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

Addressing the Image of Older Americans
Congregate Nutrition Programs

What are the issues concerning participation (or lack of it) in the Congregate Nutrition Program?

Older Americans Nutrition Programs serving meals at congregate sites have experienced a slow but steady decline in participation nationally (1). This trend, which is counter to what would be expected, given the growth in the overall older adult population, has challenged providers to identify and effectively address factors related to the decline.

The effectiveness of the Older Americans Nutrition Program is well documented. The 1993-1995 National Evaluation (2) showed that people who participate in the Nutrition Program benefit both in terms of enhanced nutritional intake and increased social contact. The evaluation also showed that the services are well targeted and serve a high percentage of individuals who are nutritionally at risk and who are in danger of increased incidence of chronic disease and loss of functionality.

Despite these facts, some view the decline in participation as simply an indicator of a reduction in need for congregate nutrition services. This conclusion is over simplified and fails to take into account factors regarding the diversity of the older adult population. Across the country, providers have been evaluating their programs as they seek to provide relevant, effective and attractive nutrition services. One example is a focus group study that the Chicago Suburban Area Agency on Aging, Chicago, Illinois conducted in March 2000 with the assistance of the Buehler Center on Aging at Northwestern University (3). The final report identified a wide range of issues and barriers to attendance, which many other providers would agree apply to their own program as well.

Using information from the Chicago Suburban Area Agency on Aging report, a previous Ask the Experts, Increasing Participation at Older Americans Act Title III Funded Congregate Meal Sites, explored several means of modifying and/or expanding meal service models and programming to meet the needs of participants. These innovations in program design are critical if the program is to remain vital and relevant. However, even the best designed programs will not succeed if the public is not aware of them or if an image problem makes them unattractive to the target population.

What's in a name?

Most Congregate Nutrition Programs operate out of senior centers, and many younger older adults don't see themselves as "senior enough" to attend. The name alone is often times enough to make them decide, "that's not for me!" An image can be conveyed solely by a name. "Congregate Meal Program," "Elderly Nutrition Program," "Senior Lunch Program," "Senior Friendship Center, " and other commonly used names may connote too institutional an image and can cause potential participants to self-select themselves out of the program. Many programs are interested in linking their meals and other services with good health but have difficulty deciding exactly what to call the program to highlight that connection.

• An inquiry on the listserve for Gerontological Nutritionists (a special interest group of the American Dietetic Association) in March 2001 solicited ideas for more appropriate program names. There were very few responses, with most of them containing the word "senior" or "elderly."
• Program staff at Senior Services of Seattle/King County, Seattle, Washington, conducted a "name the program" contest among participants. Many responses incorporated "senior" and some also included the word "café."
• The "Café" was also a popular word put forth by a senior marketing class at Purdue University, where students developed marketing plans for the Midland Meals, Inc., Frankfurt, Indiana.
• Meals on Wheels of Shawnee and Jefferson County, Inc., Topeka, Kansas, recently changed their congregate nutrition program name to "Friendship Meals," but it is too soon to determine if this change has improved participation rates.
• Choosing a name that has cultural relevance is important, whether it be the English name translated to the native language or simply another name such as Rochester New York's "Centro De Oro" (Center of Gold) in the Hispanic community.

How do we address the stigma of "charity" or a "program for the poor"?

Another obstacle to attendance for some older adults is the belief that participating in the Older Americans Nutrition Program reflects a need for charity. This impression exists even though there is no means testing and donations are suggested. The Chicago Suburban Area Agency on Aging study supported this finding. While low-income older adults are a primary target group, most programs realize value in attracting others from a broad socio-economic range. A study, conducted by Meals on Wheels of Shawnee and Jefferson County, Inc., found that the stigma of a welfare program was more pervasive in urban than rural areas, and that participants in rural areas were more likely to bring a friend.

Pat Bohse, Marketing Consultant comments, "There are times when I go to senior centers and the centers look the same: dark, dirty, and smelly. This is not a place I would want to hang around nor do the majority of the seniors in America. Unfortunately, the staff at some of these centers thinks that this atmosphere is acceptable. I believe that this attitude, 'be happy with whatever you get', continues that welfare mentality." Bohse adds, "I also know that when we do the exercise in senior centers called 'Creating the Ideal Senior Center,' the designs that the Directors and seniors come up with are wonderful. They are positive, outrageously different, fun and doable. So I think it is time to put a 'New Face on Aging' by all of us in the field."

Does your center offer programs of interest in your community?

