THE INFLUENCE OF FRAILTY IN THE ELDERLY ON THEIR MOTIVATION,
OPPORTUNITY AND ABILITY TO UTILIZE FOOD SUPPLEMENTS
THE INFLUENCE OF FRAILTY IN THE ELDERLY ON THEIR MOTIVATION,
OPPORTUNITY AND ABILITY TO UTILIZE FOOD SUPPLEMENTS
MSc Marketing Management Thesis
Commissioned by Avebe
University of Groningen
Faculty of Economics and Business
Department of Marketing
June 2018, Groningen
Thea Buseman
s3236730
Berkelstraat 6b
9725 GX Groningen
+31615150565
t.k.buseman@student.rug.nl
Abstract
Every year health expenditures in the Netherlands are growing with 2.9 percent (RIVM
2017). It is important to find a way to limit these expenditures. A preventive way to stay
healthy, when becoming older, is the utilization of food supplements. Based upon the
MOA-framework, it was investigated to what extend the motivation, opportunity and ability of
elderly had an influence on the utilization of food supplements. This framework provides the
opportunity to investigate the personal and environmental related determinants that drive the
behavior of consumers when it comes to making food choices (Bos et al. 2015; Poiesz and
Robben 1996). To what extend this behavior depends on the level of frailty of consumers was
taken into account. Semi-structured in-depth interviews were conducted in order to find the
underlying motivations and everyday challenges of elderly. The results indicated that
opportunity and ability had a positive effect on the utilization of food supplements. However,
no differences were found between frail and non-frail participants when it comes to the
motivation, opportunity and ability of elderly towards utilization of food supplements. It was
also investigated to what extend differences occur between the health promotion focus and the
health prevention focus. This was researched because motivation can be divided into two
regulatory orientations, the health promotion focus and the health prevention focus (Gomez,
Borges, and Pechmann 2013; Higgins 2002). These regulatory orientations explain whether
consumers are involved with positive or negative outcomes when they pursue a personal goal
(Higgins 2002). No differences were found between the regulatory orientations when it comes
to utilization of food supplements.
Preface
In front of you lies my MSc Marketing thesis, which is part of my final phase of the Master
Marketing at the University of Groningen. Commissioned by Avebe, a potato starch company
in the north of the Netherlands, this subject about the intake of food supplements by elderly
was originated. I would like to thank Avebe and in special dr. Martine Assié, Market Manager
Food at Avebe for the guidance and input for my final project at the university. I really
enjoyed doing research for this company, because the topic was very interesting and it is an
important contribution that will be used by the company. I would also like to thank my
supervisor dr. Jenny van Doorn for the clear and fast feedback, but also for the extra time this
topic confiscated. Next, I would like to thank my participants who invited me into their homes
and shared personal information with me. Lastly, I would like to thank my friends and family
for supporting me and helping me finding my participants.
Carrying out qualitative research and conducting in-depth interviews was new for me, but
with the help of the abovementioned persons the end result is something I am very proud of. I
hope you will enjoy reading this research as much as I did.
