Ameri­cans' Act and subsequent amendments revealed that a significant number of elderly people "do not eat adequately because (I) they cannot afford to do so; (2) they lack the skills to select and prepare nourishing well-balanced meals; (3) they have limited mobility which may impair their capacity to shop and cook for themselves; and (4) they have feelin~ of rejection and loneliness which obliterate the incentive necessary to prepare and eat a meal alone."1 As a result, government action was taken to provide hot meal programs for the elderly. More than 700 Title VII feeding programs are currently in operation across the country, providing 300,000 meals daily for elderly citizens, mostly on a five-day a week basis. 2 Most of these hot meal programs provide meals in a congregate meal setting, thereby addressing the nutritional needs of the elderly and the problems of social/psycholo­gical isolation which often accompanies old age, and contributes to poor eating habits. However, even if congre­gate meal programs are expanded, an estimated 3 to 4 million elderly Americans cannot participate in group meals because they are ill, handicapped, or otherwise home­bound.3 In an effort to reach these individuals, "meals-on­wheels" programs have been established to provide home­delivered hot meals to the homebound elderly. Title VII meals-on-wheels programs presently deliver about 30,000 meals daily, operating primarily in urban areas. This type of meal service is seldom available in small-town or rural areas where many elderly live.4 Recognizing this problem, the Texas Governor's Com­mittee on Aging (GCA) approached the National Aeronau­tics and Space Administration (NASA) in early 1974, to see if the agency's expertise in food technology could be used to improve the nutrition of the homebound elderly. In response to this request, NASA scientists and engineers at the Lyndon B. Johnson Space Center in Houston developed a shelf-stable, nutritious, and easily transported meal system for older Americans not currently served in nutri­tion programs. The NASA Meal System for the Elderly was not designed to serve as a substitute for congregate meal programs, which have social and psychological benefits for those individuals who are able to participate in them. Instead, NASA wanted to design a meal service for the rural and small-town aged who have little opportunity to participate in either congregate or home-delivered meal programs. It was intended also to serve as a supplement to feeding programs which operate in urban areas on a limited number of days each week. In these ways it was hoped that the meal system would assist in preventing or delaying the unnecessary placement of many older Americans in hospi­tals and nursing homes. PROJECT RESPONSIBILITIES NASA's Lyndon B. Johnson Space Center decided to work with other groups in planning, implementing, and evaluating the field tests. The Lyndon B. Johnson School of Public Affairs at the University of Texas at Austin (LBJ School), the Texas Research Institute of Mental Sciences (TRIMS), United Action for the Elderly, Inc. (UAE), an Austin-based Meals-on-Wheels program, and the University of Texas Medical Branch at Galveston (UTMBG) under contract to the LBJ School, helped in developing, testing, and evaluating the meal system. The duties of the various participating institutions are presented here: NASA Overall program responsibility Design and development of meal system Provide all meals LBJ School Plan, administer, and execute program evaluation • Assist in field demonstrations Advise on policy implications Meal System for the Elderly TRIMS Develop and conduct the preference and attitude survey Plan and execute the user taste test UAE Train field workers Plan, coordinate, and execute field demonstrations Responsible agent for the receipt, storage and distribution of meals UTMBG Conduct medical-nutritional screenings of partici­pants in the field demonstration NASA contracted with two private firms in carrying out its project responsibilities. Technology, Inc. provided diet planning, and food acquisition and packaging. The Martin Marietta Corporation Biomedical Applications Team was responsible for project technical support. Funding for the project was provided by NASA for program development and meal costs, the Texas Depart­ment of Public Welfare (DPW) for field demonstration activities and program evaluation, and the Ford Foundation for the medical assessment. PROGRAM APPROACH The project was approached in four phases. (See Appendix I for timetable.) The initial stage focused on the technical development of the meal system: selection of the food items, menu development, and package design. These tasks were accomplished through a series of surveys and taste tests conducted by NASA and TRIMS, in addition to design work completed by NASA. Preparations were also made for a short-term pilot demonstration. During the second phase of the project a pilot field demonstration was conducted. Forty-one elderly citizens were selected to receive meals for a two-week period. Their comments were recorded and several technical changes were made in the package design and menu composition as a result. A major field demonstration was carried out during the third phase. Meal packages were distributed to 128 elderly citizens by volunteers and through the mail, providing a hot meal daily for nine weeks. A small group continued to receive meals for an additional six weeks. Another 40 elderly persons who were participants in hot meal programs during the week received NASA meals as a weekend supplement. Detailed interviews of all meal recipients and case studies of some participants served as the major source of data for evaluating the meal system. The field demon­stration also included a medical-nutritional component to screen potential participants for health problems which would prohibit participation in the program and to assess the r.utritional impact of the meals over time. The final phase was an overall evaluation of the program. The issues addressed include: (1) the acceptability of the meals themselves; (2) the adequacy of the delivery mech­ anisms employed; and (3) the psychological, economic, and nutritional impact of the program upon meal recipients. Future uses of the meal system as a supplement to traditional feeding programs were also examined in light of current legislation. REFERENCES 1 Older Americans Act-Amendment, Sec. 701 (a), 86 Stat. 88(1972). 2 "Older Americans," Weekly Compilation ofPresidential Documents, volume 12, number 7 (Feb. 16, 1976), p. 170, Gerald R. Ford, Message to Congress, Feb. 9, 197~ 3 U.S. Congress, Senate, Select Committee on Nutrition and Human Needs, Opening Statement of Senator Charles H. Percy, Hearings on S. 3585, 94th Cong., 2d Sess., June 17, 1976. 4 /bid. Opening Statement of Senator George McGovern, "The Homebound Elderly-Our Most Dependent Citizens," Hearings on S. 3585. 94th Cong., 2d Sess., June 17, 1976, CHAPTER II SYSTEM DEVELOPMENT The initial phase of the project, extending from March to October, 1975, focused on the technical development of the meal system. Activities during this period included: (1) a Food Preference and Attitude Survey, (2) a technical taste test to screen all food items under consideration for use in the meal system; (3) a user taste test conducted over a five-day period during which a group of elderly citizens rated the food items which had successfully passed techni­cal screening; and (4) the identification of a set of technical requirements for the design of the meal packaging system. FOOD PREFERENCE AND ATIITUDE SURVEY As a first step in deciding on menu composition TRIMS conducted a survey of elderly citizens to determine their eating habits, meal preparation practices, and food pre­ferences.1 A survey instrument composed of 34 questions was administered to 100 elderly citizens, representing both rural and urban populations. Fifty-five percent of the group were white while the remaining 45 percent were black. Most of the respondents were currently active in senior citizen programs. The major findings are outlined below. 1. Eating Habits. Seventy-one percent of the elderly citizens surveyed stated that they usually ate their meals at home, although only half conunented that they preferred eating at home. Over half of the sample reported eating three meals the previous day, while the group was evenly split between those who ate their main meal in the evening and those who consumed it at breakfast or lunch. More than half of the respondents ate snacks each day, usually fruit, desserts, or beverages. Ninety-two percent reported that they drank either coffee, tea, or juice with their meals. Over two-thirds of the sample stated that they normally ate alone. 2. Meal Preparation. Ninety-two percent of the respon­dents prepared their own meals, the majority reporting no problems in preparation. Half of the sample members often used convenience foods such as frozen TV dinners, pre­pared frozen foods, and drink mixes. All the respondents had access to basic kitchen facilities. Ninety-one percent of those interviewed did their own shopping, with one-third of this group encountering problems due to impaired physical mobility. (An example cited is difficulty in pushing a grocery cart.) Several mentioned that it was troublesome to open jars and complete related tasks. 3. Food Preferences.Specific food preferences varied widely among the elderly citizens interviewed. Meat pre­ferences include fish, beef, and poultry. A variety of vegetables and fruits were mentioned while a preference for cheese items emerged from the dairy products discussed. Pies and cakes received numerous mentions among desserts. Cost and appearance were the most influential factors affecting food purchases. Taste, ease of preparation, and br.and names were also important. More than half of the respondents reported that they were on a special diet. Of this number, over 7 5 percent had their diet prescribed by a doctor. Low-sodium diets were most frequently cited. Three-quarters of the sample group said there were food items which they could not or did not like to eat. The items mentioned varied widely. The general conclusions of the TRIMS survey were that most elderly citizens interviewed consumed three meals daily, with their main meal at noon or in the evening. Almost all reported eating snacks during the day, usually desserts, fruits, or beverages. Most of the elderly citizens interviewed prepared and consumed meals in their own homes. They also did their own shopping, although some experienced difficulty in completing this task because of limited physical capabilities. While food preferences varied widely, a definite trend toward bland, low-sodium diets was evident. Cost was frequently mentioned as an important factor influencing food purchases, with weekly expendi­tures on food items averaging $10 to $15 for each individual. TECHNICAL TASTE TEST Based upon these findings, NASA obtained a variety of food items for testing purposes.2 These meal components were procured internally from NASA, the U.S. Army Natick Development Center, which develops feeding systems for military use, and several conunercial food vendors. Once the food items were received, NASA conducted a technical taste test of the numerous food items and different brand names. The purpose of this testing proce­ 3 Meal System for the Elderly dure was to ensure that only the most acceptable food items would be selected from those which were available. A total of 149 food items was evaluated over a three-week period by a panel of five to seven NASA technicians trained in sensory evaluation. The panel mem­bers evaluated each food item on a nine-point hedonic scale, with a score of nine indicating the highest rating of acceptability. Only those items receiving a consensus rating of 5.0 or above were recommended for inclusion in the program. Ninety-six items received acceptable ratings. USER TASTE TEST A second taste test was conducted by TRIMS and NASA with a potential user group in June, 1975. Seventy elderly citizens from rural Waller County, Texas-located near Houston-were selected to sample the 96 food items recommended by the technical taste test panel. This group consisted of 55 females and 15 males. Fifty-six of the group members were blacks while the remaining 14 were white. The user taste test was conducted at the Newman Center, Prairie View A & M in Prairie View, Texas (two days), and at the County Court House in Hempstead, Texas (three days). Each of the 96 food items was evaluated between 16 and 26 times. All food items were evaluated on a five-point hedonic scale. Foods were accepted only if they received an overall rating of 5.0 or above. The results of'the user taste test correlated highly with the recommendations of the technical taste test panel. Only one food item received an unacceptable rating. /• TECHNICAL REQUIREMENTS Meals All meals were designed to meet at least one-third of the daily recommended dietary allowances for males 51 years of age and older, as established in January, 1974, by the Food and Nutrition Board of the National Research Council, National Academy of Sciences. (This requirement more than meets the needs of women in the same age group.) The nutritional value of meals was based upon manufacturers' data, label information, Agriculture Hand­book No. 8, and NASA nutritional data. 3 No special menus were developed for individuals with health-related dietary restrictions or those who prefer traditional ethnic foods, though it would be technically easy to design such meals. The 95 food items which had successfully passed the user taste test were used to assemble 21 different meals. (See Appendix II for a list of the meals.) Each meal contained an entree, two side dishes, dessert, and a beverage. Fifteen of the 21 meals were composed primarily of thermostabilized "canned" items, while the remaining six meals consisted of freeze-dried and dehydrated items. Every item was packaged in single-serving sized units (approximately 5 ounces per item.) Plans were made to include several meals containing a thermostabilized retor­table "flex pouch", a foil-polyethylene pouch sealed under high pressure and high temperature. However, flex pouches were still under safety investigation by the U.S. Food and Drug Administration (FDA) and were not released in time for their use during either field demonstration. No decision System Development had been made by the FDA as of August, 1976, on whether to approve the flex pouches for commercial development. Two exceptions to this-pineapple and applesauce-were included in the project. The temporary hold did not cover them because they have a high acid content and require low retort heat processing. Packaging All meal packages were designed with the following objectives in mind: (I) protection of the food items front damage; (2) maximization of product shelf-life with no need for refrigeration prior to opening; (3) convenience of packaging for the consumer; (4) ease of transportation; and (5) aesthetic appeal for the user group. Primary packaging (that which contained the actual food product) consisted of two types: metal cans for the thermostabilized foods and foil packages for the freeze­ dried and dehydrated items. All cans had ring-top lids for easy opening while the foil containers were opened by tearing or cutting off the top of the package. As a part of the secondary packaging, a plastic tray held the primary food packages in place and also served as a container in which to prepare and eat the meal. The tray itself was sealed in a polyethylene bag and wrapped in a shrink film with the individual food items in place. Each meal was placed in an individual box. Meal boxes were wrapped together into seven-day meal packages for distribu­tion to the program participants. Labeling Each can and foil package had a label which described its contents and provided instructions for preparation. All labels were printed with blue lettering on a white back­ ~~N/'\S/'\ ~~.,,~ . ,r- MQ. ,,. M e al System For The Eld erly ground. On the inside lid of each meal box, written and graphic instructions were provided on meal preparation. Instruc­tions were printed in both English and Spanish. Meal boxes were labeled with menu number and meal contents. SUMMARY The technical development of the NASA Meal System for the Elderly was accomplished over an eight-month period in 1975. The Food Preference and Attitude Sur­vey conducted by TRIMS determined that the eating habits of the elderly are heterogeneous, although a pre­ference for bland, low-sodium diets exists. Based on this finding, NASA obtained 149 food items for testing. A technical taste test conducted by NASA resulted in the elimination of 53 food items from considera­tion for the meal system. Next, a user taste test was conducted with 70 elderly citizens to determine the acceptability of the 96 food items recommended by the technical taste panel. Only one item was found to be unacceptable. The 95 food items which passed both taste tests were used to develop 21 different meals for the field demonstra­tions. All meals were designed to meet at least one-third of the daily recommended dietary allowances of males 51 years of age and above. Food items were packaged in cans or foil containers, and held in place in plastic trays. The trays were placed in individual meal boxes which were bound together into seven-day meal packages for distribu­tion to meal recipients in the field demonstration project. All individual items had printed instructions while general bilingual and graphic instructions were provided on the inside lid of each meal box. Meal System for the Elderly REFERENCES 1 This section borrows heavily from a draft report prepared by TRIMS on the Food Preference and Attitude Survey. 2 The remainder of this chapter borrows heavily from a Technology Incorporated report. See Technology Incor­porated, "Final Report: Design and Development of a Meal System for the Elderly," Contract No. NAS-9-14672, 1 S September 1975. 