How to Motivate Congregate Meal Program Participation in Texas: Statewide Needs Assessment Findings on Program Barriers and Facilitators

How to Motivate Congregate Meal Program Participation in Texas: Statewide Needs Assessment Findings on Program Barriers and Facilitators | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article How to Motivate Congregate Meal Program Participation in Texas: Statewide Needs Assessment Findings on Program Barriers and Facilitators Nandita Chaudhuri, Anthony Jackson, Megumi Sakamoto, Ashleigh Williams, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6414417/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Aug, 2025 Read the published version in Discover Public Health → Version 1 posted 9 You are reading this latest preprint version Abstract Congregate meal programs (CMPs) are food-centric nutrition programs under Title III of the Older Americans Act (OAA), intended to reduce hunger, malnutrition, food insecurity, and social isolation in vulnerable older adults and help maintain their independence in their homes and communities. Most CMPs in Texas have suffered from a lack of older adult engagement and participation decline despite the growing older adult population in the state. A mixed-method comprehensive needs assessment study was conducted to identify strategies to facilitate CMP participation. The study utilized state-wide surveys for older adults, CMP employees, and healthcare providers. In addition, the study held twenty-nine focus group sessions to further determine barriers and facilitators of the Texas CMPs. The quantitative and qualitative data was triangulated and analyzed by five researchers. The results identified three major barriers to CMP participation: (1) low awareness, (2) facility restrictions, and (3) changes in the older adults’ lifestyle. To address these barriers, we concluded that marketing, engaging activities at the CMP in addition to meal services, and an enhanced and expanded menu would be effective facilitators. Furthermore, this study identified that games, wellness classes, and arts and crafts would attract more engaging participants to the program. The study emphasizes the importance of adapting the CMP programs to meet the community’s needs. Congregate meal programs Food security Social connection Aging Needs assessment Older adults Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Congregate meal programs (CMPs) are nutrition programs under Title III of the Older Americans Act (OAA) that serve meals in community settings such as senior centers, churches, restaurants, and senior housing to reduce hunger, malnutrition, food insecurity, and social isolation among older adults aged 60 or over. Malnutrition harshly affects older adults. In 2021 alone there were 25,195 malnutrition-related deaths among adults 65 years and older in Texas [ 1 ]. Past studies showed that regular CMP attendees achieve higher levels of socialization, reduction in depressive symptoms, and better overall mental health [ 2 , 3 ]. CMPs also add value in providing nutritional education and counseling to attendees, which helps improve the overall health of the older adult population [ 4 , 5 ]. These potential benefits are critical at a juncture when Texas confronts a large demographic shift: the number of population 65 and older is expected to diversify and more than double from 3.9 million in 2020 to 8.3 million by 2050 [ 6 ]. Despite the benefits of Congregate Meal Programs and an increasing older adult population in Texas, CMP attendance rates are at historic lows. The Administration for Community Living (ACL) indicates that Texas OAA programs served a total of 16,974 congregate meals in 2021, which is a 73 percent decrease from 2017 [ 7 ]. The declining utilization of CMPs calls for needs assessment research on older adults to facilitate their well-being and improve food security. This study's purpose is to identify the barriers and facilitators of CMP participation and to understand how to leverage the congregate meal sites’ strengths and challenges in Texas by presenting key findings from a state-wide needs assessment study. Methods This study is divided into three phases, following a complex multi-stage needs assessment model [ 8 ]. Phase 1 (pre-assessment) consists of a literature review guiding the development of survey questionnaires and focus group protocols. Phase 2 (needs assessment) includes the distribution of surveys and facilitation of focus groups, while Phase 3 (post-assessment) focuses on mixed method data analysis and data triangulation. IRB approval for all components was obtained in Phase 1. Phase 1: Study Instrument Development Phase 1 began with an exhaustive literature review. From September to October 2019, PPRI reviewed existing population surveys targeting older Americans conducted by various states, the federal government, and research outfits such as Mathematica. During this time, the institute also coordinated with the Texas Health and Human Services Commission (HHSC) staff to share literature findings and formalize the necessary components for data collection. We developed three surveys, each targeting specific congregate meal-related populations in Texas: CMP-eligible adults, CMP and Area Agencies of Aging (AAA) employees and volunteers, and physicians and nurses who could refer eligible individuals to CMPs. The first survey, hereinafter referred to as the Older Texan Survey , aimed to gather data on older adults’ knowledge about CMPs, participation in CMPs, potential barriers and facilitators for participation, and suggestions on improving participation in the programs. The questionnaire consists of 18 multiple-choice and four open-ended questions in addition to screening and demographic questions. The second survey, hereinafter referred to as the Organizational Survey , targeted nutrition program and/or Area Agency on Aging (AAA) employees, volunteers, and subject matter experts on congregate meal programs and asked program-specific questions. Participants were only included if their affiliated center or agency provided congregate meal programs. Many organizations provided home-delivered meals in addition to congregate meals, however, the survey and affiliated focus groups targeted the congregate programs and the AAAs specifically. The survey consisted of three screening questions determining eligibility to participate in the survey followed by three major sections focusing on current program conditions (29 items), innovations (five items), and perceptions of barriers and facilitators (seven items). Twelve questions across all three sections were open-ended. The third survey is referred to as the Healthcare Provider Survey , which targeted licensed healthcare providers practicing in Texas. This survey was developed to understand the role of CMPs in the healthcare system as an entry point to community-based care. The survey aimed to understand the healthcare provider’s perceptions of the CMPs (three items), the barriers and facilitators for older adults participating in CMPs in their local communities (two items), the referral processes used by the physicians and nurses (five items) and suggestions to improve participation in CMPs (two items). This survey included nine multiple-choice questions and three open-ended questions. Additionally, informed by the survey findings, we developed focus group protocols to validate the survey findings and to gather more in-depth information from CMP-eligible adults, formal and informal caregivers, and CMP-related agencies. The focus group questions were categorized into five main thematic areas: the local context of the programs, perceptions of barriers or hurdles in accessing the programs, successful program components, and innovations. Each study instrument is summarized in Table 1. Table 1. Comprehensive Needs Assessment Components Older Texan Survey Organizational Survey Community Health Provider Survey Stakeholder Focus Group Target Population People older 60 years of age who reside in Texas Employees, volunteers, and subject matter experts affiliated with Texas CMPs or AAAs Registered nurses, practicing licensed vocational nurses, practicing physicians, and practicing advanced practice registered nurses in Texas Texas nutrition providers for Title III-C1 congregate programs, people over 60 years of age, family caregivers, senior-serving community agencies, healthcare providers, senior advocacy organizations Sampling Method Online Panel (Qualtrics) Convenience sampling through the Texas HHSC Office of Aging and Disability mailing list Online Panel (Qualtrics) Convenience sampling through HHSC & recruitment through online surveys Contents CMP participation limitation Current program conditions Perception of CMPs Local context of CMPs Perceived benefits and barriers Perceived benefits and barriers Perceived benefits and barriers Perceived benefits and barriers Suggestions for CMP improvement Innovations to improve the program Referral Process Successful programs and components Method Online Survey Online Survey Online Survey Virtual Focus Group n 2,237 159 412 29 sessions with 236 participants Phase 2: Needs Assessment Implementation Older Texan Survey The Older Texan Survey was conducted as an online panel survey using Qualtrics, a reputed sampling company. Respondents were restricted to individuals 60 years of age and above residing in Texas. These respondents also served as a recruitment stage for the stakeholder focus groups described later. To incentivize participation, respondents received financial compensation ranging from $3 to $6 through Qualtrics. A total of 2,242 complete responses were collected between January 15 and February 7, 2020. Most of the responses were from older adults who had not attended congregate meals (88.6%). The survey respondents were mostly White (83%), female (57%), and between 60-70 years old (67.6%). Detailed demographic characteristics of the survey respondents are presented in Table 2. The majority of respondents were retired and not looking for work (74.4%). Approximately 27.5 percent had an annual household income below $40,000 and 22.6 percent had an annual household income of over $100,000. Table 2. Selected Demographic Characteristics of Older Texan Survey Respondents Selected Demographic Characteristic Age Percentage of Sample 60-70 67.6% 71-80 28.9% 80+ 3.5% Race Percentage of Sample White 88.0% Black or African American 5.6% Asian 1.7% American/Indian or Alaska Native 0.9% Native Hawaiian or Pacific Islander 0.04% Mixed Race 1.4% Other/Prefer not to answer 2.3% Ethnicity Percentage of Sample Hispanic/Latino 7.05% Not Hispanic/Latino 90.36% Prefer not to answer 2.59% Gender Identity Percentage of Sample Male 42.7% Female 56.8% Transgender or Gender Non-Conforming 0.04% Prefer not to answer 0.5% Current Household Income Percentage of Sample Under $20,000 9.4% $21,000 to $40,000 18.1% $41,000 to $60,000 15.2% $61,000 to $80,000 13.2% $81,000 to $100,000 9.4% Above $100,000 22.6% Prefer not to answer 12.1% Work Status Number of Participants Employed part-time 230 Employed full-time 323 Not employed, but looking for work 41 Not employed, not looking for work 61 Not able to work 95 Volunteer 137 Take care of grandkids 31 Retired 1491 Other 76 Prefer to not answer 10 Organizational Survey The survey was launched on December 5, 2019, and remained in the field until April 6, 2020, on the Qualtrics platform and generated 159 valid responses. The sample for the Organizational Survey was obtained from the Texas HHSC Office of Aging and Disability mailing list, supplemented by snowball sampling. All survey participants had extensive knowledge of congregate meals. Among them, 138 respondents were currently employed by a local congregate meal provider, one had previously worked for such a provider, and 20 were affiliated with a Texas AAA. The respondents held a range of positions within their organizations, including program directors (n = 89), administrators overseeing the nutrition providers (n = 39), and subject matter experts on congregate meal programs (n = 43). Community Health Provider Survey An online panel survey was conducted to collect data from August 3 to August 16, 2020, using Qualtrics. The survey was exclusively for registered nurses, licensed vocational nurses, practicing physicians, and practicing advanced practice registered nurses, all of whom were required to be licensed and residing in Texas. Individuals who did not meet these criteria were screened out. A total of 412 respondents completed the survey, of whom 204 were practicing physicians, 150 were registered nurses, 30 were licensed vocational nurses, and 28 were advanced practice registered nurses. Most physicians and nurses (347) served in counties classified as urban, while 65 worked in counties classified as rural. Stakeholder Focus Groups Focus groups were held over a five-month period, from February to July 2020. We recruited a diverse range of participants, including nutrition providers, individuals