Table 3 Example quotes and domains of the Process Evaluation Framework

Context: Living arrangement

“Actually, she lives with me…The house that the meals are delivered to, it’s her house, but since she’s no longer allowed to stay by herself, she lives with me now.” (Caregiver 4; frozen)

“I wish more people could get them because I know there’s a lot more people out there who need this service. I live in a retirement community and there’s probably five to 6,000 residents in this complex.” (Participant 1; frozen)

“I stay here…since my dad passed away in January.” (Caregiver 5, daily)

Context: Level of cognitive impairment

“I can leave her for a little while. I’ll tell her. She won’t remember where I’ve gone. She has a very short memory because she has dementia. I go in and tell her before I leave, I’m leaving, and so she knows that I’m going be gone for a little while.” (Caregiver 2; daily)

“I have a bad memory. That’s why the doctor giving me medicine for my brain.” (Participant 2; daily)

“... She gave up driving, right at around 79 [years old]. And then she started showing signs of memory loss, cognitive abilities. You could tell things were starting to decline. And so that’s where I had to pay even more attention to her needs and making sure she was attending all her doctor appointments, scheduling those appointments, getting her there, following up, and then taking any kind of medication that was necessary.” (Caregiver 1; frozen)

Context: Presence of a caregiver

“I know my dad, he wouldn’t want her in a nursing home…Really it’s just me…I have friends that have offered me jobs and this and that, but I can’t leave her. To be here and then to have meals sent to us, to our door is just wonderful. That makes the possibility of her being able to be here a possibility.” (Caregiver 5; daily)

“No, I don’t have anybody. I help myself alone here.” (Participant 2; daily)

“It takes both of us to take care of Mom. And I’m really low income because of the disability amount I get- and how much we have to pay for rent here at the apartment. So, I have a caregiver that comes in and helps in the house, and it takes all three of us to take care of Mom.” (Caregiver 7; frozen)

Context: Demographics

“I do like them…I mean, they could be maybe, I like Mexican food because you know, I am Hispanic myself, but they’re fine. I appreciate them.” (Participant 9; frozen)

“She has lived with us, her son being my husband and two daughters. It was time for her to retire and just be able to live without any issues, any worry so we invited her, just come and live with us. So she has lived with us for over, let’s see, 10 years now.” (Caregiver 1; frozen)

“Right now, I’m VA disabled. And they don’t know that I’m taking my dad in because I’m afraid they’ll take my disability away. But at the same time, I told my husband if I decline because of dad being here, then I will make that decision that I don’t want to make.” (Caregiver 6; daily)

Implementation: Timing of meal delivery

“They usually come about 11:30.” (Caregiver 2; daily)

“I just sit right here. They’ll tell me about what time they’ll be here. It be about the same time, around about 10:30 or 11:00. I really don’t know, but about the same time.” (Participant 6; frozen)

“I didn’t get a call, and I thought, ‘Well, maybe they’re going to come at the same time.’ And they didn’t, so I just kept sitting up and waiting, and then I decided I’ve got to go take my nap, and it wasn’t until... I don’t know. The first time it was 2:30? And so, then after that, it was 1:00, and then after that, it’s been around 11:00, 11:30.” (Participant 7; daily)

Implementation: Logistics of meal delivery

“Well, someone, you know, comes to the door and, and rings the bell or knocks. And so then, you know, they have a bag with food in it, the meals and that’s it…They just stay at the door and hand it to you.” (Participant 4; daily)

“If I knew when to expect it, for the most part I’m always going to be here... especially it’s getting hot and I can’t tell you, because it was always such a surprise to me, what time, but it’s a FedEx truck. FedEx that brings it. But if I knew ahead of time, that would be more helpful to me.” (Participant 5; frozen)

“She just knows that they brought her something. We have a camera at her house... The last time…they brought the meals, she was over here with me. When we see them delivered, then we go pick them up.” (Caregiver 4; frozen)

Implementation: Meal preparation

“It makes it a little easier because I know that them meals would be here, and I won’t have to worry about whether the little home provider, if she could feed him because she already have those meals ready. I’m like, ‘All you have to do is warm it up and mash it up a little bit.’” (Caregiver 3; daily)

“I just stick them in the freezer until I’m ready to eat them and follow the directions, slit over each compartment and nuke it for what they say. And I usually nuke it for probably about a minute longer because some of the vegetables sometimes don’t really get hot. So I just found out that if I just nuke it for an extra minute, it’s no problem.” (Participant 1; frozen)

“They come in really handy and the only thing that you need to do... I don’t use the microwave because I don’t think it comes out quite as well. I use the other method, put it on low in the conventional, in the oven.” (Participant 5; frozen)

Implementation: Number of meals received

“They come on Monday, they give for three days, three meals and then they come on Wednesday and give me for two days.” (Caregiver 2; daily)

“They come every other Friday…Every two weeks, and they’re enough for two weeks.” (Caregiver 4; frozen)

“I think six meals came, I think it was extra meals because of maybe they’re taking off on Monday or maybe... I don’t know, I wonder. It seems like it was extra meals but I can’t quite figure out... I can’t remember.” (Caregiver 6; daily)

Implementation: Interactions with meal delivery drivers

“I don’t know how you guys find these happy people, but you guys have some happy people... One guy comes every day… He’s just always total happy and just joyful. It rubs off on you. When you see his smiling face, you want to smile, too. I’m like, ‘That’s really cool. They got a really good worker.’” (Caregiver 5; daily)