3 NASA has complete nutritional data on those food items which are the same as the ones used in the space program. Also, additional nutritional data, based on ana­lytical analysis was obtained on other representative menus for verification of design specifications. CHAPTER Ill PRELIMINARY FIELD DEMONSTRATION The preliminary demonstration of the NASA Meal System for the Elderly was conducted from October 1-15, 1975. At this stage, a seven-day meal cycle was available. The two-week demonstration afforded an opportunity to obtain the reactions of a typical user group to the technical aspects of the meal system, including the individual food items, ease of preparation, and packaging. SITE SELECTION Five central Texas sites were selected for the preliminary demonstration. These included four small communities­Bastrop, Elgin, Lockhart and Smithville-which range from 3,000 to 7 ,500 in population. Located in rural Bastrop and Caldwell Counties, these communities serve as the commer­cial centers for an area dominated by agriculture and oil and gas production, Travis County was the fifth location for the two-week demonstration. Special attention was given to selecting participants from the rural areas sur­rounding the City of Austin. Small-town locations in central Texas were utilized during the two-week demonstration for several reasons: (1) rural and small-town residents were the primary target group for the major field demonstration; (2) contacts were already established with social service agencies in several small central Texas communities, facilitating prompt loca­tion of a number of potential participants; and (3) a heavy reliance upon field personnel from the Austin area for meal delivery and interviewing meal recipients. PARTICIPANT SELECTION In August, 1975, UAE and the LBJ School asked social service agencies in the sites selected for the preliminary demonstration to locate potential meal recipients. Three criteria were established for participation in the field test: (1) meal recipients were not to be bed-ridden; (2) they were to have no health-related dietary restrictions; and (3) participants were to possess a reasonable degree of mental acuity, so they could record their comments and reactiom to the meal system. An effort was also made to select an ar­ray of participants in terms of ethnicity, sex, and dexterity. The LBJ School complied with Federal regulations on the "Protection of Rights and Welfare of Human Subjects" by obtaining approval of the project from an LBJ School Committee on Human Rights. Guarantee was given to the committee that elderly people would participate in the demonstration only on a voluntary basis with full know­ledge of their right to withdraw at any time and with an understanding of project goals and purposes. To ensure participant rights, a consent form had to be signed by each participant before he/she received any meals. (See Appen­dix III.) Approximately 65 elderly citizens from the five sites were interviewed to determine their interest in participating in the preliminary demonstration. (See Appendix III for the application form.) Forty-one elderly persons were selected to receive NASA meals for two weeks. MEAL DELIVERY METHOD A personal delivery method was selected for the preli­minary demonstration. Since one objective of the field demonstration was to obtain as much information as possible on participant reactions to the meal system, it was felt that this would best be achieved through direct contact Meal System for the Elderly with meal recipients. Meals were delivered by LBJ students and site volunteers. Meal orientations were conducted at the time of the first delivery. At the second delivery, a week later, meal evaluation forms were collected from the participants and their questions answered. A final interview was conducted and meal questionnaires collected at the end of the second week. PARTICIPANTS Demographic Characteristics A breakdown by sex, age, ethnicity, and geographic location of the participants in the two-week demonstration is presented in Table IIl-1. Two-thirds of the meal recipients were female and one-half of the user group ranged from 60-70 years of age. Only one participant was less than 60 years, while 20 percent were over the age of 80. Blacks were the largest ethnic group, comprising 18 of the 41 participants. The two largest groups of meal recipients were from Bastrop and Lockhart, accounting for 50 percent of the participants in the field demonstration. Income Low-income elderly citizens were the target group for the preliminary demonstration because they have the greatest need for such a service. Table 111-2 details the income sources of the meal recipients. The two largest groups were those receiving a combination of Supplemental Security Income (SSI) payments, Social Security Adminis­tration (SSA) benefits, and U.S. Department of Agriculture Food Stamps, and those who received SSA benefits only. These two groups totaled half of the user population. Mobility While no attempt was made to systematically measure the physical capabilities of the user group, several questions were raised which assessed this factor for each meal recipient. When asked if they experienced any difficulty getting around the house, only one of the participants responded affirmatively. Arthritis and the gout severely hampered this individual's mobility. However, among those who said they experienced no mobility problems, several Preliminary Field Demonstration TABLE III-I DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS IN PRELIMINARY DEMONSTRATION No. of Participants %of Total WhTotal o Began Meals Programs Number of Participants 41 100% Sex Female Male 27 14 66 34 Age Under 60 60-70 71-80 81 and above I 21 11 8 I 52 27 20 Ethn icity Black Mexican-American Anglo 18 12 11 44 29 27 Loca tion Bastrop Elgin Lockhart Smithville Travis County 11 5 13 4 8 27 12 31 IO 20 TABLE III-2 INCOME SOURCES OF PARTICIPANTS IN PRELIMINARY DEMONSTRATION Income Source No. of Participants SSA, SSI, and Food Stamps 12 SSA only 10 SSA and SSI 5 SSI and Food Stamps 5 SSI only 6 Neither SSA, SSI, or Food Stamps 2 SSA and Food Stamps TOTAL 41 Meal System for the Elderly comments such as "have to use crutches" and "weak knees, move slowly" were recorded. Only four meal recipients said they never left their homes to run errands, relying upon friends or relatives to meet their shopping needs . Nine participants said they had friends or relatives who cooked for them, normally a spouse or "live-in" relative. A total of nine meal recipients also said they owned and operated their own automobiles. Health Status Thirteen participants indicated they had been patients in a hospital or nursing home within the past year. The reasons for their stay ranged from major surgery such as back and kidney operations to X-rays and other forms of diagnosis and treatment. The vast majority of the meal recipients in the two-week demonstration received some form of Federal assistance to cover health care expenses. As Table 111-3 illustrates, all but five of the elderly participants were enrolled in Medicaid, Medicare , or both programs. Dental Condition Responses to questions concerning current dental condi­tion indicated the poor status of the user group in this regard. Thirty percent of the participants had full sets of teeth, eight persons wore dentures, and the remainder had an incomplete set or no teeth at all. TABLE III-3 HEALTH CARE COVERAGE OF ELDERLY PARTICIPANTS IN THE PRELIMINARY DEMONSTRATION Federal Program No. of Participants Medicare Medicare and Medicaid Medicaid No Assistance 15 11 10 5 TOTAL 41 Preliminary Field Demonstration Four Recipients Dropouts During the Pilot Demonstration A better understanding of the living conditions of elderly citizens can be obtained by looking at the lives of four participants in the preliminary demonstration. While not intended to be a representative sample, these indivi­duals nonetheless typify low-income elderly citizens and the difficulties they encounter. (All names are fictional.) The oldest participant in the two-week demonstration is Mrs. Bessie Johnson, a 93-year old woman who lives in Elgin, a small central Texas community with approximately 3,800 residents. She lives alone on the outskirts of town. Leg ailments leave Mrs. Johnson almost entirely homebound, although she does manage to attend church services each week and makes a monthly shopping trip with the assistance of friends. Poor eyesight and dental condition are also troublesome, although she has not seen a doctor or dentist in over six years. Mrs. Johnson's only regular visitors are several elderly women who live in the area. Supplemental Security Income (SSI) payments are her only source of income which she supplements by purchasing food stamps. * * * Two other meal recipients are William and Emily Thomas, an elderly couple who also reside in Elgin. Both are in their mid-eighties and have a number of maladies which leaves them homebound. Mr. Thomas is very hard of hearing and shakes considerably. His wife is afflicted with arthritis in her back and hips. A community van provides transportation for the couple when it is necessary for them to travel, although they rarely leave their cluttered three-room house except for monthly shopping trips. Their daughter lives nearby and visits them occasionally. The Thomases also rely upon SSI payments for support and purchase food stamps. * * * A fourth participant is Roosevelt Jefferson, a 56-year old Smithville resident. The youngest recipient in the pilot demonstration, Mr. Jefferson is physically dis­abled and looks much older than his actual age. He recently underwent surgery for a kidney ailment. Mr. Jefferson lives alone in a small wooden-frame house which he rents for $25 per month. He seldom leaves home except when his brother takes him on a monthly shopping trip. Meals are generally prepared at home, with Mr. Jefferson frying eggs or other staples. He occasionally walks to a local cafe where he pays between 50 cents and $1 for a dinner of soup and coffee. SSI payments are Mr. Jefferson's sole source of income. He purchases food stamps regularly . A total of 35 individuals completed the two-week demonstration. Six people withdrew from the program, two for personal reasons and four as a result of health problems. The two participants who withdrew for personal reasons did not elaborate on why they no longer wished to receive meals. Several unsuccessful attempts were made at inter­viewing these individuals. The impression left was that both had simply lost interest in the project. Of those who were forced to withdraw for health reasons, two individuals had special dietary requirements as a result of ulcer conditions which they did not reveal during the initial interview. A third participant suffered a mild stroke just prior to the beginning of the field test and withdrew the second day of the program when he exper­ienced high blood 2ressure. The final health-related dropout decided against continuing in the project when she exper­ienced stomach cramps and gas after consuming two meals. Evaluation Instruments Two evaluation instruments were designed to record the reactions of participants to the meal system. An individual meal evaluation form was included inside each meal box asking the recipient to rate the individual food items with regard to taste, appearance or texture, quantity, and ease of preparation. In addition, several open-ended questions were included. These forms were printed in both English and Spanish. (See Appendix IV.) Also, a questionnaire was administered to all meal recipients by field personnel at the conclusion of the two-week demonstration, covering all aspects of the meal system. (See Appendix V.) The individual meal evaluation form was not as success­ ful in obtaining user responses to specific food items as had been hoped. The complexity of this form was a stumbling block for a number of recipients who experience difficulty in reading and writing. Also, participants reported that completing a detailed form after each meal became tedious over a two-week period, resulting in a loss of interest on the part of many meal recipients. Furthermore, several people mixed food items from the different meal packages, making it impractical to fill out the forms on a regular basis. In spite of these problems, 322 meal evaluation forms were returned in varying degrees of completion. Post-demonstration interviews were heavily relied upon to determine participant reactions to the technical aspects of the meal system. Within a week of the completion of the preliminary demonstration, a total of 31 interviews were conducted with individuals and couples who had received meals. The results of these interviews serve as the basis for many of the comments which follow. Meal System for the Elderly FINDINGS Food Items The overall reaction to most food items was favorable. All recipients said they enjoyed most of the food items and the majority felt these foods were very similar to what they normally consumed. Approximately 80 percent of the participants stated that they would purchase food items included in the NASA meals if they were available at prices which compared favorably with what they normally spent on food. Food stamp recipients also indicated a willingness (86 percent) to purchase these meals with their stamps if they were available commercially. These comments were reinforced by positive responses to open-ended questions on the meal evaluation forms . One further note is that all 12 Mexican-Americans who participated in the preliminary demonstration also re­ sponded favorably to the meal system. Although 6 indi­ viduals said the food items were dissimilar to what they typically ate, all but 2 of the 12 indicated that they would like to continue in the program. Although this group is too small to serve as a basis for any conclusions on how Mexican-Americans in general would react to the meal system, these results are encourag­ ing. They suggest that ethnic dietary preferences may not be a major obstacle to the acceptability of the meal system. Food Items Disliked In determining what food items were least liked by meal recipients, the number of fair/poor responses was totaled from the meal evaluation forms for each food item. Peas and green pea soup were the most poorly received food items. Canned (thermostabilized) peas received a total of 23 negative responses on the meal evaluation forms. Freeze­ dried peas received 14 negative votes, and 13 fair/poor responses were recorded for green pea soup. These items were also singled out for criticism in answers to open-ended questions on the meal evaluation forms and were frequently mentioned as the least-liked items during the post­ demonstration interviews. The assembled data suggest that the unfavorable reaction to the pea items can be accounted for by these factors : (1) some recipients simply do not like peas; (2) several individuals were not used to eating peas; (3) peas and green pea soup showed up too frequently in the seven-day menu cycle (five times); and, (4) there is an indication that the freeze-dried peas were not properly prepared. Several complaints focused on the "crunchiness" of the freeze­ dried peas; this suggests that an inadequate amount of time was allowed for this item to reconstitute after hot water had been added. The other soup item-vegetable soup-also received a higher than average number of fair/poor responses. Meal recipients gave this item 11 negative votes. Peanuts and almonds proved troublesome for seve.ral' members of the user group. Based on the post-demonstra~t . . ·. tion interviews, 24 percent of the participants did not eat; · ' these items at all. This is probably a result of the pod~ dental condition of many meal recipients. Of the 19 , individuals who reported that they ate the nuts, three were '· able to do so only after crushing them. Additional Dato on Food Items 1. Menu Composition. The majority of the participan~' indicated that the seven different meals provided adequate : , variety. The only problem noted in this regard was that ~· •· peas and green pea soup were included in five of the seven· meals. 2. Meal Consumption. Nearly 75 percent of the meal. · recipients prepared and consumed the NASA meal as their . main meal at mid-day. Approximately 70 percent prepared all of the contents of the meal package at one time. 3. Meal Quantity. Of the 27 responses recorded on this question, 23 individuals said the meals provided a sufficient amount of food to eat. Half of this group said they could not eat an entire meal at one sitting and saved leftover food items for use as snacks later in the day. Almost two-thirds of the recipients said that at least one meal from the seven-day cycle provided too much food to be consumed at a single sitting. 4. Freeze-Dried vs. Canned Items. Seventy percent of the participants expressed a preference for the canned items while 11 percent favored the freeze-dried foods. The remaining 19 percent expressed no preference. Comments made during the post-demonstration inter­ views suggested that the strong preference for the canned items may be related to the familiarity of participants with this type of packaging and contents. No preferences were noted with regard to the canned or dehydrated drinks, however. Food Preparation The food items used in the pilot demonstration were designed for easy preparation. The canned foods are opened with a pop-top or can opener. Some items require heating in a sauce pan while others need no further preparation. The freeze-dried foods are prepared by tearing open the top of the pouch and adding a measured quantity of hot or cold water to the contents. The powdered drinks also require the addition of a specified amount of water. Preliminary Field Demonstration On the basis of the post-demonstration interviews, it appeared that the meal recipients did not encounter any major difficulties in preparing the food items. Several minor problems were evident, however: I. Opening Pouches and Cans. Twelve percent of the respondents stated that opening the pouches was difficult. The apparent problem was the lack of a perforation or dotted line on the freeze-dried packages indicating where to tear them open. The results of the interviews also showed that 20 percent of the meal recipients experienced difficulty opening the pop-top cans. After breaking off the opening ring, several participants used scissors or knives to remove the can lids. 2. Reconstituting vs. Heating. All participants had access to stoves on which they could heat the canned foods and boil water for the freeze-dried items. They also had a sufficient number of pans in which to prepare the different food items. In reconstituting the freeze-dried foods, only two recipients reported having difficulty measuring the proper quantities of water. No other complaints were registered regarding food preparation. 3. Refrigeration. Seventy-five percent of the meal reci­pients indicated that they refrigerated particular food items such as the drinks, puddings, and cottage cheese before consuming them. Delivery Three-quarters of the participants interviewed indicated that, given the choice, they preferred having the meals delivered by a volunteer. Twelve percent expressed a desire for delivery by an impersonal method. The remaining 12 percent indicated that they had no preference. Although a majority registered a strong preference for personal meal delivery, 72 percent indicated a willingness to accept the meals by impersonal methods if no other alternative existed. Mail delivery would present a major problem for many small-town residents who do not receive mail at their homes. Several participants said they had to travel up to I 0 13 Meal System for the Elderly blocks to the local post office to pick up their mail. Carrying a seven-day meal package that weighs approxi­mately 15 pounds would be impossible for many of these elderly citizens. Only 12 percent of the user group indicated that they were willing or able to travel to a central location to pick up the meals themselves. Packaging 1. Seven-Day Package. With regard to the seven-day meal packages, 10 percent of the participants stated that they had difficulty carrying or opening the package. The weight and bulk of the package was a problem for several older women who were unable to move it without substantial difficulty. Most recipients cut the binding straps with scissors or a knife. 