Table of contents
1. Introduction
5
2. Literature review
8
2.1 Food supplement usage
8
2.2 Protein supplements
11
3. Conceptual model
12
4. Hypotheses
15
4.1 Motivation
15
4.2 Opportunity
18
4.3 Ability
20
5. Methodology
21
5.1 In-depth interviews
21
5.2 Population and sampling method
22
5.3 Sample size
22
5.4 Structure interviews
22
5.5 Data analysis and interpretation
25
6. Results
26
6.1 Utilization food supplements
26
6.2 Motivation
27
6.3 Opportunity
30
6.4 Ability
32
7. Conclusions and discussion
35
8. Managerial implications
37
9. Limitations
39
10. Directions for further research
40
11. Literature
40
12. Appendices
45
1. Introduction
The health care expenditures increase on average 2.9 percent a year in the Netherlands
(RIVM 2017). This means that the total of expenditures related to health care will be doubled
by 2040. With growing expenditures it is important to find ways that limit the increase in
expenditures. One way of doing this is looking for health preventive actions, such as the
usage of food supplements in order to protect the health of consumers and avoid
deteriorations. The increase in health care expenditures is due to the increase in population
and the fact that people become older (RIVM 2017). Until 2040 the elderly population will be
doubled in the Netherlands (CBS 2015). With elderly becoming a bigger part of society,
problems regarding this group will grow. One of these problems is that during a lifetime 40
percent of the muscles disappear, beginning when someone is only 20 years old and ending at
the end of life (Walrand et al. 2011). Especially when people have reached the age of 55 their
muscles will start to decline and this is one of the most important factors that influences
disabilities when getting older (Walrand et al. 2011). The intake of proteins by elderly is
important to postpone and treat this muscle loss (Tieland et al. 2012). However, the dietary
intake fails to support the nutritional shortcomings of elderly (Hartz et al. 1988). Moreover, it
was found that a significant part of the elderly in the United States depends on food
supplements in order to meet the nutritional requirements (Hartz et al. 1988).
did not experience any barriers to get food supplements. Elderly, on the contrary, experienced
barriers in order to get food supplements (Houston et al. 1998). Also, these consumers who
already live healthy are the ones using the products and this indicates that consumers who
might even benefit more from food supplements are not the ones using them.
As mentioned before, proteins are part of the nutritional requirements and they are
important in order to postpone or prevent the reduction of the muscles by elderly (Tieland et
al. 2012). The majority of the proteins consumed are animal proteins, but the negative side of
this is that elderly might have restricted abilities to eat this, such as difficulties with chewing
meat (Dawson, Taylor and Favaloro 2008). Because proteins are important for the older
population it is important to know how proteins can be best offered. However, at this point in
time research lacks specific information about food supplement usage by elderly above 65
years old. Moreover, it is important to investigate independently living elderly in order to
detect dietary shortcomings (Tieland et al. 2012). Little research focused on this population
group, as most research focused on institutionalized or hospitalized elderly.
The underlying motivations that influence the behavior of elderly regarding food
supplements are not yet fully investigated, even though this is important to understand what
drives consumers behavior. There is also a lack of research that focuses on events that
happens later in life (Yap and Kapitan 2017), since much research does not focus on the
oldest elderly. There is still a lot to learn about the growing elderly population and therefore
the question arises why elderly do or do not utilize food supplements. In order to investigate
this the MOA-framework (motivation, opportunity, ability) is used. The MOA-framework
makes a distinction between person related and environmental related determinants that drive
the behavior of food choices (Bos et al. 2015; Poiesz and Robben 1996). This framework was
also found to be a useful mechanism to describe differences between markets by segmentation
(Binney, Hall and Shaw 2003).
Motivation is the way a consumer pursues goals (Sabnis et al. 2013). Opportunity is
the way consumers process information without any restrictions coming from the external
environment (MacInnis et al. 1991). Ability refers to the internal skills and capacity of
consumers to behave, as they desire (Sabnis et al. 2013).
The intake of the nutritional requirements is often not sufficient for the oldest elderly
(Dawson, Taylor and Favaloro 2008; Chin et al. 2002). However, the nutritional intake is
important in order to prevent muscle loss (Tieland et al. 2012). Especially because frail
elderly have a higher risk on falling, fractures, disability and death (Ensrud et al. 2009). The
level of frailty is used as a moderator in this study, because the level of frailty and the
disabilities that comes with it might have an influence on the motivation, opportunity and
ability to utilize food supplements.
This research will investigate the underlying factors that have an influence on the
utilization of food supplements, with the level of frailty taken into consideration. The research
was conducted in the Netherlands among 18 consumers of 65 years and older. The study
intends to fill the gap that exists in literature identified earlier. Existing research lacks focus
on events that happens later in life (Yap and Kapitan 2017), much research focused only on
institutionalized or hospitalized elderly and much research focused on the demographic
factors and not on the underlying factors that drives consumers behavior. Following the
identified literature gaps, this study will contribute to the literature by finding an answer on
the following research questions:
• To what extend has the motivation, opportunities and abilities of elderly an influence
on the utilization of food supplements?
