over the next 30 years , the elderly population ( 65 years and older ) in the united states is expected to double . by the year 2040
, 20% of americans will be 65 years of age and older as compared to 12.97% in 2010 . from 2010 to 2050
, the total population is expected to increase by 142% ; the age group of 65 years old and over is expected to increase by 220% , the age group of 85 years old and over is expected to increase by 331% , and the age group of 100 years old and over is expected to increase by 761% . although there has been an increase in life expectancy , the later years may not be lived in good health . the burden associated with providing health care to an aging population is likely to increase , with nutrition being one of the most important factors for maintaining quality of life . to maintain health , independence , and well - being ,
however , many studies indicate that seniors ' diets are low in calories and other nutrients . within the community
, efforts have been made to develop nutrition programs targeting older people of high nutritional risk .
home delivered meals program , such as those provided by mow , can make a significant contribution to the nutrient intakes of the homebound . despite the sincere intentions of organizations , administrators of charitable programs often over - focus on the nutritional content of meals with little concern for recipients ' food preferences , satisfaction , or more importantly , avoidances .
therefore , this study was conducted to evaluate recipients ' perceptions of food quality , volunteer service and responsiveness , and their satisfaction of home delivered meals program .
malnutrition among the elderly may be related to illness , cognitive impairment , medication usage , functional decline , and mental illness [ 6 - 8 ] .
previous research showed that 74% to 98% of elderly recipients of mow were at nutrition risk .
furthermore , many elderly people have physical problems that make it difficult for them to consume certain foods .
used the nutrition screening initiative ( nsi ) screening tool and reported that 83% of mow participants were at high risk for poor nutritional status compared to the 74% considered at risk by the nutritional assessment criteria of their study . even though the rate of participants at high nutritional risk in this study was lower than those originally assessed from mow programs , the result still indicated that the number of participants at high nutritional risk is high . while certain groups of seniors are at greater - risk of hunger , hunger cuts across the income spectrum .
for example , over 50% of all seniors who are at - risk for hunger have incomes above the poverty line ; likewise , it is present in all demographic groups .
seniors living in non - metropolitan areas are as likely to experience food insecurity as those living in metropolitan areas , suggesting that food insecurity cuts across the urban - rural continuum . since adequate nutrition is essential for maintaining health , decreasing existing health problems , and maintaining functional independence , improving nutritional status and maintaining functional independence are seriously important to prolong good health status and well - being .
weatherspoon et al . found that enjoyable meal times and appropriate nutrition intake allow the elderly to improve their health and quality of life ; therefore , health status and quality of life might be influenced by recipients ' satisfaction with the meals and services provided from health - care facilities .
service quality assessment has received considerable attention in hospitality research [ 10 - 13 ] .
service quality is defined in the marketing literature as a customer 's post - consumption evaluation of service that compares expectations with perceptions of performance .
the evaluation of service quality is based on the manner in which the service was delivered and the outcomes that resulted from that service .
service quality addresses issues of quality only , while satisfaction may include non - quality components ( e.g. price ) .
satisfaction is an overall measure of how happy or content customers are in general with a product or service offered .
this model utilizes a 44-item measurement that compares differences between customers ' expectations of service and their assessment of actual performance .
respondents ' expectations of excellent service are evaluated first in this instrument by 22 questions ( before consumption ) , followed by another 22 matching questions rating perceived performance of the service provided ( after consumption ) .
five dimensions of service quality have been specified in servqual : reliability , responsiveness , empathy , assurance , and tangibles . despite the popularity of the servqual model
proposed an instrument called dineserv to assess customers ' perceptions of a restaurant 's service quality .
dineserv was adapted and refined from servqual containing 29 statements on a seven - point response scale .
they selected a random sample of people from telephone directories of a midsize city in the north central us and used dineserv to conduct telephone interviews with adults who had eaten out six or more times during the previous 6 months in three restaurant segments : quick service , casual / theme , and fine dining .
dineserv consists of five dimensions : assurance , empathy , reliability , responsiveness , and tangibles . in order to evaluate customer perceptions of foodservice quality , kim et al
.   conducted a study to evaluate the reliability and validity of a modified dineserv instrument to fit the needs of specific establishments : a casual italian restaurant in the us and an american - style casual restaurant in taiwan .
