Understanding food choices and practices among older people in Thailand – an exploratory study

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Understanding food choices and practices among older people in Thailand – an exploratory study

Chalobol Chalermsri

Master Degree Project in Global Health, 30 credits, spring 2019 International Maternal and Child Health (IMCH)

Department of Women’s and Children’s health Supervisor: Sibylle Herzig van Wees

Wordcount: 12,256

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Abstract

Background: Food choice and practice of older people is very significant for their health and well-being. Earlier studies have focused on the choices made by older people in developed countries. Therefore, this study aimed to explore food choices and practices among older people in Thailand from the perspectives of older people themselves and their caregivers.

Methodology: The study was performed in Samut Sakhon, Thailand. Six Focused Group Discussions and six semi-structured interviews were conducted with older people and their caregivers. The discussions and interviews explored individual food practices and the factors influencing the type and quantity of food selected. Data were transcribed using the denaturalized and verbatim approach, and analysis followed an inductive thematic approach.

Results: Both older people and caregivers shared that price and convenience were two common food choice values. Some also mentioned nutritional value as a determining factor.

Older people worried about unhygienic food and food which contained chemicals or was contaminated. They were concerned about food preparation process, dirt from pollution of the locality etc. Culture affected the way old people ate with their families, and what they chose to eat. Furthermore, the national Fishery law had a negative impact upon their food selection habits.

Conclusion: Older people’s food choice was the outcome from their personal mental processes that weighted, balanced, and prioritized each food choice value such as affordability, convenience, availability or nutritional benefits. To encourage healthy eating habits among older people, individual needs and opinions should be taken into consideration.

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Acknowledgment

I would like to express my gratitude to all those supported me and facilitated me in completing my thesis. Firstly, I would like to thank all the participants and their families who share their precious experience with me. I cannot finish my thesis without them. Also, thanks to Dr. Syed Moshfiqur Rahman and Dr. Shirin Ziaei, my supervisors, for all of helping and supporting from the first step until the end. I would like to thank my advisor, Sibylle Herzig van Wees for her advice and comments on this report. She introduced me to the world of the qualitative study. I would like to thank Dr, Soomboon Intalapaporn, my senior colleague for all of his help. This thesis would not have been complete without many community nurses at Samut Sakhon hospital and primary care units those recruited participants in this study. A special thank you to Mr. Major Kissam and Dr. Johanna McElwee for proofreading and editing my thesis.

Finally, I would like to thank my mother and my sister for understanding and supporting me in every step of my life.

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Acronyms

BMI COREQ DHA DGA

Body mass index

The Consolidated criteria for reporting qualitative research Docosahexaenoic acid

The Dietary Guidelines for Americans EFNEP

EPA

The adult Expanded Food and Nutrition Education Program Eicosatetraenoic acid

FGD FCV GDA MeHg

Focus group discussions Food choice values

The Guideline Daily Amounts Methyl mercury

PCU PUFA THB

Primary care units

The long-chain polyunsaturated fatty acids Thai Baht

UCSF The University of California, San Francisco UN

WHO

The United Nations

The world health organization

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Background

This section will provide a global definition and explain the current situations of the older population of Thailand. It will give an overview of determinants of food choice and practices among older people, articulate the roles and impact these have for caregivers of older people, examine the current state of Thailand’s older population, and discuss food and food markets in the country.

Older population: global definition and current situation

The World Health Organization (WHO)’s agreed cutoff for “older people” is 60 years of age and over (1). Globally, there is a rapid growth of the older population. In 1950, there were 205 million persons aged 60 and over in the world. However, this number is predicted to be around 2 billion by 2050 (2). Older people are commonly more vulnerable and associated with multiple morbidity and mortality, in comparison to the younger population (3). Multiple chronic diseases, as well as impaired physical and mental capacities, are commonly found among older people (4, 5). The aims of caring for these populations are the prevention of the complications of aging and diseases and maintaining their independence (4). Older people face physiological and pathological changes with unsustainability and inequity in resource assessment (6). Although some conditions in older people seem difficult to understand, the effective interventions for reducing the mortality and morbidity among this population are worth investigating (7). Currently, the number of research works on older people has been increasing rapidly. However, there were many challenges in researching this population, such as difficulty in taking consent, especially in persons with cognitive impairments and dependence (8). Thus, the researcher should consider these limitations and find strategies to overcome these challenges.

Determinants of food choice and practices in older people

Food choice is defined as how people decide on what to buy and eat (9). Food choice is an indicator of nutritional status (10, 11). A good nutritional status is important for sustaining health, preventing disability, and hence, maintaining quality of life (12). Food choice values (FCVs) are the determinants that people consider when buying or consuming each food (13).

Food choice in older people has changed over time due to the transitions of ecology, socio- economic conditions and global food systems (14). This section will explain the factors determining food choice and practice in older people starting from personal factors to society, food environments and macro-level contexts.

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7 Aging and food choice

Aging is inevitable. Sensation decline in the abilities to smell and taste is common in older people (15). The number of taste buds per tongue region decreases progressively in an older person. Older people from rural areas of New York reported that taste was the main factor for food choice consideration (16). Moreover, homebound older people explained the sensory appeal, convenience, and price as key motivations in food choice (17). Aside from sensory decline, dental problems also become common problems in older people. A study in Japanese older people showed that those with low chewing ability had a lower food variety and less frequent intake of beans, vegetables, seaweeds, and nuts than older people with high chewing ability (18). The other study in North Carolina, USA, also revealed that older people with poor oral health avoided consuming raw fruits and vegetables, meats and cooked vegetables (19).

Furthermore, many chronic diseases affect food intake in older people, such as neurodegenerative disorder or malignancy, which can affect food intake by increased inflammatory processes or neurological dysfunction (20, 21). These are related to overall survival (22). Moreover, food restriction or medications can affect eating behavior. Older people with diabetes have had recommendations to cut down on sweet or salty foods, causing poor appetite. Radermacher et al. interviewed Australian older people from different ethnic backgrounds. They mentioned health conditions and physical disability as important barriers to shopping for, preparing, and eating food (23). Conversely, in a study focusing on the Chinese people’s view on food, the role of foods in cancer and supportive cancer cares, the role of specific types of food in maintaining and enhancing general health and preventing illness was highlighted, especially herbs. Many Chinese older people reported avoiding eating certain foods, including meats or fried food (24). Thus, the aging process in both physiological or pathological change has various effects on people’s food choices and practices.