• To what extend has the level of frailty an effect on the relationships between the
motivation, opportunities and abilities of elderly and the utilization of food
supplements?
2. Literature review
Research of the usage of food supplements started many years ago. Because much
research focused on institutionalized or only frail people only studies that researched elderly
who were living on their own were included.
2.1 Food supplement usage
As a human you need to meet some nutritional values in order to stay healthy. It was
found that a significant part of the older population depends upon the intake of nutritional
supplements in order to meet the required nutritional needs (Hartz et al. 1988). The table
below shows an overview of what we already know about the usage of food supplements.
Overview over food supplement usage
Study
Findings
Usage rates
Brownie (2005)
Usage rates of consumers above 60 years old who
took food supplements differs from 16% to 60%
Gray et al. (1996)
71.5% of the participants who used supplements
(26.2%), used supplements that were a
single-ingredient product
Gray et al. (1996)
90.9% of the used supplements were
over-the-counter products
Demographics
Brownie (2005), Brownie and Myers
(2003), Gray et al. (1996), Hartz et al.
(1988), Houston et al. (1998), Lyle et
al. (1998),
Usage of food supplements was higher by women
compared to men, who are independently living
Hartz et al. (1988)
Males were found to use supplements for a longer
period of time
Brownie (2005), Freeman et al. (1998),
Gray et al. (1996), Houston et al.
(1998)
White or Caucasian ethnicities were users that
were more present in these studies
Brownie (2005), Brownie and Myers
(2003), Gray et al. (1996), Hartz et al.
(1988), Lyle et al. (1998),
supplements
Houston et al. (1998)
Education is not an indicator of supplement usage
Brownie (2005), Freeman et al. (1998),
Gray et al. (1996), Lyle et al. (1998)
Underweight seemed to be an indicator of
supplement usage; consumers with underweight or
a low BMI were more likely to take food
supplements
Schneider and Nordlund (1983)
Supplement usage increased with age
Freeman et al. (1998), Hartz et al.
(1988), Houston et al. (1998)
Supplement usage is not related to age (two out of
the three studies did not have representative
samples for an entire population)
Freeman et al. (1998)
Users of supplements were more likely to have
higher incomes
Brownie (2005), Brownie and Myers
(2003), Gray et al. (1996), Houston et
al. (1998), Lyle et al. (1998)
There was not a relationship between the income
of elderly and supplement usage
Attitude
Freeman et al. (1998)
Consumers who took food supplements regularly
had a positive attitude towards the products, are
not depending on a physician, have more social
influences coming from outside and did not
perceive barriers in using the supplements
Freeman et al. (1998)
Consumers who took food supplements had
significantly more knowledge about the
ingredients of the supplements
Houston et al. (1998)
Frequently users of food supplements were the
oldest old and those consumers did perceive
barriers in order to get the products
Brownie and Myers (2003)
Reasons for supplements usage by elderly were to
protect body and health in general or from a
specific ailment or condition and to cure
something or make up for a bad diet
Brownie (2005)
Perceived health was not an indicator of
Lifestyle
Brownie (2005), Brownie and Myers
(2003), Lyle et al. (1998)
Smoking appeared to be an indicator of
supplement usage; consumers who smoked were
less likely to be users of food supplements
Brownie (2005), Freeman et al. (1998),
Lyle et al. (1998)
Consumers who pursued a healthy or active
lifestyle were more likely to utilize food
supplements
Brownie and Myers (2003), Gray et al.
