“The Service, I Could Not Do without It . . . ”: A Qualitative Study Exploring the Significance of Meals on Wheels among Service Users and People Who Refer Them to the Service

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Introduction
Approximately 300,000 older adults in England need help with preparing meals [1] and a quarter needs help with shopping for food, particularly in deprived areas [2]. In addition, a rising number of adults live with long-term illnesses or disability [3] and multiple morbidities [4] and experience complex and multiple needs [5], including functional limitations, poor mental health, and cognitive impairment [6]. Tese individuals could beneft from Meals on Wheels (MoWs). MoWs, a service that in England has traditionally been ofered by Councils with Adult Social Services Responsibilities (CASSRs), delivers meals to older adults and people with care and support needs, who might otherwise not be able to acquire and prepare their own meals, in their homes. MoWs therefore provide a lifeline to many underserved populations, by ensuring that individuals at risk of malnutrition or social isolation can access regular social contact, at least one nutritious meal every day, and continue living in their own homes (in line with their wishes), as well as providing respite to carers [7].
Earlier studies surveying service users' experiences of MoWs programmes in the United States (US) found that MoWs improve subjectively-measured wellbeing and food security and reduce loneliness [8] and reported overall satisfaction with the meals received and the friendliness and service of the drivers delivering the meals [9]. Similarly, qualitative US studies found that MoWs recipients perceive that the service exerts many benefts. Tese include opportunities for social contact, welfare checks, convenience, the ability to remain independent, and reductions in physical risks related to mobility challenges [10,11], in addition to contributing to enhanced food security and safety, improved nutrition, emotional wellbeing, and a solution to lack of support [12]. Tere is dearth of research on the experiences of MoWs recipients with the service in England. A marketing survey of 1,125 MoWs recipients from one city in England reported that the majority (88.3%) were very satisfed or satisfed with the service [13]. Furthermore, in a recent qualitative study among 14 older adults who received MoWs from one provider in East England, aimed at exploring household food practices of MoWs recipients, participants perceived that the service had increased their overall capacity; in addition to the benefts of receiving a hot meal, participants discussed the benefts of building mutually caring relationships with the drivers who deliver the meals [14]. Although fndings from these studies suggest a wide range of benefts of MoWs to service users, they might be limited due to the research focusing on single locations and providers. In addition, no research has explored experiences with MoWs services from the perspective of family members/individuals who support MoWs recipients and/or refer them to the MoWs service ("referrers"). Furthermore, less is known about whether any modifcations or additions are required to enhance the service in England, in the light of service users' and referrers' experiences of MoWs and whether experiences with the service changed during the COVID-19 pandemic.
Te aim of this small-scale study was therefore to explore diferent dimensions of the MoWs service (i.e., aspects around the meals received, other services ofered, benefts from the service, interactions with drivers and MoWs providers, costs associated with the service, challenges faced with the service, and ways of enhancing the service), from the perspectives of MoWs service users and referrers, recruited from diferent areas in England. A secondary aim was to explore how experiences with the MoWs service might have changed during the COVID-19 pandemic.

Study Design and Participants.
Semistructured interviews with current MoWs service users and referrers of current MoWs service users, were conducted in May-July 2022. Recruitment took place from four diverse service providers (a local authority, a social enterprise, a family business, and a private provider) in diferent areas in England, covering the North West, South West, South East, and East Midlands. Tese areas were purposively selected according to geographic location (urban and semiurban). Te managers of MoWs services were invited by email to act as gatekeepers for participant recruitment. Tis involved delivering a study invitation to service users via drivers who deliver the meals, during normal delivery times, and circulating the study invitation to people who have referred someone to the MoWs service via electronic mail. Tose who were interested in taking part were asked to contact the research team directly. A total of seven service users and 22 referrers initially expressed interest in participating. Of these, one referrer was excluded as the person they referred to MoWs was not a current recipient of the service. Data collection and analysis proceeded in parallel. Te study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [15] (Supplementary Materials, Table S1).

