Process Evaluation of a National Elderly Nutrition–Care Program in Iran: Perspectives of Clients and Providers

Figures & data

Figure 1 Process and components of elderly integrated nutrition–care program in health-care centers of Iran.

Table 1 Nutritional components of elderly integrated–care program in Iran

Strategy	Action
Periodic assessment	Investigation of family history of diseases
	Investigation of health risk factors
	Investigation of lifestyle situation
	Assessment of nutrition status
	Assessment of drug history
Classification of clients	Apparently healthy elderly
	At-risk elderly
	Diseased individuals
Prevention and therapeutic care	Supplementation (vitamin D and calcium for all clients, multivitamins for elderly with BMI <22)
	Prescription of other drugs and supplementation according to state licenses
Public health education	Providing recommendations and tutorials using training packages
	Education on healthy lifestyle, disease-symptoms field (eg, unhealthy foods, low physical activity, smoking, high-risk behaviors)
	Education of elderly and their families regarding prevention of disease, self-management activities, and correct methods of taking drugs
	Reforming social misconceptions
	Group counseling
Health consultation	Individual counseling and providing diet programs
Required follow-up	Following up patient health and care status
	Following up status of service presentation to elderly by telephone calls
Referral to upper health centers	Referral of elderly to higher therapeutic levels
	Record actions taken in patient file

Figure 2 Flowchart of the study.

Table 2 Process-evaluation components

	Rationale/purpose	Capability	Data type	Asking of
				Clients	Providers
Reach	Proportion of intended audience who actually took part in the program	Generalizability	Quantitative	✓	✓
Exposure	Engaging of clients in receiving messages about the program	Dose received	Quantitative	✓
Delivery	Levels of implementation of all planned components	Completeness	Quantitative	✓	✓
Fidelity	Quality of the implementation	Quality and accuracy	Quantitative and qualitative	✓	✓
Satisfaction	Happiness of participants with the program	Improvement of running strategies	Quantitative	✓
Context	Environmental aspects that might affect implementation of the program	Control of disruptive factors	Qualitative	✓	✓

Table 4 Process evaluation of elderly integrated nutrition–care program (clients’ perspectives, n=256)

	Answer	n	%	Target
Exposure
Clients’ awareness of availability of nutrition-care services at nearby health-care center	Yes	183	77.5	Yes = 90%
	No	53	22.5
Clients’ awareness of time and place of conducted group nutrition-education sessions	Yes	206	87.3	Yes = 90%
	No	30	12.7
Clients’ awareness of available physical activity sessions	Yes	187	79.2	Yes = 90%
	No	49	20.8
Available information system	TV or radio	10	4.8	Mostly telephone calls
	Social media	56	27.2
	Telephone calls	122	59.3
	Friends and neighbors	18	8.7
Clients’ awareness of contents of posters or pamphlets	Yes	156	66.1	Yes = 90%
	No	80	33.9

Table 5 Process evaluation of elderly integrated nutrition–care program (clients’ perspectives, n=256)

	Answer	Target	Item	Answer	Target	Item	Answer	Target
Delivery
Opening private health files for clients in the last year	Yes (n=225, 95.3%)	Yes = 100%	Client presence at every group in nutrition-education sessions (number of participants)	<4 (n=33, 14.0%)	11–20 persons	Received nutrition-related pamphlets	Yes (n=143, 60.6%)	Yes = 100%
	No (n=11, 4.7%)			5–10 (n=152, 64.4%)			No (n=93, 39.4%)
Free calcium supplementation (500 mg/day) and multivitamin supplementation	Yes (n=0)	One/day calcium and one/day (for elderly with BMI <22)		>11 (n=51, 21.6%)		Received physical activity–related pamphlets	Yes (n=163, 69.1%)	Yes = 100%
	No (n=256, 100%)		Average session duration of every group in nutrition-education sessions (minutes)	<30 (n=55, 23.3%)	60–70 minutes		No (n=73, 30.9%)
Nutritional status follow-ups in the last year (number of sessions)	Zero (n=65, 27.5%)	At least one		30–60 (n=148, 62.7%)		Duration of every physical activity sessions (minutes)	<45 (n=39, 26.9%)	45–60 minutes
	One (n=16, 6.8%)			>60 (n=33, 14.0%)			45–60 (n=80, 55.2%)
	Two (n=46, 19.5%)		Regular nutrition-education sessions	Yes (n=147, 62.3%)	Yes = 100%		>60 (n=26, 17.9%)
	More than two (n=109, 46.2%)			No (n=89, 37.7%)		Conducting physical activity sessions	Weekly (n=13, 5.5%)	Weekly = 100%
Free vitamin D supplementation (50,000 IU/month; number of received pearls in last year)	Zero (n=99, 41.9%)	12 pearls	Regular physical activity sessions	Yes (n=70, 73.7%)	Yes = 100%		Monthly (n=108, 45.8%)
	One (n=27, 11.4%)			Later than the due time (n=17, 17.9%)			Yearly (n=23, 9.7%)
	Two (n=52, 22.0%)			Unstable place (n=8, 8.4%)
	More than two (n=58, 24.7%)

Table 3 Process evaluation of elderly integrated nutrition–care program (clients’ perspectives, n=256)