Mental health and malnutrition

Although older people suffer from physical limitations, retaining autonomy in individual food choice remains very important. Older people in both homebound (17) and independent settings (25, 26) stated that preference was a motivation in their food choice.

However, older people have a high tendency to suffer from psychological constraints such as depression, loneliness or stress from both neurotransmitter disturbance, worsening health conditions, social deprivation or financial compromise. Depressed mood and loneliness might culminate in loss of appetite or changes in eating habits. A study of early hospital-discharged

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8 older adults in the USA found depressive and anxiety symptoms among those unable to shop and prepare meals. People with depression may be less motivated to eat, causing less sufficient calorie consumption (27). A study in Japan demonstrated that older people who ate alone had lower food diversity and lower body mass index (BMI), higher depression and lower quality of life (28). A recent qualitative study in the USA also found attitude about eating alone impacts older people’s eating habits in terms of the motivation to cook and eat (29). This evidence proves that emotional factors can modify people’s food choices and practices.

Personal knowledge associated with cooking and eating habits

Furthermore, nutritional literacy, cooking skills, and previous experience are essential factors in ensuring nutritional intake. Hartmann et al. surveyed Swiss adults to find that cooking skills correlated positively with weekly vegetable consumption but negatively with weekly convenience food consumption (30). Besides the Swiss survey, focus group discussion (FGD) in British older people aged 65 years and over showed that the consumption of meat, ﬁsh, eggs, dairy products, nuts, and pulses were determined by personal nutritional knowledge and health beliefs (31). Additionally, a study in Canada found that dietary knowledge is associated with good quality global diet consumption in both sexes (32). Personal experiences in the past are so important in food selection. Older people in rural USA mentioned the importance of food familiarity. Food eaten during childhood still persisted in their minds. These memories shaped their food practices in later life (33). Another recent qualitative study of older people in the UK also found the previous experiences were common factors influencing participants’ interactions with food. However, some older people referred to feeling “bored” with their food and trying to find something different (29). So it is clear that adequate nutritional knowledge and cooking skills, including their previous experiences through the course of their life, can shape people’s food choices.

Social determinants as influencers or inhibitors of eating

Indeed, social determinants, including social interaction within the family or community, culture, religion, and norm are vital determinants influencing food choice.

Relationship within the family relates to nutritional status. A study among Korea’s frail and dependent older people found that participants who had close relationships with their family were less likely to follow their own preferences, as they tended to choose food from the advice of others (34). The other study among older community-dwelling people who resided in rural

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9 Lebanon found that social isolation was associated with poor nutritional status (35).

Additionally, a study focusing on associated factors of nutritional status among New Zealanders aged 75 – 85 years demonstrated that living alone was significantly related to malnutrition (36). Independent older people in the UK also discussed their shopping and cooking habits. They cooked everything only for themselves and ate alone (29). Oemichen conducted group discussions among older American people, and they stated the important role of social interaction. They preferred to eat meals at the older people center rather than the quick, easy meals alone in their rooms. They mentioned food in the older people center usually had higher and more balanced nutritional value (37). It can determine those social interactions influencing people’s food choices and practices.

Culture plays an important role in food choice and practice. Culture affects activities including shopping, cooking, and meal characteristics. It varies from culture to culture. A quantitative study of the food attitudes by comparing Euro-Americans with Costa Ricans found Costa Ricans were less concerned about weight than Euro-Americans (38). However, the attitude about food is different in Asia. The ethnographic study showed that the variety of food items within one meal, food from various locations and across seasons were the main motives in Japanese food culture (39). Furthermore, Chen et al. conducted a qualitative study to explore the dietary patterns of older Taiwanese people. They valued traditional Chinese food and they did not attempt to adopt any other cuisine. They kept the same dietary patterns through their lives and followed traditional Chinese ways of eating (40). It is clear that the norm and culture can affect people’s food choices and practices in several ways.

Food environments

Besides social determinants, the food environment, such as accessibility and convenience, is another important determinant of food choice (25). A large cross-sectional study of Japanese older people showed that not having or having few food stores within 1 kilometer of their home is associated with the intake of fruits and vegetables less than once a day (41). Additionally, older people in New York complained they depended on public transport and the nearby groceries. Thus, convenience and location were a critical issues for them, especially those with functional or health problems while a few older adults relied on food delivery services (42). The older people who resided in rural USA also mentioned the lack of a reliable transport system as a barrier to shopping in the neighboring larger town. So, they relied on local grocery stores, restaurants, superstores, and farmer markets and felt there were

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“no places to get good groceries” (33). It shows that people prefer to consume available and convenient food.

Economic factors and food choice

Financial limitations can be found in many older people. An imbalance between food price and current income is a strong factor affecting food choice, food practices and nutritional status in older people. Older people in rural USA prioritized food price as the largest barrier to food access because they had a fixed income from a pension (33). In contrast, older bereaved UK men gave different results. They did not have any financial suffering and they felt their lifestyle was modest but not extravagant (43). For survival, older people tried to manage this problem in different ways. Older people in New York mentioned that they relied on Social Security income and it affected food shopping patterns and purchasing decisions. Their shopping decisions based on which food items were listed for sale items (42). Older Thai women also expressed their experience of food insecurity due to the global economic crisis.

They attempted to adjust by simplifying their food choices, buying food with concern about food prices, delaying their payment by using a credit card, cutting meal size or frequency and avoiding cooking at home (44). It is apparent that monetary issue is still the major concern for food selection.