eligible for CMPs and their family caregivers, senior-serving community agencies, healthcare providers, social workers specializing in senior care, and senior advocacy organizations. Participants were drawn from the 28 AAA regions across Texas to ensure a comprehensive range of perspectives. The first four focus groups were conducted in person. Later, due to COVID-19-related restrictions, the focus groups transitioned to a virtual platform. A total of 29 sessions were conducted. A total of 236 unduplicated participants joined the focus groups. All sessions were video recorded and transcribed verbatim. Transcripts were imported into qualitative analysis software after anonymization. A team of five researchers consolidated findings into relevant thematic areas and synthesized results. Phase 3: Data Triangulation SPSS and Jamovi were used to analyze quantitative data. A thematic analysis was conducted for open-ended responses in all surveys. Focus group discussions were transcribed and then analyzed using Dedoose and Excel by five research assistants. Each researcher was tasked with identifying thematic areas presented in the focus groups and comparing responses with survey results. Reviews consisted of preliminary emergent coding to identify these themes, followed by cross-coding to ensure all identified themes and codes were appropriately applied. Research assistants generated summaries of each focus group as well as combined summaries for each thematic area. These summaries were triangulated with survey data to expand and inform survey responses. Results Each data collection instrument and methodology aimed to identify factors contributing to the decrease in Congregate Meal Program participation. Thematic analysis and triangulation of data revealed several barriers and recommendations to promote CMP participation. The factors associated with participation barriers are categorized as follows: lack of awareness, stigma, changing family lifestyle, participant engagement and amenities, facility and location constraints, and menu and food choices limitations. The findings are summarized thematically in Figure 1. Each needs assessment instrument asked participants to identify barriers to CMP participation. Table 3 summarizes the results of perceived barriers identified in the Older Texan Survey (the original question asked: “Which of the following issues might prevent older adults from attending a congregate meal program?”). Participants were given a scale of 1 to 5, with 1 representing “Not a problem” and 5 representing “A Serious Problem.” In addition, the survey participants who had never attended a CMP were asked to provide their reasons for not attending, allowing more than one answer. The frequency distribution of the responses is presented in Figure 2. The employees and volunteers at congregate meal sites were asked to provide a reason as to why they think the CMP participation is declining (original question asked: “Participation in congregate meals is declining in Texas, in keeping with trends across the nation. Why do you think this is happening?”) and Figure 3 displays the results. The participants were allowed to select multiple reasons. In the following sections, we present the detailed results by themes we identified. Table 3. Barriers Ranked by Severity (All participants) Potential Barriers to Participation Not a Problem (1-2) Moderate Problem (3) Severe Problem (4-5) Mean S.D. (%) Not knowing where programs are offered 8.65 15.21 76.14 4.09 .024 Lack of programs in the area 9.73 19.36 70.92 3.99 .024 Transportation difficulty 14.05 17.04 68.91 3.88 .027 Dietary restrictions 23.64 29.04 47.33 3.32 .026 Quality of meals offered 24.62 38.18 37.20 3.16 .025 Lack of variety in the meals offered 26.58 41.48 31.94 3.06 .024 Feeling unwelcomed by other participants 33.72 30.51 35.77 3.03 .029 Scheduling or timing of meals offered 29.00 39.19 31.85 3.03 .025 Dislike of location where meals are offered 27.26 44.25 28.54 3.01 .024 Stigma about what others will think 33.63 33.85 32.52 2.93 .026 Unfriendliness of staff in the meal programs 37.91 31.13 30.96 2.88 .029 Privacy concerns about group setting 33.99 39.43 26.58 2.87 .025 Lack of need for free meals 38.72 34.88 26.40 2.75 .028 Difficulty getting time off work 53.48 24.17 22.35 2.44 .029 n = 2,153 Low Awareness The lack of awareness among older adults, healthcare providers, and family caregivers is one of the most prominent barriers to program participation in this study. As outlined in Table 3, over three-quarters of the respondents (76.14%) identified “Not knowing where programs are offered” as a severe barrier. This was the second most common (42.2%) reason provided by those who had never attended a congregate meal program (n=1,965, 88.6% of all older adult respondents). Most congregate meal site staff (52.8%) and healthcare professionals (70.6%) also reported “lack of awareness” as one of the major reasons behind the decline in participation and the lack of referrals provided by healthcare facilities. Some CMP providers reported in the focus groups that older adults are aware of the existence and purpose of the senior centers, but not the CMPs. According to these participants, older adults often visit senior centers for activities but are unaware of the congregate meal services available at these locations. Stigma & Bias Another common factor attributed to the decline in CMP participation was the stigma associated with “free meals” and the embarrassment of being perceived as “needy.” The majority (88.6%) of Older Texan Survey respondents who had never attended CMPs indicated they “do not need free meals” as their primary reason for not participating, even though attendees are encouraged to make voluntary contributions toward the cost of the meals. Moreover, 29.6% of those who never participated in the CMP stated that they think they are “not frail or old enough” to seek congregate meals, which implies that CMPs are perceived as an exclusive program for those in need. The organizational survey respondents most often cited stigmas, such as the perception that CMPs serve only less fortunate, low-income, or physically frail adults, as the “primary reason older adults choose not to participate." Similarly, 59.1% of organizational survey respondents attributed low attendance to pride and embarrassment related to participating in the meal programs. CMP providers echoed this point during the focus group discussions, noting that “many in our senior community view these meals as a step above a soup kitchen, but not something for everyone.” Responses from focus groups across all Texas AAA regions reflected these sentiments, highlighting a widespread stigma surrounding the acceptance of charity, along with a desire among potential participants to reserve meals for those in greater need. Facility Restrictions Specific to the atmosphere of the congregate meal sites, all Older Texan Survey participants were asked to rate the extent to which various aspects of a potential congregate setting would be welcoming to attendees on a scale of 1 to 5. The older adults suggested that CMP sites needed to improve and enhance the interior or the settings of the CMP sites to look more inviting by making it look like a home with extensive decoration (57.7%), including views of the outdoors from dining areas (84.4%), and adding indoor greenery (71.9%). Organizational survey participants acknowledged their facilities needed improved and enhanced amenities to better cater to the needs of older adult participants. During the focus groups, some providers mentioned specific requirements for their buildings, including the need for designated pick-up and drop-off areas, as well as additional handicap-accessible parking spaces and entrances. Congregate meal site employees and volunteers also raised specific issues incorporating diverse activities into their existing locations. For example, some locations do not have large spaces for group activities like yoga, pickleball, bingo or dancing. Other locations lack private rooms for smaller classes, religious studies, or other personal interactions. Some facilities have a single large room for group meals, whereas others are split across different areas. Transportation Challenges Closely linked to facility constraints, transportation was mentioned as a barrier in all but one focus group session, especially in rural areas that require longer commutes (over 20 miles) with fewer public transit options. Consistent with the findings from the literature, many stakeholders noted that partnership with local transportation agencies could facilitate appropriate transportation infrastructures, policies, and mobility options and help reduce transport-related social exclusion among older Texans in the CMPs [9, 10]. Focus group participants, both older adults and providers, indicated that many CMP-eligible individuals do not like to drive or do not have a car. They may lack access to a personal vehicle and therefore, need to rely on family members and caregivers or public transportation services. Those who do have a car might be easily discouraged from driving because of bad weather, if they do not feel well, or because their vehicles are not always equipped to handle physical barriers such as wheelchairs and walkers. While over half of the organizations (57.4%) reported at least some transportation assistance, only two-fifths (40.5%) provide their own transportation, whereas 16.9 percent partner with another organization. This leaves nearly 43 percent of organizations that do not provide any transportation assistance to their CMP participants. Shifting Demographics Congregate meal providers in the Organizational Survey and in focus groups attributed much of the decline in participation to a changing older adult population and demographic shifts. The majority (57.9%) of organizational survey respondents indicated that they believed the decline in CMP participation was due to older adults still working or staying active. About 71 percent of older adult respondents stated that the schedule or the timing of the meal offered was a moderate or severe barrier, and about half (46.5%) chose difficulty getting time off work as a moderate or severe barrier. According to focus group participants and common literature, many older adults are taking care of their grandchildren, especially during the summer when the schools are not in session while their parents are still working. Congregate meal providers in the focus groups consistently cited the higher average age of congregate meal recipients as a barrier. According to these providers, as the older population of the congregate meal participants age and pass away, the younger contingent of the population is not coming in to replace them. One provider participant in a focus group said, “[t]he bar for when people think they should go to a senior center is pushed back further and further these days.” Providers emphasized the regional variation in the participants’ characteristics, as a provider over multiple areas noted that congregate meal providers “need to know the seniors they serve”. Suggestions Several suggestions as to how CMP participation can be facilitated emerged from the data collected through this needs assessment. To address the lack of awareness, stigma and bias, facility restrictions, and changes in older adults’ evolving lifestyles, we identified three areas to focus on for congregate meal sites and policymakers to increase CMP participation. Awareness and Marketing As discussed earlier, the lack of awareness is one of the main reasons older adults do not participate in CMPs. This suggests an ample need for better marketing strategies for congregate meal sites and government agencies supporting the sites (such as AAAs). The Older Texan Survey results show that older adults prefer to receive much of their information primarily through mail outs (51%), television (36.5%), places of worship (35%), and online (33.9%). Congregate meal providers (31.4%) suggested increasing the social media presence of the meal programs to increase awareness. The results also show that congregate meal providers should expand their target audience by reaching agencies and individuals with frequent interactions with older adults, such as local communities including places of worship, health care providers, and younger adults with parents and grandparents who are eligible for the CMP. In addition, the needs assessment results suggest that marketing for CMPs should focus on eliminating the misconception that CMPs are only there to give free food to the poor. Instead of emphasizing the cost-free or voluntary contribution to meal cost of the CMP, greater focus should be placed on highlighting the healthy meals and essential services that foster social connections and enhance the well-being of all older adults. Among the Older Texan Survey participants who have participated in CMP, many indicated that they participate in the program to socialize (68.3%) and to