Public and private institutions in the United States are at a critical point in the country's history, where they are facing the need to review their practices that have led to health disparities among specific population groups, such as racial, ethnic, and sexual minorities. This is especially relevant for older adults who are part of these groups. As stated by Espinoza and Accius,1 "By the time people of color reach an older age, they have experienced a lifetime of discrimination with a subsequent impact on their physical, emotional, and economic well-being. Because of these experiences, this population faces more serious age-related vulnerabilities than their White counterparts, including economic insecurity, social isolation, physical and cognitive decline, malnutrition, and chronic health conditions." In the United States, in 2019, 24% of the population 65 years and older were racial and ethnic minorities, and these populations are expected to increase to 34% by 2040.2 African Americans/Blacks, in particular, have the lowest life expectancy of all race/ethnicities and the greatest health inequity.3 In 2021, life expectancy for non-Hispanic Blacks was 70.8 years compared with 76.4 years for non-Hispanic Whites and 77.7 years for Hispanic populations.
Therefore, it is essential to reach out to these underserved populations with needed services, including nutrition. The Older Americans Act Nutrition Program (OAANP), part of the Administration for Community Living (ACL), is the only federal food assistance program that reaches out to older adults who have difficulties leaving home without assistance by providing them with healthy meals delivered to their homes. The program also provides meals to older community-dwelling individuals in congregate settings to promote socialization while consuming healthy meals. Along with nourishing meals, the OAANP provides periodic nutrition screening, needs assessment, education, and counseling to participants. These services are provided through the Aging Network, a partnership between federal, state, tribal, and local agencies to help older adults. The Aging Network comprises 56 state agencies on aging, 655 area agencies on aging that work with local service providers, and more than 282 Title VI Native American aging programs.
Home-delivered meals (HDMs) of the Older Americans Act (OAA) are well liked, provide quality food to needy individuals, and help individuals remain living independently.4 Home-delivered meals were also shown to decrease institutionalization of older adults and consequently healthcare expenditures.5 However, funding for the OAA has remained relatively flat and has not kept up with increased demand for the HDM program.6 Because of the projected increase in the older population, a flat budget may lead to larger waiting lists and limited program participation. Older adults tend to prefer community living and aging-in-place. Services such as those provided by the OAANP help people to remain in their homes. The latest version of the OAA, enacted in 2020 (Older Americans Act of 1965 [Public Law 89-73]), targets those most at risk of nutritional deficiencies, social isolation, and institutionalization. Racial, ethnic, cultural, or sexual minority populations are at high risk for all 3.
The intent of this article is to provide approaches that may increase equity in services provided by the OAANP or other similar programs to reach and serve the neediest and most diverse populations in the country. This article is a synopsis of a project and report undertaken by ACL and the University of Maryland. The approaches provided here are based on a synthesis of peer-reviewed and grey literature, telephone interviews of Nutrition Leads/Directors of 9 State Units on Aging and an online review of a sample of 13 State Plans. These State Plans describe the vision and strategies of State Unit on Aging on how to coordinate services for older adults. These plans are updated every three to five years. MEDLINE, Google Scholar, and Google Search engines were used to search for appropriate references, and the following search terms in various combinations were utilized: Older Americans Act Nutrition Program, OAANP, home-delivered meals, Meals on Wheels, congregate meals, health disparity, outreach, targeting, health equity, racial minority, best practices. All relevant articles are reviewed in this article. Gray literature sources included policy and practice publications, video presentations, reports, and blogs. The state plans were reviewed to determine if they included goals and objectives regarding service equity. These state plans were obtained online in March and April 2022 through the states' websites.
The criteria used to select the states for the interview were as follows: a large older adult population, a high proportion of ethnic population(s), a high prevalence of food insecure households, and the geographic location of the states. The AGID (AGing, Independence, and Disability) Program Data Portal and Census Bureau information were used as guides for the selection of these states. All interviews were conducted by the same interviewer in February and March 2022 using video interaction. A standard questionnaire, emailed ahead of the interview, was administered to all interviewees, which inquired about past, present, and future trainings in cultural competence and commitments to service equity at the state and local levels. The interviews lasted 1 to 2 hours.