another study was conducted to validate five dimensions of the dineserv instrument in korean casual dining restaurants and explored any possible differences in the perceived service quality of those restaurants .
one could easily assume that recipients would be satisfied with the meals and services of mow or other congregate meal programs because almost all meals from these programs are free , and most staff of these programs are volunteers .
however , some research has indicated that many recipients explicitly expressed their dissatisfaction ; for example , in a study by lirette , some recipients felt that the vegetables were too firm ( 19% ) and the meat was too tough ( 24% ) .
they also indicated their dissatisfaction about texture , vegetables , salads , and ethnic choices . in roy and payette 's study , nineteen subjects ( 95% )
usually or never consumed their entire meal , and eight ( 40% ) subjects reported they threw away parts of their meal .
this study indicated that fifteen ( 75% ) were satisfied with meal quality , time of delivery , variety , choice , and temperatures of foods .
these results imply that mow recipients may not eat sufficient amounts of food to meet their nutritional needs .
moreover , research has suggested that recipients ' preferences and acceptance should be strictly monitored and evaluated to ensure that meals are going to be eaten .
therefore , mow agencies must understand recipients ' perceptions about food quality , volunteer service , and level of satisfaction .
in the current study , midwest mow recipients ' perceptions and meal satisfaction were investigated . consequently , this study was designed to evaluate recipients ' satisfaction with meals and services from the mow program in lubbock , texas .
the specific objectives of this research were to : 
 evaluate the recipients ' satisfaction with meals from mow.assess the recipients ' satisfaction with services from mow.evaluate the recipients ' overall satisfaction with meals and services from mow.investigate the factors affecting the recipients ' satisfaction . 
 
based on a literature search of previously conducted satisfaction surveys , a satisfaction questionnaire was developed . this instrument was adopted and modified in order to investigate the recipients ' satisfaction .
the initial questionnaire contained 24 items , using a 5-point likert scale ranging from 1 ( strongly disagree ) to 5 ( strongly agree ) .
the final questionnaire had 21 items and used the 5-point likert scale . in order to examine factors affecting the recipients ' satisfaction ,
the recipients were asked about their experiences with meals and services they had received during this study .
the survey paper was yellow or blue instead of white because it would be easier for recipients and volunteers to distinguish them among other papers .
the questionnaire language was simply written because federal regulations advise a 7th grade reading level for written consent for ordinary adults .
questionnaires were prepared in two versions , english and spanish , because almost half of the recipients spoke and read only spanish .
another native spanish speaker then translated the questionnaire back into english in order to confirm the accuracy of the spanish questionnaire .
original and back translated documents were then compared , and it was confirmed that the spanish questionnaire was suitable for use in the study .
originally , the questionnaire used for the pilot test had 20 items and two variables .
volunteers delivering lunches for mow were asked to distribute the questionnaires when they delivered meals , and they were also asked to collect the questionnaires either the next day or the next time they completed their routes .
the 1-page ( two sided ) questionnaire was printed on 8.5"11 " paper and folded in half .
two different colors were used to differentiate the languages : yellow for english and blue for spanish .
no code numbers were used on individual questionnaires to ensure the anonymity of responses . to encourage participation , the researcher made a $ 1 donation to mow for every completed survey . the data was compiled and statistically analyzed using the statistical analysis program spss ( statistical package for social sciences ) release 15.0 for windows ( spss inc . ,
the data were analyzed following anderson and gerbing 's   two - step approach : a measurement model and a subsequent structural model .
the multiple - item scales of four constructs were subjected to a confirmatory factor analysis ( cfa ) to determine whether the manifest variables reflected the hypothesized latent variables .
the reliability levels ( coefficient alpha values ) for each construct were above the cutoff of 0.70 proposed by nunnally .
after reliability coefficients of the four dimensions reached the required level , the coefficient alpha for total items was calculated within the construct .