Legislation and marketing as common influencers of food choice

Laws, regulations, and policies can limit or encourage food choice not only for older people but also for the general population. For example, the Supplemental Nutrition Assistance Program (SNAP) from the US government has had impacts on the American diet in various directions and settings. SNAP can benefit eligible citizens, especially low-income groups, enabling them to purchase food from some providers and improving their nutritional status (37, 45). However, laws and regulations differ a lot from country to country. Turning now to the topic of marketing and advertising, it can encourage customers to purchase specific food items or brands and it can create food trends. Data from South Korea found that exposure to a local fried chicken franchise’s TV ads increased from 20% in 2004 to 50 % of all TV fast food ads in 2010 (46). However, the targeted group for food marketing is children; thus the number of studies on the effects of advertisements or marketing campaigns in older people is still limited.

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11 In conclusion, older people’s food choices come from a combination of several factors in many aspects. Thus, the best assessment should derive from the holistic approach that considers the impact of physical abilities, cultural practices and norms, the role and presence of family members, and external economic factors.

Roles and impacts of the caregiver in older people

Since older people are declining in physical and mental abilities (47, 48), caregivers become a vital support system, especially older people with dementia, physical impairments or multiple chronic diseases (49, 50). Caregivers are divided into 2 main groups: formal (paid) caregiver and informal caregivers. Informal caregivers are deﬁned as people caring for a family member, friend or neighbor (51). Caregivers usually have several roles such as general care, drug administration, mobilization, financial and psychological support (52). In the aspect of nutrition, caregivers play an important role in the eating decision of older people (52, 53). A study that examined the agreement of dietary intake reported by older people and caregivers found a moderate agreement between two grounds (the kappa correlation 0.31 – 0.39).

Therefore, information regarding food intake provided by caregivers can be implied in the case of non-communicating older patients (54).

Feeding older people is such a challenging caregiving task. A study among caregivers of Alzheimer’s disease patients in Canada found that dementia patients changed their eating habits, for example, changing food preferences, decreased food intake or food diversity.

Caregivers were faced with feeding difficulties from decreased patients’ autonomy, forgetting symptoms, other chronic diseases and their own unavailability (55). It is apparent that caregiver thought and behavior influence older people’s eating and food choices. Many older people do not have the opportunity to decide what they eat because what they eat depend on caregivers (52). However, previous studies (49, 53, 56-58) on caregivers have mainly focused on dependent older people such as dementia or cancer patients while the caregiver perspective in general community-dwelling older populations is lacking. The research that includes the perspective of community-dwelling older people’s caregivers will enhance our current understanding of food choices among this population.

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12 Thailand: Demographic data and current situations

Thailand is an upper-middle-income country in the South-East Asia region. Currently, the composition of population and family in Thailand is changing, with fewer children and more older people (59). According to data from the Department of Older Persons, Ministry of Social Development and Human Security, in 2016, Thailand has a total population of approximately 66 million and 16.5 percent of the population was 60 years old and over. The older population constituted 15 % (10 million) of the total population in 2017 and is projected to reach 20 % by 2021 (60). The extended families, which consisted of parents, children and grandparents, are the most common family type in Thai society, especially in rural areas. It means at least one working-age adult living with their parents and reflects an intergenerational relationship and support system within families (59). For this reason, the informal caregiver becomes a common type of caregiver in Thailand (53). Caregiving in Thailand does not focus only on physically or cognitively dependent older people; it also covers the older people who are healthy and independent but have old age. Caregiving was a huge task that caused a considerable burden to the caregivers. However, they had good supporters in terms of temples and older people’s centers. Moreover, they had opportunities to demonstrate gratitude and this idea was taught by Buddhists for a while (61).

Nutritional policies and lifestyle in Thailand

Thai society is increasingly urbanized, with profound changes in lifestyle. In terms of eating, Thai people tend to eat more sugar, oil, fats, animal meat and processed foods, with fewer vegetables and fruits. They have also reduced physical activities (62, 63). Thailand has launched many policies involving nutritional improvement. Several interventions have been derived from previous policies and plans. These have included establishing food-based dietary guidelines (64) and the nutrition flag, nutrition labeling in some snacks, food fortification, and the campaign “Thai people have no big belly” (65). Due to these interventions, Thailand has improved many nutritional indicators. However, the new nutritional challenges are a double burden of malnutrition. Although the prevalence of undernourishment fell from 35 percent in 1990 to 7 percent in 2016 (65), many segments of the country still face undernutrition.

Meanwhile, the prevalence of overweight, obesity, and related noncommunicable diseases have been on the rise. Nowadays, Thailand is faced with overweight and obesity problems in children, young adults and older people. The prevalence of overweight and obesity among

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13 adults increased from 12 – 17 percent to 26 – 33 percent in 2014 (65). The nutritional interventions should consider and address these challenges.

Food market in Thailand

Thailand’s food market system now consists of a local fresh market and modern hypermarkets, supermarkets, and convenience stores. Thailand has seen rapid growth in modern food retail outlets corresponding with an overall decline in the number of local markets.

Stakeholders in Thailand’s local fresh food markets have stressed they are attempting to resist the competition from supermarkets by improving convenience, food diversity, quality, and tradition. Although supermarkets use food safety to claim superiority over fresh markets, some fresh markets have upgraded their infrastructure and while putting in places practices to improve acceptance (66). Thus, the competition between trading sections is still continuing in Thailand. Lastly, the other concerns among consumers are food safety. They have worried about chemical contamination in foods and the environment, such as pesticides. Pesticides are most widely used in the agriculture sector (67). However, literature has emerged that offers a contradictory finding of exposure and health outcomes (68, 69). Thus, advocacy and education in food safety are still vital in Thai society.

From this literature review, most knowledge of food choice in older people was derived from developed countries. The application to other parts of the world has limitations, especially in particular countries where culture and religion run as the main part of daily living. The food choice assessment from the caregiver perspective is another interesting point to fulfill the knowledge gap in this area.

Aims and Objectives

Research question

What factors affect the food choice and practice of older Thai people?

Objectives

 To understand the perception and experience of older people regarding their food choice and practice.

 To explore the factors influencing practice related to food choice and practice among older people.

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 To explore caregivers’ perception influencing food choice and practice among older people.

