Developing a framework for reflection on policy-relevant care research using a study of older adults’ food and drink care-related needs

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Stacey Rand University of Kent, UK

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Lavinia Bertini Brighton and Sussex Medical School, UK

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Alan Dargan University of Kent, UK

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Monique Raats University of Surrey, UK

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Rebecca Sharp Health Innovation Kent Surrey Sussex, UK

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Background

Older adults, even in countries with developed welfare systems, are at higher risk of malnutrition and dehydration than younger adults. This is due to complex interrelated risk factors related to older age and later life, which include health conditions, limited mobility and dexterity, cognitive impairment, social isolation, the accessibility of shops, ability to use or navigate transport systems, and limited or fixed household income (Purdam et al, 2019; Dickinson et al, 2022; Walker-Clarke et al, 2022). Older adults living at home who use social care services (for example, homecare or day centres) are at higher risk of malnutrition due to their care-related needs, which are often related to physical or cognitive impairment (Dickinson et al, 2022; Walker-Clarke et al, 2022). However, by comparison to the study of food and drink in care homes, there is a relative paucity of evidence about older adults living at home (Rand et al, forthcoming[a]).

The authors were funded to conduct research on the food and drink care-related needs and quality of life (QoL) outcomes of older adults living at home and using adult social care services (for example, homecare) (Rand et al, 2023). The aim of the project was to scope existing knowledge, to determine the extent of the food and drink care-related needs of older adult living at home in England, and to identify avenues for the development of innovations and future research in the area (Rand et al, 2023).

In the project, we encountered a number of challenges in effectively engaging stakeholder audiences. These broadly related to:

  1. who the topic is of interest to, and why;
  2. how the topic is currently understood through different lenses (that is, public, academic/practitioner or policy); and
  3. how to best communicate the topic of the project, findings and recommendations in light of their multifaceted and complex nature, as well as the interdisciplinary approach to studying them.

In this article, we will not only explore these areas as they relate to this specific project but also present these as a framework for reflection that may be applied to other interdisciplinary policy-relevant studies of care and caring.

Studying a topic of interest: whose interest?

The topic of study was identified as a priority by a community of practice (CoP) convened by two of the authors (Lavinia Bertini [LB] and Rebecca Sharp [RS]) as part of the National Institute of Health and Care Research Applied Research Collaboration Kent, Surrey and Sussex (NIHR ARC KSS). A CoP is a convened group of people with a common interest – in this case, homecare. The CoP approach is recognised as a way of engaging a diverse audience with research and ensuring an effective bridge between academic, practitioner, policy and public stakeholders.

In the NIHR ARC KSS Homecare CoP, which has a membership of more than 130 people, including adult social care commissioners, care providers, people using services and policymakers, one of the aims was to identify research priorities that relate to ‘homecare in England’. In March 2022, issues around the QoL and food and drink needs of older adults using social care services were discussed in a two-hour meetings and follow-up emails. The CoP identified the food and drink needs of older people as a priority topic for future research. The limited length of homecare visits, the decrease in funded meal services, the closure of day centres at the local level and the long waiting time for referrals (for example, to community dietitians) were identified as concerns and challenges to meeting food and drink needs and supporting older people to live at home.

Homecare and other community services play an important role in addressing the food and drink care-related needs of community-dwelling older adults. In the 2021/22 English Adult Social Care Survey (ASCS) of people using publicly managed care, for example, two thirds (67.4 per cent) of older adults living at home reported that services helped them with their food and drink needs/outcomes (NHS England, 2022). However, malnutrition and dehydration among community-dwelling adults, even those that use social care services, is not a concern limited to adult social care services and the care sector. While adult social care services have an important preventative role and support older adults’ QoL, issues that relate to food and drink are also relevant to healthcare professionals, public health, voluntary and community sector organisations, and unpaid carers. These diverse groups have different interests and perspectives (as we will explore further in the next section). This can make it challenging to find a common lens to frame the narrative used to justify the research and communicate findings.