attend activities provided at the site (46.8%). The results strongly suggest that CMPs are in dire need of an improved marketing strategy, focusing on expanding the audience and highlighting the social support derived from CMP participation. Engagement and Activities As to the social activities that could facilitate older adults’ participation in CMP, the Older Texas Survey respondents identified the following activities as enticing: Games like Bingo and Poker (72.7%), wellness activities (58.2%), arts & crafts (57.4%), computer literacy courses (56.1%), and cooking and nutrition courses (51.2%). Figure 4 presents the most commonly suggested activities by all older adults. Those who had previously attended CMPs reported mostly similar activities, with higher interest in each activity listed. Some specific activities with more interest included fine arts (53% to 40%), performing arts (50% to 40%), arts & crafts (68% to 57%), dancing (45% to 34%), and games (82% to 73%). The organizational survey revealed that many of these activities were already implemented at some congregate sites. For example, 77 providers (48.4%) offer games like Bingo or board games, 56 providers (35.2%) offer arts & crafts, and 31 providers (19.5%) offer some form of dancing. Congregate meal providers in the focus groups also discussed marketing the activities such as book clubs, exercise, and bible study could reduce stigma around participation. Participants in the focus groups discussed local activity offerings that were not included in the surveys (such as a disaster planning day or a crafting day dedicated to making baby blankets for a nearby pregnancy center) as events that were relatable and able to entice participation. Menu Variety Dietary restrictions, concerns about the quality of meals, and lack of variety in the menu were some of the consistent concerns among older adults. Of all Older Texan Survey participants including those who never attended a CMP, 47.3 percent identified dietary restriction as a severe barrier, and 37.2 percent and 31.9 percent of the survey respondents selected quality of meals and lack of variety in the menu as a severe barrier, respectively. This need is echoed by open-ended responses to a question that asked for suggestions to improve the meal program. Most respondents expressed a desire for greater meal variety, along with options for healthier food choices. Some specifically mentioned a preference for lean proteins, such as turkey or fish. Many participants indicated disappointment with the frequent starchy options, as noted by the following participant’s comment: “There have been times when the vegetables offered with the meals during the week were beans/corn, beans/tater tots, beans/potatoes. The entry [entrée] would then be very starchy as well. The meal needs to be more balanced, colorful, and varied.” Two-thirds of the Organizational Survey respondents indicated that their CMP menu was a set menu that did not offer the participants any flexibility. Another 16.9 percent indicated that the menu could consist of a choice between different complete meal options (such as choosing between two types of meals), while about eight percent indicated that people could choose different food items within a meal (such as choosing between entrees, vegetables, fruits, or dessert options). While 67.9 percent of providers believe adults want more choices and variety in their congregate meals in the Organizational Survey , over half of the senior nutrition programs (55.1 percent) do not accommodate special dietary needs. The limitation on the menu is often due to a cost control measure, operating with limited funding. All menus must comply with state guidelines for compliance with the US Dietary Guidelines but may not meet specific modified or therapeutic needs for certain chronic conditions. However, the findings from the Older Texan Survey suggest that older adults are concerned that the CMP does not serve the food they can consume. Offering a choice of meals and culturally relevant food may remove the barrier for potential participants. Discussion and Conclusion It is evident, both from existing literature and data collected for this study, that stakeholders understand the potential of congregate meal programs to be more than just meals. The goals of the CMPs are to reduce hunger, food insecurity, and malnutrition; promote social engagement; and support the overall health and well-being of older adults. Participants in the needs assessment study acknowledged the significant role CMPs play in improving outcomes by providing access to nutritious meals and fostering socialization. Despite a general understanding of these benefits and the growing older adult population, participation in Texas CMPs has notably declined over the past decade. Through a combination of quantitative and qualitative analyses, this comprehensive study identifies the factors contributing to low CMP participation among older adults in Texas and offers recommendations for congregate meal providers to address these challenges. It also highlights the values that CMP participants associate with these programs and suggests strategies to enhance engagement. We identified four major barriers to older adults’ participation in CMPs: lack of awareness, stigma and bias, facility and location constraints, and changing family lifestyles. With these barriers in mind, we have isolated three specific areas of improvement to increase participation: marketing, amenities and activities, and expanding the menu. A distinct overall lack of awareness regarding congregate meals was cited in all surveys and focus groups. Over three-quarters of older Texan respondents (76.14%) stated a severe barrier was “Not knowing where programs are offered.” Over half of congregate meal site staff (52.8%) and most healthcare professionals (70.6%) also reported “lack of awareness” as one of the major reasons behind the decline in participation. Even if the older adults were more aware of the CMP in their communities, stigma might act as a prominent barrier to participation. Aligning with the larger finding that government programs perceived to target low-income participants stigmatize and deter participation [ 12 – 15 ], 33 percent of the participants in the Older Texan Survey stated that they avoid going to the CMPs because of the fear of being judged by others. Most congregate meal providers (59.1%) also believed that personal pride and embarrassment are the greatest barriers that hinder older adult participation in the CMPs. One aspect of the stigma surrounding CMPs is linked to the facilities themselves. Older adults express a preference for attending locations that feel comfortable and inviting, with appealing decorations, greenery, and views of the outdoors. Accessibility is also a key concern: transportation remains a consistent barrier across the state. While about half of CMPs offer some form of transportation assistance, many older adults, particularly in rural areas, still face significant challenges in accessing these sites. CMPs face competition from employment and other lifestyle changes for some older adults. According to the Organizational Survey respondents, the average age of CMP attendees continues to rise, suggesting a decline in participation among younger older adults (ages 65 to 74). This trend aligns with existing literature, which indicates that adults in the 60–70 age range are more likely to remain employed or prioritize family responsibilities, factors that may contribute to reduced attendance at CMP. Additionally, while many programs offer meals and activities to adults aged 60 and older, there may be a lack of tailored activities or programming that address the diverse interests and needs of different age ranges within the older adult population. This gap could be further limiting engagement and participation among younger adults who may have different expectations and preferences. The results clearly highlight an urgent need for comprehensive marketing efforts to build awareness and reduce the stigma around CMPs. These findings suggest that by addressing the specific needs and preferences of older adults and implementing an effective marketing campaign, CMP participation, awareness, and satisfaction could significantly increase. To achieve this, marketing campaigns should be tailored to the media outlets that older adults in each CMP region engage with, utilizing targeted outreach. Additionally, the benefits of CMPs may need to be reframed in a way that emphasizes their value for all older adults, rather than positioning them solely as services for those who are economically disadvantaged or underprivileged. This shift in perception could help attract a broader range of participants. In addition to marketing efforts, incorporating attractive and educational programs for older adults would be one of the most effective ways to boost participation in CMPs. According to the Older Texan Survey, only about one-third (35.5%) of older adults attended congregate meal programs primarily for the meals, while the majority attended for socialization (68.4%) or to participate in engaging activities (46.9%). Survey and focus group participants suggested a variety of activities that could enhance the appeal of CMPs, including fun activities, fitness classes, cultural events, technology classes, and intergenerational programs. Research indicates that using congregate meal sites for educational purposes or offering meaningful activities has led to significant positive outcomes, improving both engagement and overall satisfaction among older adults. [ 16 , 17 ]. Another effective way to facilitate participation is by revising the menus offered at CMPs. The Older Texan Survey identified several factors hindering participation, including dietary restrictions (47.33%), meal quality (37.2%), lack of meal variety (31.94%), and issues with meal scheduling and timing (31.85%). These factors were reported as problems or very serious problems by many participants. Expanding menu options could help address the diverse medical and nutritional needs of older adults. Additionally, with the increasing ethnic and religious diversity within the older population, there is a growing need to cater to these cultural preferences [ 18 – 20 ]. To meet these needs, CMP menu development strategies should incorporate awareness of ethnic diversity, ensuring that programs are inclusive and reflective of the communities they serve. This focus should be supported through training for senior nutrition providers to ensure they can effectively adapt their offerings. Overall, CMPs must evolve to meet the changing statewide and national landscape and needs of their older adult constituents. While the benefits of CMPs are widely recognized, participation in these programs continues to decline. Our needs assessment has pointed out key areas of concern and offered practical recommendations for adapting CMPs to better serve the current and future generations of older adults. By addressing these issues, CMPs can ensure they remain a vital resource for enhancing the well-being and social engagement of older adults. A thoughtful, proactive approach to these changes will be essential in reversing the trend of declining participation and ensuring the long-term success of these programs. Declarations Funding Statement This work was supported by the U.S. Administration for Community Living, Department of Health and Human Services under Grant 90INNU0013-01-00. The authors report there are no competing interests to declare. Ethics Statement The Institutional Review Board (IRB) at Texas A&M University determined this study as not qualifying for human subjects’ research. It is a Quality Improvement study. But the research team followed all protocols pertaining to human subjects research. Project sponsors, Texas HHSC and ACL, have provided the grantee organization (Public Policy Research Institute, Texas A&M), the right to publish from project aggregate data. Author Contributions Conceptualization: Nandita Chaudhuri; Methodology: Nandita Chaudhuri, Anthony Jackson; Formal analysis and investigation: Ashleigh Williams and Anthony Jackson; Writing – original draft preparation: Anthony Jackson, Megumi Sakamoto, Nandita Chaudhuri; Writing – review and editing: Anthony Jackson, Megumi Sakamoto, Linda Netterville, and Nandita Chaudhuri; Funding acquisition: Nandita Chaudhuri; Supervision: Nandita Chaudhuri. Data Availability Data supporting this research is available upon reasonable request, and the request can be made to the Public Policy Research Institute at Texas A&M University. Acknowledgments The authors would like to thank the U.S. Administration for Community Living, the Department of Health and Human Services and the Texas Health and Human Services Commission for providing the grant funding and permission to use the data for publication. The authors would also like to thank the research staff who supported the data analysis, and the survey