2, Meal Boxes. No complaints were recorded con­cerning the design and size of the individual meal boxes. Several recipients had trouble breaking the NASA seal on the box with their fingernails so they used a knife or scissors instead. 3. Instructions. The instructions on the inside lid of the individual meal boxes were largely disregarded or over­looked. Of the 25 responses recorded to questions con­cerning the meal box instructions, nine participants indi­cated they could not understand them. However, Mexican­American meal recipients did express satisfaction with the bilingual instructions. Most of the meal recipients relied on the instructions which appeared on the individual food items. More than 75 percent of those questioned reported no problem in following these directions. Several participants said they experienced difficulty in reading the instructions because the blue print did not provide an adequate contrast against the white background. 4. Trays. Just over half of the participants reported using the meal trays occasionally; only two recipients said they used them every day. Among those using the trays, all said they only ate from the tray and none indicated that they prepared the meals in it. DESIGN CHANGES All of the findings from the two-week demonstration were presented to NASA and UAE at an evaluation meeting held in late October. Recommendations for changes in the meal system were made to assist NASA in developing the final design of the 21-day menu cycle for the long-term demonstration. On the basis of the LBJ School's recom­mendations, NASA made a number of changes in the meal system. CHANGFS RECOMMENDED A. Individual Food Items l. Peas a. Reduce the number of times peas are used in the menu cycle; or b. Substantially improve the quality of the peas; or c. If peas were included frequently because of high nutrient levels, redistribute those nutrients among other food items. Action Taken: It was not possible to drop the pea items completely from the meal system because of their high nutrient content. However, the repetition problem was reduced during the long-term demon­stration because a 21-day menu cycle was used. Asa result, peas appeared less frequently than during the 7-day cycle used in the pilot demonstration. The preparation instructions for the freeze-dried peas were improved, and a cream sauce was added to enhance their acceptability. 2. Soups a. A greater variety of soups should be included in the 21-day menu cycle. b. The possibility of dropping the green pea soup should be investigated. Action Taken: Greater variety in the soups appeared in the 21-day menu cycle. The green pea soup was retained during the long-term demonstration. 3. Nuts Other high protein snacks should be substituted for the peanuts and almonds during the major field demonstration. Action Taken: Peanuts and almonds were dropped from the 21-day menu cycle. High protein candy bars were substituted for these items. 4. Drinks No preference was noted for the canned over the de­hydrated drinks. The significance of this finding should be explored. Action Taken: The canned drinks were phased out entirely. Dehydrated drinks were included in the long-term demonstration. This change resulted in a substantial reduction of the weight and bulk of the seven-day meal package as well as the individual meals. Preliminary Field Demonstration B. Meal Quantity The possibility of reducing the quantity of each meal while maintaining current nutrient levels should be in­ vestigated. Action Taken: NASA officials decided that this was a long-term design issue and that no specific action should be taken at this time. C. Food Preparation 1. To facilitate the opening of the pouches, a dotted line or perforation should be included along one edge of the package. 2. The pop-top mechanism of the cans should be improved. 3. Conventional cans should be substituted for those with the pop-top openers. Action Taken : l) Dotted lines were included on one edge of each pouch to assist in opening. 2) Pop-top openings were retained for all aluminum cans. All steel cans had instructions noting the conventional seal on the bottom which permits them to be opened with a can opener. 3) A greater emphasis was placed on proper opening of the pop-top cans during the orientation of meal recipients for the long-term demonstration. D. Instructions l. Freeze-dried food instructions need to be modified. The amount of water added and the time needed for reconstitution should be increased. 2. Instructions on drinks and other appropriate food items should state that the enjoyment and taste of these products would be enhanced by prior refrigera­ tion. 3. Instructions should be simplified and color coding utilized so that they are easily comprehended by participants who experience reading difficulties. 4. Bilingual instructions should be retained because these were well received by Mexican-American meal recipients. 5. The printing on the labels should be darkened and the letters enlarged to provide for easier readability. Action Taken: l) Instructions on the freeze-dried items were changed to reflect more accurately the amounts of water needed and the time necessary for reconstitution. 2) Instructions recommending refrigeration were in­cluded on appropriate food items. 3) A new, simplified color-coding system was developed for the separate food items-red indicated heat and blue indicated cold. General instructions were no longer provided on the individual meal box. 4) Instructions and labels were printed in large black letters to make reading easier. 5) With the new instruction system, it was not feasible to retain the bilingual instructions because of space limita­tions. E. Packaging System 1. Because the meal trays were used infrequently, the following alternatives should be considered : a. Substitute a lightweight aluminum tray such as used in TV dinners; b. Include only one tray per seven-day meal package; or c. Eliminate the tray altogether. 2. The graphics on the individual meal boxes should be improved, i.e., more color should be added. Action Taken: 1) The tray was eliminated entirely, reducing meal costs greatly. Light cardboard containers served as individual meal boxes and were enclosed in a large paperboard container to make up the seven-day meal package. 2) An eye-catching design consisting of red, yellow and black colors was created for the individual meal boxes. Meal System for the Elderly SUMMARY The preliminary demonstration of the NASA Meal System for the Elderly was conducted in October, 1975. Forty-one elderly citizens from four small towns and one rural site received meals for a two-week period. Their observations concerning the technical aspects of the meal system-acceptability of the food items, ease ofpreparation, and packaging-were recorded on forms accompanying each meal and detailed interviews at the conclusion of the demonstration. This information served as the basis for the redesign of the meal system. The overall reaction to the meal system was positive. The only complaint concerning the food items centered on the number of times peas were included in the seven-day meal cycle. This problem would be resolved during the long-term demonstration because a 21-day menu cycle would provide increased variety. Few problems were encountered in preparing the meals, although some indivi­duals experienced difficulty with the pop-top cans. The packaging system was altered significantly as a result of the preliminary demonstration. Few individuals used the meal tray and it was subsequently dropped from the meal system. More color was added to the graphics on the individual meal containers and labels on the food items were printed in large, black letters for easier reading. A color-coded set of instructions was developed to indicate which items required heating or refrigeration. CHAPTER IV PLANNING AND IMPLEMENTATION OF THE MAJOR FIELD DEMONSTRATION The major field demonstration was intended to test the social, economic, and psychological impact of the meal system, in addition to the acceptability of the food items, packaging, and delivery mechanisms. Planning for the demonstration was conducted during the fall of 1975. UAE and the LBJ School developed a detailed implementation plan which outlined the responsi· bilities of each of the principal agents. NASA was to provide all meals and redesign the meal system, taking into account the recommendations which emerged from the evaluation of the two-week preliminary demonstration. UAE was to plan, coordinate, and execute the field demonstration, as well as organize and control the storage and distribution of the meals. The LBJ School was responsible for assisting UAE in the planning of the field demonstration, and for evaluating the impact and feasibility of the program. Also, the LBJ School was to arrange for a medical-nutritional screening of participants to insure that they could tolerate a normal diet and to assess the nutritional impact, if any, of the meals on the participants. In planning the long-term demonstration, the LBJ School identified five major variables which might affect the acceptability of the meal system: length of participa­tion in the program; geographic environment; method of meal delivery; amount of social interaction normally experienced by the participants; and income. This section outlines the rationale behind selection of these variables. 1. Length of Participation. The long-term demonstra­tion was to run for nine weeks to gauge participant reaction to the meal system over time. It was assumed that initial participant reactions would be biased because of the novelty of the erttire system. It was hoped that, by the ninth week, this bias would not be a factor and any problems, dissatisfaction or boredom with the system could be detected. To further assess the acceptability of the system over time, 15-20 participants were to continue the program for six more weeks. 2. Geographic Location. The NASA meal system was designed to supplement existing meal programs. Since nutrition programs are mostly located in urban areas, the long-term demonstration was to be tested primarily in rural and small-town areas where no other meal programs were in operation. However, many urban elderly cannot avail themselves of meals because they are ill, have no transporta· tion or are homebound, because existing nutrition programs are full, or because there is not a meals program in the area. Thus an urban group was included in the sample to see if they reacted differently from rural or small-town partici­pant groups. 3. Method of Meal Delivery. Most participants were to receive their meals by a personal delivery method. To guard against the bias of the "halo effect", some participants were to receive meals by impersonal delivery of meals to control against reactions based on personal attention instead of on the merit of the meal system. Use of impersonal delivery also provided an opportunity to test mail and van delivery methods which, due to shortages of volunteers, would play an important role in any large-scale distribution of the NASA meals. 4. Degree of Social Contact. The degree of social contact normally experienced by participants might affect the acceptability of the meal system. For those individuals who were relatively socially isolated and who did not receive other social services, a "halo effect" would likely be observed. For those individuals with greater social contact and for those already receiving a wide range of services, less of a halo effect would be expected. Accordingly, a decision was made to evaluate the meal system both as part of a well established social network, and as the principle service. The hypothesis was that those participants receiving the fewest services prior to their participation in the NASA project would respond more favorably than those who were already receiving a wide range of services. 5. Income. Since the elderly poor are in greatest need of services, focus was on them. However, income was not considered as important a variable as dependency. So, for evaluation purposes, need for services, dependence on others for help, and degree of physical mobility were viewed as more important dependence indicators than income alone. A relationship between dependency and acceptability of the meal system could have implications for the general marketability of such a system. The LBJ School seriously considered whether or not there should be a control group for the long-term demon­stration. The idea was rejected for three reasons: (1) It would be unethical to select a sample of elderly, ask them Meal System for the Elderly questions about their eating habits and give them nothing in return. (2) It would be difficult to arrange logistiscally and monetarily. (3) Any nutritional-medical information gained from screening a control group would be of dubious validity. It was felt that choosing the sample on the basis of the five variables provided internal controls adequate for the LBJ School evaluation of the NASA Meal System. SITE SELECTION UAE and the LBJ School looked for sites which could meet the program criteria. During the summer of 1975, UAE contacted several social service agencies in central Texas to find out if they would be interested in taking part in the NASA meal system demonstration. Two considera­ tions in site selection were that: (1) the area have a large population of persons 60 years of age or older, and (2) that the site be conveniently located-preferably within four hours driving time from Austin. In addition, several service agencies contacted UAE, expressing a desire to participate in the demonstration. A preliminary list of sites was compiled and an additional site was selected to insure that a group of elderly receiving a wide range of services would be included in the sample. Since extensive outreach would be necessary to locate 170 participants, a decision was made to select a large number of sites. By doing so, the amount of outreach activity necessary in each area would be minimized. The following sites were selected: 1. San Saba County 2. Waco/Falls County 3. Wilson, Karnes, Guadalupe, Comal, and Atascosa Counties 4. Bastrop County 5. Travis County 6. Austin 7. Houston 8. Paris Each of these sites was selected because of specific charac­teristics. San Saba. San Saba County is rural-the total pop­ ulation is only 5,540. Twenty-two percent of the pop­ ulation is over the age of 65 and 47 percent of those are poor. A final consideration was local willingness to test an impersonal meal delivery system. Five-County Area. The five-county area is composed of Comal, Guadalupe, Wilson, Karnes, and Atascosa Counties. The area is predominantly rural, with a high percentage of elderly poor and a substantial Mexican-American popula­ tion. The entire area is service-poor. Agreement was reached that a personal meal delivery system would be used. Waco/Falls County. Waco (in McLennan County) and Falls County offered a mixture of conditions. Waco is an urban area with many services for the elderly. Falls County. adjacent to McLennan County is a rural area with a minimal service network for the elderly. Travis and Bastrop Counties. These two counties had several small towns with a large percentage of elderly. The proximity was convenient for UAE and the LBJ School. Also, there was no objection to using an impersonal delivery system in either county. Paris. Paris, located in Lamar County close to the Oklahoma border, was selected because of the special demonstration being conducted there by the Texas Depart­ment of Public Welfare. This project includes approxi­mately 1,200 elderly persons and is designed to determine the feasibility of providing comprehensive alternate care services in a small-town/rural area. Together, a social worker and a nurse interviewed potential clients, worked out a plan of services to meet his/her needs and then implemented the plan. Services included homemakers, transportation, and home health care. This project was well underway when the LBJ School approached DPW to determine how the meal service might be incorporated into an alternate care program. Austin-Home Health. Efforts were made to find out if any agency in the Austin area (Travis Co.) was providing alternate care to the elderly. No organization was offering a full range of services, but two agencies were offering Home Health Services. They agreed to participate in the demon­stration. The closeness of this participant group offered the LBJ School a chance to conduct extensive interviews and develop several case studies as part of the evaluation of the meal system. Houston. One of the largest congregate meal programs in Texas is operated in Houston. That site was selected to receive weekend supplements. Austin Day Care and Meals-on-Wheels. Austin was the other site receiving weekend meal supplements. There are three kinds of daily meal service in Austin: congregate meals; a noon meal served at the Austin Day Care Center; and Meals-on-Wheels, delivered by UAE. Since a congregate group was receiving weekend supplements in Houston, participants were selected from the Austin Adult Day Care Program and from UAE's client list. The number of participants to be selected from each site was established by taking into consideration the population distribution of the area, its ethnic makeup, and the outreach capacity of the coordinating agency. Once the sites were selected, a memorandum of agree­ ment was signed with the local social service agencies. This document defined the duties and rights of UAE and each service agency as a working agreement of participation in the project for the period from November 1, 1975 to May 7, 1976. Major Field Demonstration TABLE IV-1 EVALUATION VARIABLES BY SITE PARTICIPANT CHARACTERISTICS In light of the program variables, participants were selected for the long-term demonstration on the basis of income, geographic location, and access to other services. An effort was made to include elderly citizens who were relatively homebound and had few services available to them as well as those who were fairly mobile and could take advantage of a wide range of services. A representative mix in tenns of ethnicity and sex was felt to be desirable. (See Appendix Vi for application materials.) Also, meal recipients had to be relatively lucid, dis­playing the ability to understand what was being said to them and to respond in a coherent fashion. This was necessary since participants would be receiving instructions on how to prepare the food and would also be evaluating the acceptability of the meal system. Second, participants could