		Answer	n	%	Target
Reach
Visiting sessions of clients to the health-care center to receive any type of services available (not just nutritional) in the last year (visit number)		Never	20	7.8	At least one session
		One	51	19.9
		Two	59	23.0
		More than two	126	49.2
Client follow-up by telephone in the last year		Yes	206	87.3	Yes = 100%
		No	30	12.7
Attending the face-to-face nutrition-education meetings in the last year (number of sessions)		Zero	38	16.1	Depending on clients’ health status
		One	50	21.2
		Two	69	29.2
		More than two	79	33.5
Attending the group nutrition-education sessions in the last year (number of sessions)		Zero	38	16.1	More than two
		One	117	49.6
		Two	63	26.7
		More than two	18	7.6
Attending physical activity sessions in the last year (number of sessions)		Zero	141	59.7	More than two
		One	70	29.7
		Two	18	7.6
		More than two	7	3.0
Attendance for body-weight and blood-pressure measurement in the last year (number of sessions)		Never	21	8.9	At least one
		One	51	21.6
		Two	68	28.8
		More than two	96	40.7

Table 6 Process evaluation of elderly integrated nutrition–care program (clients’ perspectives, n=256)

	Answer	n	%
Fidelity
Motivation of nutritionist for face-to-face nutrition education meeting	Yes	183	92.4
	No	15	7.6
Motivation of nutritionist for group nutrition-education sessions	Yes	192	97.0
	No	6	3.0
Motivation of coaches for physical activity sessions	Yes	89	93.7
	No	6	6.3
Simple and understandable nutritional contents	Yes	189	95.4
	No	9	4.6
Quality of received pamphlets	Useful	122	84.1
	Not useful	23	15.9
Satisfaction
Clients’ long waiting–time complaints for face-to-face nutrition-education meetings	Yes	106	50.2
	No	105	49.8
Matching forms and intensity of physical activity to client’s ability	Yes	129	94.2
	No	8	5.8
High satisfaction of clients with every available EINCP service	Group nutrition-education sessions	26	21.5
	Face-to face nutrition-education meetings	37	30.6
	Physical activity sessions	16	13.2
	Body weight and blood pressure–measuring service	42	34.7
	Supplementation service	10	4.2
	Overall program	101	42.8
Sufficiency of available nutritional services for clients’ needs	Yes	185	86.0
	No	30	14.0
Devoting adequate time to clients by providers	Yes	178	86.8
	No	27	13.2
Clients’ satisfaction with performance of program providers	High	138	58.5
	Medium	72	30.5

Table 7 Barriers to implementation of elderly integrated nutrition–care program (providers’ perspectives, n=76)

	Extracted barriers	n	%
Low adherence of clients to face-to-face nutrition-education meetings	Poor cooperation of early caregivers with nutritionists	60	78.9
	Inappropriate space for face-to-face education	58	76.3
	Lack of a stationed nutritionist in a specific health-care center	51	67.1
	Preference of clients for using specialized clinics	68	89.4
	High diversity of health-care centers’ clients	68	89.4
Low frequency of telephone calls to the clients	Failure to respond	25	32.9
	Lack of time of providers	73	96.0
	Presence of only one landline in the health-care center	61	80.3
Low adherence of clients to group nutrition-education sessions	Lack of a separate educating room	24	31.6
	Inability of clients to attend alone	44	57.9
	Low literacy of clients	39	51.3
Low adherence of clients to physical activity sessions	Inefficient information system	59	77.6
	Weather conditions	18	23.7
Low duration of face-to-face nutrition-education meetings	High referrals	59	77.6
	Lack of time to devote to meetings	76	100
	Disregard of clients with regard to education	13	17.1
Low duration of group nutrition-education sessions	High demand of clients versus limited time	25	32.9
	High diversity of health-care centers’ clients	63	82.9
Unregular education and physical activity sessions	Low-motivation clients	40	52.6
	Inadequate time of providers	69	90.8
Giving pamphlets to the elderly	Pamphlet deficiency	59	77.6
	Clients’ illiteracy	16	21.0
Insufficient supplementation	Lack of provider-center support	76	100
	Lack of client referrals	61	80.3

Table 8 Instructions for elderly group nutrition-education sessions

	Teaching method	Duration (minutes)
First session
Brief introduction on educational topics	Identify the topics of each session, give a brief description of them, and conduct a pretest of the course	10
Importance of nutrition in old age and daily diet needs	Group discussion	25
Evaluation of elderly information	Questions and analysis of individuals’ answers	15
Helping decision-making of participants to improve behaviors	Run group discussion and take a final test	20
Second session
Review of educational topics and contents	Review the last session, introduce topics for second and third sessions, and take a simple test for start the course	10
Assessment of agreed target behaviors in last session	Ask one of the individuals to suggest a pattern	5
Nutritional needs of elderly (main food groups, diary group, food-replacement table, target behaviors)	Run group discussion, use educational graphs, books, and food pyramid	25
Assessment of information obtained and conclusion on target behaviors	Questions and analysis of individuals’ answers	10
Helping decision-making in the elderly to improve behavior	Run group discussion and take a final test	10
Third session
Review of educational topics and contents	Review the last sessions, introduce topics for this session, and take a simple test for start the course	10
Assessment of agreed target behaviors in second session	Ask one of the individuals to suggest a pattern	5
Nutritional needs of elderly (protein group, carbohydrate group, fruit-and-vegetable group), sugar-and-fat group), food-replacement table, and target behaviors	Run group discussion, use educational graphs, books, and food pyramid	30
Assessment of information obtained and conclusion on target behaviors	Questions and analysis of answers	15
Helping decision-making in the elderly to improve behavior	Group discussion and final test	10