and focus group participants who made this study possible. References Bergeron, C. D., John, J. M., Sribhashyam, M., Odonkor, G., Oloruntoba, O., Merianos, A. L., Horel, S., & Smith, M. L. (2021). County-Level Characteristics Driving Malnutrition Death Rates among Older Adults in Texas. The journal of nutrition, health & aging , 25 (7), 862–868. https://doi.org/10.1007/s12603-021-1626-2 Mabli, J., Gearan, E., Cohen, R., Niland, K., Redel, N., Panzarella, E., & Carlson, B. (2017). Evaluation of the effect of the Older Americans Act Title III-C Nutrition Services Program on participants’ food security, socialization, and diet quality. Washington, DC: US Department of Health and Human Services, Administration for Community Living , 2017-07. Millen, B. E., Ohls, J. C., Ponza, M., & McCool, A. C. (2002). The elderly nutrition program: an effective national framework for preventive nutrition interventions. Journal of the American Dietetic Association , 102 (2), 234–240. https://doi.org/10.1016/s0002-8223(02)90055-6 Rosenbloom, C. A., Kicklighter, R. D., Patacca, R. D., & Deshpande, K. (2004). Nutrition education in six congregate meal sites improves participant's nutrition knowledge. Journal of nutrition for the elderly , 23 (3), 73–83. https://doi.org/10.1300/J052v23n03_05 Wunderlich, S., Bai, Y., & Piemonte, J. (2011). Nutrition risk factors among home delivered and congregate meal participants: need for enhancement of nutrition education and counseling among home delivered meal participants. The journal of nutrition, health & aging , 15 (9), 768–773. https://doi.org/10.1007/s12603-011-0090-9 Angel, J., & Castillo, J. (2021, June 28). Texas has unfinished business to improve care for aging population. UT News The University of Texas at Austin . https://news.utexas.edu/2021/06/28/texas-has-unfinished-business-to-improve-care-for-aging-population/ Administration for Community Living. (2023, December 25). The AGing, Independence, and Disability (AGID) Program Data Portal . AGID. https://agid.acl.gov/release.html#StateProfile Sleezer, C. M., Russ-Eft, D. F., & Gupta, K. (2014). Complex needs assessment. In A practical guide to needs assessment (pp. 205-227). Wiley. https://doi.org/10.1002/9781118826164.ch8 Valliant, J. C., Burris, M. E., Czebotar, K., Stafford, P. B., Giroux, S. A., Babb, A., ... & Knudsen, D. C. (2022). Navigating food insecurity as a rural older adult: The importance of congregate meal sites, social networks and transportation services. Journal of Hunger & Environmental Nutrition, 17(5), 593-614. https://doi.org/10.1080/19320248.2021.1977208 Wolfe, W. S., Olson, C. M., Kendall, A., & Frongillo Jr, E. A. (1996). Understanding food insecurity in the elderly: a conceptual framework. Journal of nutrition education, 28(2), 92-100. https://doi.org/10.1016/S0022-3182(96)70034-1 Chernoff, R. (1995). Baby boomers come of age: nutrition in the 21st century. Journal of the American Dietetic Association, 95(6), 650-655. https://link.gale.com/apps/doc/A17311230/HRCA?u=txshracd2564&sid=googleScholar&xid=c823e58e Hughes, S., Williams, B., Molina, L., Bayles, C., Bryant, L., Harris, J., et al. (2005). Characteristics of physical activity programs for older adults: Results of a multisite survey. The Gerontologist, 45(5), 667–675. https://doi.org/10.1093/geront/45.5.667 Myers, D. (2013). Come together: Congregate meal participation in Illinois planning and service area 05. Capstone Projects – Politics and Government . 9. https://ir.library.illinoisstate.edu/cppg/9 Pardasani, M. (2010). Senior centers: Characteristics of participants and nonparticipants. Activities, Adaptation & Aging, 34(1), 48-70. https://doi.org/10.1080/01924780903552295 Wellman, N. S., Weddle, D. O., Kranz, S., & Brain, C. T. (1997). Elder insecurities: poverty, hunger, and malnutrition. Journal of the American Dietetic Association, 97(10 Suppl 2), S120–S122. https://doi.org/10.1016/s0002-8223(97)00744-x Brewer, D., Dickens, E., Humphrey, A., & Stephenson, T. (2016). Increased Fruit and Vegetable Intake among Older Adults Participating in Kentucky's Congregate Meal Site Program. Educational gerontology , 42 (11), 771–784. https://doi.org/10.1080/03601277.2016.1231511 Robinson, K., & Jenkins, S. (2020). Older Adults Seek Out Congregate Nutrition Programs for Socialization. Innovation in Aging , 4 (Suppl 1), 18–19. https://doi.org/10.1093/geroni/igaa057.060 Mower M. T. (2008). Designing and implementing ethnic congregate nutrition programs for older Americans. Journal of nutrition for the elderly , 27 (3-4), 417–430. https://doi.org/10.1080/01639360802265954 NANASP & The National Resource Center on Nutrition & Aging. (2019). Congregate nutrition programs: An exploration of current challenges and future opportunities. https://futureofcongregate.com/assets/uploads/NANASPNRCNA_LitReview_2019.pdf Porter, K. E., & Cahill, S. (2015). A state-level review of diversity initiatives in congregate meal programs established under the Older Americans Act. Research on Aging, 37(7), 719–740. https://doi.org/10.1177/0164027514552330 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Aug, 2025 Read the published version in Discover Public Health → Version 1 posted Editorial decision: Revision requested 22 May, 2025 Reviews received at journal 21 May, 2025 Reviews received at journal 14 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers invited by journal 08 May, 2025 Editor assigned by journal 26 Apr, 2025 Submission checks completed at journal 26 Apr, 2025 First submitted to journal 09 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6414417","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":454005577,"identity":"7f993191-34d4-4dea-81fa-c2625aa6bd12","order_by":0,"name":"Nandita Chaudhuri","email":"","orcid":"","institution":"Texas A\u0026M University","correspondingAuthor":false,"prefix":"","firstName":"Nandita","middleName":"","lastName":"Chaudhuri","suffix":""},{"id":454005578,"identity":"e5b0e64d-d3dc-4771-932f-ffb793194d02","order_by":1,"name":"Anthony Jackson","email":"","orcid":"","institution":"Texas A\u0026M 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1","display":"","copyAsset":false,"role":"figure","size":347156,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContributing Factors to Decrease in Congregate Meal Program Participation\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6414417/v1/06aaa50b3a173192fd8cb76e.png"},{"id":82794187,"identity":"1f66946b-1070-4b91-ab88-7c3a86368073","added_by":"auto","created_at":"2025-05-15 10:28:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":155124,"visible":true,"origin":"","legend":"\u003cp\u003eReasons for Not Attending Congregate Program (Non-Attendees)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003en = 1,965\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6414417/v1/98ced3d9e8e7a187bf9da3de.png"},{"id":82792269,"identity":"a64db163-b86f-43ad-9376-1cfa30436bde","added_by":"auto","created_at":"2025-05-15 10:20:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":192047,"visible":true,"origin":"","legend":"\u003cp\u003ePerceived Reasons for Participation Decline (Organization Responses)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003en = 159\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6414417/v1/de61f902e2e315a07c6839ae.png"},{"id":82792272,"identity":"3cfccb44-bdc0-4478-b125-d5eec0d729ce","added_by":"auto","created_at":"2025-05-15 10:20:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":172990,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eActivities Older Adults Might Like for Congregate Meal Program Events\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6414417/v1/459fc7b0e0194f4d178c416f.png"},{"id":82794190,"identity":"7b8aaa7b-f296-46ac-8c50-8c2a41c4dcf7","added_by":"auto","created_at":"2025-05-15 10:28:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1865328,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6414417/v1/cbafb8b9-f767-4345-88df-357e9b2765ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"How to Motivate Congregate Meal Program Participation in Texas: Statewide Needs Assessment Findings on Program Barriers and Facilitators","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCongregate meal programs (CMPs) are nutrition programs under Title III of the Older Americans Act (OAA) that serve meals in community settings such as senior centers, churches, restaurants, and senior housing to reduce hunger, malnutrition, food insecurity, and social isolation among older adults aged 60 or over. Malnutrition harshly affects older adults. In 2021 alone there were 25,195 malnutrition-related deaths among adults 65 years and older in Texas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Past studies showed that regular CMP attendees achieve higher levels of socialization, reduction in depressive symptoms, and better overall mental health [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. CMPs also add value in providing nutritional education and counseling to attendees, which helps improve the overall health of the older adult population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese potential benefits are critical at a juncture when Texas confronts a large demographic shift: the number of population 65 and older is expected to diversify and more than double from 3.9\u0026nbsp;million in 2020 to 8.3\u0026nbsp;million by 2050 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite the benefits of Congregate Meal Programs and an increasing older adult population in Texas, CMP attendance rates are at historic lows. The Administration for Community Living (ACL) indicates that Texas OAA programs served a total of 16,974 congregate meals in 2021, which is a 73 percent decrease from 2017 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe declining utilization of CMPs calls for needs assessment research on older adults to facilitate their well-being and improve food security. This study's purpose is to identify the barriers and facilitators of CMP participation and to understand how to leverage the congregate meal sites’ strengths and challenges in Texas by presenting key findings from a state-wide needs assessment study.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eThis study is divided into three phases, following a complex multi-stage needs assessment model [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Phase 1 (pre-assessment) consists of a literature review guiding the development of survey questionnaires and focus group protocols. Phase 2 (needs assessment) includes the distribution of surveys and facilitation of focus groups, while Phase 3 (post-assessment) focuses on mixed method data analysis and data triangulation. IRB approval for all components was obtained in Phase 1.\u003c/p\u003e\u003ch2\u003ePhase 1: Study Instrument Development\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Phase 1 began with an exhaustive literature review. From September to October 2019, PPRI reviewed existing population surveys targeting older Americans conducted by various states, the federal government, and research outfits such as Mathematica. During this time, the institute also coordinated with the Texas Health and Human Services Commission (HHSC) staff to share literature findings and formalize the necessary components for data collection. We developed three surveys, each targeting specific congregate meal-related populations in Texas: CMP-eligible adults, CMP and Area Agencies of Aging (AAA) employees and volunteers, and physicians and nurses who could refer eligible individuals to CMPs.\u003c/p\u003e\n\u003cp\u003eThe first survey, hereinafter referred to as the \u003cem\u003eOlder Texan Survey\u003c/em\u003e, aimed to gather data on older adults\u0026rsquo; knowledge about CMPs, participation in CMPs, potential barriers and facilitators for participation, and suggestions on improving participation in the programs. The questionnaire consists of 18 multiple-choice and four open-ended questions in addition to screening and demographic questions.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The second survey, hereinafter referred to as the \u003cem\u003eOrganizational Survey\u003c/em\u003e, targeted nutrition program and/or Area Agency on Aging (AAA) employees, volunteers, and subject matter experts on congregate meal programs and asked program-specific questions. Participants were only included if their affiliated center or agency provided congregate meal programs. Many organizations provided home-delivered meals in addition to congregate meals, however, the survey and affiliated focus groups targeted the congregate programs and the AAAs specifically. The survey consisted of three screening questions determining eligibility to participate in the survey followed by three major sections focusing on current program conditions (29 items), innovations (five items), and perceptions of barriers and facilitators (seven items). Twelve questions across all three sections were open-ended.