The ‘Cook and Eat’ Project

Kerry Delaney Specialist Occupational Therapist

Helen Jennings Senior Lecturer - OT

And SCoRe project (Students as Co-Researchers)

What is ‘Cook and Eat’? • Adaptive recipe books designed for adults with learning disabilities to support cooking occupations • Compensatory intervention strategy (Goodman and Locke, 2009)

• Consists of: – Small meals – Big meals – Cooking from Scratch – Baking

Why ‘Cook and Eat’? Reflections from practice • Desire to cook • Unable to read • Unable to understand complex language

• Cognitive skills – judgement and problem solving • Support levels

• Food safety • Cooking equipment • Food choices – Health problems

Why ‘Cook and Eat’? What the literature says… • Health inequalities

(Emerson, 2011, 2012; Mencap, 2004, 2007, 2010, 2013)

• Health problems linked to diet

(Melville et al, 2007; Bhaumik et al, 2008; Wolverson, 2012; Emerson and Baines, 2010)

Barriers to participation in cooking • Use of ready meals

(Caton et al, 2012)

• Cost of fresh food compared vs processed food

(Shoneye, 2012)

• Kitchen regulations

(Rodgers, 1998)

• Support workers may have limited cooking skills

(Caton et al, 2012)

• Limited opportunities to develop skills

(Rodgers, 1998; Shoneye, 2012)

Why ‘Cook and Eat’? What the literature says… • Occupational justice – the right to engage in a range of healthfacilitating occupations • Relationship between what we do and our health and wellbeing – social interaction and support – challenge and complexity – perceived competence and achievement

• Rights, independence, choice and inclusion – Valuing People (DoH, 2001; Townsend and Wilcock, 2004; Creek and Hughes, 2008)

The Cook and Eat formula • One step instructions

• Easy read language • Photographs • Reduced decision making and problem solving

• Failure free • No multi tasking • Concrete measuring methods

• Digital timer • Electric cooker • Food safety

Development of the books • Managerial support • Service user consultants • Professional advisors: Dietician, Food Safety, Accessible Communications • Testing recipes • Funding • Design/print • Launch • Research

‘Cook and Eat’: The service evaluation with York St. John University

Purpose, research question and approval • Service evaluation to find out how OTs were using the books and what they thought of them “What are the perspectives and experiences of occupational therapists regarding using the Cook and Eat books with people who have a learning disability?”

• Approved by SWFT and YSJ September 2014

Methodology • Research design: – Qualitative – Purposive, homogenous sample: 6 participants – Semi-structured interviews (Dickerson, 2006; Rubin & Rubin, 2012)

– Interpretative phenomenological analysis: • Idiographic • Hermeneutics • Phenomenology (Smith, Flowers and Larkin, 2009)

Findings 3 master themes generated: • ‘Service users developing as occupational beings’ • ‘Identified issues and development for the future’ • ‘Usefulness in OT practice’

‘Service users developing as occupational beings’ • Increased confidence and independence “…the books gave her the confidence to follow the recipe herself and make her meal for her dad…. It helped increase her confidence and independence.” Participant E “....It helped in their confidence, a lot more people felt better with the book there” Participant D

“ (It) boosted their self esteem and boosted their confidence and their abilities. And also it was something that they could take ownership of as well...” Participant C (Melton et al, 1998; Bennett and Cunningham, 2014)

‘Service users developing as occupational beings’ • Improved occupational performance: compensatory Adjustment to task and / or environment to compensate for decreased occupational skill

(Fisher, 2009)

“They needed less verbal instructions and the books made it easier for them to sequence tasks … not relying on me or asking me what to do next … the books made things simpler for people and easier to follow” Participant E “... the pictorial aspect of it is preferable to a normal recipe book” Participant D “… it’s not just giving you loads of information… it's … clearly explained and visual” Participant A

(O’Neal et al, 2007; Lillywhite and Haines, 2010)

‘Service users developing as occupational beings’

• Improved occupational performance: acquisitional Re-acquiring or developing occupational skill

(Fisher, 2009)

“...this one lady ...bought all 4 of them and really was off with them … going through every recipe and then moving on to the ‘Cooking from Scratch’ ones.” Participant F “One guy was not confident about using a knife and peeling things and so by practicing using the book and following very clear (instructions), they develop some skills” Participant A

‘Service users developing as occupational beings’ • Healthy eating and choice “We did a healthy lifestyle group with OT input. We used the resource in one of the sessions there ... it was trying to teach healthy meal planning and also that it was quite easy to make yourself a nutritious healthy meal” Participant D “(The books) discourage people from just going to the garage and buying a sandwich or a microwave burger’ Participant D However: “... some of the things that are for two portions, they’ve just eaten the whole thing themselves”. Participant A “...it was the baking ... they’re not particularly healthy because they’re all cakes aren’t they? So I don’t know whether that educated him much about healthy choices.” Participant A

‘Service users developing as occupational beings’ • Healthy eating and choice “(It) improves ... the ability of choice as well. Having that those recipes in front of you ready to start meal planning and having a bit of control (over) decision making about what people are going to eat”. Participant F

 Having choice does not always equal healthy choice

(Draheim 2006; Johnson 2009; Marteau et al, 2011; Caton et al, 2012; Shoneye, 2012)

‘Identified issues and development for the future’ • Right tool for the right person “(If) they (have a) mild learning disability then (they) are right for that book… It does kind of exclude people.” Participant F

“....she really struggled to follow the step by step instructions so it really does depend on the person your using it with.” Participant F “... maybe it was people with … lower IQ who struggled a little bit more” Participant D “...he was a bit put off I think by the amount of pictures and things like that in it” Participant A

‘Identified issues and development for the future’ • Practicalities “If they spill food on the book, the pages get dirty.”