(1996)
Number of health therapists visits in one year had
a positive influence on the usage of supplements
Gray et al. (1996)
Prescription drugs and supplemental health
insurance were significant predictors of
supplement usage
Side effects
Brownie (2005)
Negative effects might occur after prolonged
consumption of taking excessive amounts or when
someone takes a large dose of ingestions of
supplements in one time
Houston et al. (1998)
The safety of supplements differed between
ingredients and age and health status of a person
might also influenced the safety level
Table 1: Overview over food supplement usage
experience barriers to get the supplements are the ones using food supplements. This indicates
that the ones who will benefit the most from food supplements are not using them.
Recent research found that food supplements were mainly being used because it is
believed that it will debilitate or correct ailments instead of correcting for nutritional
shortcomings (Brownie and Myers 2003). The motivation of consumers to use food
supplements can be split up into the promotion focus and prevention focus (Higgins 1997).
The health promotion focus stated that food supplements are being used in order to improve
health instead of protecting health (Gomez, Borges, and Pechmann 2013).
Houston et al. (1998) stated that the living situation was not related to supplement
usage. But on the contrary, many researchers made distinctions between independently living,
institutionalized or hospitalized elderly. Also, much research lacked the emphasis on specific
events, such as death, illness or injuries, later in life (Yap and Kapitan 2017).
2.2 Protein supplements
As stated before the usage of food supplements depends more upon demographic
factors instead of need factors (Gray et al. 1996). However, more recent research found that
the need of proteins for the elderly is greater than generally thought by researchers (Dawson,
Taylor, and Favaloro 2008). Proteins are an important factor in order to postpone or treat
muscle loss by elderly (Tieland et al. 2012). But, ten percent of the independently living
elderly took an intake of proteins that was below the estimated average requirement (Tieland
et al. 2012). This requirement is 0.7-gram protein per kilogram of body weight per day.
Especially during breakfast the intake of proteins was low by independently living elderly
(Tieland et al. 2012). Walrand et al. (2011) stated that in order to counter for muscle loss the
intake of proteins should be focused on the improvement of quality and the distribution of
proteins during the day. Only increasing the amount of proteins without looking at the right
distribution might have negative effects on elderly who deal with kidney problems (Walrand
et al. 2011). The right distribution throughout the day might be an important influencer for
daily net protein balance (Tieland et al. 2012).
status of elderly. Dawson, Taylor and Favaloro (2008) suggested that the use of whey-based
protein supplementation was the best solution, since this type of protein is digested the fasted
compared to soy-based protein. The supplement usage seemed to reduce mortality and
complications of elderly in the hospital, but this was only the case for undernourished people
(Milne et al. 2009). The same research did not find evidence that the protein and energy
supplements helped well-nourished elderly.
Since research lacks specific information about protein supplement usage by elderly
above 65 years old, the literature review and the rest of this research is focussed on food
supplements in general.
3. Conceptual model
The framework of Moorman and Matulich (1993) about preventive health behavior of
consumers was used as the basis of the conceptual model in this study. This framework was
chosen because it includes the link to behavior that improves the health, such as the utilization
of food supplements. The preventive health behavior indicates that a person is willing to work
on improving, or at least not deteriorating, health. Moorman and Matulich (1993) investigated
two types of preventive health behaviors, namely the health information acquisition behavior
and the health maintenance behavior. The health information acquisition behavior involves
acquiring information about health. The health maintenance behavior stands for behavior that
enhances someone’s health by, for example, improving his or her diet (Moorman and
Matulich 1993). Since this current study will focus on the actual utilization of healthcare
products in order to improve someone’s health, only the health maintenance behavior will be
used as a dependent variable translated into the utilization of food supplements, as can be seen
in figure 1. Moreover, another reason to use this dependent variable was that only a
relationship between the independent variables, health motivation and health ability, on this
dependent variable, health maintenance behavior, was found (Moorman and Matulich 1993).
performed (Binney, Hall and Shaw 2003). The addition of the variable opportunity also
provides a better distinction to what extend influences are person related or situation related
(Poiesz and Robben 1996). These person and environmental related determinants drive the
behavior of food choices (Bos et al. 2015). Because this study investigates only consumers
above 65 years old, and does not make the comparison with undergraduate students as
Moorman and Matulich (1993) did, opportunity might be an important variable. Especially
since the oldest independently living elderly are included in this study it is essential to see
whether they still have to opportunities to act, as they desire. Accordingly, it was decided to
expand the health behavior framework of Moorman and Matulich (1993) with the variable
opportunity coming from the MOA framework. Through the use of the MOA framework it
was possible to identify all factors that affect the health maintenance behavior of Moorman
and Matulich (1993) and thus the utilization of food supplements.