have a wide range of physical disabilities, but none could be bedridden. Finally, participants had to be able to consume a regular diet and have no health-related dietary restrictions. Forty persons currently participating in a hot meals program were to receive two NASA meals per week as a weekend supplement to their regular service and 130 elderly were to receive seven meals per week for nine weeks, with 15-25 out of this group continuing for six more weeks. Field Network The field network was designed to ensure the maximum amount of communication between the field personnel, the LBJ School, and UAE. (The coordinating agencies are listed in Appendix VII.) Each site had a coordinator from the local service agency in charge of operations for their area. An LBJ student coordinator was assigned to each area to maintain regular phone or personal contact in order to channel information to UAE, as well as monitor site operations for evaluation purposes. Field operations-prior to the actual meal system demonstration-consisted of (I) the recruitment of volun­teers for outreach activities; (2) training of field workers Meal System for the Elderly (Orientation I); (3) interviewing of potential participants; (4) recruitment of delivery volunteers; (5) final participant selection; and (6) training of delivery personnel (Orienta­tion II). Orientation I was held in December, 1975 to familiarize the site personnel with the nature of the meal system and their responsibilities during the major field demonstration. After this orientation, outreach workers filled out applica­tion forms for potential meal recipients within their area. These were sent to UAE for review and final selection of participants for the long-term demonstration. Orientation II was held in late January, 1976 at each site after the outreach activities were completed. During these sessions, the delivery volunteers were briefed on all of the important aspects of the field demonstration, such as instructions on the preparation of meal items, hints on how to train participants to fully utilize the meal system, types of delivery systems to be used, meal storage and distribu­tion, and personnel to contact in case of difficulty. Medical Component Since a number of elderly persons cannot tolerate a normal diet, potential participants were asked to obtain certification from their personal physician indicating that they had no health-related dietary restrictions. In addition, participants in most sites were offered the option ~fa free medical-nutritional examination performed by medical per­sonnel from The University of Texas Medical Branch at Galveston. It provided medical certification for participants who had not obtained the necessary approval from their personal physicians, further assurance of safe participation from those who already had a certificate, and some preliminary information with which to judge the impact of the meal system. A second medical examination was scheduled at the completion of the nine-week demonstra­tion and a third check-up was made at the end of the 15-week program in order to assess any change in health status which might be attributable to the person's participa­tion in the program . A report describing the administration of the medical component is found in Appendix VIII. Field Operations The field demonstration began in late January and early February, 1976. The actual starting dates and number of initial meal recipients in each site were: Starting Number of Site Date Participants Paris 2/2/76 15 Five Counties 2/2/76 39 Travis/Bastrop 2/2/76 14 Waco-Falls County 1/26/76 28 San Saba 1/26/76 16 2/9/76 5 Travis County-Home Health 2/5/76 10 Austin-Weekend 1/30/76 16 Houston-Weekend 2/7/76 25 TOTAL 168 Meal Delivery Methods Participants received their meals by either a personal or impersonal delivery method during the long-term demon­ stration. The two types of delivery were distinguished by the extent and degree of contact which the field volunteers maintained with the participants. The majority of the participants had their meals deliv­ ered to their home by a site volunteer. The volunteer made an effort to establish a personal relationship with the meal recipient and was available to answer any questions about the program that might arise. In the impersonal method, participants received their meals either through the mail or from a delivery van. Deliveries for the weekend supplement participants were handled in two ways. A NASA packet consisting of two meals was distributed on Friday to those participating in congregate or day care programs. Meals-on-Wheels partici­ pants received their NASA weekend meals on Friday at the time of their hot meal delivery. Deliveries to home health and alternate care participants were made by their service providers during regular visits to the home. At the time of the initial delivery of NASA food to the participants, a volunteer gave each participant complete training in meal preparation, and answered any questions the participant had about the program. This personal orientation was given to all participants regardlt:ss of their subsequent mode of delivery, whether personal or imper­ sonal. After the initial supply of meals had been delivered to Major Field Demonstration Direct NASA -+ Site delivery distribution NASA -+ Austin Austin -+ Site I personal N = 129 delivery I impersonal N = 39 each site, additional meals were delivered once a week, or twice a month, depending upon the storage capability of each site. Communication with the Field LBJ student coordinators contacted the site coordina­tors on a weekly basis to keep abreast of any developments, and to obtain a general sense of the participants' reactions to the meals program. Any relevant information was conveyed to the LBJ project coordinator, UAE, and NASA. Site coordinators were instructed to contact student coor­dinators whenever a participant dropped out of the program, or whenever a participant received a damaged food item. In the case of program dropouts, arrangements were quickly made to administer the dropout question­naire. In the case of damaged food items, NASA recovered them to determine the problem. Replacements for damaged food items were provided. MAP IV-1 LONG TERM DEMONSTRATION MEAL DISTRIBUTION Mclennan Co. San Saba Co. ~Waco)Falls Co. I ,, II ' I Travis Co.~'__Bastrop Co. Com~~u~st'.n) -. -­Wilson Co. Guadalupe Co. Karnes Co. Atascosa Co. EVALUATION INSTRUMENTS Four evaluation instruments were used to get participant reactions to the meal system during the major field demonstration. These included the dropout interview; the post-demonstration interview; the extended demonstration interview; • the meal evaluation post card. A dropout questionnaire was developed for those participants who withdrew from the program during the first 21 days. (See Appendix IX.) Questions were asked concerning the participant's reasons for withdrawing, his/her overall assessment of the program, and his/her living environment. The questionnaire was designed to identify the factors which prompted the meal recipients to drop out of the program. It was administered by the student coordinator as soon as possible after notice was received from the site. Meal System for the Elderly Meal evaluation cards were developed to provide inform­ation about the acceptability of the individual food items in the 21-day menu cycle. (See Appendix X.) The cards were distributed to meal recipients by the delivery volunteer or were placed inside of the seven-day meal box. Each participant filled out cards for three of the nine weeks he or she received meals. The post-demonstration interview was the major evalua­tion tool used to assess the long-term demonstration. It was administered to all meal recipients at the conclusion of the program. Sections of the questionnaire covered an overall assessment of the program, packaging and delivery, fman­cial status, living conditions, transportation, self­sufficiency, and current eating habits. (See Appendix XI.) The extended interview schedule was administered to those participants who took part in the six-week extended program. Its major purpose was to provide information on the effect of the meals upon the participants' daily routine and their reaction to the meal system over a longer period of time. Several questions were designed to elicit informa­tion about possible boredom. (See Appendix XII.) SUMMARY The project evaluation had a two-fold purpose. First, it sought to provide information on the target populations' response to the meals and the delivery system. Second, it was designed to explore in detail several factors­nutritional, economic, and social-psychological variables­which are likely to be important in forming new policies. Five major variables-length of participation, geographic environment, method of meal delivery, amount of social contact, and income-which might affect the acceptability of the meal system were identified. Eight sites were selected on the basis of these variables. A total of 168 participants were selected for the long­term demonstration. Forty of them were selected to re­ceive weekend supplements; 128 were selected to receive 7 meals per week for 9 weeks and a group of 15-20 was to be selected to continue receiving the meals for an additional 6 weeks. Participants were selected on the basis of income, geographic location, and access to other services. The field network was set up to ensure the maximum amount of communication between the field coordinators for each site, the LBJ School, and UAE. Orientations were conducted to train field workers, delivery volunteers, and participants in the various aspects of the demonstration. All participants were required to have medical clearance through certification from their personal physicians or from a medical screening conducted especially for this demon­stration. The demonstration started the last week of January and first weeks of February. Meals were delivered to partici­pants by personal delivery or through impersonal delivery­the U.S. mail or van dropoff. Participant reactions to the meal system during the major field demonstration were elicited by dropout inter­views, meal evaluation postcards, post-demonstration inter­views, and interviews for those in the extended demonstra­tion. LBJ School students administered the interviews. CHAPTER V DEMONSTRATION RESULTS SAMPLE CHARACTERISTICS One-hundred sixty-eight elderly persons began the long­FIGURE V-2 term meals demonstration. Age, sex, and ethnicity are Income Sources and Other Benefits N = 136 summarized in Figure V-1. Almost three-quarters of the meal recipients were female, and nearly one-half of the user (73) group ranged in age from 71 to 80 years. Anglos were the largest ethnic group, comprising 51 percent of the sample. FIGURE V-1 AGE, SEX AND ETHNICITY Of THE PARTICIPANT POPULATION N•168 ""' .,.. SSA SSI SSI & SSA ""' ........ . . . . .. . . . .. ...... . . . . . . . . . . . . . .... (85) . . .. . . . .. . . . . . . . . . . . . . . . . . .. . . ... . . . . . . . . . . . . ... . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :::::::: ::::::::: .:·: . .·.·.·.· ·.·.·.·.· ·.·.·.·. }}ff~tt Anglo Bleck Me x-Am ETHNICITY Figure V-2 outlines the income supplements and services received by the participants. The majority , 54 percent, received Social Security benefits, while 28 percent received both Social Security and Supplemental Security Income. Sixty-five percent of the meal recipients obtained Medicare Medicaid Medicare Food Stamps benefits while 39 percent qualified for Medicaid coverage. Thirty-four percent of the user population also received Federal Food Stamps. Meal System for the Elderly Social Contact Two-thirds of the elderly participants in the NASA meal program lived alone. The remaining one-third lived with one other person, most frequently a spouse but in some cases a parent, sister, brother, or adult son or daughter. When the other occupant was elderly, both received the NASA meals. The social contacts experienced by the elderly in the program were of two kinds: 1. Contact with social service providers such as nurses, senior citizen aids, chore helpers, or homemakers. (In the case of home health, and alternate care partici­pants, service providers were often members of their family.) 2. Contact with members of their household, neighbors, friends, or relatives. When asked about their frequency of contact with social service providers, sixty percent reported having regular con­tact on either a weekly or bi-monthly basis, while 40 percent reported no regular contact. The service most frequently received by participants was transportation aid furnished by senior citizen vans or buses. (See Figure V-4.) Other services received included homemaker and chore help, congregate meals, and meals on wheels. Most persons FIGURE V-3 Social Contact N • 137 1101) (79} 66% 60% 75% (85} 40% contact 1·2 times a week 28% 33" daily contact hve alone have regular belong to have regular infrequent social service a senior contact with contact with contact citizen group or friends and friends and church group relations relatives who received homemaker and chore help were members of either the alternate care or home health group, while most who received meals were members of the weekend supplement group. The 60 percent figure is primarily a function of the way the sample was chosen. Local outreach was done through social service agencies in each site, and there was a tendency to select persons with whom contact was already estab­lished. In addition, two population groups-those in alter­nate care, and congregate and home delivered meal pro­grams-were selected because of their current service contact. Except for transportation service, many of the rural and small town residents had no other regular social service contact. 36% alternate congregate, transportation other care day care homemaker or service meals on wheels Most participants reported relatively frequent contact with friends and relatives. Twenty-eight percent had daily contact while 40 percent had contact once or twice a week. Most of this contact took the form of visits in the home of the participants, but also included seeing friends at a senior citizen center, and at church. A third of the sample was relatively isolated and only had social contact with friends and relatives every one or two months. In addition, 75 percent of the sample either belonged to a senior citizen group, church group, or participated in activities with other elderly persons. This high figure is also a function of the way the sample was chosen, and is not necessarily typical for elderly persons in Texas. Mobility Most of the NASA meal recipients were not homebound. Almost three-quarters reported they left home to run errands, pay bills,. visit the doctor, purchase food stamps, visit friends, and the like. Most were dependent, however, upon others for transportation assistance for all activities which required them to go beyond walking distance of their homes. Only 37 percent of the group owned and drove their own cars. The remaining 63 percent had to rely on friends, relatives, city buses, or senior citizen vans for transportation aid. The fact that only the urban areas of Houston and Austin have a public bus system underscores the importance of the senior citizen van as a major source of transportation for participants in the rural and small­town sites. FIGURE V-5 PARTICIPANT MOBILITY -(77) N-137 -63%== (52) _37%_ (35) (33) 26% _25" have difficulty have and do not leave shop for getting around drive home to groceries the house own car run errands weekly The poor health of the Paris alternate care participants and the Austin home health participants rendered them homebound-they did not leave their homes to run errands. Shopping was done for them by their homemakers or service providers. In other sites, approximately 20 percent of the meal recipients also reported they did not leave their homes to run errands because of poor health. Shopping was usually performed for these homebound persons by their relatives. Almost two-thirds of the elderly sample shopped for groceries, or had shopping done for them, on a weekly basis. Seventy-five percent stated that the store they shopped at most frequently was less than a mile from their house. Distance to the store was greatest in rural areas, but rural participants shopped just as frequently as did those in urban and small-town sites. When asked how they usually got their groceries home from the store, 14 percent said that they walked, 37 percent drove their own cars, 26 percent rode with friends or relatives, 11 percent used public transportation (usually senior citizen vans), and 12 percent used a combination of the preceding methods. Household Management Most NASA nieal recipients stated that they had no difficulty getting around in their homes and in performing routine cooking and cleaning chores. Arthritis, poor vision, emphysema, and heart condition did lead to some difficul­ties for approximately 20 percent of the regular 63-day and weekend participants. However, most had adapted their routines taking their medical problems into account and thus managed fairly well. A common complaint was not having as much energy as they used to because they were "getting old." When asked, "What kinds of services would you like to receive that would make living in your own home easier?", only 44 percent of the participants listed one or more Demonstration Results services. The reason for this low response rate is two-fold. First, some of the elderly participants prided themselves on their self-sufficiency and independence and felt they were getting along fine by themselves. Second, some elderly knew that they were getting all the services offered in their area, and that it would do little good to speculate about any others. For those 44 percent who did answer the question, mcst felt chore helpers for heavy yard work and cleaning, and homemakers for cooking and personal aid would make their lives easier. Eating Patterns Before NASA Meal Program Before participating in the NASA meals program, almost three-quarters of the elderly sample ate a hot meal daily. Ten percent had three to four hot meals a week, while 12 percent had a hot meal only once or twice a week. Four percent of the participants stated they never prepared a hot meal for themselves, but it is unclear whether this means they never ate hot meals or simply did not prepare them for themselves. The majority of participants usually cooked for them­selves. Only 20 percent stated they normally had someone else prepare meals for them. Of this number, most were home health or alternate care participants who had home­makers or service providers to cook their meals. In addition, there were some fairly infirm participants in the regular 63- 11.5 mg/dl 3 3 0 Triglycerides >200 mg/dl 32 34 18 Cholesterol >300 mg/di 16 18 5 Vitamin E <700 mcg/dl 8 3 0 Creatinine > 1.6 mg/dl 8 8 10 Blood Glucose >120 mg/di 3 11 5 Urea N2 > 30 mg/di 8 11 5 SGOT > 60 u/l 3 0 0 SGOP > 60 u/l 2 0 0 LDH >260 u/l 19 21 5 REFERENCES 1 Information was taken from participant application time for the computer run, thus the maximum number (N) forms. for any question is 137. Since not all participants answered 2 Information was taken from post-demonstration inter­every question, the number of responses varies from view forms. Only 137 questionnaires were completed in question to question. CHAPTER VI THE ECONOMICS OF THE NASA MEAL SYSTEM EVALUATION OF THE MEAL SYSTEM COSTS For the Nasa Meal System to be successful, it must be economically feasible besides being acceptable to its user population. Efforts have been made to determine how much the meals and a system of distribution would cost. The emphasis in this section is on the findings from the three-month field demonstration. Meal Costs NASA expended $38,950 for the 10,000 meals pro­duced for the long-term field demonstration . This figure includes the food, labeling, packaging and assembly costs of the meals and does not include any of the NASA research and development costs. When evaluating the costs of the meals for the Field Demonstration, several pertinent factors should be consid­ered. 1. Twelve of the 96 food items accounted for over 50 percent of the total food costs. These are the items that were packaged in the special single-serving sized cans. 2. Label costs were excessive because labeling could not be made part of the food production runs due to small quantities and schedule constraints. Economies of scale were impossible to achieve because of the high cost of producing such a small number of food items. 