Co-designing nutrition interventions with consumers: A scoping review

Designing the Food and Lifestyle Information Program (FLIP) culinary nutrition intervention for adults with mild-to-moderate intellectual disability

BACKGROUND

People with intellectual disability have diverse needs and experience higher rates of diet-related chronic disease such as type 2 diabetes compared to people without disability. However, they are infrequently included in development and implementation of interventions to address diet-related chronic disease. The present study describes the process to plan, develop and refine the Food and Lifestyle Information Program (FLIP) culinary nutrition intervention for adults with mild-to-moderate intellectual disability.

METHODS

The project was initiated by a disability service provider and was guided by the Cook-Ed™ model and inclusive research principles. Initially the disability service provider and academic research team members co-designed pre-program consultation and pilot studies, and draft program resources. Pre-program consultation explored paid disability support worker (n = 10) perceptions of cooking and food skills, nutrition priorities and optimal program format, which guided further program drafting. Program resources and pilot study design were further developed and refined with co-researchers with lived experience of intellectual disability who attended a pre-pilot and then pilot study sessions as remunerated co-facilitators.

RESULTS

Key characteristics of the FLIP intervention arising from pre-program consultation included providing cooking task instruction in small steps, enabling participant choice in program activities, promoting an inclusive and social atmosphere, and providing paper-based resources.

CONCLUSIONS

FLIP intervention co-design was enabled through ongoing input from the disability service provider and people with lived experience of intellectual disability. Evaluation of FLIP feasibility, acceptability and preliminary effectiveness to improve diet-related health is underway.

Co-designing The Healthy Gut Diet for Preventing Gestational Diabetes: Co-design methods and process outcomes

BACKGROUND

Gestational diabetes mellitus (GDM) is a common and costly condition of pregnancy. The Healthy Gut Diet for Preventing Gestational Diabetes study is a novel randomised controlled trial that aims to prevent GDM through a diet that modulates the gut microbiota for pregnant women with GDM risk factors. Despite increasing interest in co-designing interventions with consumers (lived experience experts), co-design methods and outcomes are often poorly reported. The present study aims to report on the co-design process used to develop The Healthy Gut Diet intervention.

METHODS

Co-design occurred across three online workshops with consumer participants (women with a lived experience of GDM, n = 11), researchers (n = 6) and workshop co-facilitators (including a consumer co-facilitator, n = 2). The workshops explored women's preferences for the mode and length of education sessions, as well as the types of information and supportive resources women wanted to receive, and undertook a "behaviour diagnosis" to understand barriers and enablers to the target behaviours (eating for gut health). The final intervention is reported according to the Template for Intervention Description and Replication.

RESULTS

A co-designed dietary intervention (The Healthy Gut Diet), delivered via telehealth, with a suite of educational and supportive resources that integrates published behaviour change techniques, was developed. Generally, the co-design process was reported as a positive experience based on participant feedback and evidenced by no participant dropouts over the 3-month study period.

CONCLUSIONS

Co-design is recognised as a process that creates a partnership between lived experience experts and researchers who can engage and empower research recipients and improve health behaviours.

Designing Child Nutrition Interventions to Engage Fathers: Qualitative Analysis of Interviews and Co-Design Workshops

BACKGROUND

Fathers play a pivotal role in parenting and child feeding, but they remain underrepresented in intervention studies, especially those focused on disadvantaged populations. A better understanding of fathers' experiences and needs regarding support access and child nutrition information in the context of disadvantage can inform future interventions engaging fathers.

OBJECTIVE

This study aims to explore fathers' experiences; perceived enablers; and barriers to accessing support and information related to parenting, child feeding, and nutrition and to co-design principles for tailoring child nutrition interventions to engage fathers.

METHODS

Australian fathers of children aged 6 months to 5 years with lived experience of disadvantage participated in semistructured interviews and co-design workshops, primarily conducted via videoconference. Creative analogies were used to guide the ideation process in the workshops.

RESULTS

A total of 25 interviews and 3 workshops (n=10 participants) were conducted, with data analyzed using reflexive thematic analysis and the Capability, Opportunity, and Motivation-Behavior model. The interview data illuminated factors influencing fathers' initiation in seeking support for parenting, child feeding, and nutrition, including their experiences. It highlighted fathers' diverse information needs and the importance of an inclusive environment and encouragement. Enablers and barriers in accessing support related to parenting and child nutrition were identified at the individual (eg, personal goals and resource constraints), interpersonal (family support and false beliefs about men's caregiving role), organizational (inadequate fathering support), and systemic levels (father-inclusive practice and policy). Digital data collection methods enabled Australia-wide participation, overcoming work and capacity barriers. Videoconferencing technology was effectively used to engage fathers creatively. Key principles for engaging fathers were co-designed from the workshop data. Interventions and resources need to be father specific, child centered, and culturally appropriate; promote empowerment and collaboration; and provide actionable and accessible strategies on the what and how of child feeding. Fathers preferred multiformat implementation, which harnesses technology-based design (eg, websites and mobile apps) and gamification. It should be tailored to the child's age and targeted at fathers using comprehensive promotion strategies.