Data
Collection. Semistructured interviews, lasting 18-49 minutes, were conducted via telephone and audio recorded. Two interview guides were developed to explore the experiences of MoWs service users, and referrers (Supplementary Materials, Tables S2 and S3). Te guides were not piloted but were informed by our recent research exploring MoWs service providers' experiences around the benefts of the service and the challenges faced by MoWs [16] and developed further to explore topics that addressed the specifc objectives of the current research. In summary, the interviews explored participants' experiences with setting up and accessing MoWs (to be reported in a separate publication), the meals received (e.g., variety, taste, and cost), perceptions around the benefts from using MoWs, interactions with drivers who deliver the meals and the MoWs service coordination/management teams, wider services received (e.g., welfare checks), whether their experiences with the service had changed as a result of the COVID-19 pandemic (if applicable), and perceptions around enhancing the MoWs service.
All interviews were conducted by the second author, an experienced qualitative researcher. No relationship had been established between the interviewer and participants before study commencement. Probes were used, as appropriate, to elicit more information from participants, and feld notes were kept during the interview to verify responses at transcription stage. At the end of the interviews, a summary of main points was provided to participants, which helped to confrm accuracy of responses [17]. No repeat interviews were carried out. Interviews were transcribed verbatim and anonymised; transcripts were compared with recordings and feld notes to verify credibility.

Data Analysis.
Informed by a phenomenological approach [18], data were analysed thematically [19]. Te second author read through all transcripts and coded them inductively, which involved initial coding of the data into broad codes. Data were then analysed line-by-line to create specifc codes. Te third author independently coded four transcripts to ensure rigour of the process [17]. Te coding process was refned after discrepancies between the coders were discussed, and the second author proceeded with coding all transcripts using this codebook, with any new codes being noted. Te codes were organised into themes and subthemes and further reviewed by the team to ensure coherence within and across themes [20]. NVivo (version 12.0, QSR, Southport, UK, 2018) was used to facilitate the coding. Findings from the two qualitative data sources (MoWs service users and referrers) were combined to demonstrate the emergent themes and subthemes, which are illustrated with representative quotations from participants (indicated as service user (SU) 1-7/referrer (R) 1-21). Additional quotations are provided in Supplementary Materials, Table S4.

Ethical Considerations.
Te study was approved by the University of Bristol, Faculty of Social Sciences and Law Research Ethics Committee (reference 0170). Participation was voluntary. All participants were provided with written information about the study before giving consent to take part in the interviews and received a £20 gift voucher as a token of appreciation.

Findings
A total of seven service users and 21 referrers took part in interviews (Table 1). Service users were mostly female (n � 5), with an age range of 76-94 years and had been using MoWs for an average of 24.6 months and for 6.1 days per week. Referrers were mostly female (n � 18), and the majority (n � 15) had referred a parent to the service, who had been using MoWs for an average of 22.4 months for 5.8 days per week. Most service users (users and referred, n � 21) were in receipt of a social care package alongside MoWs. Findings are presented under fve themes ( Table 2).

Te Importance of a Nutritious Meal and Promoting
Overall Health

Importance of a Hot Meal Tat Requires No
Preparation. Participants highlighted the importance of the MoWs service in providing a hot meal that does not require preparation, with service users reporting that they "like to have a hot meal in the middle of the day" (SU2) and referrers highlighting that the meal delivery itself was perceived to act as a prompt for service users with cognitive decline that eating is "an activity that needs doing" (R3). Tis was particularly relevant for older service users who were not only keen on the hassle of preparing a hot meal but also those with mobility issues and/or dementia. . Te meals were perceived to be tasty and healthy, with one referrer praising the fact that containers included the meals' nutritional information and others that meals accounted for special dietary needs, such as for people who have just been discharged from hospital and people with swallowing difculties. Vegetarian, gluten-free, and other dietary needs were also catered for. When discussing the variety of meals, participants reported that menus are provided in rotas (every three weeks or every couple of weeks). Participants were largely happy with what is on ofer as ". . .you have quite a choice. . . so you don't get the same meal" (SU3), and referrers perceived that MoWs are mostly used by older adults, who might be more habitual eaters than younger adults. Some, however, would welcome the inclusion of less "English-centred" meals like chilli or curries (R12), while one service user, despite being overall satisfed, suggested the need for more variety to be introduced as "it becomes a bit boring" (SU1). It is noteworthy that those who would welcome more varied meals also perceived that this would probably not be "practically feasible or viable" (R1) from the perspective of service providers. Portion size was also a divergent issue, with some participants reporting that "the portion size is very good" (R21), while others perceiving "they were a little on the small side to the point sometimes I'm still hungry afterwards" (SU6