3. NASA reported that meal assembly could have been accomplished with less-skilled personnel. 4. No NASA overhead or R & D costs were included except as they appear in the cost of the meal assembly. According to the NASA figures, the costs of the meals can be broken down as follows: Items Total $ $ Per Meal Food and primary packaging $28,800 $2.88 Labels 7,500 . 75 Secondary Package 300* .03 Multi-meal box 350* .035 Meal assembly 2,000 .20 Total $38,950 $3.90 The highest and lowest cost meals are itemized below: High Cost-Menu No. 19 Item Cost Com $1.46 Beans w/tomato sauce 1.46 Chicken a' la King 1.46 Applesauce .50 Instant Vanilla Drink .30 Labels .40 Total $5.58 Low Cost-Menu No. 6 Item Cost Beef and rice w/onions $ .59 Creamed peas .38 Cottage cheese .45 Chocolate Crunch Bar .20 Instant Vanilla Drink .30 Labels .41 Total $2.33 The food items packaged in cans tended to be extra­ordinarily expensive because the small cans were produced especially for this meals program. This special production resulted in a very large per unit cost for the items packaged in these single-serving sized cans. According to NASA, use of the smaller cans increased the per unit average cost from $.25 for the standard size can to $1.46 for the cans specifically produced for this project. While the average cost per meal for food and primary packaging was $2.88, the average cost per meal would be approximately $1.60 once adjustments are made for the high cost of single-serving cans. These figures dramatically illustrate the high cost of the canned food items. The com, beans, and chicken items in Menu No. 19 were all packaged in the special run cans. Their costs can be compared to the costs of the food items in Menu No. 6-most of which were freeze-dried food items. The food costs for Menu No. 19 are only $1.55 when the high cost of special packaging is subtracted . *These figures are estimates of costs based on large production quantities. These items were provided to NASA by the manufacturer at no cost. Distribution and Delivery Costs Distribution costs were the expenses of transporting meals from Austin, the distribution center, to the field sites. Delivery costs consisted of reimbursements for mile­age for site volunteers taking meals to participants. Most of the distribution costs were incurred by LBJ students who delivered the meals (1) with their own cars (mileage reimbursement at 16 cents per mile), (2) with a university car (reimbursement for gas expenses only), or (3) by renting a car or van (all expenses). For a fair representation of the Field Demonstration distribution costs, note should be made of the following points: 1. NASA absorbed the costs of (a) transporting meals to Austin for further distribution, (b) delivering meals to Paris, (c) mailing meals to selected participants, and (d) transporting meals to the Houston site after the first delivery. 2. Several trips could have been avoided had there been fewer schedule conflicts. 3. If a greater number of meals were delivered, the program would have benefited from economies of scale. Delivery costs for the meals ranged from $1.55 to $.87 per seven-day pack for mileage reimbursement to volunteers making home deliveries. The average cost was about $1.20 per pack or $.17 per meal. (These costs are based on reimbursement figures for the five-county area since they were the only group to request payment on a consistent and well-documented basis.) Meals were mailed to 15 participants for 5 weeks and to 5 participants for an additional 5 weeks. Mailing costs were about $1.20 per seven-day pack-a cost comparable to the average cost of personal delivery. It should be noted that delivery in Waco, Falls County, Travis County, Houston, and Paris was incorporated into existing service systems, incurring no new delivery costs. OTHER CONSIDERATIONS An alternate meal system for the elderly should revolve around the creation of a complete, nutritionally balanced, shelf-stable, conveniently packaged, single-serving sized meal. At present, private enterprise has not used the concept of complete shelf-stable meals nor has it really advanced the development of single-serving sized con­tainers. According to the U.S. Army Natick Development Center, the main factor inhibiting innovations of this type has been the reluctance of private enterprise to gamble on new marketing ideas in this field. Two reasons for this are: (1) the traditional reluctance to gamble or experiment with new products and, (2) the spiraling costs of aluminum cans which makes single-serving food items relatively more expensive. Economics of the NASA Meal System If the cost of the meal system cannot be made competitive with the food presently marketed for the public, some alteration of the food system is in order. Flex pouches, currently awaiting FDA approval, provide a low-cost method for packaging single-serving food items. The items can be easily incorporated into a nutritionally balanced meal that is easily delivered by mail or volunteer. The savings in weight and bulk over the metal cans would be considerable-especially if the meals were to be mail­delivered. POLICY IMPLICATIONS Meal Cost Guidelines; Title VII Both Title VII of the Older Americans Act and Title XX of the Social Security Act provide for food services to the elderly. The ability of social service agencies to furnish meals with these funds up to this date has been grossly inadequate. At every congregate meal site visited for this project, long lists of elderly people waiting to join the programs indicate a large demand for services that is going largely unmet. A social worker with the home health agencies in Austin is discouraged by her inability to provide home-delivered meals for her patients. Further, many of the elderly who participated in this NASA meals project had never heard of, nor been invovled in a meals program, although they all fit the eligibility criteria. A conclusion to be derived from this situation is that there is a need for a substantial increase in the total appropriations for food programs through Title VII of the Older Americans Act and Title XX of the Social Security Act. Even with all of the meals programs being run at capacity, the need has hardly been touched. There is an apparent contradiction in the Federal legislation that expresses the desirability for alternate care (home care) over institutional care and yet severely limits the percentage of funds available for home-delivered meals. The elderly participants in the NASA meals project­especially those most likely to enter nursing homes­indicated an appreciation of the independence the meals system provided. This suggests that a meals system similar to the NASA system could play an integral role in maintaining the elderly in their own homes. However, it should be noted that before such a system could be made available on a larger scale, Title VII would have to be amended to provide for more home-delivered meals. Con­ gress has a bill before it which would do just this. (See Appendix XV.) Competitive Pricing-Costs of Other Food Programs To be considered as a partial solution to the nutritional needs of the elderly, the NASA system must be competitive Meal System for the Elderly with the costs of existing meal services. 1. Costs of Home-Delivered Meals According to the director of UAE, the major provider of home-delivered meals in Austin, the costs of that program are as follows: Number of clients as of 10/1/75 181 Number of clients as of 3/31/76 180 Number of meals served 10/1/75-3/31/76 27,790 Total cost per person per meal $ 1.76 Total operating costs $48,824.81 Total food costs $15,073.21 Raw food costs per meal $ 0.54 Six meals are delivered to each participant each week. Each meal consists of: (I) 2 oz. serving of cooked meat or meat alternative (1) 3 oz. serving of a starch (I) 3 oz. serving of a cooked vegetable (1) 3 oz. serving of a complementary vegetable or fruit ( 1) serving of bread (I) 8 oz. half pint of milk (1) 3 oz. serving of fruit or dessert Each meal attempts to provide one-third of Recommended Dietary Allowances (RDA). 2. Costs of Congregate Meals The costs of congregate meal programs were calculated from records from the Texas Governor's Committee on Aging (GCA). These calculations indicated a wide range of costs per meal, from a low of $1.92 per meal to a high of $2.97. Economies of scale are a major reason for the cost differences. Costs for the Travis County (Austin) site in the 1975 budget year were itemized as follows: Personnel $ 10,255 Equipment 3,250 Raw food 0* Travel 1,000 Consultants 300 Other 130,456* Total $145,261 Supplemental Social Services 30,441 Administration 25,041 Total $200,743 *A caterer provides the food and thus accounts for these two figures. A total of 404 elderly citizens are served each day at the seven congregate meal sites in Austin. The average cost per meal, including support and administration, is approxi­mately $1.90. Food costs are $1.29 per meal. According to the guidelines, each meal provides: (1) 3 oz. serving of meat ( 1) Yi cup serving of vegetables/fruit ( 1) serving Yi pint ot milk and pat of butter ( 1) serving bread or alternate (1) serving of Yi cup dessert 3. Costs of Homemaker Services Homemakers (funded through Title XX) often prepare meals for elderly citizens. A private contractor provides the services for the elderly, and charges the Texas Department of Public Welfare $7.35 per hour for homemaker services­which include light household chores, as well as meal preparation. Since most contract homemakers are only scheduled once every two weeks, they are not a regular source of meal preparation. However, individual providers may provide daily meal service through individual DPW contracts. The Texas DPW Director of Services for the Elderly welcomed the NASA meals because the elderly need every source of independence they can get. SUMMARY In order to be considered a viable alternative and/or addition to the current food programs for the elderly, the NASA meal system must be competitive in cost with the current food programs when operated on a larger scale. In other words, the cost of the food, administration, and delivery should range between $1.75 and $3. It appears that the new packaging technique of the flex pouches would greatly enhance the viability of this type of meals system. The total cost for the NASA meals ranges from a maximum of $5.80 to a minimum of $2.45 with an average cost of $3.05 per meal. If the high cost of special packaging could be reduced, the average cost per meal would be $2.17. (These figures all include meal costs and delivery costs.) Thus, should production of single-serving sized cans or flex pouches occur on a large scale, NASA meals would certainly become a viable option and a necessary supple­ ment to existing meal programs. CHAPTER VII THE POLICY IMPLICATIONS OF THE MEAL SYSTEM The Meals for the Elderly demonstration showed shelf­stable, nutritious, single-meal units to be popular, and beneficial. However, these types of meals are not currently available to the general public, or to public agencies. If mass produced, the cost of the meal system may fall within federal guidelines for Title VII meals for the elderly. The meals could also be used in a number of federal programs with similar cost guidelines. In addition, the meals may be inexpensive enough to be attractive for general use. What are the implications of this successful demonstra­tion? Should such meals be produced for the elderly? Are there other users who might find this meal concept equally beneficial? The potential of the meal system to meet a wide range of needs will be examined in the sections which follow. SOCIAL SERVICES This report has shown that the meals system can serve the needs of the elderly. But the system could also be of benefit to the handicapped, the ill, those without trans­portation, and those needing emergency relief on a short­term basis. The meals could be used to help many individuals who are homebound and prevented from shop­ping easily or regularly. For the handicapped, ease of preparation of the meals may mean less frustration in preparing ·hot meals, and thus promote a greater sense of personal independence. The Veterans' Administration is considering use of the meals system for their homebound veterans. Certain emergency situations-such as a house fire, or a severe personal problem-often arise creating a need for quickly available, easily prepared balanced meals . Providing prepackaged meals for persons in the midst of emergency situations would be an efficient way of taking care of their food needs. There may be situations where the meals could be used as a supplement or an adjunct to the food stamp program­for use on weekends before recipients can go to the food stamp office or during the waiting period between applica­tion for and receipt of the food stamps. Certain food stamp eligibles who cannot go shopping regularly might prefer to use their food stamps to purchase meals instead of purchasing individual food items in the grocery store . To those who criticize the food stamp program because it does not guarantee that recipients will buy a balanced diet , the meal system may be one way to achieve this objective. Thus there are many situations where the meals could fit into existing social service programs not so much as a substitute for current services, but as a flexible option to meet special needs as they may arise . DISASTER RELIEF AND EMERGENCY AID During the fifties considerable attention was given to the need for civil defense and emergency preparedness. While these concerns are less visible at the present time, con­ditions can change rapidly. The meals system needs to be evaluated for its potential in this context. The same is the case with regard to natural disasters, such as earthquakes and floods. Traditionally, aid to disaster victims takes the form of mass feeding programs, using army-type cooking facilities. Central food preparation makes it possible to control purity of water used-a consideration of prime importance following disruption of normal service. At the same time , dispersed individuals often are not reached and may go without food for several days in a row. The NASA meals system might provide additional flexibility in emergency and disaster relief efforts. Perhaps a supply of sterile water, sufficient for preparing the food items contained in each box, could be provided. Where use of freeze-dried foods is impractical, meals could consist wholly of canned or flex pouch items and water purification tablets could be included. The Defense Department, in particular the Army laboratory in Natick, Massachusetts, is developing emergency rations which will meet similar needs. INSTITUTIONAL USE The NASA meals system should be examined for potential use in hospitals , nursing homes, schools, and prisons. Complete conversion to individually prepared NASA-type meals is unlikely to meet the needs of any institution. But occasional use, during weekends, or to meet temporary manpower shortages might provide better and 45 Meal System for the Elderly more varied service than is now available. The meals could be used in some institutions as a first step in rehabilitation of some patients who would value the self sufficiency of a personally prepared meal. Having a standby meal system in case of equipment or power failure is also a consideration. New accreditation standards for hospitals require a minimum one-week standby supply of food. Many hospitals and nursing homes have to make arrangements to prepare special diet meals for patients. If the actual number needing such meals is low, the cost of the service is high. Purchase of a large order of prepackaged, shelf-stable. special diet meals may save time and money. RECREATIONAL AND PERSONAL USE Presently, freeze-dried foods are available at a high price to campers and recreational groups. The NASA meals eliminate the need for the careful calculations needed to put together several appetizing menus from mass quantity items. For those who do not need food for extended periods, packing several NASA meals could provide every­ thing necessary for a weekend hiking trip. Also , production of the NASA meals for many users would tend to lower the price of the meals to individuals. Many people want convenience foods which are of better quality than frozen foods or which take even less time to prepare. Others would like the convenience of having a preplanned, balanced meal as an alternative to TV dinners. The NASA meals could fill this need if they were commercially available at a reasonable price. INDUSTRY In the long run the meals concept developed by NASA will only survive if industry finds it commercially attractive. Many of the individual food items used as part of the meals are already commercially avaifable. However, rarely-if ever-is the concept carried to the point where food items are assembled into full meal units. Also the distribution system presently used for prepackaged meals is highly specialized, being restricted mainly to outlets catering to backpackers or mail order houses. In many instances food items have to be ordered in large numbers, which is attractive for such users as the Boy Scouts or Girl Scouts but not for individual consumers. Individuals can buy "a year's supply", but this requires a large investment at the time of purchase. In several countries, such as Japan, small individual-sized serving units similar to those used as part