Towards meeting the needs for cultural foods in long-term care homes

Abstract

Introduction Canada’s older adult population is both growing and becoming more culturally diverse, necessitating adaptations in our health care service, and specifically long-term care homes (LTC), a continuous residential form of health care. Immigration is a key driver for these demographic changes; earlier waves of immigrants are now aging and increasingly represent those aged 65 years and above. As a result, there is a growing proportion of residents in Canadian LTC homes who were not born in Canada. LTC in Canada provides care for those who have chronic health conditions and functional limitations, affecting their ability to live independently in the community, even with support. In Ontario, residents receive approximately four hours per day of direct care to support their activities of daily living (e.g. bathing, washroom use, medication management) as well as all meals and snacks and housekeeping. The increasing proportion of residents in LTC homes from diverse cultural backgrounds, necessitates understanding how food provision is aligned or not with their cultural traditions. A few studies have explored the experiences of culturally diverse residents and their families with services provided in LTC homes and have noted challenges with receiving cultural foods. Yet, this information is limited and does not sufficiently demonstrate the impact of misaligned food offerings. Unfamiliar foods or foods that do not align with cultural preferences could reduce food intake, making it a major risk factor of malnutrition. Providing meals based on ethnic and cultural preferences is also an identified challenge for registered dietitians and food service managers in LTC homes. However, there is limited research that has examined specific barriers these menu planners encounter in meal provision for a diverse resident population. Further, potential strategies to support culturally inclusive meal provision need to be identified. There are notable gaps in research understanding the impact of misaligned food offerings for culturally diverse residents and their family members, as well as dietitians and food service managers current practices, experiences and confidence in creating culturally inclusive menus, and what barriers they face in doing so. This thesis investigates how culturally inclusive meal provision can be better supported in Ontario LTC homes by addressing these gaps. The overarching objective of this dissertation is to understand current practices, their impact on culturally diverse residents, and to identify strategies to improve culturally inclusive meal provision in LTC. This dissertation comprises three interconnected studies with the following objectives: 1) to understand the perspectives of culturally diverse resident and family members, including the challenges they face and what has facilitated accessing and attaining culturally inclusive foods within LTC homes; 2) to describe the perspectives, experiences, practices and confidence of food service managers and registered dietitians, including reported barriers/facilitators, to developing culturally inclusive menus in Ontario LTC homes and determine the factors associated with confidence and cultural inclusivity of current menus; and 3) to provide an in-depth examination of current menu planning practices from the perspectives of LTC registered dietitians and food service managers and comprehensively assess key facilitators and barriers to menu planning for a culturally diverse population, and how they potentially interact. Methods This thesis encompasses three interconnected studies. To address the first objective, a reflexive thematic qualitative study was conducted using semi-structured interviews from diverse cultural backgrounds in Ontario LTC homes. Data was collected from February to December 2024 through in person and virtual interviews. Reflexive thematic analysis was employed to identify patterns of meaning across the dataset. The Life Nourishment Theory (LNT) supported interpretation of findings. For study 2, an online survey was completed by registered dietitians and food service managers working in Ontario LTC homes (November 2022-April 2023). The COM-B (Capability, Opportunity, Motivation-Behaviour) model of the Behaviour Change Wheel was used to develop survey questions. Data were analyzed using descriptive statistics, bivariate tests (Kruskal-Wallis, Wilcoxon signed-rank), and multivariable ordinal and linear regressions. Qualitative content analysis was conducted on open-ended responses. Finally, study 3 was a qualitative study that used focus groups and interviews with registered dietitians and food service managers working in Ontario LTC homes between September and December 2024 to gain further insight into barriers and facilitators and potential strategies for including cultural food in LTC menus. Data were analyzed using qualitative description with open inductive coding. Making the Most of Mealtimes (M3) framework and the Person-Centered Care (PCC) model supported interpretation of findings. Results There were 15 participants (n = 10 family members of LTC residents, n = 5 LTC residents) in study 1. Three themes were developed: 1) Losing my food, losing myself: Lack of cultural food availability and disconnect from culture, 2) Surviving on unfamiliar food: Eating without cultural connection or pleasure, and 3) Bridging the gap: Families and staff reconnecting residents to culture through food. In study 2, a total of 123 registered dietitians and food service managers from Ontario participated in the survey with 85 completing all questions. The majority of participants were female (94%, n = 80/85), White (53%, n = 45/85), and experienced (62%, n = 51/84 with 10+ years working in LTC). Participants rated cultural inclusivity as important (median = 8, IQR = 6.25-10; 10-point scale) but only reported a moderate rating when asked about current menu inclusivity (median = 7, IQR = 5-8; 10-point scale). Their confidence was neutral (median = 3, IQR = 2-4; 5-point scale) for creation of menus that are culturally inclusive. The most frequently reported barriers were: too few residents from diverse cultures not served by current menus; lack of cooking staff skills with cultural recipes; increased expense for culturally unique ingredients; lack of time to prepare cultural dishes; and limited selection of ingredients and food products through third party purchasing organizations. Suggested facilitators included resident feedback opportunities, availability of cultural demographic data, incorporation of cultural days as a way to introduce new foods, and resource availability (e.g. budget, cultural ingredients and staff skill). Sixty-five percent (n = 62/96) of participants had received no training on incorporating cultural preferences while menu planning. The ordinal logistic regression model indicated that perceived likelihood of adapting menus was significantly associated with higher odds of reporting greater confidence (OR = 1.38, 95% CI [1.14,1.68], p<0.001), and selection of ‘other challenges’ was significantly associated with lower odds of reporting greater confidence (OR = 0.23, 95% CI [0.06, 0.79], p = 0.022). Perceived likelihood of adapting menus was significantly associated with higher inclusivity ratings (B = 0.24, 95% CI [0.07,0.41], p = 0.007). Use of resident questionnaires as a meal satisfaction evaluation method was significantly associated with higher inclusivity ratings (B = 1.05, 95% CI [0.12, 1.99], p = 0.03). However, perceiving cultural foods as difficult to eat was negatively associated with inclusivity of the menu (B = -1.29, 95% CI [-2.47, -0.31], p = 0.014). In study 3 there were 15 participants (n = 10 registered dietitians, n = 5 food service managers). Three thematic categories resulted from the qualitative analysis: 1) Building cultural knowledge through collaborative inquiry and strategies, 2) Varying individual ability for cultural meal provision impacted by systemic barriers, and 3) Requiring systemic changes for cultural meal provision. Conclusion These studies provide valuable insights into the challenges and opportunities for culturally inclusive meal provision in Ontario LTC homes from provider, resident and family perspectives. The findings emphasize the importance of addressing cultural food preferences when menu planning to support resident well-being and promote quality of life. This dissertation contributes to knowledge by framing culturally inclusive meal provision as a multi-level issue shaped by individual, organizational, and system level factors, rather than solely the skills and practices of registered dietitians and food service managers. It highlights how structural constraints limit the ability to deliver culturally inclusive care, a core component of PCC. In response, this research offers recommendations across multiple levels (government, sector, organizational, staff, and resident), emphasizing the need for coordinated efforts to support meaningful change.