Motivation is the way a consumer pursues their personal goals (Sabnis et al. 2013).
Motivation related to health is consumers’ goal-directed ambition to engage in health
prevention behavior (Moorman and Matulich 1993). However, recent research found that
health promotion behavior, instead of health prevention behavior, is related to the utilization
of food supplements (Gomez, Borges and Pechmann 2013). Therefore, it is assumed that
motivation related to health is consumers’ goal-directed ambition to engage in health
promotion behavior. Motivation can be divided into two regulatory orientations (Higgins
1997). These regulatory orientations are the health promotion focus and the health prevention
focus (Higgins 1997).
To make sure that consumers will meet their set goals, they should have sufficient
opportunities to do so (Sabnis et al. 2013). These opportunities include to which extend
consumers have the priorities and resources that allows consumers to pursue goals (Clark,
Abela, and Ambler 2005). This comes down to act without any restrictions coming from the
external environment (MacInnis et al. 1991). There is a lack of opportunity when someone is
unable to act, as they desire, because there are no environmental mechanisms at hand
(Rothschild 2000).
The intake of dietary nutrition is often not sufficient in frail elderly people (Dawson,
Taylor and Favaloro 2008; Chin et al. 2002). It was also found that frail elderly had more risk
on falling, fractures, disability and death (Ensrud et al. 2009). These events, where frail
elderly have to deal with, might have an influence on their motivation, opportunity and ability
to utilize food supplements. Age might be an important indicator of frailty. This is because it
was found that the level of frailty increased with age (Fried et al. 2001). This might be caused
due to the deterioration in lean body mass and an increase in body fat when people get older
even though they keep exercising (Phillips 2003). However, it is chosen to use the level of
frailty as a moderator and not age, because the oldest old might be physically healthy, while a
much younger persons might experience physical restrictions that influence their actual
behavior. Concluding, the level of frailty is used as a moderator in this study in order to find
out to what extend the level of frailty has an effect on the relationship of the MOA framework
on health maintenance behavior and thus utilization of food supplements.
Physical frailty is a state of diminished physiological reserves due to an increased
sensitivity to disability (Fried et al. 2001). Some indicate frail elderly as elderly above 70
years old, need healthcare, are physical inactive and have a low body mass index (Tieland et
al. 2012). However, a more widely used scale to determine frailty was defined by Fried et al.
(2001). Fried and colleagues (2001) identified that a person is frail when they can tick of three
or more of five criteria related to this topic. The criteria are (1) weight loss of 4.5 kg in the
last year, (2) experiencing exhaustion, (3) powerless grip strength, (4) walking slow and (5) a
low level of physical activity (Fried et al. 2001).
Pechmann 2013; Higgins 2002). Also the opportunity to utilize food supplements might be
moderated by the level of frailty. This is because frail elderly might not be able to visit the
store even though they know about the availability and affordability of food supplements. In
this way frail elderly do not get the opportunity to buy and thus utilize food supplements.
Moreover, frail elderly might have other health care expenses in order to compensate for their
frailty. The ability of utilizing food supplements depends on whether or not consumers have
the right internal skills and capacity (Moorman and Matulich 1993). Because the criteria to
identify the level of frailty by a consumer is mainly based upon physical factors this will
influence the ability to use food supplements. Therefore, the level of frailty might have an
effect on the relationship of ability on the utilization of food supplements.