the adequacy of the items was assessed by composite reliability , convergent validity , and discriminant validity . once the measures were validated , structural equation modeling ( sem )
this study used several fit indexes : chi - square to df ratio ( /df ) , which is the chi - square fit index divided by degrees of freedom .
the comparative fit index , cfi , compares the existing model fit with a null model that assumes the indicator variables ( and hence also the latent variables ) in the model are uncorrelated ( the " independence model " ) . the normed fit index ( nfi ) ,
nfi was developed as an alternative to cfi , but one which did not require making chi - square assumptions .
the incremental fit index , ifi , is relatively independent of sample size and is favored by some researchers for that reason .
root mean square error of approximation , rmsea , is also called rms or rmse or discrepancy per degree of freedom .
rmsea is a popular measure of fit , partly because it does not require comparison with a null model and thus does not require the author to posit as plausible a model in which there is complete independence of the latent variables , as does for instance , cfi .
the tucker - lewis index , tli , is similar to nfi , but penalizes for model complexity .
sem also offers some important , additional benefits over these techniques , including an effective way to deal with multicollinearity , and methods for taking into account the unreliability of consumer response data .
there were five latent variables in this model : food quality , volunteer issues , responsiveness , satisfaction , and behavioral intention .
based on a literature search of previously conducted satisfaction surveys , a satisfaction questionnaire was developed . this instrument was adopted and modified in order to investigate the recipients ' satisfaction .
the initial questionnaire contained 24 items , using a 5-point likert scale ranging from 1 ( strongly disagree ) to 5 ( strongly agree ) .
the final questionnaire had 21 items and used the 5-point likert scale . in order to examine factors affecting the recipients ' satisfaction ,
the recipients were asked about their experiences with meals and services they had received during this study .
the survey paper was yellow or blue instead of white because it would be easier for recipients and volunteers to distinguish them among other papers .
the questionnaire language was simply written because federal regulations advise a 7th grade reading level for written consent for ordinary adults .
questionnaires were prepared in two versions , english and spanish , because almost half of the recipients spoke and read only spanish .
another native spanish speaker then translated the questionnaire back into english in order to confirm the accuracy of the spanish questionnaire .
original and back translated documents were then compared , and it was confirmed that the spanish questionnaire was suitable for use in the study .
forty questionnaires were distributed , and 20 questionnaires were collected in march 2008 . originally , the questionnaire used for the pilot test had 20 items and two variables .
unnecessary items were removed and some necessary items were added . for efficiency , extra distributors and collectors were not employed .
volunteers delivering lunches for mow were asked to distribute the questionnaires when they delivered meals , and they were also asked to collect the questionnaires either the next day or the next time they completed their routes .
the 1-page ( two sided ) questionnaire was printed on 8.5"11 " paper and folded in half .
two different colors were used to differentiate the languages : yellow for english and blue for spanish .
no code numbers were used on individual questionnaires to ensure the anonymity of responses . to encourage participation , the researcher made a $ 1 donation to mow for every completed survey .
the data was compiled and statistically analyzed using the statistical analysis program spss ( statistical package for social sciences ) release 15.0 for windows ( spss inc . ,
the data were analyzed following anderson and gerbing 's   two - step approach : a measurement model and a subsequent structural model .
the multiple - item scales of four constructs were subjected to a confirmatory factor analysis ( cfa ) to determine whether the manifest variables reflected the hypothesized latent variables .
the reliability levels ( coefficient alpha values ) for each construct were above the cutoff of 0.70 proposed by nunnally .
after reliability coefficients of the four dimensions reached the required level , the coefficient alpha for total items was calculated within the construct .
the adequacy of the items was assessed by composite reliability , convergent validity , and discriminant validity . once the measures were validated , structural equation modeling ( sem )
this study used several fit indexes : chi - square to df ratio ( /df ) , which is the chi - square fit index divided by degrees of freedom .
the comparative fit index , cfi , compares the existing model fit with a null model that assumes the indicator variables ( and hence also the latent variables ) in the model are uncorrelated ( the " independence model " ) . the normed fit index ( nfi ) ,
nfi was developed as an alternative to cfi , but one which did not require making chi - square assumptions .
the incremental fit index , ifi , is relatively independent of sample size and is favored by some researchers for that reason .