BARRIERS TO OUTREACH, TARGET, AND RETENTION OF MINORITY POPULATIONS
Outreach, targeting, and retention are essential to reach people at risk in neighborhoods with high racial and ethnic diversity. A 2015-2016 national evaluation of the OAANP indicated that 66% of congregate meal participants and 71.8% of HDM participants were non-Hispanic Whites. Approximately 0.3% of HDM participants were Asian, 8.7% were Hispanic, and 17.7% were non-Hispanic Black.7 This is an underrepresentation of the minority population, considering that they are at a higher risk of food insecurity and experience a higher prevalence of chronic conditions and disabilities. From the literature review and interviews with states, several overlapping reasons were cited for the low participation of older minority populations in the OAA meal program, including misinformation due to language barriers, lack of menus that can accommodate cultural preferences, lack of familiarity with and dislike of the foods served, discomfort with staff due to cultural and linguistic differences, fear and distrust of formal systems, and inadequate transportation to congregate meal sites.8,9 Taste and cultural food preferences are critically important in attracting and retaining racial, ethnic, and cultural minority populations in the programs. For example, a study by Song et al. showed that African Americans were less likely to prefer most foods offered by meal programs compared with Whites.10 Additional barriers to service delivery obtained from interviews with Nutrition Leads/Directors included staff shortages; lack of understanding of communities' needs, lack of cultural competence, lack of awareness of resources available for training, lack of providers of ethnic meals, difficulty in reaching rural populations without the internet, ineffective outreach due to language barriers, and lack of staff reflecting the background of the people being served.
In addition to issues related to meal offerings, there may be a lack of cultural competence at the management level. The results of a survey, conducted by Porter and Cahill, and which was administered to the 50 state units on aging and the District of Columbia showed that 17 states offered no diversity initiatives, with 6 of these states having a high prevalence of minority populations.11 The authors identified lack of funding, lack of perceived need for cultural programs, and issues specific to rural areas as main barriers. Some programs stated that they did not feel that outreach to minority communities was necessary because they serve "all people." Such responses to questions from the survey indicate that in some states staff may lack cultural competence and do not recognize the importance of being culturally competent. Other barriers included revolving management and a lack of communication with local providers. The percentage of minority populations in a state is predictive of the number of diversity initiatives used in community meal programs. These findings, in addition to the results from our interviews with Nutrition Leads/Directors, indicate that an increase in minority participation in the OAANP varies by state. Whereas some states actively embraced cultural competence in training and planning outreach activities, others were not as active in undertaking new approaches or had limited resources.
Nevertheless, the percentage of minority populations participating in the OAANP increased from 29% to 32% between 2014 and 2018.12 This increase may be attributed to the number of initiatives undertaken by area agencies on aging, such as hiring minority staff, developing materials in languages other than English, locating programs in communities identified by census data as low-income or high-minority populations, and marketing programs through minority media.
OPPORTUNITIES AND BEST PRACTICES
There are a number of best practices synthesized through the literature review and communication with nutrition leads/directors that may be used to begin to remedy some of the institutional and service biases toward ethnic minorities. These are presented in the Table. Once barriers to designing and implementing diversity initiatives have been identified, remedies can be devised. The suggested approaches and opportunities provided in this study are presented within the context of the socioecological model (SEM) framework.
Socioecological model provides an understanding of the range of factors in the complex interplay between individual, interpersonal, organizational, community, and public policies (Figure). It visually demonstrates how an activity at one level influences activities at other levels in this complex relationship. With this approach, individuals from any sphere of the model have a common understanding of the intended goals and are receiving and utilizing the same information and strategies to achieve a common result. Using this approach is more likely to lead to the desired results of reaching and serving the neediest and most diverse older adult populations under the OAANP or other similar programs to redress inequities in service. These are illustrated in the Figure and are outlined in the Table.
Federal and State Policy
An example of an action that may drive change at the state level and potentially have an impact at other levels of the SEM is federal guidance from the ACL. This guidance requires that any new OAA state plan taking effect on or after October 1, 2022, include goals and objectives to increase service equity to underserved populations and must address activities to support these goals.13 Each state must submit a state plan every 3 to 5 years. This guidance is in line with 1 of the 4 key priorities articulated by the Biden administration, which are COVID-19 recovery, advancing equity, expanding access to home and community-based services, and building a caregiving infrastructure.13 This guidance to incorporate a plan for diverse and culturally competent approaches has stimulated states that currently do not have a plan that emphasizes equity or those that are in the process of revising theirs. In addition to this federal guidance, interest in social policy reform as an aftermath of George Floyd's tragic death and other recent violent events against racial and ethnic minorities, has spurred action in some states. For example, several states created, strengthened, or received new requirements for departments of Diversity, Equity and Inclusion (DEI) to lead initiatives, train employees, develop educational materials, and hire 1 or more individuals to strengthen their DEI programs.