CONCLUSIONS

Fathers faced barriers to accessing support and information related to parenting and feeding that may not adequately address their needs. Future interventions could integrate the co-designed principles to engage fathers effectively. These findings have implications for health service delivery and policy development, promoting father-inclusive practice.

Exploring hospital mealtime experiences of older inpatients, caregivers and staff using photovoice methods

AIM

To gather and understand the experience of hospital mealtimes from the perspectives of those receiving and delivering mealtime care (older inpatients, caregivers and staff) using photovoice methods to identify touchpoints and themes to inform the co-design of new mealtime interventions.

METHODS

This study was undertaken on acute care wards within a single metropolitan hospital in Brisbane, Australia in 2019. Photovoice methods involved a researcher accompanying 21 participants (10 older patients, 5 caregivers, 4 nurses and 2 food service officers) during a mealtime and documenting meaningful elements using photographs and field notes. Photo-elicitation interviews were then undertaken with participants to gain insight into their experience. Data were analysed using inductive thematic analysis, involving a multidisciplinary research team including a consumer.

RESULTS

Themes were identified across the three touchpoints: (1) preparing for the meal (the juggle, the anticipation), (2) delivering/receiving the meal (the rush, the clutter and the wait) and (3) experiencing the meal (the ideal, pulled away and acceptance). Despite a shared understanding of the importance of meals and shared vision of 'the ideal' mealtime, generally this was a time of tension, missed cares and dissatisfaction for staff, patients and caregivers. There was stark contrast in some aspects of mealtime experience, with simultaneous experiences of 'the rush' (staff) and 'the wait' (patients and caregivers). There was an overwhelming sense of acceptance and lack of control over change from all.

CONCLUSIONS

This study identified themes during hospital mealtimes which have largely gone unaddressed in the design of mealtime interventions to date. This research may provide a framework to inform the future co-design of mealtime interventions involving patients, caregivers and multidisciplinary staff, centred around these key touchpoints.

PRACTICE IMPLICATIONS

Mealtimes are experienced differently by patients, caregivers, nurses and food service officers across three key touchpoints: preparing for, delivering/receiving and experiencing the meal. Improving mealtime experiences therefore necessitates a collaborative approach, with co-designed mealtime improvement programs that include specific interventions focusing each touchpoint. Our data suggest that improvements could focus on reducing clutter, clarifying mealtime roles and workflows and supporting caregiver involvement.

IMPACT

What problem did the study address? Mealtimes are the central mechanism to meet patients' nutritional needs in hospital; however, research consistently shows that many patients do not eat enough to meet their nutritional requirements and that they often do not receive the mealtime assistance they require. Interventions to improve hospital mealtimes have, at best, shown only modest improvements in nutritional intake and mealtime care practices. Gaining deeper insight into the mealtime experience from multiple perspectives may identify new opportunities for improvement. What were the main findings? Patients, caregivers and staff have shared ideals of comfort, autonomy and conviviality at mealtimes, but challenges of complex teamwork and re-prioritisation of mealtimes in the face of prevailing power hierarchies make it difficult to achieve this ideal. There are three discrete touchpoints (preparing for, delivering/receiving and experiencing the meal) that require different approaches to improvement. Our data suggests a need to focus improvement on reducing clutter, clarifying mealtime roles and workflows and supporting caregivers. Where and on whom will the research have an impact? The research provides a framework for multidisciplinary teams to begin co-designing improvements to mealtime care to benefit patients, caregivers and staff, while also providing a method for researchers to understand other complex care situations in hospital.

REPORTING METHOD

This manuscript is written in adherence with the Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers were involved in the conception and design of the study through their membership of the hospital mealtime reference group. A consumer researcher (GP) was involved in the team to advise on study conduct (i.e. recruitment methods and information), data analysis (i.e. coding transcripts), data interpretation (i.e. review and refinement of themes) and manuscript writing (i.e. review and approval of final manuscript).

Scoping Review of Available Culinary Nutrition Interventions for People with Neurological Conditions

People with neurological conditions may face barriers to meal preparation. Culinary nutrition interventions aim to facilitate the building of knowledge and skills for meal preparation. This scoping review aims to map the available evidence for culinary nutrition interventions for people with neurological conditions and evaluate the quality of these interventions based on program design, delivery and evaluation. After a systematic search of online databases (MEDLINE, CINAHL, Embase, Scopus and Proquest) and reference lists, a total of ten publications describing nine interventions were included. Most interventions were designed for people with stroke and/or Transient Ischemic Attack (n = 3) and Multiple Sclerosis (n = 3); others were for traumatic brain injury (n = 1), mild dementia (n = 1) and Parkinson's Disease (n = 1). Overall, the included culinary nutrition interventions had good program delivery (inclusion of motivational experiences, delivered by appropriate health providers) but needed improvements in program design (lack of consumer engagement and neurological symptom accommodations) and evaluation (lack of complete process, outcome and impact evaluations). In conclusion, the evidence base for culinary nutrition interventions for people with neurological conditions remains sparse. To bridge the gap between theory and practice, it is important to consider the following aspects in culinary nutrition intervention planning/improvement: (I) the involvement of consumers; (II) the accommodation/tailoring for post-condition effects; and (III) the coverage of all disease-specific culinary nutrition aspects.