root mean square error of approximation , rmsea , is also called rms or rmse or discrepancy per degree of freedom .
rmsea is a popular measure of fit , partly because it does not require comparison with a null model and thus does not require the author to posit as plausible a model in which there is complete independence of the latent variables , as does for instance , cfi .
the tucker - lewis index , tli , is similar to nfi , but penalizes for model complexity .
sem also offers some important , additional benefits over these techniques , including an effective way to deal with multicollinearity , and methods for taking into account the unreliability of consumer response data .
there were five latent variables in this model : food quality , volunteer issues , responsiveness , satisfaction , and behavioral intention .
the socio - demographic characteristics of respondents in this study are exhibited in table 1 . out of 398 questionnaires , 265 ( 66.6% )
were collected , and 209 questionnaires ( 52.5% ) were used for the statistical analysis .
the average age of respondents was 75.7 years old , and the largest group ( 22.0% ) out of five age groups was less than 70 years old .
more than half ( 52.1% ) of the respondents were older than the average age , above 76 years old .
the income level was very low ; the largest portion of the group ( 44.0% ) made less than $ 10,000 per year . except for the respondents who did not answer this question , more than 90% were making less than $ 20,000 per year .
most of them had retired long ago , so they were largely relying on a government subsidy or pension .
about one fifth ( 21.5% ) of the respondents did not answer this question , possibly because they did not remember how long they had been served meals from this organization .
the average length of time respondents had been receiving meals was 2.84 years ; the largest group ( 23.9% ) had been receiving meals between 1 and 2 years .
the following average scores of perceptions toward meals and services were calculated : flavor ( 3.62 ) , taste ( 3.69 ) , vegetables ( 3.81 ) , meat / fish ( 3.71 ) , temperature ( 3.55 ) , dessert ( 4.00 ) , drinks ( 4.04 ) , portion size ( 3.63 ) , variety ( 3.82 ) , appearance ( 4.68 ) , kindness ( 4.75 ) , attitude ( 4.72 ) , meal schedule ( 4.13 ) , and response ( 4.23 ) .
the results show that items for meals were rated slightly lower than those for service .
specifically , temperature , flavor , and portion size were quite low compared to others .
therefore , if mow organizations address the quality of these items , recipients will be more satisfied with this program .
the level of internal consistency in each construct was acceptable , with cronbach 's alpha estimates ranging from 0.698 to 0.939 .
all of the composite reliabilities of the constructs were over the cutoff value of 0.50 , ensuring adequate internal consistency of multiple items for each construct   ( table 2 ) .
in addition , the average variance extracted ( ave ) of all constructs exceeded the minimum criterion of 0.454 , indicating that a large portion of the variance was explained by the constructs .
the aves were greater than the squared correlations between any pair of constructs , suggesting discriminant validity .
the ratio of  to degrees of freedom was 2.433 ( p < 0.001 ) . given the known sensitivity of the  statistics test to sample size , several widely used goodness - of - fit indices demonstrated that the confirmatory factor model fit the data well ( nfi = 0.873 , cfi = 0.986 , ifi = 0.921 , rmsea = 0.083 ) . as a second step , the mow recipients ' perception model
1 ) . the estimation produced the following statistics :  ( 119 ) = 167.508 ( p < 0.005 ) , /df = 1.408 , nfi = 0.927 , cfi = 0.977 , ifi = 0.978 , rmsea = 0.044 .
the model 's fit as indicated by these indexes was satisfactory and path coefficients were analyzed .
two paths between ( 1 ) volunteer issues and behavioral intention and ( 2 ) responsiveness and behavioral intention were not significant .
the path for predicting a positive relationship between food quality and satisfaction was supported ( 11 = 0.733 , t = 2.68 , p < 0.01 ) .
the results show that having high food quality may create recipient satisfaction . also , food quality significantly influenced positive behavioral intention ( 21 = 0.762 , t = 12.38 , p < 0.001 ) .
while volunteer issues such as appearance , kindness , and attitude had less influence on satisfaction ( 12 = 0.238 , t = 5.68 , p < 0.001 ) than food quality and responsiveness ( 31 = 0.331 , t = 6.38 , p < 0.001 ) .