Participant C

“(If) you’ve got a gas cooker, because in the book it’s electric.” Participant B “I found that particularly hard to find actually, the spaghetti measurer” Participant A “... it might be nice to have a little section ... saying it's important to wash your hands before and then when you're handing raw meat.” Participant A (Bennett & Cunningham, 2014; Cabinet Office, 2005; Emerson et al, 2012)

‘Identified issues and development for the future’ • Diversity “I worked with a lot of, a large proportion of Asian men in forensic services, and a lot of the recipes didn’t really apply to their kind of needs. They liked more kind of what was relevant to them which was curries” Participant C “I think it would be really good to make … one of the Cook and Eat books for different cultures … probably bring in some Indian cooking, some Caribbean cooking” Participant B “... a vegetarian recipe book, or a book for somebody with diabetes...” Participant B

‘Usefulness in OT practice’ • Affordability • Transferability “…really cost effective, yeah, very cheap. And cheap enough for the service users to buy...” Participant A

“I think its probably pitched about right” Participant F “I think if you were buying all four then it seems like quite a lot of money ... I don’t believe people would go out and buy all four, they would just select the ones they wanted which would make them more cost effective.” Participant E (Emerson et al, 2012, Robertson et al, 2014)

“...maybe people in the earlier stages of dementia” Participant E “people with dementia ... maybe mental health settings as well” Participant D “you could use them with paediatrics, you could use it in possibly brain injury units.” Participant C “I mean even for kids ... trial out in like, primary schools or something.” Participant B

What do people with learning disabilities think? “It’s very easy, you can just get on with it”

“It’s better than microwave meals!”

“I’ve never had salmon before!”

“It’s delicious, can I make it again?”

“you can go on my 2nd whistle, 3,2,1 go!”

“I love cooking – I’m a chef”

“Easy Peasy!”

“Actually – not much to wash up!”

Implications for practice and conclusions Preliminary findings suggested: •

The books help to meet to aims of policy and can promote health and wellbeing through improving confidence, independence, choice and supporting task completion

•

There is some limited data to suggest they may aid healthy eating interventions

•

They are easy for (some) clients to understand and can act as a compensatory or acquistional aid

•

These books are not right for everyone and therapists must be person-centred when considering their suitability

•

The range could be extended

Limitations and future research Limitations: • Novice researchers (Smith et al 2009, Hefferon et al 2011) • Small sample size and lack of transferability • Bias – personal and professional allegiance

Future research: • Investigating the views of people with LD who use the books • Observational measures of change in occupational performance • Effectiveness of the books with other clinical populations e.g. dementia, traumatic brain injury

What has happened since the evaluation • 4,000 book reprint completed • In negotiations with Amazon for distribution • Negotiations with Public Health Wakefield and Public Health Doncaster for ‘Grow and Eat’ and ‘Healthy Eating’ • Book review - Mencap • Writing up for journal submission

The ‘Cook and Eat’ Project With great thanks to: Our student researchers • Cavern Hall, Chris Jacobs, Naomi Monks, Lauren Patrick, Rachel Stanley, Caitlin Thomson and David Tose

And to our OT participants and their service users!

References •

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Adolfsson, P., Ylva Mattsson Sydner, Y. M., Fjellström, C., Lewin, B. & Andersson, A. (2008) Observed Dietary Intake in Adults With Intellectual Disability Living in the Community. Food & Nutrition Research, 52, pp. 1-6. Bennett, A. & Cunningham, C. (2014) A Qualitative Evaluation of a Healthy Cookery Course in Ireland Designed for Adults with Mild to Moderate Intellectual Disability. Journal of Intellectual Disabilities, 18(3), pp. 270-281. Bhaumik, S., Watson, J. M., Thorp, C. F., Tyrer, F., & McGrother, C. W. (2008) Body mass index in adults with intellectual disability: Distribution, associations and service implications. A population-based prevalence study. Journal of Intellectual Disability Research, 52, pp. 287 – 298 Bull, E. (2012) Healthy Eating for People with Learning Disabilities: Exploring Social Care Staff Views. Scotland: NHS Grampian Cabinet Office (2005) Improving the Life Chances of Disabled People: Final Report. London, Cabinet Office. Caton, S., Chadwick, D., Chapman, M., Turnbull, S., Mitchell, D. & Stansfield, J. (2012) Healthy lifestyles for adults with intellectual disability: Knowledge, barriers and facilitators. Journal of Intellectual and Developmental Disability, 37 (3), pp. 248 – 259.