Methodology

Research Design

This study aimed to experience and factors that influence food choices and

consumption habit among older people. Thus, an exploratory qualitative study was conducted to address the research objective (70). The researcher decided to use qualitative research as this method is appropriate for the primary exploration of any topic through an inquiry into people’s perceptions and practices (71). Furthermore, qualitative research can be adapted based on the initial experience of data collection and can, therefore, promote the

accumulation of better-quality data with the progress of the study (72, 73).

Research setting

The study took place in Samut Sakhon Province, located in the central part of Thailand.

This province is about 60 km from Bangkok, the capital of Thailand (Annex 1.). The total area of Samut Sakhon is 872.35 km², and it is divided into 3 districts and 12 municipalities. Muang, one the three districts of this province, was selected as study site. There are 3 public and 6 private hospitals in Samut Sakhon province (total inpatient bed more than 2,000) and 17 primary care units (74). According to the national statistical office in Thailand, the number of individuals aged 60 years and over living in Samut Sakhon was approximately 79,700 (14%) in 2017, whereas the national estimate of people over 60 years or more is 16.1% (75). There was not much difference between the national estimate and provincial estimate. The researcher selected this site because the researcher wanted to understand the food choice and practice of a suburban setting. Moreover, Mahidol University, Thailand, had planned to establish a training center in this province for distributing knowledge regarding care for older people. So it was assumed that the study would provide some relevant data on the older people of this province to the University.

Participant sampling

This study was a collaboration between the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand and Samut Sakhon Province hospital, Thailand. This study was a part of the researcher’s field research course during the third semester of the master study in Global Health. After the research proposal was finalized, the researcher contacted a prominent coordinator who was the head of the nurses at Samut Sakhon province hospital. The researcher

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15 discussed with the main coordinator about the detail of the study, as well as inclusion and exclusion criteria. The researcher decided to select the participants from primary care units as those are the closest to the community. The main coordinator helped by providing a list of Primary Care Units (PCU) of the selected district (Muang) and the study sites were select randomly. After the study sites’ selection, the community health workers in each primary care unit were contacted with the help of the main coordinator. They received the information about the study’s detail, as well as inclusion and exclusion criteria, from the main coordinator. The inclusion criteria for older people were being aged 60 years old and over, residence in Muang District, Samut Sakhon, and ability to communicate in Thai. People who had any condition that affected their communication were excluded from the study. The inclusion criteria for the caregiver group were being an informal caregiver and ability to communicate in Thai regardless of age and sex.

There is “the older people club” in every primary care unit, and these clubs hold a meeting every month to share information and recreation. Apart from older people, young people or caregivers could also join these meetings. The community health workers announced information about study in the club meeting. With the help of community health workers, participants who were willing to participate after becoming aware of the study and also had time available were recruited using purposive (theory-based) sampling methods. This method was appropriate for studies that aim to outline a theory based on the exploration of a topic (76, 77). Following sampling appointments with participants were organized by the community health workers in each primary care unit (PCU) and the study schedules relied on the participants’ convenience. However, community health workers did not get any training for the recruitment process.

This study consisted of 6 focus group discussions (2 with male older people, 2 with female older people, and 2 with caregiver groups) and 6 semi-structured interviews (2 with male older people, 2 with female older people, and 2 with caregivers). Three participants in these interviews came from the previous FGDs and three persons were the new people who did not participate in FGDs. The researcher used the convenience sampling method to recruit FGD participants for the interview. FGD participants who had time to participate in the interview were interviewed again after the FGDs were conducted. Three other interviewees were recruited using the purposive sampling method. Participant characteristics have been provided in Annex 2.

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16 Data collection

Data were collected using two different collecting methods: focus group discussions and semi-structured interviews. The topics discussed during the focus group discussions were further explored in the semi-structured interviews. The reasons the researcher chose the two qualitative data collecting methods were that each method provided semi-structured information and explored complex processes in different aspects (70). FGDs could provide rich data about people’s perception and felling (78) when semi-structured interviews were useful for the exploration of details of thoughts, attitudes, and knowledge (70).

The FGD and interview guides were developed based on literature review, discussion with supervisor and other researchers. The guides included questions on participants’ previous and current food choice and practice, also influences on their food choice. Data collection was done over 4 months between July and October 2018. Demographic data such as age, gender, education, marital status, and the number of family members were collected from all participants. The information was collected by a face-to-face interview in the private part in the conference room before conduction of FGDs or interviews. These demographic data were used in the analysis process and reported in the findings and discussion section to provide an explanation regarding food choice and practice of study participants. Both FGDs and interviews were conducted in the Thai language and captured on tape recorders.

All FGDs were conducted at the primary care unit (PCU) as the place was convenient for the participants. The conference room of PCUs was selected because those rooms provided privacy, comfort, convenience and already had enough physical facilities such as a round table and chairs for facilitating the discussion (70). On the other hand, interviews were conducted at participants’ house, health center or coffee shop.

This study had two research assistants. They had some experience in conducting qualitative research. However, before involving them in the study, the researcher explained the study as well as the process of conducting a focus group discussion and interview. The roles of the research assistants were to organize the study participants at the pre-decided venue on the scheduled day, and they also performed the responsibility of note-taking (70). In addition, they observed the data collection and noted the sequences of conversations and non-verbal responses. Participants were recruited until data saturation was reached. Data saturation is the point when no new relevant knowledge emerged from data collection from new participants.

As a part of the analysis process, and to identify themes to dig down further, the researcher

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17 listened to the audiotape record twice and also took notes. This process allowed the researcher to understand whether the saturation point was reached (79).

FGDs were conducted before the interviews. FGDs could provide an understanding of current practices on food choice in a diverse range of points of view and demonstrate group dynamics rigorously (80). The researcher acted as facilitators. The researcher used the discussion guide and facilitated the discussion. The researcher also tried to ensure that all participants were engaged in the discussion process. After the informed consent was taken, the facilitator started the discussion, explaining the study’s objectives and general rules. Following that, the facilitator engaged the participants in a discussion on the study’s themes: past and current individual practice on food choice and practice, factors that influence what and how much they eat in a normal day, opinions about the food choices of people at their age and suggestions. Participants in FGDs were allowed to discuss freely (81). In 6 FGDs that were conducted, the researcher grouped participants according to gender and also separated older people from caregivers because participants would usually feel more comfortable and prefer the company of others who shared the same characteristics (70). The duration of each discussion session ranged from 65 – 85 minutes. (see FGD guide in Annex 3.)