“Sometimes we have a nice chat. Sometimes I said, ‘Hi.’ Or they say, ‘How are you doing? You are doing all right?’ I said, ‘Yes, I’m okay.’ They are nice people.” (Participant 2; daily)

“They just bring them and knock on the door. And if I don’t answer, then they call me because it takes me a while to get out of bed. So I make it to the door…Well I’ve got a walker and they say, ‘Can I help?’ I said, ‘Just put it on the walker.’” (Participant 3; daily)

Mechanisms of impact: Satisfaction with meals/delivery

“The hardest part was what to fix. I don’t mind cooking it, but to come up with a menu, I guess, I should say. And the Meals on Wheels is well rounded. You get tired of it, but it’s still well rounded. You always get some kind of an entree, then you get vegetables, usually two vegetables. They also bring drinks, orange juice and apple juice. They seem to give you some for every day and some fruit. We’ve been getting bananas and apples. Which are very tasty and help.” (Caregiver 2; daily)

“She only knows that the meals are delicious. She doesn’t know who cooked them. No, really, every time we feed her the meals, she’s like, ‘Oh, this is very tasty. You cooked this?’ She wants to know who cooks them. Yes. And she eats, I mean, the variety of the meals it’s excellent. It’s a lot of food and selections that she would normally eat. The chicken, the meatloaf, the fish with a lot of vegetables.” (Caregiver 1; frozen)

“They’re good quality meals. I mean, it’s almost like going out to a restaurant... It’s not like a fast food thing. I mean, and they’re healthy, they’re nutritious, they’re low in calories, low in sodium. They’re very health conscious. I don’t find anything really wrong with them.” (Participant 1; frozen)

Mechanisms of impact: Benefits of meals

“I don’t have to buy all the food that it takes to make all the food that we get. Really, it’s a lot of money because you have a big variety....A lot of those vegetables or fruits or healthy stuff is expensive…If I had to go buy the food today, I just wouldn’t be able to, but she’s got three meals, so she’s good for another couple of days, too. Me, I’m fine with sandwiches. I’m okay, but my mom, she needs to have food that where it’s going to give her substance and nutrition and where she’ll have enough energy to get up and move around. If she doesn’t continue walking, then she will completely forget how to do it… I wouldn’t be able to afford all the vegetables and everything that you guys supply and bring.” (Caregiver 5; daily)

“I would say it has affected, again, my stress level, worrying about, ‘Okay, I got to get her fed’ or, ‘Oh my god, what would I need to fix the day for her?’ Or what have you. So it has definitely helped to reduce a certain level of stress in my life, free up some time to spend with her otherwise." (Caregiver 1; frozen)

“Because he has food and as long as I remind him to eat it, then he is able to maintain his strength, which keeps him from being weak, which keeps him from falling, which keeps him from being in the hospital. So food, it does provide safety in an indirect way.” (Caregiver 6; daily)

“I think it has helped. Because before, I definitely don’t believe I was getting enough nutrition.” (Participant 7; daily)

Mechanisms of impact: Challenges with meals

“There’s a lot of stuff in there on the meals that are stuff Mom won’t eat. So, like beans and stuff, she doesn’t eat beans. And they’ll have stuffed manicotti, which she doesn’t like ricotta cheese. And fish, she will not tolerate, so she’s allergic to milk products if she eats too much, and we don’t do anything with oranges. She doesn’t like them... When it first started out, the hardest part was the fact that they were sending two boxes every other week, which meant I had a storage problem. Because that was 20 meals, trying to find a place to put them, and they finally got that straightened out. And what I’ve had to do the last couple of times is one of the small freezer boxes I got, I just put the refreezable packs in the freezer and just keep them in the box and keep the freezer packs in there because I just don’t have room in the freezer for that many meals. They just don’t fit.” (Caregiver 7; frozen)

“If I’m not here, I put the bag out there. But when I put the bag out there and I’m not here, they don’t put the food in there. And if I leave a note, ‘I'll be right back. Please put the food.’ When I get here, the empty bag was there and I saw a note on it that they’re not supposed to leave the food if I’m not here.” (Participant 2; daily)

“The only thing that was a bit challenging or stressful was the whole holiday thing. On that Monday. It’s like dad didn’t get the Monday delivery…So he went without meals and I didn’t know. And so then, I found out that if it’s a holiday on Monday, they don’t deliver. So I thought, ‘Okay, I have to plan ahead. If a holiday’s coming, I need to buy some TV dinners to have in there, to kind of be there for just in case.’ And I did that.” (Caregiver 6; daily)

Mechanisms of impact: Overall experience

“I really appreciate that I’m getting them because otherwise, you know, I don’t know how often I’d be eating.” (Participant 9; frozen)

“It’s providing the value nutrition that she needs. The proteins, the minerals, vitamins from the vegetables, which in turn, it’s keeping her healthy. She does take vitamin supplements because obviously she can’t eat all the requirements of minerals and vitamins that’s necessary, but it really provides the nutrition and hence the energy she needs to keep living. And it was a very needed thing and it really just keeps her going.” (Caregiver 1; frozen)

“The meals that we get? Well, generally they’re, they’re very good. And I know I like them.” (Participant 4; daily)