Figure 1: Conceptual model
4. Hypotheses
4.1 Motivation
focus and the prevention focus (Higgins 1997). Thus, motivation can be promotion focused or
prevention focused. The promotion focus entails to which extend self-adjustment is concerned
with positive outcomes (Higgins 2002). Gomez, Borges and Pechmann (2013) connected the
regulatory focus theory with health aspects. People who concentrate on the health promotion
focus are involved with improving their health or they want to achieve health-related gains
(Gomez, Borges and Pechmann 2013). It was found that consumers who adopted the health
promotion focus would make of use food supplements (Gomez, Borges and Pechmann 2013).
The prevention focus involves to which extend self-adjustment is concerned with the presence
of negative outcomes (Higgins 2002). Consumers embracing the health prevention focus are
more concerned with the protection of their health and want to avoid health-related losses
(Gomez, Borges and Pechmann 2013). This focus predicts that consumers would make use of
prescriptions and over-the-counter drugs, instead of food supplements (Gomez, Borges and
Pechmann 2013). Regulatory orientations, the prevention and promotion focus, can be
influenced by physiological needs, moods and the social role of someone (Avnet and Higgins
2006).
The value of a personal goal will increase when it is pursued using the right strategy
that is in line with the regulatory orientation (Higgins, 2000). This is also called the regulatory
fit. For example, a person who adopted the health promotion focus and uses food supplements
in order to improve his or her health, will reach a regulatory fit. When a person wants to
improve his or her health but consumes junk food, a regulatory fit will not be reached. A
stronger regulatory fit will result in (1) that people will tend more towards a goal with higher
regulatory fit compared to other goals with lower regulatory fit, (2) that the motivation of
people is higher towards that goal, (3) that the feelings towards a goal will be perceived as
more positive by a desired outcome, but it will also be experienced more negative by an
unwanted outcome, (4) that the evaluations of a goal afterwards will be more evaluated
positive and (5) that higher monetary value will be assigned to objects based upon choices
with higher regulatory fit (Higgins, 2000).
possibility that they would complete their goal. Also, the goals of older participants (above 60
years) were focused on the avoidance of losses and only a few goals were aimed at gains
(Heckhausen 1997). These findings indicated that the majority of the elderly were pursuing an
avoidance strategy. This strategy might not always be the best option to choose, because it
was proposed that the avoidance strategy had a negative effect on the physical health (Elliot
and Sheldon 1998).
Previous research predicted that consumers pursuing the health promotion focus
would buy food supplements in order to improve their health status (Gomez, Borges and
Pechmann 2013). On the contrary, older people tend to focus on the avoidance strategy and
this strategy tends to have a negative effect on the physical health (Elliot and Sheldon 1998;
Heckhausen 1997). This might be the case because this strategy focuses on protecting health
instead of improving someone’s health and thus the state of health does not improve and in
the worst case it even worsens unwillingly. This is in line with the health prevention focus,
which indicated that consumers would want to avoid health-related losses instead of
improving their health (Gomez, Borges and Pechmann 2013). However, Gomez, Borges and
Pechmann (2013) showed that consumers who want to improve their health, and thus follow
the health promotion focus, are the ones making use of food supplements. These consumers
are consciously engaged with improving their health instead of the prevention of
deterioration. Therefore, it is hypothesized that that the health prevention focus, compared to
the health promotion focus, has a weaker effect on the utilization of food supplements and
that the health promotion focus, compared to the health prevention focus, has a stronger effect
on the utilization of food supplements.
H1a: Health prevention focus, compared to the health promotion focus, has a weaker effect
on the utilization of food supplements
H1b: Health promotion focus, compared to the health prevention focus, has a stronger effect
on the utilization of food supplements
and Charles 2003). Therefore, it is assumed by the socio-emotional selectivity theory that
elderly are more pursuing emotional-related goals. One reason for this assumption might be
the negative relationship between age and eagerness of elderly to explore new innovations
(Cole et al. 2008). This present orientation indicates that elderly perceive goals that are
emotionally meaningful are more important than knowledge-related goals (Carstensen, Fung
and Charles 2003). Therefore, elderly who perceive their time as limited are not motivated to
learn about new product innovations, because they pursue their emotional-related goals
instead of learning new things to pursue their knowledge-related goals. Because frail elderly
experience physical difficulties it is expected that they perceive their time as more limited
compared to someone who does not experience these physical difficulties. Resulting in that
elderly who are not frail will be more motivated to learn and pursue knowledge-related goals.