Semi-structured interviews were conducted after FGDs were complete. As the

researcher used to listen to the FGD recoding and took notes, the researcher could identify the uncommon topics that were not already included in the interview guide. Some of those topics were the fishery law in Thailand, buying ready-cooked meals, etc. Thus, the researcher wanted to collect more information on those topics and included questions based on them in the interview guide. The researcher interviewed older people and caregivers to get the detail on specific topics such as cultural and societal changes, religion, street food or ready-cooked meals, chemical contamination in food, new fishery law, advertisements. Each interview lasted approximately 40 – 62 minutes. After the study, they got 2-kg rice bags or essential drugs as a gift. They were not informed about this before data collection were complete) (see interview guide in Annex 4.)

Data analysis

The researcher transcribed the recordings of each interview verbatim, whereas the denaturalized approach was used for FGD transcriptions. A denaturalized transcription approach is another method to transcribe information by correction the grammar, removal of interview noises such as pause and manner that do not affect the analysis (82). The researcher also used field notes to ensure that the transcripts contained the details of what was expressed

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18 by the study participants (data including non-verbal behaviors). The researchers transcribed all data without returning transcripts to participants for comments.

The transcripts were translated from Thai to English before coding was started. The researcher used both English and Thai transcriptions for analysis because the researcher wanted to assure that the data was available for any non-Thai speaker to review. After that, the researcher checked all of the transcripts to ensure translation accuracy by repeat-reading all transcripts. Then, the researcher read and re-read all transcripts many times before analysis to understand the meanings.

The analysis was conducted using the inductive thematic approach. Inductive thematic analysis was the method used for analyzing and interpreting the pattern of data’s meaning or theme. Themes in this method came from the data themselves and directly (83, 84). The researcher analyzed and created the initial codes following a line-by-line of the transcriptions.

After reading all transcripts multiple times, the researcher identified initial coding, and the data were organized under these codes by developing a coding system (85) using the NVivo software program (NVivo 12 pro, the UK). Definitions of all codes were developed by the researcher to ensure uniformity in the coding process. The code definitions were strictly followed in the data-organizing process under each code. The matrix was read and re-read to ensure that data were put under the code consistently. The code list and their definitions were discussed with peers (master students in Global Health at Uppsala University). The peers also reviewed the matrix and shared their opinion regarding consistency/validity of the coding process. All the feedback from peers were due to the lack of clarity regarding the research and were solved by the researcher through a further explanation.

For the validity of this research, the researcher ensured the triangulation by performing more than one qualitative method for answering the same research question (85). However, they gave their opinions about codes, categories and theme development without the responsibility to analyze or manipulate any data (85).

Reflexivity

The researcher is a Thai woman studying for a Master’s degree in Global Health at Uppsala University. The researcher also works as a consulting geriatrician and instructor at the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand. The researcher has experience in quantitative research, community research, geriatric medicine, and nutrition disorders. The researcher is familiar with the study site because she worked as a general

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19 practitioner in this area 10 years ago. The researcher knew some community health workers personally. So, it was easier to contact them. As discussed earlier, the community health workers communicated the message about the study among older people, who got enrolled in the study voluntarily. The community health workers did not have any influence on the participants’ enrollment in the study. Moreover, the researcher followed the consent-taking process of explaining the study objectives, benefits, risks, incentives, voluntariness of participation, right of withdrawal, confidentiality, etc. to the participants. Although the researcher did not have previous experience of conducting FGD, the researcher received lesson on this during the Master’s course. In addition, the researcher also consulted books and online sources to gather the knowledge required for conducting FGD.

There were two research assistants in this study. They used to work at the Department of Preventive and Social Medicine, Mahidol University, as general practitioners. One research assistant was studying in the masters of public health at Johns Hopkins University, USA. She has experience in public health advocacy and community health. Another research assistant had experience of working as a visiting scholar at the Memory and Aging Center, University of California, San Francisco (UCSF), USA. She also had experience in clinical research in older people. As the study was done in the researcher’s native country, language was not a barrier and there was hardly any cultural difference. Moreover, healthcare professionals are respected in Thai society. This respect might help us get access to the participants comparatively easily.

Therefore, it might have influenced the research. To elaborate, the participants felt more important as health care professionals approached them to know about their food preferences and practices. If the researchers were someone other than health care professionals, participants probably would feel less enthusiastic about sharing information. The researchers felt that some participants tried to explain and answer from an academic point of view. For example, they talked about insulin resistance and diabetes mellitus in the academic sense. It showed that they had good knowledge. However, the researcher primarily asked about their exact practices. They accepted that their eating habit was influenced by many factors. Knowledge was not the only factor for their food selection. This issue might influence the collected data. Health concerns might be overestimated. Some participants also asked the researchers to share their opinions or questions during discussions. However, the researchers politely declined to share their opinions because it could influence the participants’ perceptions and beliefs.

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20 Ethical considerations

This study followed the Consolidated criteria for reporting qualitative research (COREQ) (86). To protect the wellbeing of participants, all studies involving human subjects had to get approval from the appropriate Institutional Review Board before data collection. The researcher had to complete the course in human research ethics before submitting the research protocol for ethical approval (see Thai version research protocol in Annex 5.) and obtaining the certificate in human ethics. (Annex 6) This study was approved by Siriraj Hospital’s Human Rights Committee for research on humans. (Annex 7)

The community health worker at primary care units had the responsibility to identify potential participants for the study and brief them on the study in the monthly older people’s club of the community. If someone was found to be interested in this study, the health worker arranged for them to meet the researcher on the study day. Some participants were communal heads, socially active persons in the community, health volunteers or ordinary people. Some of them were patients in PCUs, some were not. However, with support from the main coordinator, the researcher confirmed that none of the participants’ health care received from PCUs was affected due to participation in the study. The community health workers only helped in identification of the participants using their network and provided the scope to conduct data collection at the PCU. At the beginning of each study session, participants were informed about the study objectives, methods, benefits, risks, incentives and their rights as contained in the Thai version of the participant information sheet. Participants were allowed to ask any question about what they suspected. They were informed about the voluntary nature of the participation and that they could withdraw themselves from the study at any point they wanted to. They were also assured that their withdrawal from the study would not affect any services they received.