Appropriateness of Discussing and Promoting Physical
Activity. When asked how they would feel if drivers who delivered the meals encouraged service users to move more, if appropriate, participants' views were mixed. Some perceived that "a reminder to go out in the garden would be really good" (R12) or that service users might beneft from being encouraged "to stand up occasionally" (R4). Others reported that unless they were trained, this was not the drivers' job and that discussing physical activity might actually prevent service users from eating their meal on time and while it is hot. "If they're delivering a meal, then I don't want him to be getting up at that point" (R20). A few referrers also questioned whether drivers would have the time to discuss physical activity with service users, as "they've got a lot of houses to go to" (R2), or whether it would be appropriate/ relevant to promote physical activity to service users with mobility issues. argued this was a beneft stemming from the consistency of the service and the relationship developed between drivers and service users. Drivers would get to know people they deliver to well, so that they are able to notice any changes in their appearance or behaviour and fag any concerns accordingly.  . Some participants acknowledged that consistency of deliveries depended on the circumstances that drivers encounter in service users' homes, "because what they're also doing is checking on the welfare of the person they're delivering the meal to" (SU2). Nevertheless, the overall consistency and the interaction with the same drivers were perceived as particularly benefcial for service users with dementia, as this was felt to provide a sense of routine that "is very important to someone with Alzheimer's" (R13).

Importance of Interactions in Reducing Isolation and
Loneliness. Te daily social interaction between service users and drivers who deliver the meals was also perceived as an essential component of MoWs for participants, as it helps tackle loneliness and "it gives a point to the day" (SU2). Tis was deemed important even when MoWs service users were in receipt of other social services and were visited by carers. Participants particularly praised the human contact provided by MoWs, which, even if brief, was essential in promoting overall wellbeing. "Because you can get quite lonely when you're on your own" (R3).

Promoting Independence and "Ageing in Place".
Enabling service users to stay at home and preventing the move into residential care was deemed as a crucial beneft of the MoWs service by referrers, as this was perceived to not only allow many service users to continue living in the community, in line with their wishes, but also to prevent subsequent costs to social care services and the NHS. "Yes.

Efciency and Flexibility of Customer Service.
All participants praised the efcient customer service and characterised the MoWs management ofce as "incredibly responsive and very accessible" (SU3), and "always available" (R5) to rectify any problems and answer questions, as "you can tell they really care and it's not just all about proft for them" (R6). Participants also discussed how the MoWs service adapts to accommodate individual needs and preferences, e.g., drivers would plate meals up for service users who are unable to do so themselves or not deliver meals that service users mentioned they did not like. ". . . because my dad is a very fussy eater and Meals on Wheels were brilliant, they just altered the menu for my dad, which was lovely" (R17). Te service was also perceived to be tremendously fexible in changing circumstances, e.g., they ofered the possibility of cancelling a meal delivery if a service user would be visited by/have lunch with family.

Friendliness of Drivers who Deliver the Meals.
Te drivers who deliver the meals were commended for being friendly and approachable, and the good relationships developed between them and the service users were deemed to enhance the feeling of support that the MoWs service provides. "Tey're really friendly and you get the feeling they really care. You know, if something is wrong they do something about it. . ." (SU4). Participants also highlighted how drivers would often help service users with chores around the house if needed, such as opening the mail, picking up things that have fallen on the foor, or putting the meal cartons in the bin.

