This study is a closed cohort stepped wedge design in which the timing of the intervention is randomized by cluster, with the sequential crossover of clusters from control to intervention until all clusters have received the intervention. With this design, each cluster contributes data when they are participating in the intervention and when they are not. Stepped wedge designs are useful for several reasons. First, they allow all participants to receive the intervention, and each intervention arm can serve as its control, which decreases the number of units needed. Second, the design is practical in a situation with limited resources where the intervention logistically cannot be carried out all at once. Third, the design allows researchers to examine any effects of time on the intervention’s effectiveness [36,37]. Baseline data on current dietary intake, food security, malnutrition, technology use and attitudes, physical activity, social isolation, loneliness, and demographics were collected from all participants at Time 0. Each of the 12 centers was randomly assigned to one of 2 cohorts. Participants in Cohort 1 received the intervention first. Once Cohort 1 participants finished the intervention, a crossover occurred as Cohort 2 participants began the intervention. At the 12-month time point, the second cohort completed the intervention. Data will be collected for both groups each time point from T0 to T3 (Figure 1).

The City of San Antonio Senior Services Division, which oversees the CMP in Bexar County, along with Older Adults Technology Services (OATS) and the University of Texas at San Antonio (UTSA), researchers with expertise in nutrition and physical activity devised the Digital Nutrition Education Intervention. The intervention included a 5-week technology intervention, designed to address defining features of the digital divide such as access, knowledge, and usage. The 15-week online nutrition course aimed to improve food security and increase overall diet quality, while providing accurate information about nutrition and physical activity through virtual sessions.

A pilot study (5 weeks) was conducted in June and July 2022 with 4 older adults who attended a local community center located in San Antonio and completed a technology class with OATS in May 2022. The community center does not have a congregate meal program. All baseline and posttesting measures and created the surveys for feedback were tested in the pilot study. Pilot data were used to inform the full 15-week intervention. All participants were satisfied with the nutrition topics, recipes, and resources provided, as well as the Friday lunch Zoom socials. A total of 75% were satisfied with the goal sheets and weekly surveys in Google Forms. All participants were satisfied with Google Classroom, but some preferred accessing the class materials by email. During the pilot study, only a single session was offered to participants. Based on their feedback, participants recommended that multiple sessions be provided to enhance scheduling, flexibility, and accommodate different availability. Process evaluation materials were finalized for the technology and nutrition intervention to document fidelity, knowledge gained, and participant satisfaction.

The creation of both the technology and nutrition intervention was informed by an advisory board consisting of UTSA researchers, key Department of Human Services (DHS) and OATS staff, and focus groups consisting of older adult CMP participants. Researchers conducted 14 focus groups with 109 CMP participants in Spring 2022 to determine the choice of technology device and nutrition topics to be incorporated into the nutrition intervention plan. Participants preferred iPads (Apple Inc) over LG tablets due to their big screen, brightness, and user-friendliness. The focus group informed the nutrition topics covered: food security and support resources, fruits and vegetables, whole grains, protein, lean meats, low-fat dairy, healthy snacks, hydration, sodium, healthy eating on a budget, reading food labels, dietary supplements, and food safety. Chronic disease-specific topics were not covered and were linked to the prevention and management of nutrition-related chronic conditions. Special emphasis on food security and the Supplemental Food Assistance Program, and other assistance programs that may help alleviate the cost of food. Three out of 5 older adults are eligible for assistance programs and do not apply for benefits [39]. Additional assistance was provided if food access was an issue. Many grocery stores and food delivery services require digital apps or online ordering, which was covered during the intervention.