In addition, the researcher assured them that their identity would be kept confidential, and that data they provided would be used anonymously and only for research purpose. FGDs and interviews were conducted after participants were briefed and taken through the participant information sheet and had signed their names in the consent form. The thumb print was an alternative method for signing in the consent form if participants could not write. (Annex 8. in Thai). The demographic data was collected in the private segment of the conference room one- by-one to keep participants’ confidentiality. All personal information was anonymous.

Information in the computer was stored in password-protected files. The researcher was the

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21 only one who knew the password. All of the data will be destroyed after 5 years of finishing the study.

Results

The table below summarizes the demographic information of the study participants. The age range of older people was 60 – 81 years, and that of older people’s caregivers was 49 – 72 years. Half of older people and 15 % of caregivers were male. The majority of participants graduated from primary education and were married. The number of the household members was 3 and 4 persons in older people and the caregiver group, respectively. (Table 1)

Table 1. Sociodemographic data of older participants and caregivers

Characteristics Older people

(n=26)

Caregivers (n=13) Age (years); n (%)

< 60 0 (0.0) 3 (23.1)

60 -69 12 (46.2) 6 (46.2)

70 – 79 12(46.2) 4 (30.8)

80 - 89 2 (7.7) 0 (0.0)

Gender, male; n (%) 13(50.0) 2 (15.4)

Education; n (%)

No formal education 3 (11.5) 0 (0.0)

Primary education 19 (73.1) 9 (69.2)

Secondary education or higher 4 (15.4) 4 (30.8)

Marital status; n (%)

Single 1 (3.8) 2 (15.4)

Married 18 (69.2) 8 (61.5)

Separated or widowed 7 (26.9) 3 (23.1)

Number of people in household include self; median (IOR)

3 (2.0 – 6.0) 4 (2.5 – 6.0)

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22 The following section presents 4 themes regarding food choice that emerged from this study.

Theme 1. Variety of negotiating processes for food choice

Both older people and caregivers experienced various food choice values (FCV). They prioritized and balanced each food choice value, and then they developed individual strategies for their food choice in different ways. Their negotiating strategies varied from just only one FCV to multiple FCVs.

Subtheme 1.1. Cost related to the food and income of older people

The most common food choice value they referred to and added into their negotiating process was price. Older people, especially those who claimed they had inadequate income, reported that they preferred the cheapest food:

We focus on the price. We will think about what is reasonable. I take the cheapest ones. If we buy expensive items, we have to look at our resources. [FGD 6, female older people]

Moreover, older people who had concerns about their inadequate income sought a balance between price and their preference. Thus, they created a strategy for managing this situation by buying just small amounts of food. So they did not pay too much money:

We see something we like and want to eat such as when we buy this fruit. We buy a little bit. It is enough. Like oranges, they are expensive.

We buy a little. [FGD 6, female older people]

Price and convenience were two common food choice values that both older people and caregivers balanced in the negotiating process. They demonstrated their strategy in the form of ready-cooked meal consumption. Both older people and caregivers reported that they purchased ready-cooked meals for themselves and their families. Older people in the interview explained the reasons he relied on ready-cooked meals. They thought the ready-cooked meal was available and affordable food. In the words of the older person:

The ready-cooked meal [has] its benefits, which are 2 of them. First is because [it is] quick. [I] could prepare and just put it in a microwave.

Second, it [ready cooked meal] is economical. When we buy the cooked meal that I like, for example, mixed-vegetable spicy curry, it is only 40 Thai Baht (THB) [If I want to make the same menu] .... To cook one pot

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23 would cost more than 100 THB. One portion of the ready-cooked meal

we bought would be half a pot we make. [interview 1, male older person]

Besides ready-cooked meal consumption, older people and caregivers also focused on the place where they could access food at the most affordable price. One male older person often purchased foods from Sunday (temporary) markets since the price was cheaper and it was available in their community. It showed he prioritized convenience and price:

They would have to get food from the market in the area they live in.

(The market) is a savior for the people. (The stuff) sold there is very cheap. It is possible that it comes directly from the farms to be sold. The flea market is the heart and soul of the community. Every (neighborhood) has one. [interview 5, male older person]

However, convenience was not the only value older people and caregivers prioritized.

They also mentioned the price of transportation to buy food and then they demonstrated the strategy for this by buying food from a mobile food vendor who came to sell foods in their village. It was the evidence that there were more than two values they weighted and balanced:

In my community, there is a mobile food vendor that sells vegetables and pork every day. I have to buy them. I don’t know what the quality of chicken is. I ride the bicycle to buy something at the market. The oil price is expensive. It cost 30 baht for a round-trip route. If it {mobile food vendor] comes, we buy. [FGD2, male older people]

Subtheme 1.2. Realization of healthy food choice and consumption practice

The next common eating strategy in older people and caregivers was fish consumption.

They focused on the nutritional benefits and its texture. They preferred fish because fish was the soft food easy to chew. This demonstrated that both older people and caregivers were concerned about the physiological and pathological changes from aging such as dental or digestive problems, and they adapted older people’s menu to compensate for their physical condition. In the words of the member in this FGD:

Most of the food (I) choose is fish. (I) rarely have pork, and even less beef. (I) also have vegetables. Fish is easy to eat and digest and it is healthy food. [FGD2, male older people]

One caregiver mentioned the nutritional benefits of fish:

Fish is good food. Having fish is usually good in many ways. Fish don’t have any fat. They would not harm you, or very little.” [interview 3, female caregiver]

Moreover, the study site was along the Thai Gulf Coast, thus fish, especially sea fish, was available in this area. This male older person explained he ate fish very often because of its availability:

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24 (I) eat fish very frequently. Oh, (you) all know this is the seaside city;

we have many choices like mackerel. [interview 1, male older person]

Consuming a high variety of foods was one of the healthy eating habits among older people. Older people and caregivers thought they tried to eat a variety of food because of nutritional reasons. In their words:

It’s better [to eat the variety of food]. It’s not boring. We are bored eating vegetables every day sometimes…and they will be beneficial to the body. They make our bodies strong. [FGD 2, male older people]

Subtheme 1.3. Trust modified people’s food choice and eating habit

Trust was an important factor in both older people and caregivers’ negotiating process.