A particular challenge, which is relevant here, is the culture and focus of ‘adult social care’ in England. For example, the emphasis of social care support is on enabling a person to retain their personhood, independence, dignity and sense of self through exercising choice and autonomy, even if choices may be ‘unhealthy’. This is quite distinct, for example, from the emphasis on ‘healthy eating’ framed as an individual choice and responsibility through a public health lens. There are also different goals or aims of intervention, for example, whether it is to promote healthy ageing, to prevent cognitive or functional decline, to reduce health and care disparities, or to address the immediate impact of care needs, which may be influenced by life course and economic, social or cultural inequalities. Across everything, there is an ongoing pressure from political and public discourse to reduce or minimise public expenditure, which is often portrayed as a ‘burden’ and tends to underplay the public value of such investment, in terms of the benefit to public and social well-being and dignity.

Therefore, a particular challenge in research in this area is the need to understand the diverse reasons for interest in a topic and their underlying assumptions. While it may not be possible to resolve tensions, especially in research areas that are contested, bridge professional or academic disciplinary boundaries, or require multiple framings to effectively ‘understand’ the topic, by developing a map of the different interests, it may be possible to develop and target communications that pre-empt or address likely misconceptions or pitfalls in the process of explaining the research.

Framing the topic: public, professional and policy lenses

To develop a view of the different lenses applied to the topic, we will briefly explore the broad public, professional and policy perspectives. By considering each, it is possible to identify the challenges in framing the topic, as well as how to address them.

First, we consider the public health discourse on the topic, which strongly influences media and public narratives by emphasising the role of individual lifestyle choices on health and ageing. This focus on ‘healthy eating’ influences how older people, especially those who are not yet in contact with services or require support, understand and relate to food and drink. In addition, there has also been a focus on the issue of ‘food poverty’ affecting ‘families’ (defined as working-age adults with younger, school-age children), as well as social action and policy responses (for example, food banks). Less attention is given to food and drink care-related issues relevant to older adults and the impact of later-life poverty (Purdam et al, 2016; 2019).

Therefore, there is a need to explain why older adults and food/drink are of interest, especially when public discourse typically presents older adults in the UK as ‘better off’ than working-age adults. Some older adults are at risk of adverse well-being and health outcomes due to health and care-related needs (for example, limited mobility). This can be compounded by ‘care poverty’ (a lack of the right intensity or quality of care to address the person’s needs, including with food preparation and consumption) and/or ‘food poverty’ (an inability to purchase or access food due to limited resources). To convey the importance of the topic, the concept of ‘care poverty’ alongside ‘food poverty’ and a basic description of how or why people need support (for example, reminders to eat/drink due to memory problems) may be useful, especially as support with eating/drinking is often a relatively hidden aspect of care.

Second, among academic researchers and practitioners, there is a stronger emphasis on food and drink in residential care homes, with less focus on the majority of older adults who live at home, either independently or with support. Our scoping literature review found that studies have tended to apply the medicalised lens of malnutrition and dehydration, which frames the topic as ‘natural processes’ associated with older ag, and privileges healthcare interventions led by professionals, whether nurses or dieticians (Rand et al, forthcoming[a]). The contribution of care workers, especially homecare staff, tends to be overlooked, despite the importance of person-centred care that takes into account people’s preferences, needs and values in promoting older people’s independence, dignity and QoL, which may also play a preventative role that reduces downstream healthcare use/expenditure. There is clearly a need to broaden the understanding of care to include support for older adults living at home and to consider the impact of care services on people’s QoL, both older adults and their carers, beyond health outcomes or healthcare expenditure (even if this is often an important consideration to policymakers and the public) in order to understand the full value of such care.

Finally, we also consider the policy perspective. In addition to the influence of public discourse on policy discourse, as considered earlier, there is also the challenge that the topic brings into the open an issue that has been relatively hidden. Our project identified that the levels of high-level unmet need (defined as not being able to access sufficient or timely food and drink, with a risk to health) among older adults in England using community social care services was consistently low over time, at around 1 per cent. However, there has been an increase in overall unmet need, including people with some needs, even if they do not (yet) pose a risk to health (Rand et al, forthcoming[b]). This indicates that there is cause for concern, which adds another priority to the already-crowded arena of social care policy. One approach to address this is to consider how the topic relates to other policy priorities and has complex interrelationships that inform both the basis of interest and policy recommendations.