Training in Cultural Competence
Overall, we suggest that training for all nutrition employees at both the state and local levels be mandatory and include topics on cross-cultural awareness, cultural competence, and gender identity. In interviews with the states, a few requested additional training materials on cultural competence, and some states expressed interest in receiving these materials from ACL. To ensure consistency in messaging, a training curriculum may be developed by the ACL and adapted for use by states. These materials may be useful throughout the Aging Network and can be adapted for local use. At the interpersonal level, training of staff is essential as there is a need to reach out to leaders of ethnic communities, provide or sponsor cultural events, establish a warm welcoming environment at meal sites, and involve family members. In the past, the federal government provided resources that local institutions may have adopted for their own use. For example, the Administration on Aging developed a toolkit for use by the aging network to better serve the diverse communities.14
Diversity, Equity and Inclusion
An important next step may be to conduct an evaluation of the demographics of staff within agencies at all levels of the Aging Network to inform the need for diversification of employees. This could also be followed by an examination of recruitment and hiring practices. Other opportunities include outreach to communities at the state and local levels to assess needs and develop partnerships with faith-based and community-based organizations and with restaurants serving ethnic foods. For example, Maryland developed a partnership with a Korean organization to design a nutrition program tailored to the interests and needs of Korean seniors. Staff became knowledgeable about Korean culture and food consumption and developed a program appropriate to their needs while meeting the local state and OAA requirements. A Korean group provided a site at a church, staffed the program with Korean volunteers, and managed culturally tailored activities, including nutrition education and physical fitness. A Korean restaurant provided meals at a reasonable cost. A year later, a Vietnamese organization requested a similar arrangement, which was followed by a similar arrangement with a Chinese organization. These programs have expanded and have served an increasing number of older adults. The success of such programs requires a champion in ethnic communities and the willingness of providers to be educated in the needs of different communities.15
Hiring staff to reflect the ethnic population living in the communities of interest would improve reaching out to clients and volunteers. Finally, at the individual level, staff need to be trained to be aware of cultural sensitivities and on how to adjust menus according to preferences and cultural considerations.
Leveraging of Resources
Leveraging of Existing Resources Is Essential to Successful Nutrition Services
One such resource is the ACL National Resource Center on Nutrition and Aging website (https://acl.gov/senior-nutrition), which can be used as a repository of best practices, case studies, and other information for use in the Aging Network. The Resource Center, which already has useful materials such as ethnic-specific menus shared by users, can continue to expand as a repository for menus and materials in various languages, including developing a database of menus of ethnic foods.
These approaches are in line with the US Department of Health and Human Services, Office of Minority Health's National CLAS Standards (culturally and linguistically appropriate services), which are a set of 15 action steps intended to advance health equity, improve quality, and help eliminate healthcare disparities.16
SUMMARY
The results of this project show that states are very different in their readiness to initiate programs that would increase equity in services. Some states are highly aware of health disparities and service inequities and have ongoing programs to rectify these issues, whereas others are just beginning to consider what approaches to adopt to address inequities in their jurisdictions. State plans, with guidance on this topic from the federal government, can be a good conduit to begin developing goals and objectives for increasing cultural competence among staff and also outreach to underserved communities. In addition, the White House Conference on Hunger, Nutrition and Health, held in September 2022, identified as 1 of its 5 national strategy pillars enhancing nutrition and food security research to inform policy on issues of equity, access, and disparities.17 These federally led initiatives, coupled with innovative programs at the state and/or local levels, are critical if diversity, equity, and inclusion are to become integral to OAANP initiatives.
The strength of this paper is that it utilized several approaches to learn about policies and best practices in the United States generally and in several states selected systematically to inform change and then using the SEM as a guide to implement this change. Follow-up work is essential to examine the progress of states in becoming more inclusive in their programs and to determine whether the efforts of these 9 states are representative of the United States overall.
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