Trust in health care providers such as physicians or community health workers made older people’s eating habits change. Many older people reported that they gained nutritional knowledge from health care providers via direct advice:

The doctor said… my blood sugar is a little too high. Because I like dessert, ice cream, and cake. [I] have been trying. [My] doctor told me to keep my blood sugar below 100 [interview 2, female older person]

Another example of demonstrating trust as the common value of older people’s food choice was an advertisement. Older people said they purchased a pizza after they saw the advertisements because it was new and looked delicious:

But we wanted to try it. We can say that the pizza was delicious. We went to try it and see how it was. [FGD 1, female older people]

However, there were divergent views about this. Some people felt this was propaganda and did not believe it:

I don't believe any ads. It's beyond the truth. (In the advertisement) it stretches when cutting, but it didn’t stretch when we cut it at home. It was very dry. [FGD 1, female older people].

It was obvious that the negotiating process was the interactions between each food choice value. The negotiations were crucial processes to develop personal eating habits. Both older people and caregivers needed to collect, weigh and prioritize food values using their different mental processes, and consequently, they developed various personal strategies for the most acceptable food choice within their own context.

Theme 2. Food contamination and hygiene

Both older people and caregivers were concerned about food safety. They thought foods in their community were contaminated with many chemical substances and they felt

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25 insecure to eat these foods. One caregiver avoided consuming some specific kinds of seafood because of this issue. She explained:

Squids also have many chemical [contamination], stuff that keeps them fresh. [It’s] hard (to find) food without any chemical. [contamination].

[They] are everywhere. [interview 3, female caregiver]

Although fish was their preferred food, many older people claimed that safety was the obstacle to fish consumption. They stated:

Today, growth accelerator is given to fish. I feel fish fillet is strange.

Fish has never been odorous but it has a strong odor when cooking.

[FGD 1, female older people]

Apart from chemical contamination in seafood, other foods such as fruits and vegetables were also suspected to be contaminated. One female older person shared:

It's terrible. Consumers are getting bad. Sellers add toxic substances.

Vegetables used to be watered naturally but now they have insecticides, a growth accelerator agent for sale after a few days. For example, watermelon has a red-coloring accelerator agent. [FGD1, female older people]

One older person also shared her own and her relatives’ experiences. She claimed that not only were insecticides used directly on food but the residual of this chemical substance also accumulated in the environment and disrupted the food chain in nature:

Pork also is harmful. The pork is white. It is like it is injected with the growth accelerator. We rarely eat pork at home. We eat mostly vegetables, such as kale and collard greens. But they are sprayed with chemicals. My grandchildren plant morning glory. They told me that you do not buy the morning glory because it is sprayed. Because there are lots of worms…. Farmers spray chemicals to make it look beautiful. The chemicals are concentrated. The chemicals contaminate in the rice field; it affects the fish. [FGD 6, female older people]

Besides chemical contamination, older people are concerned about dirt from pollution in their areas. They felt fear towards some foods they thought were not clean enough:

What kind of pork is sold by street vendors? The pork looks like a rope.

Sun-dried pork. It is tied with rope on hangers, 5 pieces. People eat them on cars. They are full of dust and fuel smoke. Ash grows up in the air.

Like grilled banana, it is blended and taken up. Everything is dangerous when a wooden stick is used to stir it. [FGD 1, female older people]

Furthermore, some older people reported that they felt fear and thought the market was not clean and the food preparation in some markets had not enough hygiene:

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26 (If) you ask me, I have to say (the markets are) not clean. Maybe it is

normal for other people. (I) feel like some places are (just) slicing the catfishes openly and right next to it is another food stall. I saw it and felt weird. When I see it, it felt… But (I guess) that is how they live.

[interview 5, male older person]

Theme 3. Influence of culture on food choice

Both older people and caregivers shared that culture had a noteworthy effect on food choice and the cooking process in many situations. Older people disclosed that their living condition had affected their food consumption significantly. Eating together with family or friends was one of the norms in Thai society. One older single person informed that she skipped her meal sometimes because she lived alone and had to eat alone. She shared that she would eat a lot of food if she was accompanied by her friend. In her words:

Now there is only me…If [I] am alone, [I] will only eat when [I] am hungry...Sometimes [I] will sleep and skip a meal. ……If (I) go with my friend, I have to eat whatever they eat. (I) can eat anything, all kinds of food like stir-fried or fried fish. [interview 2, female older person]

There were other instances of the social norm as well. Some older people reported that their offspring would take them outside to have food on special occasions. It was the norm in their society:

It's a Thai habit. I think that they bring me to eat good and expensive food because it makes the offspring proud to make their parents happy.

It is their pride…It is to make something special for their parents. …the son is happy. Up to him. He’s proud, and we feel warm that he takes care of us… This is important for the values. Nowadays, the Thai values are entirely like these. Children have to take parents to have meals. This is the current Thai values, and we really feel that way that they take us.