OATS is a nonprofit organization established in 2004 with a mission to help older adults live better in the digital age. OATS focuses on key areas of financial security, health and wellness, civic engagement and advocacy, social engagement, creative expression, and lifelong learning. Based in New York, OATS expanded to 6 states, including Texas in 2018, with over 26 locations. OATS has served over 30,000 older adults and has engaged San Antonio’s Mayor in the Aging Connected pledge to have 1 million seniors engage online. After participation in technology services, OATS reported 76% of participants felt more connected, 39% reported better health, 44% lost weight, 86% felt less lonely, and 94% felt more connected to the world around them. OATS has over 70 online courses and 45 online videos to support its programming.

The technology intervention addresses three key elements of the digital divide: (1) access to the internet and digital devices; (2) digital literacy or skills; and (3) internet usage and value. Access and use of the internet were reported by 67% of adults 65 years or older in the United States [19]. Although internet usage in older adults has increased significantly over the past 5 years [40], digital inequalities and disparities exist for at-risk populations. Digital inequalities can further describe the digital divide in terms of usage, skills, social support, and self-perception. Older adults who use the internet could have limitations in skill, social support, and attitudes that can further describe passive participation in our digital society [41]. Disparities in racial or ethnic minorities further expand the digital divide and are compounded by low socioeconomic status [42,43].

Using OATS’ expertise in providing technology education and services, enrolled participants received a technology bundle. The technology bundle included a tablet computer device selected by the focus groups and covers 1 year of internet connectivity and technical support provided by OATS. The participants attended a 5-week iPad course that provides information on iPad essentials, introduction to digital culture, and physical activity resources in small groups of less than 15 in person at the CMP sites. In addition, peer navigators (participants who identified as being comfortable in technology skills) were recruited from CMP sites to assist those struggling with technology and having trouble completing weekly tasks in Google Classroom.

The nutrition intervention aims to restore and enhance nutrition programming for congregate meal participants online after bridging digital connectivity, access to devices, and the applied use of technology. Key intervention strategies to address technology and nutrition will be used to improve diet quality, food security, physical activity, technology use, and socialization (Figure 2). Long-term maintenance of the online curriculum will be managed by DHS Senior Services program, and the sustainability of the project will be measured after 6 months.

Suggestions from the literature recommend soliciting older adult participation in the technical intervention design and considering barriers to technological intervention [31]. Our nutrition intervention was developed in coordination with input from a subset of older adult CMP participants and the registered dietitian from DHS Senior Services. In addition, we designed the intervention based on successful dietary behavioral change interventions and successful digital interventions with older adults by the following: defined and clear topics relevant to older adult health and the population, using proven behavioral theories, using incentives, and sufficient contact. The intervention was informed by the Social Cognitive Theory that addresses intrapersonal and interpersonal influences on behavior change. Weekly goal setting and goal evaluation were incorporated to increase participants’ self-efficacy in eating healthy. Social support systems embedded in the intervention encouraged and rewarded behavior changes. All materials were created at a sixth-grade reading level or below and made available in English and Spanish. Only 1‐2 learning objectives for each topic were created. A digital reward-based program was created to provide incentives for participation and behavior change. Rewards were in the form of digital “badges” like what is used in online sites and applications for achievements [44,45]. The benefits of this system include a no-cost reward system that may motivate participation and signify progress in learning [45,46]. Weekly and monthly rewards were given for attendance and completing weekly tasks which were captured in a digital format. Graduates of the program were given a certificate at a graduation ceremony conducted at the centers in person.

Weekly modules in Google Classroom included nutrition, Microsoft PowerPoint presentations and supplementary resources, handouts, videos, and recipes to enhance learning and practical application. Physical activity resources such as prerecorded (<10 min) classes and resources, videos, and handouts were included to complement the nutrition intervention. The physical activity classes were designed to cater to the specific needs and abilities of older adults, including low-impact activities designed to be gentle on the joints and help improve cardiovascular health, strength, balance, and flexibility. The physical activity classes also provided information on the importance of nutrition and how it can enhance physical performance and recovery.

