Table 3 Key changes made to ensure intervention materials were optimally meaningful to older adults

Strengthen perceived relevance of the booklets

Booklets not useful for those who already know about healthy eating and who are self-reliant

• Added emphasis that booklets provide new information on how eating needs change in older adulthood NOT general healthy eating advice

• Added emphasis that suggestions in the booklets/goal setting can support continued independence and meeting eating needs

• Added rationale that self-care ‘can help you to keep meeting your eating needs’

Misunderstood purpose of booklets: interpreting them as purely promoting healthy eating rather than supporting eating for those with low appetite, weight loss or underweight

• Changed cover design to show varied high-energy food examples, including cake.

• Entitled the main booklet ‘Meeting your eating needs as you get older’.

• Clarified intended purpose on first page of each booklet (e.g. to address low appetite and unintended weight loss)

Belief that weight loss is normal/inevitable and intervention not needed

• Clarified weight loss is not normal and highlighted the intervention can provide support to address reasons contributing to weight loss

Booklets did not include enough information to suit individual needs and circumstances

• Expanded range of food suggestions to suit a variety of preferred and prescribed diets, following guidance from dietitians and nutritionists

Acknowledge and validate users’ prior experiences

Booklets did not acknowledge the range of challenges experienced by participants

• Added acknowledgement that it can be difficult to follow the advice and suggestions when appetite is low or you are unwell or in pain

• Expanded content to address specific challenges experiences by participants e.g. changing taste sensations, reasons for finding cooking and shopping a chore, preparing food when in pain

Booklets perceived as dictatorial and condescending

• The tone of the booklets was adjusted to offer suggestions to try

Encourage participants to seek support

Concern that nurses and doctors did not have enough time to discuss the booklets

• Added a ‘talk’ symbol to indicate key sections where discussion with a nurse or doctor would be most useful (e.g. making plans and goals).

• Clarified that other people could also offer support (e.g. friend, family member, carer)

Use appropriate language

Confusion about key strategies for increasing nutritional intake

• Simplified key strategies and renamed to ‘adding tasty extras’ and ‘eating little and often’

Specific phrases were off putting

• Replace aversive phrases with participants own language (e.g. ‘eating more’ replaced with ‘eating regularly’ or ‘adding tasty extras’, ‘snack’ replaced with ‘small bite’

• Removed reference to ‘full fat’ or ‘sugar’ and included these elements within a range of examples, e.g. adding cheese, fruit, jam or honey

• Rationale and stories added to emphasise and model the benefits of regular eating and drinking