of the NASA demonstration, are widely available in commercial retail outlets. The German airlines use the system for some of their in flight meal service. Detailed market research con­cerning consumer reaction and cost comparisons with conventional food will need to be undertaken by industry itself. In the meantime there needs to be discussion between industry and government about possible coopera­tion in developing the meals concept prior to full com­mercialization. Such cooperation might take the form of government guaranteeing a certain production level for public sector use while industry simultaneously test mar­kets the meals. Since the meals do not need refrigeration once pro­duced, simple shelf storage is all that would be required on the part of supermarkets as well as the individual consumer. In contrast, 'TV dinners" need to be kept frozen from production through distribution to eventual consumption. Perhaps a research project should be initiated to measure the potential energy savings of a shelf-stable meals system. THE NEXT STEPS The meals for the elderly demonstration was only the first step in a longer process of testing which when completed, will show whether this new meals concept will survive and grow or join the ranks of stillborn innovations. In concluding this report, it is useful to reflect on the next steps in the development of the system. It should be noted, however, that neither NASA nor the LBJ School is in a position to take the leading role in this process. Our role will be limited to two functions: (1) to widely disseminate the results of the field demonstration, and (2) to help in assessing the potential of the meals system for a variety of public and private sector uses. This report, obviously, will be a principal source of information on the demonstration of the meals system with the elderly. A brochure highlighting program objectives and results was prepared and distributed by NASA. NASA also filmed a 20-minute documentary which is available to interested groups upon request. Faculty and student mem­bers of the LBJ research team have responded-and continue to do so-to invitations requesting reports on the project, and testimony was presented before two Congres­sional committees (see Appendix XIV). A number of articles are being prepared for publication in professional journals. Activities of this kind will continue for some time to come. The second task-assessing the potential of the meals system to meet a variety of needs, particularly in the public sector-is presently underway. Testimony to the U.S. Senate Select Committee on Nutrition and Human Needs preceded the introduction of the "National Meals-on-Wheels Act of 1976" in both Houses of Congress (S.3585, H.14450). The general thrust of this legislation is to improve nutritional services for the homebound elderly and thereby reduce the need for premature institutional care. A national demonstration of the meals system was proposed as part of the legislation: Policy Implications The bill would establish a demonstration project to study the National Aeronautics and Space Adminis­tration Meal Systems for the Elderly ... The NASA Meal System can effectively serve those persons who are geographically isolated, live in areas where no program exists, or are on waiting lists of programs with limited case loads. The pilot project would be conducted in portions of three States, chosen to provide an appropriate mix of rural and urban enviornments. Each demonstration project will include a medical evaluation to assess, at minimal inconvenience to the participants, the health benefits of nutritional support for the elderly. At the conclusion of the demonstration project, the Commissioner (Administration on Aging, HEW) shall report the results to Congress, together with recom­mendations for legislation which he deems appro­priate. (Senator George McGovern on introducing S. 3585, Congressional Record, June 17, 1976, p. S9755). The proposed legislation did not reach the floor for decision in either the House or Senate during the remaining months of the 94th Congress. However, the legislation is expected to be re-introduced early in 1977. The informa­tion and experience gained through the NASA demonstra­tion of the meals system will be at the disposal of those planning the larger demonstration proposed by the Con­gress. A number of local, state, and federal agencies have expressed interest in initiating demonstration projects of their own which would test the applicability of the system for a variety of user groups. The Veterans Administration, for example, is considering a project involving a substantial group of their homebound patients. For projects of this kind, the Johnson Space Center in Houston is prepared to make available its expertise and to establish contacts between user agencies and industry for production of the required number of meal units. The possibility of pooling requests of this nature, thus reducing production costs due to economies of scale, is being discussed. The culmination of the LBJ School/NASA efforts will be a jointly sponsored conference, to be held in the Spring of 1977. The conference will focus on the potential of the meals system to meet a variety of needs in the public sector and will provide a forum for industry-government dialogue. CONCLUSION The long process of technology transfer, in the case of the meal system, is still in its early stages. All those associ­ated with the project realize that this process is dependent on social and economic arrangements for making use of a new technical concept. The technological changes which are embodied in the meals system are simple and almost trivial: they consist of nothing more than reduction in size of food containers and assembling different food items into full meal units. These simple innovations now need to be tested for a variety of social uses, all necessitating some rethinking of delivery systems and "consumer" relations. What made sense for the user group of the elderly may not make sense for other groups. In each case, the social need to be served and the institutional mechanisms to achieve this goal have to receive detailed attention. The meal system has real potential when the technology used in the NASA meal system can help in meeting concrete social or economic needs. APPENDIX I NASA MEAL SYSTEM FOR THE ELDERLY-PROJECT SCHEDULE PROJECT OVERVIEW NASA MEAL SYSTEM FOR THE ELDERLY Milestones .j>. 00 Phase I System Development Phase 11 Preliminary Demonstration Phase 111 Field Demonstration 1975 1976 J F M A M J J A S 0 N DI J F M A M J J A S 0 N D ---·----­-·----­ ---· ······-·-" " -··-·. ·+--·-·· - .. --·---···-··· Phase IV Program Assessment \0 """ PHASE I: SYSTEM DEVELOPMENT NASA MEAL SYSTEM FOR THE ELDERLY Milestones J F M A M 1975 J J A S 0 N DI J F M A M 1976 J J A S 0 N D Preference and Attitude Survey Food System Design Food Selection, Technical Taste Test and Menu Development User Taste Test I :i:... 'ts 'ts ~ ::s l:l. !=(' ...... ~ !:.. ~ ~ "'~ Cl' .... ;;. "' ~ .... ~ Vl 0 PHASE 11 : PRELIMINARY DEMONSTRATION 1975 Milestones J F M A M J J Planning A S 0 N NASA MEAL SYSTEM FOR THE ELDERLY 1976 DI J F M A M J J A s 0 N D t---------------+------------------------------+----------------------·---·-----·-·· Participant Selection Demonstration Quick-Look Evaluation and Program Review I Final Evaluation and Design Review I PHASE IV: PROGRAM ASSESSMENT NASA MEAL SYSTEM FOR THE ELDERLY Milestones Final Report Workshops, Conferences* and Seminars 1975 1976 J F M A MJJASON DI J F M A M J J A s 0 N D :i:... ~ ;:s "' ~ 17<· *Conference planning will continue through March 1977. ...... APPENDIX II Menu 1 Menu 2 Menu 3 Menu 4 Menu 5 Menu 6 Menu 7 Meat Balls in BBQ Sauce Lima Beans Pineapple Peanut Butter Bar Instant Chocolate Drink Chicken Stew Tomato Soup Rice and Chicken Lemon Instant Pudding Instant Strawberry Drink Spaghetti and Beef in Tomato Sauce Cream Style Chicken Soup Lima Beans Chocolate Crunch Bar Instant Vanilla Drink Beef Stew Cream Style Corn Mixed Fruit Tapioca Pudding Instant Chocolate Drink Chicken a la King Green Pea Soup Corn Peanut Butter Bar Instant Strawberry Drink Beef and Rice w /Onions Creamed Peas Cottage Cheese Chocolate Crunch Bar Instant Vanilla Drink Chili Con Carne w /Beans Macaroni and Cheese Mixed Vegetables Banana Pudding Orange Drink MEAL SYSTEM FOR THE ELDERLY MENU LISTING AND NUTRITIONAL DATA January, 1976 Menu 8 Menu9 Menu 10 Menu 11 Menu 12 Menu 13 Menu 14 Noodles and Stroganoff Sauce w /Beef Cottage Cheese Creamed Peas Chocolate Instant Pudding Instant Strawberry Drink Beans and Franks in Tomato Sauce Cream of Mushroom Soup Green Beans Diced Peaches Instant Chocolate Drink Boned Chicken 'n Broth Cream Style Corn Stewed Tomatoes Vanilla Pudding Instant Strawberry Drink Vienna Sausage Corn Mixed Vegetables Butterscotch Pudding Hot Cocoa Drink Boned Turkey 'n Broth Sweet Potatoes Green Beans Mixed Fruit Instant Chocolate Drink Tuna a la Neptune Bean Soup Chicken Pilaf Lemon Instant Pudding Instant Vanilla Drink Spaghetti and Beef in Tomato Sauce Cream of Mushroom Soup Peas Chocolate Fudge Pudding Instant Strawberry Drink Appendix II MENU LISTING (CONTINUED) Menu 15 Boned Chicken 'n Broth Menu 19 Chicken a la King Scalloped Potatoes 'n Ham Beans w/Tomato Sauce Mixed Vegetables Com Peanut Butter Bar Applesauce Orange Drink Instant Vanilla Drink Menu 16 Chili-Mac Menu 20 Boned Turkey 'n Broth Cream Style Com Mixed Vegetables Stewed Tomatoes Applesauce Rice Pudding Tapioca Pudding Instant Vanilla Drink Instant Chocolate Drink Menu 17 Beef Almondine Menu 21 Vienna Sausage Spring Vegetable Soup Macaroni and Cheese Chicken Pilaf Green Beans Vanilla Instant Pudding Peanut Butter Bar Instant Chocolate Drink Hot Cocoa Drink Menu 18 Vegetable Stew w/Beef Tomato Soup Potatoes and Beef w/Onions Vanilla Instant Pudding Instant Chocolate Drink NOTE: Plans included the possibility of using thermostabilized foods in flexible pouches during the course of the demonstration. Should this have occured, the following six-menu substitutions would have been made. Menu l(FP) Chicken and Gravy Menu l 2(FP) Beef Loaf Lima Beans Lima Beans Pineapple Mixed Fruit Peanut Butter Bar Chocolate Crunch Bar Instant Chocolate Drink Instant Chocolate Drink Menu 5(FP) Beef and Onions Menu 15(FP) Beef Pattie Green Pea Soup Scalloped Potatoes Corn Mixed Vegetables Peanut Butter Bar French Apple Dessert Instant Strawberry Drink Instant Vanilla Drink Menu lO(FP) Ham Pattie Menu 19(FP) Frankfurters Green Beans Beans in Tomato Sauce Beans in Tomato Sauce Corn French Peach Dessert Applesauce Instant Strawberry Drink Instant Vanilla Drink ~ ~ ~ r:., Meat Balls in BBQ Sauce Lima Beans Pineapple Peanut Butter Bar Chocolate Instant Drink TOTALS 4.8 oz. 283 0.240 5.00 4.62 582 20.8 38.0 172.0 0.070 10.30 2.30 15.60 ~ ... ~ 5 oz. 110 0.60 7.00 218 0.060 6.2 32.0 81.0 0.030 0.30 2.80 21.00 5 oz. 87 0.045 15.00 0.45 0.6 24.0 12.0 90 0.150 0.15 0.60 22.65 1.5 oz. 210 20.25 0.090 5.00 6.0 1000 50.0 50.0 0.300 11.00 4.50 21.00 8 oz. 210 21.15 15.0 1500 0.540 5.00 350.0 300.0 0.390 1.00 4.50 35.00 813 48.6 22.75 115. 25 494.0 0.975 15.67 68.40 615.0 3390 14.70 0.940 mg. mg. Menu No. 2 IU mg. mg. gm.CHO mg.Ca mg.P. mg.Fe Vit A Thiamin Riboflavin Niacin Vit C Food and Description Kcal gm.Pro gm.Fat .. Chicken Stew Vt Tomato Soup Rice 'n Chicken Lemon Instant Pudding Strawberry Instant Drink TOTALS 0.038 8 oz. 216 15.68 7.84 21.52 20.03 46.85 0.32 449.8 0.060 1.89 3.30 0.72 0.80 0.036 1.00 80 1.00 20.00 6 oz. 17.00 47.52 0.090 1.08 2.00 10.80 3.31 24.05 0.62 53.9 0.086 8 oz. 324 9.36 0.225 0.45 4.00 31.00 150.00 325.00 250.0 0.045 4 oz. 140 0.540 5.00 21.15 8 oz. 210 15.00 1.00 35.00 350.00 0.390 300.00 4.50 1500.0 .951 45.34 8.77 152.04 970 20.64 543.34 6.16 0.559 26.90 695.90 2253. 7 mg. mg. mg. Menu No. 3 mg. IU Vit C Food and Description Riboflavin Niacin Thiamin gm.Pro gm.Fat gm.CHO mg.Ca Vit A Kcal mg.P. mg.Fe Spaghetti 'n Beef 7.5 oz. 3.70 0.170 0.170 238 11.8 14.7 27.0 26.0 1802 128.0 2.60 Cream Style Chicken Soup 6 oz. 0.060 0.32 2.0 5.0 10.0 --~-­ 90 7.00 0.030 0.60 Lima Beans 5 oz. 0.060 6.2 21.0 0.3 218 110 2.80 32.0 81.0 5.00 Chocolate Crunch Bar 1.5 oz. 0.300 6.0 21.0 0.090 12.0 220 4.50 50.0 50.0 5.00 Vanilla Instant Drink 8 oz. 35.0 0.390 21.1 5 15.0 1.0 210 1500 0.540 4.50 350.0 300.0 114.0 33.3 868 41.0 TOTALS 3520 0.890 28.15 458.0 14.40 14.62 0.920 559.0 Vl Vl -----------~-----~~c_o_-=--·-I ----~"'."'.--c-I • ---'"-' I ~=> --= '"-"' I ....,_~,,,... _.,. I ---=-=----'------­ mg. mg. mg. mg. Menu No. 4 IU VitC Niacin Riboflavin Food and Description Thiamin mg.Fe Vit A Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. 4.00 Beef Stew 7.5 oz. 0.170 4513 0.080 186.0 16.90 73.0 2.600 5.60 16.40 38.0 7.08 0.090 1.26 Cream Style Corn 5 oz. 0.038 3.15 0.60 30.00 94.5 0.680 132.3 189 0.40 45.00 200 0.036 Mixed Fruit 5 oz. 100.0 27.00 0.360 30.00 170.0 0.030 0.180 3.00 4.00 150.0 0.40 100.0 0.360 Tapioca Pudding 5 oz. 35 .00 0.390 0.540 210.0 1.00 350.0 1500 21.15 15.00 300.0 4.500 5.00 Chocolate Instant Drink 8 oz. 1.016 798.3 138.40 0.538 11.06 11.20 538.0 6400 73.23 38.05 567.5 8.500 TOTALS ----···----·-··-----­ ·----­ Menu No. 5 Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe IU Vit A mg. Thiamin mg. Riboflavin mg. Niacin mg. VitC Chicken a la King Green Pea Soup 5.0 oz. 6.0 oz. 186.0 130.0 19.10 7.00 5.00 1.00 7.50 20.00 50.0 20.0 193.00 ---­ 1.30 I.44 174.0 ---­ 0.010 --­ 0.220 0.144 6.37 1.20 2.00 -­ Corn Peanut Butter Bar Strawberry Instant Drink 5.0 oz. 1.5 oz. 8 oz. 98.0 210.0 210.0 2.82 6.00 15.00 0.88 11.00 1.00 23.21 21.00 35.00 5.9 50.0 350.0 71.78 50.00 300.00 0.59 4.50 4.50 400.4 1000.0 1500.0 0.044 0.300 0.390 0.077 0.090 0.540 1.34 5.00 5.00 7.43 20.25 21.15 TOTALS 834.0 49.92 18.88 106.71 475.9 614.78 12.33 3074.4 0.744 1.071 18.91 50.83 Menu No. 6 IU mg. mg. mg. Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe Vit A Thiamin Riboflavin Niacin Beef & Rice w/Onions 8 oz. 256.0 13.36 5.60 38.60 7 .13 48.00 1.00 3.6 0.086 0.100 1.400 Creamed Peas 4.5 oz. 151.9 5.30 2.80 22.30 60.10 118.41 1.12 207.0 0.095 0.080 0.910 Cottage Cheese 5 oz. 135.0 5.28 4.92 17.43 209.00 54.00 1.18 ----­ 0.008 0.201 0.098 Chocolate Crunch Bar 1.5 oz. 220.0 6.00 12.00 21.00 50.00 50.00 4.50 --­ 0.300 0.090 5.000 Vanilla Instant Drink 8 oz. 210.0 15.00 1.00 35.00 350.00 300.00 4.50 1500.0 0.390 0.540 5.000 TOTALS 981.9 44.94 28.82 134.33 676.23 570.41 12.30 1710.6 .879 1.011 12.408 mg. Vit C 2.75 IO .SO 21.15 34.40 :i:... :g ;::s ~ >(• ~ Ul "' Menu No. 7 mg. JU Food and Description Thiamin Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe Vit A Chili Con Carne w/Beans 7.75 oz. Macaroni & Cheese 7.5 oz. Mixed Vegetables 5 oz. Banana Pudding 5 oz. Orange Drink 8 oz. TOTALS 295.0 213.8 100.0 180.0 132.0 920.8 17.40 8.78 5.00 3.00 34. 18 14.40 9.00 0.46 5.00 28.86 23.9 24.0 20.9 30.0 32.8 131.6 77.0 186.8 39.0 100.0 84.0 486.8 227 171 98 100 139 735 4.7 0.9 2.0 0.1 7.7 1451 248 7734 2077 11510 0.09 0.11 0.19 0.03 0.42 ---r.·­ Menu No. 8 mg. mg. JU Food and Description Kcal gm.Pro Riboflavin gm.Fat gm.CHO mg.Ca mg.P. mg.Fe Vit A Thiamin Beef Stroganoff 8 oz. Cottage Cheese 5 oz. Creamed Peas 4.5 oz. Chocolate Instant Pudding 4 oz. Strawberry Instant Drink 8 oz. TOTALS 240.0 135.0 151.9 150.0 210.0 886.9 10.16 5.28 5.30 4.00 15.00 39.74 12.76 4.92 2.80 1.00 1.00 21.88 23.94 17.43 22.30 34.00 35.00 132.67 15.70 209.00 60.10 150.00 350.00 469.80 37.70 54.00 118.41 375.00 300.00 884.81 0.36 1.18 1.12 4.50 7.16 71 207 250 1500 2028 0.020 0.008 0.095 0.045 0.390 0.558 -----··· mg. Riboflavin mg. Niacin 0.180 0.225 0.109 0.180 0.694 0.040 0.201 0.080 0.225 0.540 1.086 5.5 0 0.90 1.72 8.12 mg. Niacin ~--·-'"' 0.590 0.098 0.910 5.000 6.598 mg. Vit C 12.50 185.00 197.50 mg. Vit C _.......,.,, _____ .25 10.50 .45 21.15 32.35 [ ~ '"' ~ 'C' .... .... ;:,­ ~ ~ ~ .... ~ Menu No. 9 Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe JU Vit A mg. Thiamin mg. Riboflavin mg. Niacin mg. Vit C Beans & Franks in Tomato Sauce 8.75oz. 399.0 20.40 17.7 39.14 157 28.40 6.00 319 0.18 0.180 2.70 --­ Cream of Mushroom Soup 6 oz. 100.0 2.00 3.0 17.00 40 --­ ---­ -­ ---­ 0.108 0.40 --­ Green Beans 5 oz. 25.2 1.26 --­ 5.04 38 25.20 0.90 788 0.04 0.090 0.25 2.80 Diced Peaches 5 oz. 110.0 --­ --­ 28.00 --­ --­ 0.36 300 --­ 0.360 0.80 45.00 Chocolate Instant Drink 8 oz. 210.0 15.00 1.0 35.00 350 300.00 4.50 1500 0.39 0.540 5.00 21.15 TOTALS 844.2 38.66 21.7 124.18 585 353.60 11. 76 2907 0.61 1.278 9.15 68.95 Menu No. 10 Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe IU Vit A mg. Thiamin mg. Riboflavin mg. Niacin mg. Vit C Chicken 'n Broth Cream Style Corn Stewed Tomatoes Vanilla Pudding Strawberry Instant Drink 5 oz. 5 oz. 5 oz. 5 oz. . 8 oz. 215 132 44 190 210 37.50 3.15 1.00 3.24 15.00 7.0 0.6 -5.0 1.0 -­30.0 10.0 32.0 35.0 20 -­40 100 350 205.0 94.5 20.0 100.0 300.0 2.00 0.68 0.72 4.50 4.50 345 189 750 --­1500 0.05 0.04 0.06 0.03 0.39 0.150 0.090 0.036 0.180 0.540 13.00 1.26 0.80 -­5.00 -­7.08 15.75 --­21.15 TOTALS 792 59.89 13.6 107.0 510 719.5 12.40 2784 0.57 0.996 20.06 43.98 Menu No. 11 Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca. mg.P. mg.Fe IU Vit A mg. Thiamin mg. Riboflavin mg. Niacin mg. Vit C Vienna Sausage Corn Mixed Vegetables Butterscotch Pudding Cocoa Drink 5 oz. 5 oz. 5 oz. 5 oz. 6 oz. 360.0 98.0 100.0 180.0 100.0 21.00 2.82 5.00 3.00 4.00 29.70 0.88 0.46 5.00 --­ 0.45 23 .21 20.90 31.00 22.00 12.0 5.9 39.0 100.0 100.0 299.50 71.28 98.00 100.0 -­ 3.15 0.59 2.00 -­0.36 --­400.4 7734.0 --­- 0.120 0.044 0.190 0.030 .030 0.195 0.077 0.109 0.180 0.180 3.90 1.34 1.72 -- --­7.43 12.50 -0.90 TOTALS 838.0 35.82 36.04 97.56 266.9 568.78 6.10 8134.4 0.414 0.741 6.96 20.83 Vl -.l Menu No. 12 Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe IU Vit A mg. Thiamin mg. Riboflavin mg. Niacin mg. Vit C Turkey w/Broth 5 oz. 303.0 31.35 18.75 --­ 20.0 205.0 2.10 195 0.030 0.210 7.05 -­ Sweet Potatoes 5 oz. 171.0 1.50 0.30 41.25 19.5 43.5 1.05 7500 0.045 0.045 0.90 12.00 Green Beans 5 oz. 25 .2 1.26 -­ 5.04 38.0 25.2 0.90 788 0.040 0.090 0.25 2.80 Mixed Fruit 5 oz. 100.0 -­ -­ 27.00 -­ -­ 0.36 200 ---­ 0.036 0.40 45.00 Chocolate Instant Drink 8 oz. 210.0 15 .00 1.00 35.00 350.0 300.0 4.50 1500 0.390 0.540 5.00 21.15 TOTALS 809.2 49.11 20.05 108.29 427.5 537.7 8.91 10,183 0.505 0.921 13.60 80.95 :i:.. '1::S '1::S "';::i ~ ):(• t::: mg. mg. mg. Menu No. 13 mg. JU Vit C Niacin Riboflavin Food and Description Thiamin mg.P. mg.Fe Vit A Kcal gm.CHO mg.Ca gm.Pro gm.Fat [ Tuna a la Neptune 5 oz. 157.9 12.00 5.47 15.26 ---­ ---­ --­ ----­ ----­ ----­ ---­ ---­ . Bean Soup 6 oz. 110.0 6.00 1.00 18.00 40.0 ----­ 1.80 -----­ -----­ 0.036 0.40 ----­ Chicken Pilaf 8 oz. 328.0 11.76 11. 