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Crawley, H. (2007) Eating Well: Children and Adults with Learning Disabilities. Nutritional and Practical Guidelines. Hertfordshire, UK: Caroline Walker Trust Creek, J. & Hughes, A. (2008) Occupation and health: a review of selected literature. British Journal of Occupational Therapy, 71(11), 456-468. Department of Health (2001) Valuing People: A New Strategy for Learning Disability for the Twenty-First Century. London, UK: Department of Health Dickerson, A, E. (2006) Securing Samples for Effective Research Across Research Designs. In: Kielhofner, G. (ed) Research in Occupational Therapy: Methods of Inquiry for Enhancing Practice. Philadelphia, F. A. Davis Company. Draheim, C. (2006). Cardiovascular disease prevalence and risk factors of persons with mental retardation. Mental Retardation and Developmental Disabilities Research Reviews, 12(1):3-12. Emerson, E., Baines, S., Allerton, L. & Welch, V. (2011) Health Inequalities and People with Learning Disabilities in the UK: 2011. UK: Improving Health & Lives; Learning Disability Observatory. Emerson, E., Baines, S., Allerton, L. & Welch, V. (2012) Health Inequalities & People with Learning Disabilities in the UK: 2012. London, Department of Health.

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Fisher, A. (2009) Occupational Therapy Intervention Process Model: a model for planning and implementing top down, client centered, occupation based interventions. Fort Collins. Three star press. Goodman, J. & Locke, C. (2009) Occupations and the Occupational Therapy Process. In: Goodman, J., Hurst, J. & Locke, C. Occupational Therapy for People with Learning Disabilities. Edinburgh, Churchill Livingstone. Groenewald, T. (2004) A Phenomenological Research Design Illustrated. International Journal of Qualitative Methods, 3(1), pp. 1-26. Hefferon, K. Gil-Rodriquez, E. (2011). Methods: Interpretative phenomenological analysis. The Psychologist, 24 (10) 756-759. Hurst, J. (2009) Occupations and health promotion. In: Goodman, J., Hurst, J. and Locke, C. (eds) Occupational Therapy for People with Learning Disabilities: A Practical Guide. Edinburgh, Elsevier Limited. Johnson, C. (2009). The benefits of physical activity for youth with developmental disabilities: a systematic review. American Journal of Health Promotion, 23(3): 157-167.

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Lillywhite, A., and Haines, D. (2010) Occupational therapy and people with Learning Disabilities: Findings from a research study. London, College of Occupational Therapists. Marteau T., Ogilvie D., Roland M., Suhrcke M., Kelly M. P. (2011). Judging nudging: can nudging improve population health? British Medical Journal. 342 pp. 263–265 Melton, J. (1998) How do Clients with Learning Disabilities Evaluate their Experience of Cooking with the Occupation Therapist? British Journal of Occupational Therapy, 61(3), pp. 106-110. Melville , C. A. , Hamilton , S. , Hankey , C. R. , Miller , S. , & Boyle , S . (2007) The prevalence and determinants of obesity in adults with intellectual disabilities. Obesity Reviews, 8, pp. 223 – 230

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O’Neal, S., Dickerson, A. E. & Holbert, D. (2007) The Use of Theory by Occupational Therapists Working with Adults with Developmental Disabilities. Occupational Therapy in Health Care, 21(4), pp. 71-85. Robertson, J., Emerson, E., Baines, S & Hatten, C. (2014) Obesity and Health Behaviours of British Adults with Self-Reported Intellectual Impairments: Cross Sectional Survey. BMC Public Health, 14(1), pp. 219-226. Rubin, H, J. and Rubin, I, S. (2012) Qualitative Interviewing: The Art of Hearing Data. 3rd ed. Los Angeles, SAGE Publications. Shenton, A., K., (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information. 22, pp.63–75. Shoneye, C. (2012) Prevention and treatment of obesity in adults with learning disabilities. Learning Disability Practice, 15 (3), pp. 32 – 36 Smith, J. (1996) Beyond the Divide Between Cognition and Discourse: Using Interpretative Phenomenological Analysis in Health Psychology. Psychology and Health, 11(2), pp. 261-71. Smith, J.A., Flowers, P. & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method and research. London: Sage.

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Townsend, E. & Wilcock, A.A. (2004) Occupational justice and client-centred practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 71 (2), pp. 75 – 87 Whalley-Hammell, K. R. (2013) Client-centred practice in occupational therapy: critical reflections. Scandinavian Journal of Occupational Therapy. 20 (3), pp. 174 – 181. Willig, C. (2001). Introducing Qualitative Research in Psychology. Buckingham: Open University Press. Wolverson, M. (2012) Reducing health disparity in people with disabilities. Practice Nursing, 23 (12), 617 – 622. World Federation of Occupational Therapists (2011) Definition “Occupation” [online] Available from: http://www.wfot.org/aboutus/aboutoccupationaltherapy/definitionofoccupationalther apy.aspx [Accessed 18.03.15]