The Congregate Nutrition Program cannot afford to be just a "meals program." Each center and their center director must know their community and be able to tap its resources. Meals on Wheels of Shawnee and Jefferson Counties, Inc. found that activities vary at centers and much of what goes on is dependent on the center manager and whether the center is directly operated by the nutrition program. Some ideas to promote interest in the program include:

• Attracting younger older adults to the program by providing "lighter fare" on the menu, a "grab and go" option, and enhanced nutrition education programming to emphasize the preventive aspects of good nutrition are examples of activities developed in response to specific requests from typically more active older adults.
• Offering greater menu selection and choices, time of service, and a pleasant dining atmosphere all play a part in attracting participants. The Ask the Experts topic, "Providing food services to meet the needs of your culturally diverse participants" addresses the cultural and food services aspects of the program that warrant consideration.
  
• Providing health and wellness programs such as chair exercises, dance aerobics, blood pressure and cholesterol screening, help attract participants (Meals on Wheels of Shawnee and Jefferson Counties, Inc. and the Johnson County Nutrition Program, Olathe, Kansas).
• Gearing programs to specific ethnic groups are critical to attract people in those communities. The Monroe County Office for Aging, Rochester, New York, contracts with a major Hispanic Agency in the county to serve the Puerto Rican community at the "Centro De Oro."
• The Johnson County Nutrition Program Task Force (1997) recommended that the following activities be available:
  • Continuous recreation opportunities for an individual or group;
    
• Resource center;
• Exercise equipment;
• Learning activities; and
• Computer and Internet accessibility.

Is your center and program well managed and inviting?

Often, center operations and participation are dependent on the person managing or directing the center. A center manager must involve participants in the planning and implementation of activities, programs, and the design of the facility if they are to feel ownership in the program. A center manager and a few well chosen participants can bring enthusiasm to the program and increase participant satisfaction and attendance. A prerequisite to hiring center managers at Midland Meals, Inc. is that they have an outgoing personality, a positive attitude, and a desire to be a part of the Program.

• A recent survey by Encore Community Services in New York City, states Pat Bohse, Marketing Consultant and board member, asked participants, "Why do you come to the center?" The responses (which we would all like to see) were:
  • We get respect from the staff;
  • The staff cares about us;
  • The food is really good; and
  • The place is clean, warm and welcoming.

Two ideas that improved participation follow.

• Training volunteers as "greeters" to welcome visitors and make them feel at home is a component of the Johnson County Nutrition Program. The program relies on getting many of its' volunteers from the "Shepard Center, " a faith-based senior volunteer organization that empowers older adults to contribute to the community.
• Focus groups at Midland Meals, Inc. encouraged fellow participants to bring friends, to get involved in center activities, and to build community ownership of the program to increase participation and avoid site closings.

Does your facility need a face-lift?

By and large, most programs have been in place and operated in the same facilities for some time. As these facilities and equipment have aged, capital dollars for updates and improvements have been difficult to secure. Often times, scarce dollars are prioritized for programs and services, and the facility and equipment needs have, by necessity, fallen to a lower priority. We are forced to ask a difficult question, "Even with the best programming, would I want to come here for a meal?"

Often, a little redecorating, such as general painting and/or painting murals, wallpapering, hanging curtains, and landscaping, can go a long way toward making the facility more inviting. Effective capital campaigns have been launched in many areas, specifically for the purpose of improving the site's appearance. Many potential donors respond well to a list of specific items that are needed, such as paint and wallpaper, tables and chairs, light fixtures, landscaping materials, curtains, tablecloths, dishes, transportation vehicles, and kitchen equipment. Some successful ideas for facility improvements follow.

• Midland Meals, Inc. required a new kitchen facility. They created interest and enthusiasm by giving tours of the old facility and displaying the plans for the new one. Their capital campaign raised $2.2 million.
• Monroe County Office for Aging's "Centro De Oro" is located where many older adults live. The eating area of the center has a skylight providing a sunny ambiance year round. There are native plants and pictures of Puerto Rico around the center. One room has a table for playing dominos that is popular with the men. Transportation is available and the food is prepared by a Hispanic cooking staff. Nutrition education is provided by an English-speaking dietitian, but most materials are in Spanish. This center took many years to develop as a focal point and Nutrition Program site.
• The Kansas State Nutrition Task Force (4) recommended that centers change their institutional atmosphere and move towards a home-like atmosphere incorporating contemporary design with dedicated space for older adults. Ideal space includes functional areas for eating, socialization, recreation, multipurpose use, and kitchens. It is important to allow flexible utilization inside as well as outside.

The Marketing Process

"Marketing is a social and managerial process by which individuals and groups obtain what they need and want through creating and exchanging products and value with others (5)." The goal of marketing is to know and understand your customer so well that your product or service "fits" or sells itself.

Karen D. Goldman, PhD, CHES (Certified Health Education Specialist), a Health Education and Social Marketing Consultant, presented at the National Association of Nutrition and Aging Services Program Conference in Nashville, June 2001. A brief summary follows to illustrate the comprehensiveness of a true marketing strategy beyond the facility fix-ups, center manager savvy, and program add-ons.