Developing recommendations: considering complexity

In developing recommendations from the findings, we found that it was important to consider the complexity of the context and the phenomenon of study. As outlined earlier, the food and drink needs of older adults are not simply a factor of inability to purchase or access food (food poverty) but also related to other factors that relate to an individual (for example, health needs or mobility), home environment (for example, kitchen layout or living with others or alone), local environment (for example, transport, shops, social connectedness and community) and the wider economic context or food systems. Among older adults using social care, there is also the consideration of ‘care poverty’, whereby needs arise due to the shortfall between the person’s needs (defined not only as malnutrition and dehydration but also to consider personal, cultural and social aspects of food and drink) and the care/support to address those needs, whether from social care services, unpaid carers or other services (for example, healthcare).

There is considerable complexity here, especially when you also consider wider social and policy contexts. These may be specific to countries or regions, for example, the chronic underfunding of care systems, workforce retention and recruitment issues, and an increased proportion of the older population ageing without children – all of which affect England, among other countries. Some issues may be apparent globally too, for example, ageing populations and associated demographic shifts in populations, the impact of migration, and changing attitudes about women’s social and economic roles, including increased participation in labour markets, which have affected ‘traditional’ patterns of care within families. Global crisis or pressures, including climate change, may also affect these factors or generate new considerations that affect the issues of ‘food poverty’ (for example, the impact of the changing climate on food systems) and ‘care poverty’ (for example, migration affecting care availability, both paid and unpaid, against rising demand).

In discussing the project among stakeholders, there was also initially a favouring of relatively quick and easy-to-implement interventions or innovations, for example, knowledge and skills training for care workers, digital/tech solutions, or using volunteers to alleviate pressures on paid and unpaid carers, as well as reduce costs. While some of these may offer benefits, there is also reason to be cautious. Studies indicate that, for example, the main barrier to quality in care delivery is not the skills and knowledge of staff but how services are funded, planned and delivered, especially the use of short-duration visits (Watkinson-Powell et al, 2014). Despite the popularity of innovative solutions in policy narratives, they often do not engage with or ‘solve’ the key underlying factors at the systems level, namely, in England, that the role of homecare in supporting food and drink needs/outcomes is undervalued, not sufficiently visible or inadequately funded, even though it is the most widely used type of support for older adults living at home.

The adoption of a systems-level perspective may offer a better means to consider the impact of policy and practice, for example, the effect of investment into social care on the rates of unmet food and drink care-related need. Our project, for example, found that a higher average intensity of care per older adult in English local authorities was associated with lower rates of unmet need. This indicates that investment into community-based care could reduce unmet need, even if the project is, however, limited due to the use of cross-sectional data (Rand et al, forthcoming[b]). It may be challenging to advocate for immediate policy change on the basis of this evidence, but it does indicate an avenue for further research to build the case for investment into care.

To do this will require a reframing of the discourse on ‘care’ that focuses on its social and societal value as a way of supporting people’s well-being and QoL, its preventative role (considering both its QoL/well-being and economic impacts), and the wider social and economic contribution of the social care sector and its workforce. In doing so, the complexities outlined earlier also need to be considered and effectively applied in building the case for support and investment. This not only applies to the project we present as an example but is also relevant across a number of topics and areas of research in care and caring, albeit with slightly different emphases and considerations.