Thus, it is hypothesized that motivation plays a bigger role for non-frail consumers, compared
to frail consumers, for the utilization of food supplements.
H1c: Motivation plays a bigger role for non-frail consumers, compared to frail consumers,
for the utilization of food supplements
4.2 Opportunity
Opportunity includes the priorities and resources of consumers that allow them to
pursue goals, without any restrictions coming from the external environment (Clark, Abela,
and Ambler 2005; MacInnis et al. 1991). Rozin et al. (2011) researched to what extend
changes in the availability of food had an effect on the food intake. When the availability of
food changes, it was found that this had an effect on the actual intake of food (Rozin et al.
2011). This means that when it was difficult for consumers to reach the products, the intake of
the products was lower. Moreover, it was found that when consumers perceive that products
are available, they are more likely to buy the products (Giskes et al. 2007). This is in line with
the study of McCormack et al. (2004), who found that when consumers perceive that
environmental factors are available this would have a positive influence on their physical
activity. Therefore, when consumers perceive that food supplements are physically available,
it is expected that their utilization of food supplements will also become higher.
people start eating healthy, the prices of unhealthy food should increase to make it less
attractive (Epstein et al. 2010; Giesen et al. 2011). However, consumers must be financially
capable in order to be able to afford food supplements. The discounted utility model assumed
that consumers make unambiguous trade-offs at different moments in their life between the
costs and benefits of their decisions (Rick and Loewenstein 2008). These unambiguous
trade-offs have something to do with time discounting. It was proposed that when people make
daily life trade-offs, such as spending decisions, these choices were implicit and consumers
did not consider what they could have purchased later with that money (Rick and
Loewenstein 2008). When consumers lived their life valuing the present more than the future
it might be that consumers did not save enough money for their old days. They did not have
the right priorities back then and this results in that they have less money to spend on health
products, such as food supplements, which results in fewer opportunities to buy products that
will increase their health and help pursuing goals.
When consumers perceive that food supplements are available and financial attractive,
it is expected that this will have a positive effect on the utilization of food supplements.
However, it is important that consumers are also financially capable to buy food supplements.
When consumers still have the financial resources and they perceive that food supplements
are available and financially a good choice, they will have the opportunity to utilize food
supplements. Therefore, it is hypothesized that the creation of more opportunities will lead to
more usage of food supplements.
H2a: Opportunity has a positive effect on the utilization of food supplements
might also have more expenses on other health care goods besides food supplements. This
leaves frail elderly with less financial opportunities to spend on other products, such as food
supplements, that may increase their health.
Because frail elderly have less opportunities when it comes to visiting the stores and
paying for food supplements, it is hypothesized that opportunity plays a bigger role for frail
consumers, when it comes to the utilization of food supplement, compared to non-frail
consumers.
H2b: Opportunity plays a bigger role for frail consumers, compared to non-frail consumers,
for the utilization of food supplements.