Step #1: Assessing the environment
Analyze the external environment in the community and compare the program to the competition (other programs and services). Ensure that the work required or desired has realistic service goals and objectives. Evaluate how the work and community environments influence what is done and how it is done prior to any decision about which services will be offered and what their features will be. Incorporate questions about desired services or desired attributes of services into an existing community needs assessment process. Self-evaluate or assess your organization's and department's internal environment. Find out how user-friendly your services are? Assess individual and organizational performance potential, resources, and limitations.

Step #2: Segmenting the market
It is up to the agency to identify different market segments, select one or more of these segments as target populations, and develop marketing strategies and positions ("cozy café" position versus "bustling cafeteria" image) tailored to each target population. Market segmentation is classifying customers into groups exhibiting different needs, characteristics or behaviors. Each market segment should consist of consumers who respond in a similar way to a given set of stimuli. A good market analysis, developed with a thorough knowledge and understanding of a few major target populations, will result in the creation of marketing strategies so well tailored to particular audiences that they are far more likely to succeed than one strategy applied to a variety of very different market segments (ie, well, able-bodied versus physically challenged, single, male, female, over 70, over 90, etc.).

Step #3: Setting goals and objectives
Every organization has one basic mission statement that is the fundamental crux of all its activities. In an organization that provides multiple services, a marketing plan is necessary for each individual program or service offered to the market. However, before developing marketing objectives for any product or service, a clear understanding of the organization's overall goals and objectives is necessary. The long-term vision of where the organization is going establishes the boundaries within which objectives, strategies, actions (program and service development) must be developed.

Step #4: Developing a marketing mix
Once a market segment is chosen, identify all of the nutrition services currently available to participants in this marketing segment. Recognize that every service is a bundle of perceived features. Therefore, identify the features of a particular service that are critical to the potential participant when it comes times for them to decide whether or not to use the service. Use the knowledge you have to choose the appropriate features for specific market segments. Make sure that you consider the concepts of Product (including what the service is, who provides it, and what it is called); Price (including money, time, emotions, and energy); Place (where you offer your program and how that setting looks); and Promotion (advertisements, person to person "sales" approaches, incentives, and public relations).

Pat Bohse, Marketing Consultant, states "Marketing has to do with everything a program does from its signage, stationery, how the staff answers the telephone, quality service, name of the center, location, etc." She says that marketing is the key to success for nutrition centers in the future. At a workshop at the National Association of Nutrition and Aging Services Program Conference in Nashville, June 2001, Ms. Bohse described the 6 Ps of marketing:

• Public - who are the people that you serve and care about?
• Product - what services do you provide and are they of good quality?
• Production - can you handle more people? If you do outreach can you handle more customers?
• Place - is the center safe, clean, welcoming?
• Promotion - an important step but not the only one.
• Price - the cost or investment

When the agency does marketing, the message must be consistent, out there all the time, and on a regular basis (at least four times a year) to be noticed. Develop media relationships with television, radio, and print personnel. Provide them with press releases, develop public service announcements, and get television and radio coverage of special events. Develop a speaker's bureau and have subject matter experts. Work with participants to be program ambassadors. The agency must go directly to the audience they want to serve and that means leaving the center (Pat Bohse).

National Marketing Initiatives

Meals On Wheels Association of America (MOWAA) is partnering with the world's largest public relations firm, Fleishman-Hillard, to implement a "Meals on Wheels Marketing Campaign." "We could not be more excited about this opportunity. Every organization needs public relations help, and we are most fortunate to be getting that help from the best in the business," said Enid Borden, MOWAA Executive Director.

For Fleishman-Hillard to get the message out to the public and to potential corporate supporters, they need to be "armed" with lots of facts and figures about the Program. A survey has been distributed to MOWAA's 800 members (December, 2001) and the answers will help Fleishman-Hillard better understand how programs work and provide them the tools needed to "persuade" corporations to partner with local programs. Information is power.

In 2002, the National Policy and Resource Center on Nutrition and Aging will conduct an Issues Panel on Marketing Older Americans Nutrition Programs. This meeting will call together experts in marketing, nutrition, and aging. The need to develop a marketing plan of action came out of the Center's Nutrition 2030 Expert Advisory Council Strategic Planning Conference (6). The "Marketing Plan," see below, illustrates that beyond local marketing needs is a national marketing prospective which can help attract older Americans to the Nutrition Program throughout the country.

Developing an effective plan for marketing and promoting the program must incorporate the cultural and ethnic diversity, differences in socio-economic background, differences in health status, food preferences, life style and activity level, the "competition," and individual values. This can be a daunting prospect. While most programs attempt to do some marketing and promotion, it is the rare program that has developed a comprehensive marketing plan with assistance from marketing experts. This is about to change.