[FGD 2, male older people]

Older people also told that culture modified the types of food people eat. Older people shared that they preferred local foods. It was the tradition carried on from generation to generation:

Our local foods still exist. We still eat sour soup, fried chili, boiled salted fish, and Gaeng Kua¹ as before. We are still the same at home, but we don't cook often. We still eat boiled salted fish as before. We still eat salted mangrove crabs. Currently, we still eat the same. We eat chili paste with vegetables, pumpkin Tom Jek²….Desserts are still the

1 Name of one type of Thai curry made from prawn, pineapple, coconut milk and curry paste

2 Name of one type of Thai dessert made from ginger

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27 same, such as pumpkin in coconut milk, sweet sticky rice with corn and

coconut cream,…., steamed banana cake. But we rarely cook them by ourselves. [FGD 4, female older people]

Both older people and caregivers preferred food provided by local people. It demonstrated that they preferred the local cooking style in the aspect of taste, ingredients, and processes. One older participant shared:

In terms of food, if we eat local food, we can eat it. It is well and delicious like sour soup, … We can't eat sour soup … cooked by others, they are not tasty. It’s hard to cook sour soup.… When I went to eat sour soup at my mother-in-law’s house in Suphanburi (a different province), it’s different. It's a different recipe…. About food, we would say If we eat in a different place, we don’t like it. [FGD 2, male older people]

Furthermore, older people and caregivers preferred to buy food from Thai food providers. It showed that older people and caregivers favored the taste and cooking style with which they were familiar:

(I) have never done so. I fear to buy (from foreigners)…. (I) usually choose a stall that (is owned) by a Thai or doesn’t have (many) foreigners. (The food) is made by Thais. (I) am more confident in the hygiene. (I choose) food that is not too robust, just in mild flavor, not too spicy or salty. [interview 3, female caregiver]

It was obvious to note that culture was the vital element in society and it affected food choices in older people in many ways.

Theme 4. Adverse effect of the fishery law

Older people were also worried about the amount and quality of food. The new fishery law in Thailand was another cause of insecure feelings about food among older people. Some older people claimed that the new laws and regulations affected their food choice. The study site was one province along the Thai Gulf Coast. Many local people were involved in fishing, and like many others, older people also used to be consumers of fishes caught by those fishermen. Older people complained that the current fishery law controlled their marine equipment size. Thus, some local fishermen could not find fish by themselves. The main sources of fish and other seafood came from middle or large-scale marine businesses. They thought that fish or other seafood from middle or large-scale marine businesses did not gain good quality. Some of the older people perceived that middle or large fishing boats took longer time to supply fish to consumers than local fishermen. Some large fishing boats caught fish far from the coast and they needed some storage methods to keep the seafood fresh. So, older

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28 people thought fish from local fishermen was fresher than fish supplied by large boats.

Furthermore, they believed that fish from local fishermen was free from preservatives:

Local fishermen died. The villagers doing fishery in the shallow water die as well…. The [local] fishery is prohibited … now, we can’t find any fish.... It (fish from large fishing boats) is not fresh. How can fish be fresh for months? But we have to eat…. The boat goes out for 15 days and comes back for 15 days. Big snappers weighted 1.4-1.5 kilograms are pickled on the boat. How long before the fish gets to us?

How long after they were dragged? They were frozen on the boat. [FGD 2, male older people]

Discussion

Price is one of the key factors that was found to influence the older people’s food choice. It is a widespread practice and is supported by other similar literature. A cohort study conducted in the Netherlands reported that price was one of the factors that had significant influence on older people’s food choice. Other factors that were also reported as influential factors are healthiness, travel time and taste of the food (25).

Older people and caregivers often preferred ready-cooked meals for nutritional, economic and convenience reasons. This finding is similar to previous studies. Globally, the consumption of ready-cooked meal or convenience food has increased rapidly (87, 88).

Although a ready-cooked meal is considered as having a positive impact on nutrient intake (89), not all ready-cooked meals are healthy. Numerous studies have attempted to identify the nutritional content in ready-cooked meals. There was a cross-sectional study examining the nutritional value in 100 ready-cooked meal samples from 3 supermarkets in England.

Surprisingly, none of these meals complied with the World Health Organization (WHO)’s recommendations, especially sodium content (90). Additionally, the other study on 166 chilled and frozen ready-meal samples from supermarkets in England found that, on average, ready-meals were high in saturated fat and salt and low in sugar, while only one-fifth of the sampled meals were considered healthy by the criteria of amounts of fat, salt, and sugar (88).

Furthermore, previous studies have reported the health impacts of ready-cooked meals. A nationwide survey in the Luxembourg population aged 18 – 69 years revealed that

increased consumption of ready-cooked meals was significantly associated with abdominal obesity (91). However, a later study in older people did not support the

Luxembourg study. The investigation among French people aged 70 years and over found

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29 that people who consumed ready-meals 2 times or more per week were associated with

frailty, cognitive and physical impairments, and depression but not obesity. One of the possible reasons for the negative relationship might be that the frequency of ready-meal consumption was quite low, with 90% of participants consuming ≤ 1 ready-cooked meal per week. The trivial prevalence could affect the association and distort from the general older population (92).

However, it is difficult to compare the ready-cooked meal in this study with Western countries because there are many different factors. Thai ready-cooked meals are made by small, local food sellers. These foods are sold in plastic bags and customers usually eat them within the day of purchase or a few days after, whereas in Western countries, ready-cooked meals a found in both chilled and frozen foods. The common concerns with chilled and frozen foods have been microbial contamination and nutrient loss. Temperature is the main factor affecting bacterial growth. The amount of vitamin loss from fruits and vegetables also relies on the storage temperature (93).

Apart from nutritional benefits, both older people and caregivers mentioned that ready- cooked meals were convenient foods that they could buy everywhere they wanted such as markets, Sunday markets, restaurants or street food vendors. This also accords with earlier observations. People aged 60 – 88 years in New York in the USA reported that they often bought foods from the nearby grocery. However, participants distrusted some food stores in their communities because they suspected many business malpractices (42). It is obvious to note that, although there are many food vendors in the area, participants still buy their foods from the sources they trust.

Like the global trend, the proportion of older people is increasing in Thailand as well.

Inappropriate food choice among this group of the growing population can lead to a huge burden of undernutrition. Therefore, it is important to ensure that the food they consume contains the required nutritional supplements. One way to do this is labeling the nutritional value of these foods. A previous intervention study in New Zealand focused on the effects of labels on food choice. They found that the food items in which participants read the label and subsequently purchased were significantly healthier than the food items where labels were viewed but the product was not purchased. It showed that food labels influenced the customer’s decision (94). In Thailand, the Guideline Daily Amounts (GDA) nutrition label was introduced more than 5 years ago. This label has shown 4 fundamental nutrients (energy, sugar, fat, and sodium), and the label is on the packages of some processed snack foods (95). However, an in-

Understanding food choices and practices among older people in Thailand – an exploratory study