76 42.78 3.7 52.8 .64 53.9 0.070 0.110 1.57 1.85 Lemon Instant Pudding 4 oz. 140.0 4.00 ---­ 31.00 150.0 325 .0 ----­ 250.0 0.045 0.225 ---­ 0.45 Vanilla Instant Drink 8 oz. 210.0 15.00 1.00 35.00 350.0 300.0 4.50 1500.0 0.390 0.540 5.00 21.15 TOTALS 945.9 48.76 19.23 142.04 543.7 677.8 6.94 1803.9 0.505 0.911 6.97 23.45 ~ "' ~ 'C' .... .... ~ "' t?:J IS: .... "' ~ mg. mg. mg. mg. JU Menu No. 14 Vit C Niacin Riboflavin mg.Fe Vit A Thiamin gm.CHO mg.P. gm.Pro gm.Fat mg.Ca Food and Description Kcal 3.70 1.170 1802 0.170 2.60 14.7 27.0 26.0 128.0 238 11.8 Spaghetti 'n Beef 7.5 oz. 0.108 0.40 40.0 17.0 2.0 3.0 Cream of Mushroom Soup 6 oz. 100 9.92 0.095 0.090 1.00 1.13 630 25.2 63.0 12.6 Peas 5 oz. 4.4 0.6 69 0.180 0.40 1.08 0.030 100.0 31.0 100.0 4.0 6.0 190 Chocolate Pudding 5 oz. 0.540 5.00 4.50 35.0 0.390 21.15 350.0 1500 300.0 15.0 1.0 Strawberry Instant Drink 8 oz. 210 2.088 3932 0.685 9.31 10.50 122.6 541.2 31.07 591.0 37.2 25.3 TOTALS 807 Ul 00 Menu No. 15 Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe JU Vit A mg. Thiamin mg. Riboflavin mg. Niacin mg. Vit C Chicken 'n Broth 5 oz. 215.0 37.50 7.00 --­ 20.0 205.0 2.00 345 0.050 0.150 13.00 -­ Scalloped Potatoes 'n Ham 7.5 oz. 209.5 16.31 2.79 23.60 71.9 149.2 2.04 181 .214 .151 1.40 18.24 Mixed Vegetables 5 oz. 100.0 5.00 0.46 20.90 39.0 98.0 2.00 7734 0.190 0.109 1.72 12.50 Peanut Butter Bar 1.5 oz. 210.0 6.00 11 .00 21 .00 50.0 50.0 4.50 1000 0.300 0.090 5.00 20.25 Orange Drink 10 oz. 132.0 -­ -­ 32.80 84.0 139.0 0.10 2077 - -­ -­ 185.00 TOTALS 866.5 64.81 21.25 98.30 264.9 641.2 10.64 11,337 0.754 .500 21.12 235.99 mg. mg. mg. mg. IU Menu No. 16 Vit CNiacinRiboflavinThiaminVit Amg.P. mg.Fe Food and Description gm.Pro gm.Fat gm.CHO mg.Ca Kcal 4.30 10.60 - 1250 0.170 3.30 162.0 0.170 Chili-Mac 8.5 oz. 275.0 13.5 31.4 77.0 1.26 7.08 Stewed Tomatoes 5 oz. 0.60 0.68 0.090 0.038 94.5 18930.0 Cream Style Com 5 oz. 132.2 3.15 0.80 15.75 Rice Pudding 5 oz. 0.036 0.72 0.060 - 75020.0 44.0 10.0 40.0 1.00 .030 0.80 0.144 5.00 34.0 100.0 150.0 200.0 4.00 5.00 4.50 21.15 0.540 15001.00 0.390 15.00 35.0 210.0 350.0 300.0 Vanilla Instant Drink 8 oz. 11.16 43.98 10.20 0.980 368917.20 0.688 TOTALS 861.2 36.65 140.4 617.0 676.5 Menu No. 17 IU mg. mg. mg. mg. Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe Vit A Thiamin Riboflavin Niacin Vit C Beef Almondine 6 oz. 165.0 12.96 5.87 14.54 -­ --­ ---­ ---­ --­ --­ -­ --­ Spring Vegetable Soup 6 oz. 45.0 1.00 1.00 8.00 -­ -­ .36 ---­ ---­ .036 .40 -­ Chicken Pilaf 8 oz. 328.0 11.76 11.76 42.78 3.70 52.80 .64 53.9 .070 .110 1.57 1.85 Vanilla Instant Pudding 4 oz. 140.0 4.00 --­ 31.00 150.00 325.00 --­ 250.0 0.045 0.225 -­ 0.45 Chocolate Instant Drink 8 oz. 210.0 15.00 1.00 35.00 350.00 300.00 4.50 150.0 0.390 0.540 5.00 21.15 TOTALS 888.0 44.72 19.63 131.32 503.70 677.80 5.50 1103.9 I 0.505 0.911 6.97 23.45 V\ \D mg. mg. mg. Food and Description mg. IU Menu No. 18 Riboflavin Vit C mg.P. mg.Fe Vit A Thiamin Niacingm.CHO mg.Ca gm.Pro gm.Fat Kcal 0.026 0.45 505.9 0.040 0.56 2.75 7.12 25.52 6.98 12.00 216Vegetable Stew w/Beef 8 oz. 0.80 0.72 0.036 1.00 17.00 20.00 1.00 80Tomato Soup 6 oz. 14.10 27.90 42.30 2.17 0.085 0.187 3.14 23.64 13.32 162.00 288Potatoes w/Beef 8 oz. 325.00 250.0 0.045 0.225 31.00 150.00 0.45 4.00 140Vanilla Instant Pudding 4 oz. 350.00 4.50 1500.0 0.390 0.540 35.00 300.00 5.00 21.15 1.00 210 15.00 Chocolate Instant Drink 8 oz. 0.560 9.50 787.00 7.84 2255.9 22.44 136.42 569.28 1.014 46.10 47.99934 TOTALS ·­ ::i... ~ ~ ;:s "' 1:1. >(• q - mg. mg. Menu No. 19 mg. mg. IU Vit C Niacin Food and Description Riboflavin Thiamin Kcal gm.Pro mg.P. mg.Fe Vit A gm.Fat gm.CHO mg.Ca Chicken a la King 5 oz. 6.37 2.00 7 .50 50.0 0.010 5.00 193.00 174.00 186.0 19.10 1.30 0.220 l.35 0.050 0.135 Beans in Tomato Sauce : 5 oz. 204.0 424.50 10.35 1.95 36.30 196.50 2.55 85.5 7.43 l.34 0.077 Corn 5 oz. 0.044 98.0 2.82 400.40 0.88 23.21 71.28 0.59 5.9 1.49 0.015 Applesauce 5 oz. 0.030 135.2 0.30 0.75 59.40 0.15 35.34 7.48 5.9 21.15 5.00 1500.00 0.390 0.540 Vanilla Instant Drink 8 oz. 4.50 15.00 35.00 1.00 350.0 300.00 210.0 14.06 32.07 0.609 9.69 2558.30 0.902 TOTALS 47.57 8.98 137.35 497.3 768.26 833.2 [ ~ .., ...... "" °C' .... ;;. "" ~ ~ .... ~ ----·-~· Menu No. 20 Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe IU Vit A mg. Thiamin mg. Riboflavin mg. Niacin mg. Vit C Turkey w/Broth Mixed Vegetables Applesauce Tapioca Pudding Chocolate Instant Drink 5 oz. 5 oz. 5 oz. 5 oz. 8 oz. 303.0 100.0 137.6 170.0 210.0 31.35 5.00 0.30 3.00 15 .00 18.75 0.46 0.15 4.00 1.00 --­20.90 35.99 30.00 35.00 20.0 39.0 6.0 150.0 350.0 205.0 98.0 7.6 100.0 300.0 2.10 2.00 0.75 0.36 4.50 195 7734 60 ---­1500 0.030 0.190 0.030 0.030 0.390 0.210 0.109 0.015 0.180 0.540 7.05 1.72 --­0.40 5.00 --­12.50 1.50 --­21.15 TOTALS 920.6 54.65 24.36 121.89 565.0 410.6 9.71 9489 0.670 1.054 14.17 35.15 0 °' Menu No. 21 Food and Description Kcal gm.Pro gm.Fat gm.CHO mg.Ca mg.P. mg.Fe IU Vit A mg. Thiamin mg. Riboflavin mg. Niacin mg. Vit C Vienna Sausage 5 oz. 360.0 21.00 29.7 0.45 12 299.5 3.15 --­ 0.12 0.195 3.90 --­ Macaroni & Cheese 7.5 oz. 213.8 8.78 9.0 24.00 186 171.0 0.90 248 0.11 0.225 0.90 --­ Green Beans 5 oz. 25.2 1.26 ---­ 5.04 38 25.2 0.90 788 0.04 0.090 0.25 2.80 Peanut Butter Bar 1.5 oz. 210.0 6.00 11.0 21.00 50 50.0 4.50 1000 0.30 0.090 5.00 20.25 Cocoa Drink 6 oz. 100.0 4.00 --­ 22.00 100 -­ 0.36 --­ 0.03 0.180 -­ 0.90 TOTALS 909.0 41.04 49.7 72.49 386 545.7 9.81 2036 0.60 0.780 10.05 23.95 APPENDIX Ill PARTICIPANT APPLICATION AND AGREEMENT FORMS NAME AGE BIRTHDATE ADDRESS CITY ZIP PHONE # ETHNICITY DATE SEX INTERVIEWER'S NAME SOCIAL SECURITY #--­ 1. FINANCIAL RESOURCES: (INDICATE MONTHLY AMOUNT) SSI SS MEDICARE ___MEDICAID____PENSION___OTHER(SPECIFY) ____ t.. MONTHLY EXPENSES: (INDICATE MONTHLY AMOUNT) RENT_________ UTILITIES FOOD STAMPS DR. OR DRUGS TAXES INSURANCE FOOD AND NECESSITIES OTHER_______ 3. DOES APPLICANT LIVE ALONE? __IF NOT, WHO LIVES WITH THIS PERSON? GIVE ANY RELEVANT DETAILS -------------------~ 4. DOES THE APPLICANT HAVE A CAR?__IS HE/SHE ABLE TO DRIVE? _____ DOES HE/SHE DO ROUTINE SHOPPING ALONE?___WITH HELP? ____ HOW OFTEN? WHERE? 5 . CAN THE APPLICANT READ AND/OR WRITE? _____ HOW MANY YEARS OF EDUCATION HAS HE/SHE HAD?_____________________ 6. HOW FAR IS THE APPLICANT FROM HIS/HER MAILBOX?___________ 7. WHERE IS THE APPLICANT LOCATED IN RELATION TO A POPULATION CENTER? 8. DOES THE APPLICANT HAVE ANY DIETARY RESTRICTIONS?_________ DIABETIC_____CALORIC INTAKE/DAY___SODIUM RESTRICTION___ ______GRAM INTAKE______OTHER (SPECIFY) _________ 9 • DATE OF LAST MEDICAL CONTACT NAME OF DOCTOR-----­ 10. WHAT SERVICES HAS THE APPLICANT RECEIVED IN THE PAST FIVE YEARS? ~NTHS IN THE LAST 6 _______________________ 11. HOW HAS APPLICANT MANAGED TO DATE? WHAT CONTACTS DOES HE/SHE HAVE WITH FRIENDS, FAMILY, ETC.?____________________ 12. ANY OTHER INFORMATION THAT WOULD BE HELPFUL IN UNDERSTANDING THE APPLICANT'S SITUATION?______________________ Meal System for the Elderly 13. DOES THE APPLICANT HAVE A: STOVE~~HOT PLATE~~REFRIGERATOR~~~ RUNNING WATER COOKING UTENSILS ~~~--~~~~~~~~~~~~~~~­ *+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+*+ NET INCOME~~~~~~~-APPLICANTS NAME CAME FROM: SITE COORDINATOR OUTREACH WORKER SERVICE WAITING LIST OTHER ~~~~--~~~~--~~~~~~­ NASA, the LBJ School of Public Affairs, and United Action for the Elderly (UAE) have joined in a venture to deliver shelf-stable, nutritious meals to homebound elderly persons with no known dietary restrictions. Each meal will provide at least 1 /3 of the daily recommended dietary allowance for your age group. In addition, all foods and packaging you will receive have been approved by the Food and Drug Administration (FDA). This program seeks to know. .. l. If the food is acceptable (tastes good, easily chewed, etc.) 2. If the food is easy to prepare 3. If the packaging is easy to open 4. If the packaging is convenient for storage purposes Your name has been suggested as a participant in this project. Knowing the purposes of the project, as outlined above, we would like to have your consent to participate in it. You will be provided with one meal a day, * for * * . The meal packages will be delivered to you once a week. If you agree to participate, we would like your comments on the meals, the meal packaging, the system of delivery , and the overall program. All personal information you may provide us will remain strictly confidential. Your name will not be used in any report or description of the project. You have the right to withdraw from the project at any time. Having read and understood the above, and having had the possible and attendent risks explained to me, I agree to participate in the NASA, LBJ School, UAE project in Meal Systems for the Elderly. FILL IN THE APPROPRIATE BLANK *seven days a week Signature of Subject *two days a week **nine weeks Date **fifteen weeks Signature of Witness APPENDIX IV RES ~ ME~ MEAL EVALUATION FORM-2 WEEK DEMONSTRATION 1. PLEASE FILL IN THE TIME OF DAY YOU ATE THIS MEAL -------A.M. PJ,EASE CIRCLE ONE ANSWER FOR EACH OF THE FOLLOWING QUESTIONS 2. THIS MEAL WAS EATEN ON MON TUES WED THURS FRI SAT SUN 3. OPENING THE INDIVIDUAL FOOD PACKAGES WAS .••• EASY A LITTLE HARD VF:RY HARD COMMENTS 4. · PREPARING THE FOOD ITEMS WAS EASY A LITTLE HARD VERY HARD COMMENTS -------------------------------­CIRCLE THE ANSWER THAT BEST DESCRIBES YOUR FEELING ABOUT EACH FOOD ITEM. s. BEEF & RICE W/ ONIONS 6. PEAS 7. COTTAGE CHEESE 8. CHOCOLATE CRUNCH BAR 9. VANILLA DRINK HOW FOOD TASTES GOOD FAIR POOR GOOD FAIR POOR GOOD FAIR POOR GOOD FAIR POOR GOOD FAIR POOR HOW FOOD LOOKS GOOD FAIR POOR GOOD FAIR POOR GOOD FAIR POOR GOOD FAIR POOR GOOD FAIR POOR 10. AS A WHOLE, THE MEAL WAS ••.. GOOD FAIR POOR 11. DID THIS MEAL GIVE YOU ENOUGH TO EAT? YES NO 12. WHICH FOOD ITEMS DID YOU HAVE LEFT OVER? 13 . WHICH FOOD ITEM DID YOU LIKE THE MOST?---------------~ NHY? ---------------------------------­ 14. WHICH FOOD ITEM DID YOU LIKE THE LEAST?---------------~ 15. WHAT ELSE HAVE YOU EATEN TODAY? Meal System for the Elderly 16. WHAT ELSE DO YOU PI.A.~ TO EAT TODAY? 17. WOULD YOU LIKE TO EAT THIS MEAL AGAIN? YES NO WHY? 18. WHAT ARE YOCR OVERJ'\L~ ~0Ml-'£NTS A~OVT THIS MEAL (FOOD, PACKJ\GING, ? REPARATION , ETC) ---------------------------------·-· RES MEA~L-G-.A-.-­ LA FORMA DE EVALUCATION DE COMIDA NOMBRE __________________ FECHA ------------­ I 1. POR FAVOR DE INDICAR LA HORA EN QUE TOMO ESTOS ALIMENTOS. A.M. P.M. POR FAVOR MARQUE LA RESPUTA INDICADA 2. lEN QUE DlA TOM6 ESTOS ALIMENTOS? LUN MAR MIE JUE VIE SAB DOM 3. lTUVO DIFICULTAD AL ABRIR LOS PAQUETES? NO SI-I'OCA SI-MUCHA COMENTARIOS 4. lTUVO DIFICULTAD EN LA PREPARACI6N DE LOS ALIMENTOS? NO SI-POCA SI-MUCHA COMENTARIOS POR FAVOR MARQUE LA RESPUTA INDICADA I ESTABA SABROSA SE MIRA 5. RES CON ARROZ y CEBOLLA BUENO REGULAR MALO BUENO REGULAR MALO 6. CHICHAROS BUENO REGULAR MALO BUENO REGULAR MALO 7. QUESO DESCREMADA BUENO REGULAR MALO BUENO REGULAR MALO 8. POSTRE DE CHOCOLATE !BUENO REGULAR MALO BUENO REGULAR MALO 9. BEBIDA DE VAINIL!A !BUENO REGULAR MALO BUENO REGULAR MALO 10. k\ ~OMIDA ENTERA FUE BUENA REGULAR MALA COMENTARIOS SI NO lQUEDO USTED SATISFECHO DESPUES DE ESTA COM!DA? COMENTARIOS 11. Appendix JV 12. lSOBRO COMIDA? SI NO lQUE PLATILLO SOBRARON? _____~~­lPORQUE? 13. lQUE PLATILLO LE GUSTO MAS? lPORQUE? 14. lQUE PLAT!LLO NO LE GUSTO? lPORQUE? 15. lQUE MAS HA COMIDO USTED HOY? 16. cOUE MAS VA A COMER USTED HOY? 17. lLE GUSTARIA COMER ETOS PLATILLOS OTRA VEZ? SI !J(l (. PORQUE? lP.. ST USTED DESEA, OUEDE COMENTAR S0!3RE LA COMIDJ\ EN GSNERJ\L. ------------------·-·--------------~--------­ APPENDIX V POST-DEMONSTRATION QUESTIONNAIRE-2 WEEK DEMONSTRATION PARTICIPANT'S NAME PARTICIPANT'S ADDRESS INTERVIEWER DATE Overall Program Evaluation 1. What did you think about this meals program? 2. What did you like most about this program? 3. What did you like least about the program? 4. Would you continue in this meals program if you could? YES NO If not, why? 5. Would you recommend this food program to your friends? YES NO 6. Did you enjoy the kind of food in this program? YES NO 7. Some people prefer either the canned or the freeze-dried food. Which did you prefer? CANNED FREEZE-DRIED (circle one) 8. How similar was this food to the food that you ordinarily eat? 9. Was there anything that kept you from using arid enjoying these meals? YES NO Comments: 10. Would you like to eat this type of meal every day? YES NO Comments: 11. Did these meals cause constipation? YES NO 12. Did these meals cause any other health problems? YES NO If so, what? 13. Has this meals program changed your eating habits? YES NO How? Appendix V 14. Describe the difference in each meal. (Breakfast, Lunch, Supper:) 15. Describe the meals that you ate the day after you completed this program: (Breakfast, Lunch, Supper) 16. Ifyou had the chance, would you spend the amount you presently spend on a meal on buying a meal of the type used in this program? YES NO 17. If you receive food stamps, would you use food stamps for these meals? YES NO 18. Would you have friends/family over for a meal if you had extra meals of this type? YES NO 19. Ifyou could, would you like more than one of this type of meals per day? YES NO 20. As a result of your participation in this program, did you use as many food stamps as usual this month? YES NO 21. Did these meals give enough to eat? YES NO Comments: 22. Did you generally prepare all the food items at one time? YES NO 23. Was this too much to eat in any one meal? YES NO Which ones? 24. Did you usually eat the entire meal at each single setting? YES NO Comments: 25 . What did you do with leftovers? 26. Did you often save something from the meal for a snack? YES NO What did you save? 27. Did you ever prepare one part of the meal and eat it, then go back later and prepare another part and eat it? YES NO Ifyes, describe: 28. Did you ever select meal items from different packages to put together to make your meal? YES NO Why? 29. Did you usually eat these meals in: Morning Mid-day Evening? (circle one) 30. Did you add any seasoning to the food? YES NO What? 31. Did you supplement these meals with any other foods (e.g. bread/butter, crackers, milk, coffee, tea)? YES NO What? 32. Were you able to prepare the foods at the temperature that was satisfactory to you? YES NO Comments: 33. Did you cool any part of the meal (e.g. drinks, pudding)? YES NO Which parts? 34. Did you use the drinks in these meals? YES NO If not, why? 35. Do you have a measuring cup? YES NO 36. Did you have any trouble with measuring hot water and preparing the dehydrated foods? YES NO Comments: 37. Were the meal menus worked out to provide you with enough variety from day to day? YES NO 38. What were your favorite-meals? food items? 39. What were your least favorite-meals? food items? 40. Did you eat the nuts? YES NO If not, why? 41. Was there anything that you didn't like about the appearance, smell, or texture of these meals? YES NO What? 42. Did you eat the meals in numerical order ( 1 through 7)? YES NO If not, what order did you use? Meal System for the Elderly Packaging and Preparation 43. What did you like about the food packaging? 44. What did you dislike about the food packaging? 45. Was it convenient to have a whole meal in one package? YES NO Why? 46. Did you have any difficulty carrying or opening the seven-day (large) food package? YES NO Suggested changes: 47. Did you have any trouble with the individual meal boxes or wrappers? YES NO Suggested changes: 48. Did you understand the instructions on the meal box? YES NO If not, why? 49. Were the instructions on the individual food items understandable? YES NO If not, why? SO. Could you read the labels on the boxes and food items? YES NO If not, why? SI. Did you make use of the plastic tray provided in each meal? YES NO How? Appendix V 52. Was the tray and its compartments big enough? YES NO 53. Did you have any problems with the tray? YES NO Describe: 54. Did you have any difficulty opening any of the cans or individual food item packages? YES NO Describe: 55. Did you spill any food when opening the pop-top cans? YES NO 56. If you could receive meals like these in the mail, would you like that? YES NO 57. Would you rather have the meals personally delivered? YES NO 58. Would you rather pick the meals up yourself? YES NO 59. What did you think about the method of delivery? Mobility and Self-Sufficiency 60. Do you have difficulty getting around the house? YES NO Why? 61. Do you leave your house for errands? YES NO 62. Do you drive? 63. Do you have a car? 64. Do you walk to your neighbor's house? YES NO 65. Do you walk to the grocery store? YES NO 66. How far is the nearest grocery store or supermarket that you use the most? How do you get your groceries home from the store? 67. Ho:w often do you go to the grocery store? 68. Do you usually cook for yourself? YES NO 69. Do you have a relative or friend who cooks for you or helps around the house? YES NO 70. How many times per week do you prepare a full meal for yourself? 71. Do you often just fix a snack or a sandwich for yourself instead of a full meal? YES NO 72. Do you have trouble using your stove? YES NO If so, why? 73. Did you have enough pans to prepare these meals? YES NO 74. Was there any problem cleaning up after any of these meals? YES NO 75. Did you have someone help you fill out the evaluation forms included in the meal packages? YES NO Who? 76. Do you have difficulty reading? 77. Do you have difficulty writing? 78. Are you able to make your bed and change the sheets? YES NO 79. Do you have any difficulty with a can opener? YES NO 80. Do you get food stamps? YES NO Meal System for the Elderly 81 . Do you go to the post office for food stamps? YES NO If no, who picks them up for you? 82. Do you have dentures? YES NO 83. Did your dentures prevent you from enjoying any part of these meals? YES NO Which food items? 84. Do you have a full set of teeth? YES NO Alternate Care 85 . Does anyone help you with your household chores? YES NO Who? 86. Have you been in a hospital or nursing home recently? YES NO When? 87. Does a public nurse come into your home? YES NO How often? 88. Do you participate in community activities with other elderly persons? YES NO 89. Have you heard about meals-on-wheels, group dining, or congregated meals programs? YES NO 90. Have you participated in any of these programs? YES NO Interview Opinion 91. Where on a continuum between complete independence of outside household assistance and total dependence would you rate this person? Independence Dependence 5 4 3 2 1 92. Could the participant hear well? YES NO 93. Is the mailbox of this participant of adequate size to accomodate the seven-day meal package? YES NO 94. How far is this person's mailbox from his/her house? 95. What was the climate of this interview (e.g. friendly, hostile, defensive)? 96. General Comments: Time interview took: SIGNATURE OF INTERVIEWER : APPENDIX VI PARTICIPANT APPLICATION FORM-63 DAY DEMONSTRATION Field Location----------------­15. Have garden or access to fresh vegetables: Yes __No Interviewer------------------_Raise chickens? Yes __ No-------­ Date of Interview________________ Participant Referred By______________ Have Car 16. Drives I. Name ___________________ 17. Read: Spanish English Address------------Phone ___ Write: Spanish English City County Zip___ 18. Stove Hot Plate 2. Age____Birthdate Sex ------Refrigerator Cooking Utensils Measuring Cup 3. Ethnic l.D. ______ S.S. # _______ 19. Financial Resources: SSI SS -­Pension Other Medicaid ___ 4. Diet Restrictions Yes___No -----­Are you on a Special Diet or supposed to be? Medicare Food Stamps-------­ Yes No______________ Type ___________________ 20. Social Agency Contact: Self Report M.D. Certificate ____ Public Health .. ______· #Times ----­Housekeeping #Times----­ 5. Name of Doctor--------------­Transportation #Times ----­Social Service Address -----------------­ Counseling _______ # Times -----­ 6. Date last visit/medical contact __________ Yes__ No _ _ 21. Do you prepare your own meals? 