Length of Interactions with MoWs Drivers. Even though MoWs drivers "don't hang around but they don't rush"
(SU4), the interactions were deemed benefcial for the wellbeing of service users. Participants discussed how interactions were brief, acknowledging the time pressures of drivers having to deliver hot meals to many service users within tight timeslots. "Tey've only got a limited two or three minutes to spend with people" (SU1). Tat was not always perceived to be an issue. "To be honest, Mum is so used to having her dinner straight away she probably wouldn't want to chat that long anyway because she'd want to get on with her dinner" (R17). In addition, the length of interaction seemed to depend on the time a service user was scheduled to be delivered a meal, with service users being "at the end of the round" perceived to potentially have longer interactions with MoWs drivers. Nevertheless, the social interaction obtained from MoWs was deemed to be one of the most important aspects of the service. One referrer (R22) recommended that there could be more social interaction if there were more drivers delivering the meals and having smaller rounds, which would allow drivers to spend more time with those service users who might need it the most. Tis might also contribute to service users who are at the beginning of a round to receive their lunch a bit later (i.e. instead of 11.30 am), which was raised as an issue by a few referrers. ". . . is quite early, when he perhaps hasn't had his breakfast until 9.00. And then, if he leaves it too long, it's cold before he eats it. So the delivery is possibly one area where it could be improved, but I completely understand they're constrained to the number of vans they can aford to run" (R11).

Reliability during Pandemic Restrictions.
Service users continued to receive their meals on a daily basis throughout the COVID-19 pandemic and lockdowns, which ofered reassurance and "peace of mind" to both users of the service and referrers, particularly as the latter were not able to visit due to travelling restrictions. ". . . they never failed me, not one day did they, no, even under all the pressure they were all under" (SU3). One referrer (R14), however, expressed concerns about whether food supplies would be afected if there was another outbreak concurrently with the war in Ukraine, and another discussed that if the service stopped due to another future lockdown, this would have a major impact on the service user they referred, especially because "he would have to go into residential care, which would not be easy. . . a lot of the care homes were not able to take in new residents (during the pandemic)" (R11).

Impact of the Cost-of-Living Crisis.
Participants reported that the price of receiving MoWs had recently increased, likely due to the current cost-of-living crisis and the war in Ukraine. However, they emphasised that the service was "still value for money" (SU1) and "money well spent" (R2) due to the social care benefts associated with its provision and because "I don't know anybody else who could provide a tasty, hot meal for that price" (SU3