If you are willing to share information on your program's marketing experiences with the Aging Network, please contact the Center by mail, email, or fax. This may include suggestions for program names, other marketing ideas and activities, giving the center a face-lift, comments concerning the stigma of charity and other issues, and additional resources. In addition, let the Center know of your interest in participating in the Issue Panel and/or issues to be addressed.

Resources:

"Learning to Think Like A Marketer" Handbook. A manual of the Social Marketing Training Presentation for the Leadership Academy of the National Association of Nutrition and Aging Services Programs, Nashville, TN, June 7, 2001 by Karen Denard Goldman, PhD, CHES, Health Education and Social Marketing Consultant. See contact information below. The complete "Handbook" as presented at the conference is available in PDF format. http://www.fiu.edu/~nutreldr/Ask_the_Expert/Image_OACNP/Marketer.pdf

"Marketing Your Senior Center to Traditional and Non-traditional Users." Pat Bohse, President, Bohse and Associates. See contact information below.

Senior Linkage Line®: Integrating the National Family Caregiver Support Program with other Title III Programs. Topics include rethinking how we market services to older adults. PowerPoint presentation from the Administration on Aging.
http://www.aoa.dhhs.gov/carenetwork/nfcspconf01-papers/presentations/varpness.ppt

Resources from the Administration on Aging Website with articles on the Senior Market, government statistics, and Marketing Organizations and Newsletters.
http://www.aoa.dhhs.gov/naic/notes/marketingseniors.html

MarketingPower.com: The American Marketing Association website. "A comprehensive and customizable source for all things marketing."
http://www.marketingpower.com/index.php?&Session_ID=536f87c085e67118c9c43bb218ca9b89

Contributors:

• Pat Bohse, President, Bohse and Associates, PO Box 225, Middletown, NJ, 07748; (732) 291-8038 or pbohse@bohse.com
• Elaine Brovont, Executive Director, Midland Meals, Inc., PO Box 505, Frankfurt, IN, 46041; (765) 659-3125 or mmeals@netusa1.net
• Karen Denard Goldman, PhD, CHES, Health Education and Social Marketing Consultant, 184 Columbia Heights, Suite 1A, Brooklyn, NY, 11201; url: www.karendenardgoldman.net.
• Jane Metzger, Executive Director, Meals on Wheels of Shawnee and Jefferson Counties, Inc., 1500 West 10th St., Topeka, KS, 66604; (785) 354-5420.
• Linda Netterville, MA, RD, Nutrition Program Manager, Johnson County Nutrition Program, 11875 S. Sunset, Suite #200, Olathe, KS, 66061; (913) 447-8119 or linda.netterville@jocoks.com
• Mary Podrabsky, RD, Associate Director Nutrition Projects, Senior Services of Seattle/King County, 1601 2nd Ave., Suite 800, Seattle, WA, 98101; (206) 727-6240 or MaryP@seniorservices.org
• Patricia Swayze, Nutrition Program Administrator, Monroe County Office for the Aging, City Place, 50 West Main St., Suite 4100, Rochester, NY, 14614; (616) 428-4966 or pbswayze@yahoo.com

References:

1. Administration on Aging. 1998 State Performance Reports. Available at: http://www.aoa.gov/napis/97spr/tables/table3.html. Accessed September 6, 2001.
2. Mathematica Policy Research, Inc. Serving Elders at Risk, the Older Americans Act Nutrition Programs: National Evaluation of the Elderly Nutrition Program 1993-1995, Volume I: Title III Evaluation Findings. Washington, DC: US Department of Health and Human Services; 1996: 103-105, 203.
3. Evaluation of Dine-Out Programs. Prepared by Suburban Area Agency on Aging (SAAA) and Community Nutrition Network. August 9, 2000. Contact: Diane Slezak, Deputy Director, Suburban Area Agency on Aging; 708-383-0258 or diane.slezak@s3a.com
4. Netterville, L. Retooling the Congregate Program. Presented at: Meals on Wheels Association of America Annual Conference; September 4, 1999; Madison, WI.
5. Kotler, P., Armstrong, G. Principles of Marketing. 8th ed. Englewood Cliffs, NJ: Prentice Hall; 1998.
6. National Policy and Resource Center on Nutrition and Aging. Nutrition 2030 Expert Advisory Council: Strategic Planning Conference; November 8-9, 1999; Washington, DC.
   

Compiled by Mary Podrabsky, RD and Lester Rosenzweig, MS, RD, and staff of the National Policy and Resource Center on Nutrition and Aging, Florida International University, Miami, FL. Contact: nutritionandaging@fiu.edu

This project is supported, in part, by a grant from the Administration on Aging,
Department of Health and Human Services (DHHS). Grantees undertaking projects under government
sponsorship are encouraged to express freely their findings and conclusions.
Points of view or opinions do not, therefore, reflect official DHHS policy.

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Posted on 2/01/02