Conclusion

In this article, we have drawn on the example of a particular project (Rand et al, 2023) to reflect on the challenges encountered in engaging with diverse audiences and stakeholders in policy- and practice-relevant care research. These relate to ‘interest’ (who the topic is of interest to, and why), the ‘different perspectives’ that influence current understanding (public, academic/practitioner or policy) and how to fully ‘account for complexity’, especially consideration of a systems-level view, in recommendations developed from research. For the project considered here (Rand et al, 2023), the challenges were most evident due to multiple stakeholders with an interest in the subject, the diversity of perspectives that affect understanding and the dominance of particular framings (that is, public health over social care), and the challenge of moving away from ‘quick-fix’ responses to those that fully consider the systems level. This exploration also offers a framework for reflection by researchers and their partners that may usefully inform the planning and delivery of knowledge exchange, impact and engagement activities for other similar projects.

Funding

This article is the product of independent research funded by the National Institute for Health and Care Research School for Social Care Research (NIHR SSCR) (Grant Reference Number: 26147). Rebecca Sharp and Monique Raats were part-funded by the National Institute for Health and Care Research Applied Research Collaboration Kent, Surrey and Sussex (NIHR ARC KSS). The views expressed in this publication are those of the authors and not necessarily those of the NIHR SSCR, NIHR ARC KSS, the NIHR or the Department of Health and Social Care.

Acknowledgements

We would like to acknowledge and thank the project’s Advisory Group and the patient and public involvement and engagement (PPIE) research advisors, Karin Webb and Della Ogunleye, for their advice and support of the project.

Conflict of interest

The authors declare that there is no conflict of interest.

References

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  • Walker-Clarke, A., Walasek, L. and Meyer, C. (2022) Psychosocial factors influencing the eating behaviours of older adults: a systematic review, Ageing Research Reviews, 77: 101597. doi: 10.1016/j.arr.2022.101597

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  • Watkinson-Powell, A. et al. (2014) Food provision for older people receiving home care from the perspectives of home-care workers, Health and Social Care in the Community, 22(5): 55360. doi: 10.1111/hsc.12117

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  • Dickinson, A. et al. (2022) Food security and food practices in later life: a new model of vulnerability, Ageing and Society, 42(9): 2180205. doi: 10.1017/s0144686x20002020

    • Search Google Scholar
    • Export Citation
  • NHS England (2022) Personal social services Adult Social Care Survey, England, 2021–22, https://digital.nhs.uk/data-and-information/publications/statistical/personal-social-services-adult-social-care-survey/england-2021-22.

  • Purdam, K., Garratt, E. and Esmail, A. (2016) Hungry? Food insecurity, social stigma and embarrassment in the UK, Sociology, 50(6): 107288. doi: 10.1177/0038038515594092

    • Search Google Scholar
    • Export Citation
  • Purdam, K., Esmail, A. and Garratt, E. (2019) Food insecurity amongst older people in the UK, British Food Journal, 121(3): 65874. doi: 10.1108/bfj-05-2018-0301

    • Search Google Scholar
    • Export Citation
  • Rand, S. et al. (2023) Food and drink-related needs & outcomes of older people who use community-based social care, www.pssru.ac.uk/foodanddrink.

    • Search Google Scholar
    • Export Citation
  • Rand, S. et al. (forthcoming[a]) Food and drink-related needs and outcomes of older adults using homecare: an international scoping review.

    • Search Google Scholar
    • Export Citation
  • Rand, S., Bertini, L. and Raats, M. (forthcoming[b]) Food and drink-related quality of life of older adults using community-based care in England.

    • Search Google Scholar
    • Export Citation
  • Walker-Clarke, A., Walasek, L. and Meyer, C. (2022) Psychosocial factors influencing the eating behaviours of older adults: a systematic review, Ageing Research Reviews, 77: 101597. doi: 10.1016/j.arr.2022.101597

    • Search Google Scholar
    • Export Citation
  • Watkinson-Powell, A. et al. (2014) Food provision for older people receiving home care from the perspectives of home-care workers, Health and Social Care in the Community, 22(5): 55360. doi: 10.1111/hsc.12117

    • Search Google Scholar
    • Export Citation
Stacey Rand University of Kent, UK

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Lavinia Bertini Brighton and Sussex Medical School, UK

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Alan Dargan University of Kent, UK

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Monique Raats University of Surrey, UK

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Rebecca Sharp Health Innovation Kent Surrey Sussex, UK

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