Discussion
Tis study aimed to explore the experiences of service users and people who refer them to the service, with MoWs. Our fndings highlight a multitude of benefts derived from using the MoWs service, including the daily provision of a hot meal, the conduct of welfare checks, the service's efciency and reliability in promoting independent living, thereby reducing pressures on families and carers, and the importance of daily interactions in reducing social isolation and loneliness. Te COVID-19 pandemic was not perceived to have afected participants' experiences with MoWs, and despite an ongoing cost-of-living crisis, MoWs were largely perceived to be value-for-money, due to the benefts derived from the service. Several areas for enhancing the service were identifed, which could inform future interventions and policies aiming to assist adults with care and support needs to live in the community. Te benefts of receiving MoWs services demonstrated in the current study mirror those reported in our recent qualitative work among MoWs service providers in South West England, where service managers and drivers who deliver meals highlighted how encouraging service clients to eat, the conducted safeguarding and welfare checks, reducing isolation and loneliness, and promoting independence are important for MoWs recipients' and their families' wellbeing [16]. Tese fndings are also in agreement with recent research conducted among recipients of MoWs. For example, a recent study among 22 MoWs recipients in Central Texas found that the daily safety check, social contact, and ability to maintain independence comprise important elements of MoWs, particularly among adults with mobility issues [10]. In addition, a study in 14 MoWs clients in the east of England showed that participants value the provision of a hot meal, which frees them from the work required to prepare a cooked meal, the wellbeing checks, which provide them with a feeling of safety, and the relationships developed with MoWs drivers, which help address loneliness [14]. Tese fndings are important in light of the rising number of adults with care and support needs. Tere are nearly 11 million older adults (aged ≥65 years) living in England [21]. Alongside the rising number of adults living with complex needs, many of these individuals present growing rates of loneliness and isolation or experience social and physical challenges in accessing and preparing food Health & Social Care in the Community [22][23][24]. Tese factors signifcantly increase the risk of malnutrition, which further exacerbates physical and mental ill-health and increases the likelihood of (re)admissions to hospitals and care homes [25,26]. In addition, currently more than 1.3 million older adults in England live with malnutrition, most of whom live in the community [27]. Tis places immense pressures on health and social care services, as the cost of malnutrition in England exceeds £19.6 billion, of which half is spent on older adults [28]. Collectively, these fndings support the importance of MoWs services in enhancing the wellbeing of adults with care and support needs, while potentially leading to considerable savings for adult social care services and national health systems.
A unique fnding of the current study involved how participants viewed the possibility of MoWs services encouraging service users to engage in physical activity. Our recent work suggested that some drivers do encourage their MoWs clients to move more, for example, by getting up and going to the table to eat their meal [16], which was perceived as benefcial by some participants in the current study. Some participants in this study, however, highlighted disadvantages and/or barriers to MoWs drivers promoting physical activity, including potential delays in the actual meal consumption, the need for training to provide such advice, the limited time drivers have available with each service user, and the appropriateness of discussing physical activity with people with mobility challenges. However, given the importance of promoting physical activity to older adults and adults with disabilities [29], who form a considerable proportion of MoWs recipients [30], future research should further explore the potential benefts and opportunities of utilising MoWs services to promote physical activity in this population.
Another unique fnding of the current study was that both MoWs service users and referrers perceived MoWs to be an integral part of the care they receive, with some highlighting that the service should be formally acknowledged as "part of the social care package." Te Care and Support (eligibility criteria) Regulations 2014 defne "managing and maintaining nutrition" as the frst outcome that adults should be able to achieve [31]. In addition, food and nutrition comprise a domain of the Adult Social Care Outcomes Framework (ASCOF) that contributes to socialcare-related quality of life [32]. However, councils with adult social care responsibilities in England ofer no statutory entitlement to MoWs. Essentially, acknowledging MoWs as an essential part of social care was deemed important to allow service users to continue living independently in their homes and communities and prevent the move into residential care homes, in line with their wishes. Tis beneft has also been highlighted in earlier research [10,11]. Terefore, the lack of statutory entitlement to MoWs is, arguably, at odds with the Care and Support Regulations and deserves further attention to establish how MoWs services are viewed within the wider social care system in England.
Participants highlighted a few areas where the MoWs service could be enhanced. Some of these referred to the meals provided, with some participants expressing the view that the variety of meals on ofer and the portion size, as well as the presentation and packaging of the meals could improve. Similar views have been reported in earlier research among MoWs recipients in the United States [9,12], Australia [33], and England [13], suggesting that MoWs services could consider developing these aspects of the meals further to tailor the service to the needs of recipients. Other areas related to aspects of service operation, namely, the delivery times, which were not always perceived to conform to what might be considered common as "lunch time." Te time of meal delivery has also been acknowledged as an area of potential improvement in an earlier study among MoWs recipients in Australia [33]. Early delivery times are likely the result of drivers having to deliver meals to many service users during a specifc time period, whereas late deliveries might be due to some service users requiring more assistance than others, thereby necessitating drivers who deliver the meals to spend more time in a service user's home, when, e.g., faced with an emergency situation [16]. Increasing the time that MoWs drivers spend with service users was also identifed as an area that could beneft some service users, particularly as a means to further address social isolation and loneliness. In addition, restrictions in the time available to spend with MoWs service users were identifed as an area of concern by managers of the service in our earlier work [16] and earlier studies among MoWs recipients [9,34] and have been suggested to potentially compromise the quality of social interactions and ability to carry out welfare checks [35]. Even though stafng of MoWs services would depend on social care budgets, this suggests that MoWs providers and commissioners of social care and community support services in England should reconsider their provision to maximise the beneft to service users. For example, this could incorporate smaller delivery rounds by adopting volunteer provision models. Earlier research has highlighted that drivers who deliver the meals form equally rewarding relationships with service users and value working for the service [16,36], and highlighting these benefts during stafng processes might attract more volunteers to work for the MoWs service.
Despite the aforementioned areas for improvement identifed in the current study, it is noteworthy that participants valued MoWs, commended the friendliness of the drivers and customer service, and praised the reliability of the service to deliver under any circumstances, including during adverse conditions. Appreciation and gratitude towards MoWs and the services provided have also been expressed in other studies [10,11,14], which highlights the importance of the service as a crucial community resource for adults with care and support needs, which at the same time ofers reassurance to service users' carers and families. It should be noted that despite the current cost-of-living crisis, participants largely considered MoWs to be value-formoney due to the convenience of having a hot meal delivered, thus saving on costs associated with food shopping and preparation and also due to the social care benefts derived from using the service. However, participants still drew attention to the likelihood that not everyone might be able to aford MoWs. An earlier study among 199 adults, aged ≥60 years, who received MoWs in Cook County, Illinois, showed that participants perceived to be saving money by using MoWs, while others found it challenging to aford the service [12]. Many of the older adults currently living in England have complex needs [3][4][5][6] and many live in poverty [37], rendering the issue of afordability of food crucial to ensure these individuals' wellbeing and their ability to access nutritious meals. Future research should therefore explore the afordability of MoWs in more detail, to ensure that provision models are afordable for service users and their families but also viable for service providers.