The 2-week systematic review (2weekSR) method was successfully blind-replicated by another team: a case study

OBJECTIVE

To assess the replicability of a 2-week systematic review (index 2weekSR) created with the assistance of automation tools using the fidelity method.

METHODS

A Preferred Reporting Items for Systematic reviews and Meta-Analyses compliant SR protocol was developed based on the published information of the index 2weekSR study. The replication team consisted of three reviewers. Two reviewers blocked off time during the replication. The total time to complete tasks and the meta-analysis results were compared with the index 2weekSR study. Review process fidelity scores (FSs) were calculated for review methods and outcomes. Barriers to completing the replication were identified.

RESULTS

The review was completed over 63 person-hours (11 workdays/15 calendar days). A FS of 0.95 was achieved for the methods, with 3 (of 8) tasks only partially replicated, and an FS of 0.63 for the outcomes, with 6 (of 7) only partially replicated and one task was not replicated. Nonreplication was mainly caused by missing information in the index 2weekSR study that was not required in standard reporting guidelines. The replication arrived at the same conclusions as the original study.

CONCLUSION

A 2weekSR study was replicated by a small team of three reviewers supported by automation tools. Including additional information when reporting SRs should improve their replicability.

Are Malnourished Inpatients Treated by Dietitians Active Participants in Their Nutrition Care? Findings of an Exploratory Study of Patient-Reported Measures across Nine Australian Hospitals

BACKGROUND

Inpatient malnutrition is a key determinant of adverse patient and healthcare outcomes. The engagement of patients as active participants in nutrition care processes that support informed consent, care planning and shared decision making is recommended and has expected benefits. This study applied patient-reported measures to identify the proportion of malnourished inpatients seen by dietitians that reported engagement in key nutrition care processes.

METHODS

A subset analysis of a multisite malnutrition audit limited to patients with diagnosed malnutrition who had at least one dietitian chart entry and were able to respond to patient-reported measurement questions.

RESULTS

Data were available for 71 patients across nine Queensland hospitals. Patients were predominantly older adults (median 81 years, IQR 15) and female (n = 46) with mild/moderate (n = 50) versus severe (n = 17) or unspecified severity (n = 4) malnutrition. The median length of stay at the time of audit was 7 days (IQR 13). More than half of the patients included had two or more documented dietitian reviews. Nearly all patients (n = 68) received at least one form of nutrition support. A substantial number of patients reported not receiving a malnutrition diagnosis (n = 37), not being provided information about malnutrition (n = 30), or not having a plan for ongoing nutrition care or follow-up (n = 31). There were no clinically relevant trends between patient-reported measures and the number of dietitian reviews or severity of malnutrition.

CONCLUSIONS

Malnourished inpatients seen by dietitians across multiple hospitals almost always receive nutritional support. Urgent attention is required to identify why these same patients do not routinely report receiving malnutrition diagnostic advice, receiving information about being at risk of malnutrition, and having a plan for ongoing nutrition care, regardless of how many times they are seen by dietitians.

Digital behaviour change interventions to increase vegetable intake in adults: a systematic review

BACKGROUND

Digital interventions may help address low vegetable intake in adults, however there is limited understanding of the features that make them effective. We systematically reviewed digital interventions to increase vegetable intake to 1) describe the effectiveness of the interventions; 2) examine links between effectiveness and use of co-design, personalisation, behavioural theories, and/or a policy framework; and 3) identify other features that contribute to effectiveness.

METHODS

A systematic search strategy was used to identify eligible studies from MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Library, INFORMIT, IEEE Xplore and Clinical Trial Registries, published between January 2000 and August 2022. Digital interventions to increase vegetable intake were included, with effective interventions identified based on statistically significant improvement in vegetable intake. To identify policy-action gaps, studies were mapped across the three domains of the NOURISHING framework (i.e., behaviour change communication, food environment, and food system). Risk of bias was assessed using Cochrane tools for randomized, cluster randomized and non-randomized trials.

RESULTS

Of the 1,347 records identified, 30 studies were included. Risk of bias was high or serious in most studies (n = 25/30; 83%). Approximately one quarter of the included interventions (n = 8) were effective at improving vegetable intake. While the features of effective and ineffective interventions were similar, embedding of behaviour change theories (89% vs 61%) and inclusion of stakeholders in the design of the intervention (50% vs 38%) were more common among effective interventions. Only one (ineffective) intervention used true co-design. Although fewer effective interventions included personalisation (67% vs 81%), the degree of personalisation varied considerably between studies. All interventions mapped across the NOURISHING framework behaviour change communication domain, with one ineffective intervention also mapping across the food environment domain.

CONCLUSION

Few digital interventions identified in this review were effective for increasing vegetable intake. Embedding behaviour change theories and involving stakeholders in intervention design may increase the likelihood of success. The under-utilisation of comprehensive co-design methods presents an opportunity to ensure that personalisation approaches better meet the needs of target populations. Moreover, future digital interventions should address both behaviour change and food environment influences on vegetable intake.