7. Have you been hospitalized within the last year? Yes No __ For what Medical Condition __ 22. Type of food (you) prepare and eat: (hot meals)________________ 8. Have you ever had a major operation? Yes_No__ For what reason---------------23 . When do you eat your main meal of the day?---· 9. Are you taking medicines? Yes_No ______ 24. Are there any foods that disagree with you? Name ___________________ Name .. 25 . Do you have any allergies to food? Sub Group Name_________ _ ____ ____ _R Sm T u 26. Have you ever participated in a meals program before? Yes No ____ Type ___________________ 10. Are you taking a Mineral or Vitamin supplement? Yes_No_ Name_____________ Describe in detail the physical and/or mental disabilities or abilities of the person. -------------­(Expense and transportation provided) 11. Willing to undergo Medical: Yes __No ___ 12. Number of Occupants in Residence.;..·------­ Interviewer's Comments------------­ Includes Spouse Yes --No-------­ 13. Extent of Contact: Family/Neighbors/Church? Yes ____ No _____ 14. Routine Shopping: How Often----------------­ Who Helps---------------­ APPENDIX VII FIELD NETWORK Site Contact Agency Site Coordinators Areas Involved Field Coordinators LBJ School Coordinators San Saba County Hill Country Maureen Romero San Saba Martha Jones Joe Motter Community Louise Long Richland Springs Vada Taylor Action Agency Cherokee HCC AA Box 846 San Saba/76877 Waco/Falls County Area Agency on Lynn Pearson Waco Minny Maloy Peggy Wilson Aging/Hot Cog Marian Waco Meals on Wheels Kathey Terrel Satin Director Lott 110 South 12th St. Rosebud Gladys Reyes Waco/76701 Marlon Senior Citizens -.J IV 5-County Area Community Council R. A. Sanders Atascosa County David Davidson Barbara Dydek of South Central Karnes County Elline Schmidt Texas Wilson County Eva Travieso Dan Casey R. A. Sanders Comal County R. A. Sanders Director Guadalupe County Garner Anderson New Braunfels/7 8130 Bastrop County Community Action Steve Quitta Elgin Bobby Hatch Al Giles Agency of Bastrop Smithville Willie Mae Harris Steve Quitta Bastrop Frances Hornsby Director P. 0. Box 753 Smithville/78957 Travis County United Action for Sandra Cohen Pflugerville/ Caroline Ward Al Giles the Elderly, Inc. Caroline Ward King's Village Janet Perino Janet Perino Clarksville Director P. 0. Box 6235 Austin/78762 Contact Areas Field LBJ School Site Agency Site Coordinators Involved Coordinators Coordinators ALTERNATE CARE Paris D.P.W. Paris Francine Pegues Bobby Kennedy Austin Home Health Schlesinger Home Care Ruth Siler Austin Hanna Eisner 600 West 28th Austin/78705 Rita Seymour Travis/Bastrop Girling Home Health Jolie Hutchison Austin Hanna Eisner Services, Inc. Deborah Hodson, R.N. Rita Seymour 4205 Marathon Betty Brooks Austin/78756 Ben Garcia TWO-DAY SUPPLEMENT Austin United Action for Caroline Ward Edna Youngblood John Hunt the Elderly, Inc. Meals on Wheels Janet Perino -J w Director P. 0. Box 6235 Sandra Brooks Suzanne DeLunne Austin/78762 Austin Adult Day Care Houston Harris County Senior Margaret Sharp Harris County Julius Whittier Citizens Program Karen Absher Senior Luncheon 406 Caroline, Room 201 Project (Houston) Houston/77002 :i:.. ~ ;:s "' ~ ):(• ;:s ....... APPENDIX VIII MEDICAL COMPONENT I. PURPOSE AND GOALS The original March, 1975, implementation plan for the Meals for the Elderly Program specified that only persons able to tolerate a normal diet could participate in the pro­ject. No provision would be made for special diets required by persons suffering from such medical conditions as diabetes, extreme hypertension, or ulcers. Over the summer and fall of 1975 , the LBJ School began to consider the type of medical clearance which would be required of potential participants. At that same time, inte­rest was expressed in gathering medical-nutritional informa­tion on the elderly involved in the feeding program, and if possible, in measuring any change in their physical status which might be attributable to participation in the meals program. The need for medical clearance of each participant was underscored by events during the two-week pilot demonstra­tion when four persons dropped out of the project for health reasons. All four had a medical condition which restricted their diets although none had acknowledged them at the time of their application interview. These cases pointed out the need for systematic medical clearance for participants in the 63-day demonstration. The search for a group which could carry out the medical-nutritional evaluation began in the fall of 1975. In January, the LBJ School contracted with the University of Texas Medical Branch (UTMB) at Galveston to perform medical-nutritional evaluations before and after the long­term demonstration. II. IMPLEMENTATION Medical clearance was required of every participant receiving daily meals. Clearance could be obtained through medical certification by a private physician or through the medical-nutritional evaluation conducted by the UTMB team. Applicants who obtained a private physician's clear­ance were invited to also undergo the UTMB exam for the following reasons: 1. to protect the health of the participant 2. to demonstrate the improvement or maintenance of health of the participant 3. to conduct medical-nutritional research involving a partially known dietary intake of consistent composition 4. to establish baseline data on the health status of the elderly population represented by the program participants All applicants consenting to undergo the medical screen­ings were examined a week or so before meals were to be delivered. All participants who volunteered for the exam were asked to return for a follow-up at the end of the 63­day period. Those participating in the extended program underwent a third exam at the end of that period. The exams were offered to applicants from San Saba, Falls County, Waco, Travis and Bastrop Counties, and the five-counties area. In setting up locations and dates for the examinations several factors had to be considered such as the distance applicants would have to travel to the exam, available facilities, distance between sites (to allow exams in two or three sites in one day), medical personnel schedules, and site volunteer schedules. Site Place of Exam Date of exam l st 2nd 3rd 5-county Pleasanton l /31 4/2 area Seguin 1/30 4/3 5/15 Kennedy l /31 4/2 5/15 New Braunfels 1/30 4/3 5/15 Travis/ Austin 2/1 3/28 5/15 Bastrop Waco/Falls Waco 1/7 3/27 San Saba San Saba 1/7 3/27 Arranging the medical-nutritional clearance for partici­pants was a more difficult task than originally anticipated. The problems encountered included: Appendix VIII 1. Doctors in some areas resented having "another welfare program" in their area. 2. Some doctors refused to sign the medical clearance form without charging a fee. 3. Many elderly had not seen a doctor in years and had no desire to see one to obtain a clearance. 4. Some doctors felt that their elderly patients might be mistreated while serving as subjects in a medical experiment. Letters were sent to County Medical Societies in an effort to enhance cooperation. Despite the difficulties, 75 applicants consented to undergo the screenings, and 61 returned for the follow-up. Sixteen of the 18 expected participants went through the final exam at the end of the extended program. APPENDIX IX DROPOUT QUESTIONNAIRE Participant's Name:-----------------------------------­ Participant's Social Security Number:---__------­ *A. Type of Delivery Personal. . . . .... .. .... . ...... . ... . ......1 Less Personal ... . . .. ... . ... . ......... . .. . 2 *B. Program Type 63-day . .... .... .... ........ .... ........ 1 6 3-day extended . . . . . . ...... .... ...... .. . . 2 Home health care . . . . . . . . . .... . . . ........ . 3 Weekend . . .. . ... .. .... .. . . ........ . ....4 Alternate Care (Paris) ..... ......... . . . .... . . 5 *C. Setting Rural ......... ......... ......... ......1 Small-town . .. . . .. ... . . . . . . .. ........... . 2 Urban .. . ..... . . .... ........ . ..... .. ...3 Home Health Care/Paris Weekend ... .... ......... .......... ..... 4 *D. Site San Saba ............................... 1 Travis/Bastrop . . . . ... . ... .. . .. . . ... .... . . 2 Falls/Waco ..... . . . . . .. ..... ........ . . .. . 3 Five-Counties ... .. .. . .. .. .... . . ..... .... . 4 Paris . . . . ......... ... . . . ......... ..... . S Houston ........ .. .. ..... .......... ....6 *E. Ethnicity Black .. ... . . .. . . .. . . .... . ... ... .......1 Caucasian... . ....... ... . .. .... . .. . .. . ...2 Mexican-American . .. ... . ...... . .. . .. . .....3 Other .... ........ .. ........... .. ... ... 4 *Also used for Questionnaires in Appendices XI and XII. Background-ask of all participants 1. About how many meals did you eat before you decided to drop out of the program? 2. What was your main reason for deciding to drop out of the program (circle as many as applicable). a. Health problems related to the meals received. (Specify) b. Health problems not related to the meals. (Specify) c. Difficulty in preparing food . Appendix IX d. Unpleasant taste and/or unfamiliarity with food items. (Specify) e. Damaged food items. f. Unexpected departure from home area during food demonstration. g. Lack of contact from volunteer. h. Lack of interest in the program. i. Delivery problems. j. Other (Specify) A. Health Reasons Related to Food Consumption I. Did you feel that the food caused you any health problems? YES NO Specify. 2. Were there any specific food items that caused you any health problems? YES NO Which items: 3. How soon after you noticed these problems did you stop eating the food? immediately the next day within one week over a week a. How soon after did you contact your volunteer and request food delivery be stopped? immediately the next day within one week over a week 4. What was it about the food that didn't agree with you? (Spices, consistency, quality, other, etc.) Specify? S. Did you need to contact a doctor about these health problems? YES NO Name of doctor: 6. If these health problems had not arisen, would you have continued in the program? YES NO UNSURE Additional Comments: B. Health Reasons Not Related to Food Consumption I. Did this health problem begin before you started the meals or afterwards? Before After 2. If you had this health problem before you began the meals program, do you feel eating the food made any difference? (Leave blank if not applicable.) Better Worse No Difference 3. Did you contact your volunteer about your health difficulties? YES NO 4. Did you need to contact a doctor? YES NO Name of Doctor: 5. If you had not had this health problem, would you have continued in the meals program? YES NO UNSURE Additional Comments: Meal System for the Elderly C. Difficulty in Preparing Food 1. Did you have any trouble in opening the food packages? YES NO a. Did you have any trouble in opening the cans? YES NO 2. What kind of difficulties did you have? 3. Did you generally have any trouble measuring the correct amount of water to be added to the food? YES NO 4. Did you generally have any trouble in heating the food? YES NO 5. Did you generally have any trouble following the food preparation directions on each package or can of food? YES NO Specify: 6. Were the pictures on the cans and packages which showed how to prepare the food helpful to you? Very Helpful Helpful Not Helpful Enough Confusing Not Needed 7. If the preparation of the food were made easier, would you have wanted to continue in the program? YES NO UNSURE Additional Comments: D. Unpleasant Food Taste/Unfamiliarity With Food Items 1. Did the food taste unpleasant or bad to you? YES NO Comments: 2. Were there any specific items which were particularly unpleasant to you? YES NO Which ones: 3. What was it about the food that made you dislike it? (Flavor, color, texture, portion size, smell, etc.) 4. Did you feel any ill effects from the food? YES NO Specify: 5. Did you add anything to the food to try to improve its taste and make it more to your liking? YES NO Specify: 6. Did you contact your volunteer about this problem? YES NO 7. If the food would be improved to suit your tastes, would you continue in the meals program? YES NO UNSURE Additional Comments: E. Damaged I. What kind of damage did your meals suffer? (Crushed boxes, seals not intact, spillage, other, etc.) 2. Was there any damage to the individual meal boxes? YES NO 3. Was there any damage to the individual food items within the meal boxes? YES NO Appendix IX 4. Were you generally able to eat the meals even though they were damaged? YES NO S. Do you have any idea what caused the damage? YES NO Specify: 6. If the meals had been delivered undamaged, would you have continued in the program? YES NO UNSURE Additional Comments: F. Unexpected Departure 1. If you had not left the area, would you have continued in the meals program? YES NO UNSURE 2. When did you contact your volunteer and request delivery be stopped? 3. How long was this after you left the area? (Answer in days) Additional Comments: G. Lack of Contact From Volunteer 1. How often did you see or talk to your volunteer while you were receiving meals? more than once a week about once a week about once every two weeks once every 3 weeks 2. Did you ever attempt to get in touch with your volunteer? YES NO If so, how many times? 3. Did you have questions about, or problems with the food that you wanted to discuss with your volunteer? YES NO Specify: 4. If you had received additional contact from your volunteer, would you have continued in the program? YES NO UNSURE H. Lack of Interest l. Did you get tired of eating these meals? YES NO 2. Please tell us of any other reasons why you lost interest in this program? 3. Did you contact your volunteer regarding this situation? YES NO 4. Did you ask that food deliveries be stopped? YES NO I. Delivery Problems 1. What kind of delivery problem did you have? 2. If the meals had been delivered on time and intact, would you have continued in the program? YES NO UNSURE Meal System for the Elderly J. Other Specify: Overall Program Evaluation 1. What did you like the most about the program? amount of contact with volunteers Jack of exp the food ense method of preparation other (specify) delivery method 2. What did you dislike most about the program? amount of contact with volunteers the food method of preparation other (specify) delivery method 3. Was this food similar to the food you ordinarily eat? similar somewhat different very different 4. The meals you received had canned foods, and freeze-dried foods. Did you prefer one or the other? (Find reasons for any preference.) canned freeze-dried no preference Reasons for preference: 5. If you receive food stamps, would you use your food stamps to buy these meals? YES NO UNSURE NO ST AMPS 6. While you were participating in this meals program did you use fewer food stamps than usual? YES NO NO ST AMPS About how many fewer? 7. Did you generally get enough to eat with each meal? YES NO 8. Did you often have leftovers from the meals? YES NO 9. If you had leftovers, did you eat them later in the day for a snack, or as part of another meal? (If not applicable, leave blank.) snack part of another meal other (specify below) 10. Did the meals provide you with enough variety? YES NO 11 . Were any of the food items repeated too often? YES NO If so, which ones: Packaging and Preparation I. Did you have any trouble carrying or lifting the seven-day food package? YES NO Did not receive a 7-day meal pack 2. Did you have any trouble opening the seven day food package? YES NO Did not receive a 7-day meal pack 3. Did you have any trouble measuring the correct amount of water? YES NO 4. Did you have any trouble heating the food? YES NO 5. Did you have any trouble following the food preparation directions on each package or can of food? YES NO Detail any difficulties: 6. Did you have any trouble opening the individual food items? YES NO Specify : Appendix IX Social 1. Does anyone help you with your household chores? Who? YES NO 2. Do you participate in community activities with other elderly people? What kind of activities? (church, social, etc.) YES NO 3. Have you heard about meals-on-wheels or group-dining programs? YES NO 4. Have you participated in any of these programs? YES NO 5. Does a public health nurse or a visiting nurse come to your home? YES NO 6. What kind of services would make living in your home easier for you? (e.g., transportation, homemaker, etc., probe) Questions to Second Party If Participant Is Unavailable for Questioning l. Please give reasons for the participant's withdrawal from the meals program: 2. Why is participant unavailable for questioning? Specify: 3. Do you feel that the participant would have stayed in the program if his problem was remedied? YES NO UNSURE 4. What did the participant like most about the program? the food method of preparation delivery method amount of contact with volunteers lack of expense other (specify below) 5. What did the participant dislike the most about the program? the food method of preparation delivery method amount of contact with volunteers other (specify below) Additional comments: To Be Completed By Interviewer Please describe your overall impression of the participant with particular emphasis on his reasons for withdrawing from the program. Date Interviewer's Signature APPENDIX X MEAL EVALVATION CARDS PLEASE COMPLETE AND RETURN THIS CARD AS SOON AFTER COMPLETING THIS MEAL AS POSSIBLE **CIRCLE THE APPROPRIATE ANSWER** QUALITY OF FOOD 117 BEEF AND RICE W/ONIONS ~ FAIR POOR 203 CREAMED PEAS ~J FAIR POOR 153 COTTAGE CHEESE FAIR POOR ~ 135 CHOCOLATE CRUNCH BAR @ FAIR POOR 113 INSTANT VANILLA DRINK ~ FAIR POOR -d ' . l COMMENTS Y"< / -_ /. ·1 L /~.! .:__c . -~ 1 .· ..$j~ _;,_...;.._~~_.__.__.;...;..~---~""""'-~~~--'---~-=-~~~~ , MY NAME IS ~~~~~~~~~~~~~~~~~~~~~ PLEASE COMPLETE AND RETURN THIS CARD AS SOON AFTER COMPLETING THIS MEAL AS POSSIBLE **CIRCLE THE APPROPRIATE ANSWER** QUALITY OF FOOD 78 MEAT BALLS IN BBQ SAUCE "'6ooD FAIR POOR 201 LIMA BEANS GOOD ~AIR POOR 160 PINEAPPLE !"GOOD FAIR POOR 148 PEANUT BUTTER BAR v--GOOD FAIR POOR 108 INSTANT CHOCOLATE t/ DRINK GOOD FAIR POOR MY NAME IS Appendix X PLEASE COMPLETE AND RETURN THIS CARD AS SOON AFTER COMPLETING THIS MEAL AS POSSIBLE **CIRCLE THE APPROPRIATE ANSWER** QUALITY OF FOOD 88 BEEF STEW FAIR POOR ~ 140 CREAM STYLE CORN FAIR POOR ~ 34 MIXED FRUIT ~ FAIR POOR 28 TAPIOCA PUDDING §/ FAIR POOR 108 INSTANT CHOCOLATE ~) DRINK ~_9.!Y FAIR POOR COMMENTS J} ~~uwlSt>A-