Implications for Practice and Policy.
Findings from this small-scale study have important implications for adult social care policy and practice. Te wide range of benefts exerted by MoWs on both service users and people who refer them to the service suggest that MoWs should be recognised as a crucial preventative resource in maintaining the physical and mental wellbeing and independence of adults with care and support needs. Findings also highlighted that MoWs should form an essential part of the care package that adults with care needs receive. Considering the increasing number of local authorities that terminate their MoWs services [38], this fnding stresses the importance of reviving and/or reintroducing MoWs services at the national level, or making MoWs an integral part of social care services, to ensure that adults with care needs have access to at least one hot meal on a daily basis. We also found that MoWs service users would beneft from longer interactions with drivers who deliver the meals, as a means to further reduce social isolation and loneliness. Social care commissioners and the national government should therefore prioritise funding for MoWs and explore diferent models of provision to allow drivers to spend longer time with service users who might beneft from this social interaction.

Strengths and Limitations.
Te current study adds to the limited global evidence base around the experiences of service users with the MoWs service and is the frst, to our knowledge, to explore and document the perceptions of people who refer an adult with care and support needs to MoWs. Participants were recruited from diferent areas in England, including urban (in the South West) and rural or semirural (in the South East), in addition to more deprived areas (in the North West), and diferent providers (e.g., a local authority, a social enterprise, a family business, and a private company outsourced by local authorities). Terefore, we believe we have gathered diverse experiences across diferent localities, areas of deprivation, and MoWs provision models. An additional strength of this work is the use of rigorous methodology and reporting according to current guidelines [15]. Nevertheless, several limitations hinder the external validity of our fndings. We did not aim to collect data on ethnicity of our participants, and we are therefore unsure if our sample was ethnically diverse. In addition, the sample size of MoWs service users recruited into the study was small, limiting the ability to generalise the fndings to recipients of MoWs services with diverse needs (e.g., due to age, physical, or mental disabilities). Nevertheless, there were various reasons why participants had accessed MoWs, which helped obtain a wide range of insights. However, service users were not recruited from two of the four areas that this study recruited from. Tis highlights that future studies should explore potential challenges in recruiting MoWs service users, in order to obtain more representative views and perceptions on the service and to include the perspectives of those who have stopped using MoWs.

Conclusion
Tis small-scale study highlights several important benefts of MoWs from the perspectives of people with lived experiences of the service. Participants commended the service on its reliability of provision, being value-for-money, and the social care benefts acquired by using MoWs, while ofering essential insights on how MoWs services could be further enhanced. Te view that MoWs should form an essential part of social care services was a unique fnding that should mobilise social care commissioners and local and national governments into reviving and enhancing MoWs services. Tis will aid the increasing numbers of adults with care and support needs, who are unable to access or prepare a hot meal and would beneft from the social interaction and safeguarding that MoWs services provide, to live independently in their communities for longer.

Data Availability
Te interview guides used to collect data, as well as processed data, are available in the Supplementary Materials of this article. Other data that support the fndings of this study are available from the corresponding author upon reasonable request.