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe third survey is referred to as the \u003cem\u003eHealthcare Provider Survey\u003c/em\u003e, which targeted licensed healthcare providers practicing in Texas. This survey was developed to understand the role of CMPs in the healthcare system as an entry point to community-based care. The survey aimed to understand the healthcare provider\u0026rsquo;s perceptions of the CMPs (three items), the barriers and facilitators for older adults participating in CMPs in their local communities (two items), the referral processes used by the physicians and nurses (five items) and suggestions to improve participation in CMPs (two items). This survey included nine multiple-choice questions and three open-ended questions.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Additionally, informed by the survey findings, we developed focus group protocols to validate the survey findings and to gather more in-depth information from CMP-eligible adults, formal and informal caregivers, and CMP-related agencies. The focus group questions were categorized into five main thematic areas: the local context of the programs, perceptions of barriers or hurdles in accessing the programs, successful program components, and innovations. Each study instrument is summarized in Table 1.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 1. Comprehensive Needs Assessment Components\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOlder Texan Survey\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrganizational Survey\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity Health Provider Survey\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStakeholder Focus Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTarget Population\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003ePeople older 60 years of age who reside in Texas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eEmployees, volunteers, and subject matter experts affiliated with Texas CMPs or AAAs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eRegistered nurses, practicing licensed vocational nurses, practicing physicians, and practicing advanced practice registered nurses in Texas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eTexas nutrition providers for Title III-C1 congregate programs, people over 60 years of age, family caregivers, senior-serving community agencies, healthcare providers, senior advocacy organizations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSampling Method\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eOnline Panel (Qualtrics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eConvenience sampling through the Texas HHSC Office of Aging and Disability mailing list\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eOnline Panel (Qualtrics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eConvenience sampling through HHSC \u0026amp; recruitment through online surveys\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eCMP participation limitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eCurrent program conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003ePerception of CMPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eLocal context of CMPs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003ePerceived benefits and barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003ePerceived benefits and barriers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003ePerceived benefits and barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003ePerceived benefits and barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eSuggestions for CMP improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eInnovations to improve the program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eReferral Process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eSuccessful programs and components\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eOnline Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eOnline Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eOnline Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eVirtual Focus Group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e2,237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e412\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e29 sessions with 236 participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003ePhase 2: Needs Assessment Implementation\u003c/h2\u003e\n\u003ch3\u003eOlder Texan Survey\u003c/h3\u003e\n\u003cp\u003eThe Older Texan Survey was conducted as an online panel survey using Qualtrics, a reputed sampling company. Respondents were restricted to individuals 60 years of age and above residing in Texas. These respondents also served as a recruitment stage for the stakeholder focus groups described later. To incentivize participation, respondents received financial compensation ranging from $3 to $6 through Qualtrics. A total of 2,242 complete responses were collected between January 15 and February 7, 2020.\u003c/p\u003e\n\u003cp\u003eMost of the responses were from older adults who had not attended congregate meals (88.6%). The survey respondents were mostly White (83%), female (57%), and between 60-70 years old (67.6%). Detailed demographic characteristics of the survey respondents are presented in Table 2. The majority of respondents were retired and not looking for work (74.4%). Approximately 27.5 percent had an annual household income below $40,000 and 22.6 percent had an annual household income of over $100,000.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Selected Demographic Characteristics of Older Texan Survey Respondents\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelected Demographic Characteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage of Sample\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e60-70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e67.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e71-80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e28.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e80+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e3.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage of Sample\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e88.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eBlack or African American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eAmerican/Indian or Alaska Native\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eNative Hawaiian or Pacific Islander\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e0.04%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eMixed Race\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e1.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eOther/Prefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e2.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage of Sample\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eHispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e7.05%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eNot Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e90.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e2.59%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender Identity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage of Sample\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e42.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e56.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eTransgender or Gender Non-Conforming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e0.04%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent Household Income\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage of Sample\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eUnder $20,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e9.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e$21,000 to $40,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e18.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e$41,000 to $60,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e15.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e$61,000 to $80,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e13.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e$81,000 to $100,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e9.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eAbove $100,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e22.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e12.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eEmployed part-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eEmployed full-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e323\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eNot employed, but looking for work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eNot employed, not looking for work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eNot able to work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eVolunteer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eTake care of grandkids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e1491\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003ePrefer to not answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Organizational Survey\u003c/p\u003e\n\u003cp\u003eThe survey was launched on December 5, 2019, and remained in the field until April 6, 2020, on the Qualtrics platform and generated 159 valid responses. The sample for the Organizational Survey was obtained from the Texas HHSC Office of Aging and Disability mailing list, supplemented by snowball sampling. All survey participants had extensive knowledge of congregate meals. Among them, 138 respondents were currently employed by a local congregate meal provider, one had previously worked for such a provider, and 20 were affiliated with a Texas AAA. The respondents held a range of positions within their organizations, including program directors (n = 89), administrators overseeing the nutrition providers (n = 39), and subject matter experts on congregate meal programs (n = 43).\u003c/p\u003e\n\u003ch3\u003eCommunity Health Provider Survey\u003c/h3\u003e\n\u003cp\u003eAn online panel survey was conducted to collect data from August 3 to August 16, 2020, using Qualtrics. The survey was exclusively for registered nurses, licensed vocational nurses, practicing physicians, and practicing advanced practice registered nurses, all of whom were required to be licensed and residing in Texas. Individuals who did not meet these criteria were screened out. A total of 412 respondents completed the survey, of whom 204 were practicing physicians, 150 were registered nurses, 30 were licensed vocational nurses, and 28 were advanced practice registered nurses. Most physicians and nurses (347) served in counties classified as urban, while 65 worked in counties classified as rural.\u003c/p\u003e\n\u003ch3\u003eStakeholder Focus Groups\u003c/h3\u003e\n\u003cp\u003eFocus groups were held over a five-month period, from February to July 2020. We recruited a diverse range of participants, including nutrition providers, individuals eligible for CMPs and their family caregivers, senior-serving community agencies, healthcare providers, social workers specializing in senior care, and senior advocacy organizations. Participants were drawn from the 28 AAA regions across Texas to ensure a comprehensive range of perspectives. The first four focus groups were conducted in person. Later, due to COVID-19-related restrictions, the focus groups transitioned to a virtual platform. A total of 29 sessions were conducted. A total of 236 unduplicated participants joined the focus groups. All sessions were video recorded and transcribed verbatim. Transcripts were imported into qualitative analysis software after anonymization. A team of five researchers consolidated findings into relevant thematic areas and synthesized results. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePhase 3: Data Triangulation\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; SPSS and Jamovi were used to analyze quantitative data. A thematic analysis was conducted for open-ended responses in all surveys. Focus group discussions were transcribed and then analyzed using Dedoose and Excel by five research assistants. Each researcher was tasked with identifying thematic areas presented in the focus groups and comparing responses with survey results. Reviews consisted of preliminary emergent coding to identify these themes, followed by cross-coding to ensure all identified themes and codes were appropriately applied. Research assistants generated summaries of each focus group as well as combined summaries for each thematic area. These summaries were triangulated with survey data to expand and inform survey responses.