moreover , satisfied recipients have positive behavioral intention for mow programs ( 12 = 0.907 , t = 18.38 , p < 0.001 ) .
one reason for there being no significant association between volunteer issues / responsiveness and behavioral intentions could be related to recipients ' experiences .
the average length of time respondents had been receiving meals was from 2.84 years and they were already satisfied and not concerned about retention of the service or word - of - mouth aspects .
the structural equation model was re - estimated by constraining the direct effect of satisfaction on behavioral intentions ( 12 = 0 ) .
baron and kenny 's ( 1986 ) first three conditions were met in the original structural model ( 11 , 12 , and 12 were significant ) .
the fourth condition was also satisfied ; the parameter estimate between satisfaction and behavioral intentions program ( 12 = 0.907 , t = 18.38 ) in the mediating model became less significant ( partial mediation ) than the parameter estimate (  to bi = 0.31 , t = 2.093 ) in the constrained model .
the difference in  value between the constrained model (  ( 120 ) = 171.6 ) and the mediating model (  ( 119 ) = 167.508 ) was statistically significant (  d(1 ) = 4.092 , p < 0.05 ) , indicating that the mediating model was a significant improvement over the constrained model .
thus , the mediating effects of satisfaction clearly demonstrate that excellent food attributes produce favorable future behavior outcomes through satisfaction .
this study aimed to evaluate recipients ' satisfaction with meals and services from the mow program in the usa .
this allowed for better understanding of recipient 's satisfaction and behavioral intentions in the mow program .
second , this study examined the way in which satisfaction mediates between perceived food quality and consumer behavioral intentions .
the mediating effects demonstrate how consumer perceptions of food quality can affect behavioral intentions via the creation of satisfaction .
the results also empirically support that satisfaction has a stronger positive indirect effect than the direct effect from other attributes on behavioral intentions .
third , the results show that not all the proposed relationships were supported along with the effects of volunteer and responsiveness stimuli in association with satisfaction and behavioral intentions
. this empirical evidence could establish the important links among food quality , volunteer issues and responsiveness , satisfaction , and behavioral intentions however , this study has limitations in terms of survey procedures , reliability , and generalization issues .
. therefore , the reliability of the response can not be 100% certain because mow recipients may fear exclusion from the service if they respond with dissatisfaction .
when the questionnaire was developed , the director of mow restricted some items such as ethnicity and illness records of recipients .
moreover , this study did not deal in depth with nutritional issues . according to previous research ,
therefore , for future studies , greater development of the items and concern about nutritional issues is needed .
if this study had been conducted in different segments of the mow program , the results may have shown different relationships among the studied constructs .
 this study was conducted to evaluate recipients ' perception of service quality , satisfaction , and behavioral intention in home delivered meals program in the us . out of 398 questionnaires , 265 ( 66.6% ) 
 were collected , and 209 questionnaires ( 52.5% ) were used for the statistical analysis . a confirmatory factor analysis ( cfa ) with a maximum likelihood was first conducted to estimate the measurement model by verifying the underlying structure of constructs . 
 the level of internal consistency in each construct was acceptable , with cronbach 's alpha estimates ranging from 0.7 to 0.94 . 
 all of the composite reliabilities of the constructs were over the cutoff value of 0.50 , ensuring adequate internal consistency of multiple items for each construct . 
 as a second step , a meals - on - wheels ( mow ) recipient perception model was estimated . 
 the model 's fit as indicated by these indexes was satisfactory and path coefficients were analyzed . 
 two paths between ( 1 ) volunteer issues and behavioral intention and ( 2 ) responsiveness and behavioral intention were not significant . the path for predicting a positive relationship between food quality and satisfaction was supported . 
 the results show that having high food quality may create recipient satisfaction . 
 the findings suggest that food quality and responsiveness are significant predictors of positive satisfaction . 
 moreover , satisfied recipients have positive behavioral intention toward mow programs . 
Introduction
Subjects and Methods
Questionnaire
Pilot test
Statistical analysis
Results
Discussion