All sessions were conducted virtually using the Zoom videoconferencing platform. Email reminders for Zoom sessions and links were sent through Google Classroom and provided in Google Calendar. Each week, 3 sessions were conducted in English at different times of the day, and one session was conducted in Spanish, and participants were encouraged to attend live sessions conducted by a registered dietitian or a supervised dietetic student to provide sufficient contact and flexibility. Each session lasted between 40 minutes and an hour and included a Microsoft PowerPoint presentation based on the predetermined weekly topics (Table 1). Time was allocated at the end of each interactive session for questions and answers. One English session and 1 Spanish session were recorded and sent to all participants midway through the week for viewing if they missed attending the live session or if they would like to rewatch.

Participants were required to complete a weekly goal-setting survey, a goal check-in survey, and a week-specific survey. An optional satisfaction survey was sent each week to gather feedback. In addition, optional weekly Zoom social sessions hosted by dietetic and public health students were offered twice a week to facilitate social interaction in the digital space. This was mutually beneficial for the students and the older adults in providing cross-generational interactions to facilitate a greater understanding and empathy for other generations [47]. Older adults may also have added health benefits from this type of interaction [48]. Dietetic students benefited from the practical training experience, while older adults benefited from the socialization.

Table 2 lists all the measurements incorporated in the study.

The process evaluation design is informed by the National Institutes of Health Behavior Change Consortium Treatment Fidelity Workgroup’s best practice recommendations [68]. Multiple indicators will be used to evaluate the fidelity and completeness of the implementation of all intervention components and determine the contribution of each component to the primary and secondary outcomes. All process evaluation measures present a minimum participant burden. Three major aspects of process evaluation will be measured. First, the intervention dose delivered (ie, the extent to which the technology and nutrition intervention is delivered as planned to older adult participants) will be measured by: (1) technology use records that will measure the times the participant interacted with the intervention materials; (2) completion of delivery schedule from OATS staff to indicate technology equipment and support has been delivered to the participants; (3) evaluation of staff training; and (4) monthly auditing of intervention lesson delivery. Second, the intervention dose received (ie, the extent to which the older adult participants understand and learn the technology and nutrition knowledge and skills delivered in the intervention) will be assessed by: (1) attendance records collected when older adults log in to the intervention site; (2) pre and post knowledge test after each intervention activity; and (3) poststudy focus groups on program delivery process and feedback with intervention staff (n=10). Third, participants’ responses to the intervention (ie, the extent to which the older adult participants use and apply the knowledge and skills learned in the intervention in daily life) will be evaluated by: (1) monthly surveys to gather feedback from older adults on their use and satisfaction with the intervention materials; and (2) poststudy focus groups with a subgroup of participants to assess their satisfaction with intervention components/activities and ideas for improving the intervention in the future.

Our sample size calculation was conducted based on examining the effect sizes of similar studies in the current literature [68]. Effect sizes for fruit and vegetable intake ranged from 0.41 to 0.8 [9,28]. Using the smaller effect sizes and considering the stepped wedge design as a clustered randomized trial, with an Interrelation Class Coefficient of 0.016 [37] estimated from the literature (thereby reducing our effective sample size), a total of 210 participants (105 per group) is required to reach 80% power. With an expected N=410 participants in the analytic sample (effective N=374), we will be able to detect an effect size of 0.30 with 80% power and 97.7% power to detect an effect of 0.41 [69]. To detect a difference with an effect size of 0.3 or greater with 80% power at an alpha level of 0.05, 352 participants are required in the analytic sample. Power was calculated using the stepped wedge command in STATA/SE (12.1; StataCorp LLC). The details are described in Hemming and Girling [36].

This study is approved by the University of Texas at San Antonio Institutional Review Board (IRB protocol FY20-21-241). The baseline phase of the study involved obtaining institutional review board approval through a comprehensive review, followed by participant recruitment and baseline data collection. During this phase, participants also reviewed and signed consent forms in writing.