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Results","content":"\u003cp\u003eEach data collection instrument and methodology aimed to identify factors contributing to the decrease in Congregate Meal Program participation. Thematic analysis and triangulation of data revealed several barriers and recommendations to promote CMP participation. The factors associated with participation barriers are categorized as follows: lack of awareness, stigma, changing family lifestyle, participant engagement and amenities, facility and location constraints, and menu and food choices limitations. The findings are summarized thematically in Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach needs assessment instrument asked participants to identify barriers to CMP participation. Table 3 summarizes the results of perceived barriers identified in the Older Texan Survey (the original question asked: \u0026ldquo;Which of the following issues might prevent older adults from attending a congregate meal program?\u0026rdquo;). Participants were given a scale of 1 to 5, with 1 representing \u0026ldquo;Not a problem\u0026rdquo; and 5 representing \u0026ldquo;A Serious Problem.\u0026rdquo; In addition, the survey participants who had never attended a CMP were asked to provide their reasons for not attending, allowing more than one answer. The frequency distribution of the responses is presented in Figure 2. The employees and volunteers at congregate meal sites were asked to provide a reason as to why they think the CMP participation is declining (original question asked: \u0026ldquo;Participation in congregate meals is declining in Texas, in keeping with trends across the nation. Why do you think this is happening?\u0026rdquo;) and Figure 3 displays the results. The participants were allowed to select multiple reasons. In the following sections, we present the detailed results by themes we identified.\u003c/p\u003e\n\u003cp\u003eTable 3. Barriers Ranked by Severity (All participants)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePotential Barriers to Participation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot a Problem (1-2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModerate Problem (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSevere Problem (4-5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS.D.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot knowing where programs are offered\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e8.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e15.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e76.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e4.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of programs in the area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e9.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e19.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e70.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransportation difficulty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e14.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e17.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e68.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDietary restrictions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e23.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e29.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e47.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of meals offered\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e24.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e38.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e37.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of variety in the meals offered\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e26.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e41.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e31.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeeling unwelcomed by other participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e33.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e30.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e35.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScheduling or timing of meals offered\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e29.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e39.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e31.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDislike of location where meals are offered\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e27.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e44.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e28.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStigma about what others will think\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e33.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e33.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e32.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnfriendliness of staff in the meal programs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e37.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e31.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e30.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrivacy concerns about group setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e33.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e39.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e26.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of need for free meals\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e38.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e34.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e26.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficulty getting time off work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e53.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e24.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e22.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003en = 2,153\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eLow Awareness\u003c/h3\u003e\n\u003cp\u003eThe lack of awareness among older adults, healthcare providers, and family caregivers is one of the most prominent barriers to program participation in this study. As outlined in Table 3, over three-quarters of the respondents (76.14%) identified \u0026ldquo;Not knowing where programs are offered\u0026rdquo; as a severe barrier. This was the second most common (42.2%) reason provided by those who had never attended a congregate meal program (n=1,965, 88.6% of all older adult respondents). Most congregate meal site staff (52.8%) and healthcare professionals (70.6%) also reported \u0026ldquo;lack of awareness\u0026rdquo; as one of the major reasons behind the decline in participation and the lack of referrals provided by healthcare facilities. Some CMP providers reported in the focus groups that older adults are aware of the existence and purpose of the senior centers, but not the CMPs. According to these participants, older adults often visit senior centers for activities but are unaware of the congregate meal services available at these locations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStigma \u0026amp; Bias\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother common factor attributed to the decline in CMP participation was the stigma associated with \u0026ldquo;free meals\u0026rdquo; and the embarrassment of being perceived as \u0026ldquo;needy.\u0026rdquo; The majority (88.6%) of Older Texan Survey respondents who had never attended CMPs indicated they \u0026ldquo;do not need free meals\u0026rdquo; as their primary reason for not participating, even though attendees are encouraged to make voluntary contributions toward the cost of the meals. Moreover, 29.6% of those who never participated in the CMP stated that they think they are \u0026ldquo;not frail or old enough\u0026rdquo; to seek congregate meals, which implies that CMPs are perceived as an exclusive program for those in need.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe organizational survey respondents most often cited stigmas, such as the perception that CMPs serve only less fortunate, low-income, or physically frail adults, as the \u0026ldquo;primary reason older adults choose not to participate.\u0026quot; Similarly, 59.1% of organizational survey respondents attributed low attendance to pride and embarrassment related to participating in the meal programs. CMP providers echoed this point during the focus group discussions, noting that \u0026ldquo;many in our senior community view these meals as a step above a soup kitchen, but not something for everyone.\u0026rdquo; Responses from focus groups across all Texas AAA regions reflected these sentiments, highlighting a widespread stigma surrounding the acceptance of charity, along with a desire among potential participants to reserve meals for those in greater need.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFacility Restrictions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSpecific to the atmosphere of the congregate meal sites, all \u003cem\u003eOlder Texan Survey\u003c/em\u003e participants were asked to rate the extent to which various aspects of a potential congregate setting would be welcoming to attendees on a scale of 1 to 5. The older adults suggested that CMP sites needed to improve and enhance the interior or the settings of the CMP sites to look more inviting by making it look like a home with extensive decoration (57.7%), including views of the outdoors from dining areas (84.4%), and adding indoor greenery (71.9%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOrganizational survey participants acknowledged their facilities needed improved and enhanced amenities to better cater to the needs of older adult participants. During the focus groups, some providers mentioned specific requirements for their buildings, including the need for designated pick-up and drop-off areas, as well as additional handicap-accessible parking spaces and entrances. Congregate meal site employees and volunteers also raised specific issues incorporating diverse activities into their existing locations. For example, some locations do not have large spaces for group activities like yoga, pickleball, bingo or dancing. Other locations lack private rooms for smaller classes, religious studies, or other personal interactions. Some facilities have a single large room for group meals, whereas others are split across different areas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTransportation Challenges\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eClosely linked to facility constraints, transportation was mentioned as a barrier in all but one focus group session, especially in rural areas that require longer commutes (over 20 miles) with fewer public transit options. Consistent with the findings from the literature, many stakeholders noted that partnership with local transportation agencies could facilitate appropriate transportation infrastructures, policies, and mobility options and help reduce transport-related social exclusion among older Texans in the CMPs [9, 10]. Focus group participants, both older adults and providers, indicated that many CMP-eligible individuals do not like to drive or do not have a car. They may lack access to a personal vehicle and therefore, need to rely on family members and caregivers or public transportation services.\u0026nbsp;Those who do have a car might be easily discouraged from driving because of bad weather, if they do not feel well, or because their vehicles are not always equipped to handle physical barriers such as wheelchairs and walkers. While over half of the organizations (57.4%) reported at least some transportation assistance, only two-fifths (40.5%) provide their own transportation, whereas 16.9 percent partner with another organization. This leaves\u0026nbsp;nearly 43 percent of organizations that do not provide any transportation assistance to their CMP participants.\u003c/p\u003e\n\u003ch3\u003eShifting Demographics\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eCongregate meal providers in the Organizational Survey and in focus groups attributed much of the decline in participation to a changing older adult population and demographic shifts. The majority (57.9%) of organizational survey respondents indicated that they believed the decline in CMP participation was due to older adults still working or staying active. About 71 percent of older adult respondents stated that the schedule or the timing of the meal offered was a moderate or severe barrier, and about half (46.5%) chose difficulty getting time off work as a moderate or severe barrier. According to focus group participants and common literature, many older adults are taking care of their grandchildren, especially during the summer when the schools are not in session while their parents are still working.