Data are collected using Research Electronic Data Capture (REDCap; Vanderbilt University) surveys and are managed and stored in REDCap and in a UTSA-secured site where only the study team has access to participant files. REDCap is a secure, web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for data integration and interoperability with external sources [70,71]. All data and records generated during this study comply with confidentiality procedures and protocols in accordance with UTSA and Health Insurance Portability and Accountability Act (HIPAA) policies. We will not share any identifiable data with outside study partners unless specified in the consent form. Data collection is the responsibility of the research study staff at the site under the supervision of the site investigator.

Participants receive a compensation of US $20 local grocery store gift card for each data collection event and the opportunity to win a US $5 local grocery store gift card during the bingo games.

Inadequate nutrition and a lack of physical activity can lead to complications from chronic diseases in older adults and a decline in health [72,73]. The COVID-19 pandemic disrupted essential nutrition services like CMP sites in San Antonio, Texas [18]. The “digital divide” exacerbated the negative impact of the COVID-19 pandemic on older adults [18]. To address this, improving technology access and knowledge, and providing evidence-based online nutrition programs are essential and have the potential to benefit the vulnerable homebound population, thereby becoming an integral part of OAA-funded services.   

The program’s strengths lie in the potential for its integration into the existing CMP infrastructure, bolstering support and resources for participants most in need. The proposed intervention follows a community-based participatory research approach, seeking essential input and feedback from the DHS Senior Services, OATS, and older adult CMP participants to enhance the intervention’s chances of success [74]. Seeking the assistance of the voluntary peer navigators at the centers provided additional in-person support to participants experiencing challenges in completing the intervention. The technology intervention addresses key barriers to older adults adopting technology by providing internet services and devices, offering support through a 5-week training program conducted by OATS, and providing continued technical support and internet access for one year [14,41]. In addition, OATS also provided practice Zoom sessions and in-person help to improve participant self-efficacy in navigating through the Zoom sessions and the nutrition modules in Google Classroom. The DHS team acted as a medium of communication between the study team and the participants.

A second strength of the study is the closed-cohort stepped-wedge design. In this approach, cohorts are randomly assigned the timing of the intervention, with a sequential transition from control to intervention for each cohort until all participants have received the intervention. This design ensures that all participants benefit from the intervention and allows each group to serve as its own control. It is practical when resources are limited and allows for the analysis of the influence of time on the intervention’s effectiveness.

Given the increased reliance on technology post-COVID-19, offering a digital nutrition intervention has the potential to positively impact food security and diet quality among vulnerable populations [75]. Moreover, this project has the potential to enhance physical activity, improve socialization, and mitigate loneliness in an at-risk, predominantly Hispanic population in South Texas.

Although the proposed intervention offers technology training, support, and access to the internet and devices, some limitations exist. A few participants may continue to experience challenges in understanding and using technology to engage in the online nutrition sessions conducted via Zoom. Moreover, the technical support and internet access provided by OATS ceased after the one-year service period, thereby restricting participants from using their devices except at the CMP site or locations offering complimentary Wi-Fi connectivity. Furthermore, the accuracy of survey completion may be affected by recall bias and introspective ability. To enhance the long-term sustainability of the project, mitigate associated costs, and strengthen the scope of incorporation into OAA services, it is important to investigate alternative options that offer low-cost internet access and affordable devices.

This intervention study, conducted in collaboration with community partners and older adults, is focused on delivering a culturally tailored digital nutrition curriculum to at-risk older adults who frequently attend congregate meal sites. This initiative followed the allocation of technological resources and requisite support. The study’s developed materials are designed for implementation across all senior center locations in San Antonio. If successful, the project has the potential to reach over 2000 older adult congregate meal participants throughout San Antonio. Furthermore, it could serve as a replicable model for other OAA-funded nutrition services. The study’s outcomes will be disseminated through publication in high-impact journals and presentations at regional and national nutrition conferences dedicated to nutrition and aging.