\u003c/p\u003e\n\u003cp\u003eCongregate meal providers in the focus groups consistently cited the higher average age of congregate meal recipients as a barrier. According to these providers, as the older population of the congregate meal participants age and pass away, the younger\u0026nbsp;contingent\u0026nbsp;of the population is not coming in to replace them. One provider participant in a focus group said, \u0026ldquo;[t]he bar for when people think they should go to a senior center is pushed back further and further these days.\u0026rdquo; Providers emphasized the regional variation in the participants\u0026rsquo; characteristics, as a provider over multiple areas noted that congregate meal providers \u0026ldquo;need to know the seniors they serve\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eSuggestions\u003c/h2\u003e\n\u003cp\u003eSeveral suggestions as to how CMP participation can be facilitated emerged from the data collected through this needs assessment. To address the lack of awareness, stigma and bias, facility restrictions, and changes in older adults\u0026rsquo; evolving lifestyles, we identified three areas to focus on for congregate meal sites and policymakers to increase CMP participation.\u003c/p\u003e\n\u003ch3\u003eAwareness and Marketing\u003c/h3\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;As discussed earlier, the lack of awareness is one of the main reasons older adults do not participate in CMPs. This suggests an ample need for better marketing strategies for congregate meal sites and government agencies supporting the sites (such as AAAs). The Older Texan Survey results show that older adults prefer to receive much of their information primarily through mail outs (51%), television (36.5%), places of worship (35%), and online (33.9%). Congregate meal providers (31.4%) suggested increasing the social media presence of the meal programs to increase awareness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results also show that congregate meal providers should expand their target audience by reaching agencies and individuals with frequent interactions with older adults, such as local communities including places of worship, health care providers, and younger adults with parents and grandparents who are eligible for the CMP. In addition, the needs assessment results suggest that marketing for CMPs should focus on eliminating the misconception that CMPs are only there to give free food to the poor. Instead of emphasizing the cost-free or voluntary contribution to meal cost of the CMP, greater focus should be placed on highlighting the healthy meals and essential services that foster social connections and enhance the well-being of all older adults. Among the Older Texan Survey participants who have participated in CMP, many indicated that they participate in the program to socialize (68.3%) and to attend activities provided at the site (46.8%). The results strongly suggest that CMPs are in dire need of an improved marketing strategy, focusing on expanding the audience and highlighting the social support derived from CMP participation.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eEngagement and Activities\u003c/h3\u003e\n\u003cp\u003eAs to the social activities that could facilitate older adults\u0026rsquo; participation in CMP, the\u0026nbsp;\u003cem\u003eOlder Texas Survey\u003c/em\u003e respondents identified the following activities as enticing: Games like Bingo and Poker (72.7%), wellness activities (58.2%), arts \u0026amp; crafts (57.4%), computer literacy courses (56.1%), and cooking and nutrition courses (51.2%). Figure 4 presents the most commonly suggested activities by all older adults. Those who had previously attended CMPs reported mostly similar activities, with higher interest in each activity listed. Some specific activities with more interest included fine arts (53% to 40%), performing arts (50% to 40%), arts \u0026amp; crafts (68% to 57%), dancing (45% to 34%), and games (82% to 73%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe organizational survey revealed that many of these activities were already implemented at some congregate sites. For example, 77 providers (48.4%) offer games like Bingo or board games, 56 providers (35.2%) offer arts \u0026amp; crafts, and 31 providers (19.5%) offer some form of dancing. Congregate meal providers in the focus groups also discussed marketing the activities such as book clubs, exercise, and bible study could reduce stigma around participation. Participants in the focus groups discussed local activity offerings that were not included in the surveys (such as a disaster planning day or a crafting day dedicated to making baby blankets for a nearby pregnancy center) as events that were relatable and able to entice participation.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eMenu Variety\u003c/h3\u003e\n\u003cp\u003eDietary restrictions, concerns about the quality of meals, and lack of variety in the menu were some of the consistent concerns among older adults. Of all \u003cem\u003eOlder Texan Survey\u003c/em\u003e participants including those who never attended a CMP, 47.3 percent identified dietary restriction as a severe barrier, and 37.2 percent and 31.9 percent of the survey respondents selected quality of meals and lack of variety in the menu as a severe barrier, respectively. This need is echoed by open-ended responses to a question that asked for suggestions to improve the meal program. Most respondents expressed a desire for greater meal variety, along with options for healthier food choices. Some specifically mentioned a preference for lean proteins, such as turkey or fish. Many participants indicated disappointment with the frequent starchy options, as noted by the following participant\u0026rsquo;s comment: \u0026ldquo;There have been times when the vegetables offered with the meals during the week were beans/corn, beans/tater tots, beans/potatoes. The entry [entr\u0026eacute;e] would then be very starchy as well. The meal needs to be more balanced, colorful, and varied.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eTwo-thirds\u0026nbsp;of \u003cem\u003ethe Organizational Survey\u003c/em\u003e respondents indicated that their CMP menu was a set menu that did not offer the participants any flexibility. Another 16.9 percent indicated that the menu could consist of a choice between different complete meal options (such as choosing between two types of meals), while about eight percent indicated that people could choose different food items within a meal (such as choosing between entrees, vegetables, fruits, or dessert options). While 67.9 percent of providers believe adults want more choices and variety in their congregate meals in the \u003cem\u003eOrganizational Survey\u003c/em\u003e, over half of the senior nutrition programs (55.1 percent) do not accommodate special dietary needs. The limitation on the menu is often due to a cost control measure, operating with limited funding. All menus must comply with state guidelines for compliance with the US Dietary Guidelines but may not meet specific modified or therapeutic needs for certain chronic conditions. However, the findings from the Older Texan Survey suggest that older adults are concerned that the CMP does not serve the food they can consume. Offering a choice of meals and culturally relevant food may remove the barrier for potential participants.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003eIt is evident, both from existing literature and data collected for this study, that stakeholders understand the potential of congregate meal programs to be more than just meals. The goals of the CMPs are to reduce hunger, food insecurity, and malnutrition; promote social engagement; and support the overall health and well-being of older adults. Participants in the needs assessment study acknowledged the significant role CMPs play in improving outcomes by providing access to nutritious meals and fostering socialization. Despite a general understanding of these benefits and the growing older adult population, participation in Texas CMPs has notably declined over the past decade. Through a combination of quantitative and qualitative analyses, this comprehensive study identifies the factors contributing to low CMP participation among older adults in Texas and offers recommendations for congregate meal providers to address these challenges. It also highlights the values that CMP participants associate with these programs and suggests strategies to enhance engagement.\u003c/p\u003e\u003cp\u003eWe identified four major barriers to older adults’ participation in CMPs: lack of awareness, stigma and bias, facility and location constraints, and changing family lifestyles. With these barriers in mind, we have isolated three specific areas of improvement to increase participation: marketing, amenities and activities, and expanding the menu. A distinct overall lack of awareness regarding congregate meals was cited in all surveys and focus groups. Over three-quarters of older Texan respondents (76.14%) stated a severe barrier was “Not knowing where programs are offered.” Over half of congregate meal site staff (52.8%) and most healthcare professionals (70.6%) also reported “lack of awareness” as one of the major reasons behind the decline in participation.\u003c/p\u003e\u003cp\u003eEven if the older adults were more aware of the CMP in their communities, stigma might act as a prominent barrier to participation. Aligning with the larger finding that government programs perceived to target low-income participants stigmatize and deter participation [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], 33 percent of the participants in the Older Texan Survey stated that they avoid going to the CMPs because of the fear of being judged by others. Most congregate meal providers (59.1%) also believed that personal pride and embarrassment are the greatest barriers that hinder older adult participation in the CMPs. One aspect of the stigma surrounding CMPs is linked to the facilities themselves. Older adults express a preference for attending locations that feel comfortable and inviting, with appealing decorations, greenery, and views of the outdoors. Accessibility is also a key concern: transportation remains a consistent barrier across the state. While about half of CMPs offer some form of transportation assistance, many older adults, particularly in rural areas, still face significant challenges in accessing these sites.\u003c/p\u003e\u003cp\u003eCMPs face competition from employment and other lifestyle changes for some older adults. According to the Organizational Survey respondents, the average age of CMP attendees continues to rise, suggesting a decline in participation among younger older adults (ages 65 to 74). This trend aligns with existing literature, which indicates that adults in the 60–70 age range are more likely to remain employed or prioritize family responsibilities, factors that may contribute to reduced attendance at CMP. Additionally, while many programs offer meals and activities to adults aged 60 and older, there may be a lack of tailored activities or programming that address the diverse interests and needs of different age ranges within the older adult population. This gap could be further limiting engagement and participation among younger adults who may have different expectations and preferences.\u003c/p\u003e\u003cp\u003eThe results clearly highlight an urgent need for comprehensive marketing efforts to build awareness and reduce the stigma around CMPs. These findings suggest that by addressing the specific needs and preferences of older adults and implementing an effective marketing campaign, CMP participation, awareness, and satisfaction could significantly increase. To achieve this, marketing campaigns should be tailored to the media outlets that older adults in each CMP region engage with, utilizing targeted outreach. Additionally, the benefits of CMPs may need to be reframed in a way that emphasizes their value for all older adults, rather than positioning them solely as services for those who are economically disadvantaged or underprivileged. This shift in perception could help attract a broader range of participants.\u003c/p\u003e\u003cp\u003eIn addition to marketing efforts, incorporating attractive and educational programs for older adults would be one of the most effective ways to boost participation in CMPs. According to the Older Texan Survey, only about one-third (35.5%) of older adults attended congregate meal programs primarily for the meals, while the majority attended for socialization (68.4%) or to participate in engaging activities (46.9%). Survey and focus group participants suggested a variety of activities that could enhance the appeal of CMPs, including fun activities, fitness classes, cultural events, technology classes, and intergenerational programs. Research indicates that using congregate meal sites for educational purposes or offering meaningful activities has led to significant positive outcomes, improving both engagement and overall satisfaction among older adults. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnother effective way to facilitate participation is by revising the menus offered at CMPs. The Older Texan Survey identified several factors hindering participation, including dietary restrictions (47.33%), meal quality (37.2%), lack of meal variety (31.94%), and issues with meal scheduling and timing (31.85%). These factors were reported as problems or very serious problems by many participants. Expanding menu options could help address the diverse medical and nutritional needs of older adults. Additionally, with the increasing ethnic and religious diversity within the older population, there is a growing need to cater to these cultural preferences [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e–\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. To meet these needs, CMP menu development strategies should incorporate awareness of ethnic diversity, ensuring that programs are inclusive and reflective of the communities they serve. This focus should be supported through training for senior nutrition providers to ensure they can effectively adapt their offerings.\u003c/p\u003e\u003cp\u003eOverall, CMPs must evolve to meet the changing statewide and national landscape and needs of their older adult constituents. While the benefits of CMPs are widely recognized, participation in these programs continues to decline. Our needs assessment has pointed out key areas of concern and offered practical recommendations for adapting CMPs to better serve the current and future generations of older adults. By addressing these issues, CMPs can ensure they remain a vital resource for enhancing the well-being and social engagement of older adults. A thoughtful, proactive approach to these changes will be essential in reversing the trend of declining participation and ensuring the long-term success of these programs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding Statement\u003c/p\u003e\n\u003cp\u003eThis work was supported by the U.S. Administration for Community Living, Department of Health and Human Services under Grant 90INNU0013-01-00. The authors report there are no competing interests to declare.\u003c/p\u003e\n\u003cp\u003eEthics Statement\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Institutional Review Board (IRB)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eat Texas A\u0026amp;M University determined this study as not qualifying for human subjects\u0026rsquo; research. It is a Quality Improvement study. \u0026nbsp;But the research team followed all protocols pertaining to human subjects research. Project sponsors, Texas HHSC and ACL, have provided the grantee organization (Public Policy Research Institute, Texas A\u0026amp;M), the right to publish from project aggregate data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eConceptualization: Nandita Chaudhuri; Methodology: Nandita Chaudhuri, Anthony Jackson; Formal analysis and investigation: Ashleigh Williams and Anthony Jackson; Writing \u0026ndash; original draft preparation: Anthony Jackson, Megumi Sakamoto, Nandita Chaudhuri; Writing \u0026ndash; review and editing: Anthony Jackson, Megumi Sakamoto, Linda Netterville, and Nandita Chaudhuri; Funding acquisition: Nandita Chaudhuri; Supervision: Nandita Chaudhuri.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data Availability\u003c/p\u003e\n\u003cp\u003eData supporting this research is available upon reasonable request, and the request can be made to the Public Policy Research Institute at Texas A\u0026amp;M University.\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the U.S. Administration for Community Living, the Department of Health and Human Services and the Texas Health and Human Services Commission for providing the grant funding and permission to use the data for publication. The authors would also like to thank the research staff who supported the data analysis, and the survey and focus group participants who made this study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBergeron, C. D., John, J. M., Sribhashyam, M., Odonkor, G., Oloruntoba, O., Merianos, A. L., Horel, S., \u0026amp; Smith, M. L. (2021). County-Level Characteristics Driving Malnutrition Death Rates among Older Adults in Texas. \u003cem\u003eThe journal of nutrition, health \u0026amp; aging\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(7), 862–868. https://doi.org/10.1007/s12603-021-1626-2\u003c/li\u003e\n\u003cli\u003eMabli, J., Gearan, E., Cohen, R., Niland, K., Redel, N., Panzarella, E., \u0026amp; Carlson, B. (2017). Evaluation of the effect of the Older Americans Act Title III-C Nutrition Services Program on participants’ food security, socialization, and diet quality. \u003cem\u003eWashington, DC: US Department of Health and Human Services, Administration for Community Living\u003c/em\u003e, 2017-07.\u003c/li\u003e\n\u003cli\u003eMillen, B. E., Ohls, J. C., Ponza, M., \u0026amp; McCool, A. C. (2002). The elderly nutrition program: an effective national framework for preventive nutrition interventions. \u003cem\u003eJournal of the American Dietetic Association\u003c/em\u003e, \u003cem\u003e102\u003c/em\u003e(2), 234–240. https://doi.org/10.1016/s0002-8223(02)90055-6\u003c/li\u003e\n\u003cli\u003eRosenbloom, C. A., Kicklighter, R. D., Patacca, R. D., \u0026amp; Deshpande, K. (2004). 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Texas has unfinished business to improve care for aging population. \u003cem\u003eUT News The University of Texas at Austin\u003c/em\u003e. https://news.utexas.edu/2021/06/28/texas-has-unfinished-business-to-improve-care-for-aging-population/\u003c/li\u003e\n\u003cli\u003eAdministration for Community Living. (2023, December 25). \u003cem\u003eThe AGing, Independence, and Disability (AGID) Program Data Portal\u003c/em\u003e. AGID. https://agid.acl.gov/release.html#StateProfile \u003c/li\u003e\n\u003cli\u003eSleezer, C. M., Russ-Eft, D. F., \u0026amp; Gupta, K. (2014). Complex needs assessment. In \u003cem\u003eA practical guide to needs assessment\u003c/em\u003e (pp. 205-227). Wiley. https://doi.org/10.1002/9781118826164.ch8\u003c/li\u003e\n\u003cli\u003eValliant, J. C., Burris, M. E., Czebotar, K., Stafford, P. B., Giroux, S. A., Babb, A., ... \u0026amp; Knudsen, D. C. (2022). Navigating food insecurity as a rural older adult: The importance of congregate meal sites, social networks and transportation services. Journal of Hunger \u0026amp; Environmental Nutrition, 17(5), 593-614. https://doi.org/10.1080/19320248.2021.1977208\u003c/li\u003e\n\u003cli\u003eWolfe, W. S., Olson, C. M., Kendall, A., \u0026amp; Frongillo Jr, E. A. (1996). Understanding food insecurity in the elderly: a conceptual framework. Journal of nutrition education, 28(2), 92-100. https://doi.org/10.1016/S0022-3182(96)70034-1\u003c/li\u003e\n\u003cli\u003eChernoff, R. (1995). Baby boomers come of age: nutrition in the 21st century. Journal of the American Dietetic Association, 95(6), 650-655. https://link.gale.com/apps/doc/A17311230/HRCA?u=txshracd2564\u0026amp;sid=googleScholar\u0026amp;xid=c823e58e\u003c/li\u003e\n\u003cli\u003eHughes, S., Williams, B., Molina, L., Bayles, C., Bryant, L., Harris, J., et al. (2005). Characteristics of physical activity programs for older adults: Results of a multisite survey. The Gerontologist, 45(5), 667–675. https://doi.org/10.1093/geront/45.5.667\u003c/li\u003e\n\u003cli\u003eMyers, D. (2013). Come together: Congregate meal participation in Illinois planning and service area 05.\u003cem\u003eCapstone Projects – Politics and Government\u003c/em\u003e. 9. https://ir.library.illinoisstate.edu/cppg/9 \u003c/li\u003e\n\u003cli\u003ePardasani, M. (2010). Senior centers: Characteristics of participants and nonparticipants. Activities, Adaptation \u0026amp; Aging, 34(1), 48-70. https://doi.org/10.1080/01924780903552295\u003c/li\u003e\n\u003cli\u003eWellman, N. S., Weddle, D. O., Kranz, S., \u0026amp; Brain, C. T. (1997). Elder insecurities: poverty, hunger, and malnutrition. Journal of the American Dietetic Association, 97(10 Suppl 2), S120–S122. https://doi.org/10.1016/s0002-8223(97)00744-x\u003c/li\u003e\n\u003cli\u003eBrewer, D., Dickens, E., Humphrey, A., \u0026amp; Stephenson, T. (2016). Increased Fruit and Vegetable Intake among Older Adults Participating in Kentucky's Congregate Meal Site Program. \u003cem\u003eEducational gerontology\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(11), 771–784. https://doi.org/10.1080/03601277.2016.1231511\u003c/li\u003e\n\u003cli\u003eRobinson, K., \u0026amp; Jenkins, S. (2020). Older Adults Seek Out Congregate Nutrition Programs for Socialization. \u003cem\u003eInnovation in Aging\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(Suppl 1), 18–19. https://doi.org/10.1093/geroni/igaa057.060\u003c/li\u003e\n\u003cli\u003eMower M. T. (2008). Designing and implementing ethnic congregate nutrition programs for older Americans. \u003cem\u003eJournal of nutrition for the elderly\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(3-4), 417–430. https://doi.org/10.1080/01639360802265954\u003c/li\u003e\n\u003cli\u003eNANASP \u0026amp; The National Resource Center on Nutrition \u0026amp; Aging. (2019). Congregate nutrition programs: An exploration of current challenges and future opportunities. https://futureofcongregate.com/assets/uploads/NANASPNRCNA_LitReview_2019.pdf\u003c/li\u003e\n\u003cli\u003ePorter, K. E., \u0026amp; Cahill, S. (2015). A state-level review of diversity initiatives in congregate meal programs established under the Older Americans Act. Research on Aging, 37(7), 719–740. https://doi.org/10.1177/0164027514552330\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Congregate meal programs, Food security, Social connection, Aging, Needs assessment, Older adults","lastPublishedDoi":"10.21203/rs.3.rs-6414417/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6414417/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCongregate meal programs (CMPs) are food-centric nutrition programs under Title III of the Older Americans Act (OAA), intended to reduce hunger, malnutrition, food insecurity, and social isolation in vulnerable older adults and help maintain their independence in their homes and communities. Most CMPs in Texas have suffered from a lack of older adult engagement and participation decline despite the growing older adult population in the state. A mixed-method comprehensive needs assessment study was conducted to identify strategies to facilitate CMP participation. The study utilized state-wide surveys for older adults, CMP employees, and healthcare providers. In addition, the study held twenty-nine focus group sessions to further determine barriers and facilitators of the Texas CMPs. The quantitative and qualitative data was triangulated and analyzed by five researchers. The results identified three major barriers to CMP participation: (1) low awareness, (2) facility restrictions, and (3) changes in the older adults\u0026rsquo; lifestyle. To address these barriers, we concluded that marketing, engaging activities at the CMP in addition to meal services, and an enhanced and expanded menu would be effective facilitators. Furthermore, this study identified that games, wellness classes, and arts and crafts would attract more engaging participants to the program. The study emphasizes the importance of adapting the CMP programs to meet the community\u0026rsquo;s needs.\u003c/p\u003e","manuscriptTitle":"How to Motivate Congregate Meal Program Participation in Texas: Statewide Needs Assessment Findings on Program Barriers and Facilitators","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 10:12:48","doi":"10.21203/rs.3.rs-6414417/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-22T14:33:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-22T01:47:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-15T00:31:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19950496825058181500949063074832293204","date":"2025-05-14T19:32:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120041332113301032887312155916409802328","date":"2025-05-14T15:20:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-08T23:23:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-26T09:42:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-26T09:38:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-04-09T18:59:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"827fa1f1-e659-4eec-9634-1dcc1e4bbdd6","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T16:40:12+00:00","versionOfRecord":{"articleIdentity":"rs-6414417","link":"https://doi.org/10.1186/s12982-025-00880-4","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2025-08-24 16:29:27","publishedOnDateReadable":"August 24th, 2025"},"versionCreatedAt":"2025-05-15 10:12:48","video":"","vorDoi":"10.1186/s12982-025-00880-4","vorDoiUrl":"https://doi.org/10.1186/s12982-025-00880-4","workflowStages":[]},"version":"v1","identity":"rs-6414417","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6414417","identity":"rs-6414417","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}