4.3 Ability
Ability refers to the consumers who have the right skills and capacity and are able to
implement health promotion behavior (Moorman and Matulich 1993). Physical factors, such
as having difficulties with walking or driving, could also be a reason why older consumers
would simplify their choice processes or they decrease the number of stores to visit (Cole et
al. 2008). The cognitive impairments associated with becoming older are having difficulties
with memorizing and processing information (Cole et al. 2008). The ability of consumers to
implement health prevention behavior might be influenced by the level of their perceived
self-efficacy. Perceived self-efficacy refers to which extend people belief they have the
capabilities to have control over how they function and how events affect their life (Bandura
1991). This theory is concerned with consumers’ perception of whether or not they have the
ability to perform a behavior (Ajzen 2002). So, when elderly perceive they are not capable of
doing something this will influence their actual behavior. For example, when an older person
thinks he or she is no longer able to prepare his or her own food due to walking or exhaustion,
this will result in having food delivered by family, the store, or other organisations. On the
contrary, when consumers are able to do their groceries and prepare their food the chances
will become bigger that they are able to use food supplements. And thus it is expected that
ability has a positive effect on the utilization of food supplements.
H3a: Ability has a positive effect on the utilization of food supplements
energy that frail elderly might not have. Also frail elderly might not be able to open packages
due to their insufficient grip strength. Because the five criteria to identify when a person is
frail or not - weight loss, experiencing exhaustion, powerless grip strength, walking slow and
low physical activity - (Fried et al. 2011) are mainly physical, this might have influence on
the internal skills and capacities of elderly. When a person can tick of three out of the five
criteria they are identified as frail (Fried et al. 2011). However, this indicates that when a
person can tick of three, four or all criteria, this person is also less able to perform behavior he
or she would like to do, such as the utilization of food supplements. Therefore, it is proposed
that frailer elderly are less able to utilize food supplements. Thus, it is hypothesized that
ability plays a bigger role for frailer consumers, compared to non-frail consumers, when it
comes to health maintenance behavior and thus the utilization of food supplements.
H3b: Ability plays a bigger role for frail consumers, compared to non-frail consumers, when
it comes to the utilization of food supplements.
5. Methodology
In order to test the hypothesis formulated before, in-depth interviews were held.
In-depth interviews were chosen because this method provides greater details of the views,
opinions, and ideas of participants that otherwise would not have been captured. In this
section the qualitative field study will be described.
5.1 In-depth interviews
Neale 2006). During the whole process, of conducting in-depth interviews, this was taken into
account in order to minimize the bias as much as possible.
5.2 Population and sampling method
The in-depth interviews were held with Dutch citizens aged 65 years and older. One
condition to participate was that these elderly lived independently, meaning that those elderly
do not live in a nursing home or in a community house. The participants were selected based
on their age and living situation. In order to maximize the diversity among the participants,
participants with different ages, gender, and living areas were interviewed.
On average the interviews took about forty minutes. All participants gave permission
to record the interviews, which made it possible to transcribe and code all data. During the
interviews notes were made as an instrument to make the interviews run smoothly.
5.3 Sample size
The sample consisted was of 18 participants. The ages of these participants varied
between 65 and 97 years old. Ten participants indicated themselves as not frail and eight
participants indicated themselves as frail, which makes the sample size sufficient for
qualitative research. Five participants are currently living in a city and the other participants
lived in a smaller village.
5.4 Structure interviews
A semi-structured in-depth interview was conducted. This semi-structured approach
allows the researcher to cover a list with specific topics (Britten 1995; Jarratt 1996). With the
help of this specific topic list unexpected factors or perspectives can be easily discovered
during the interviews (Sampson 1972). These factors or perspectives would otherwise be
precluded when using a standardized interview schedule (Barriball and While 1994). In this
way new viewpoints may emerge freely during the conversations and thus questions will
follow from the responses of the interviewee (Aira et al. 2003; Guion, Diehl, and Mcdonald
2011). In other words, with the use of semi-structured in-depth interviews further questions
and perspectives arise from the information given by the participants and the subtopics
provide as a clear overview of the topics discussed. In accordance with the conceptual model
the main topics of the semi-structured in-depth interview were motivation, opportunity and
ability.
looked like in order to start the interviews easy, an overview of the questions can be found in
appendix II. After those introductory questions, questions about the motivation to use food
supplements were asked. Moorman (1990) found that health motivation was influenced by the
consumer characteristics and stimulus characteristics. Consumer characteristics include the
interest in health and nutritional information, the knowledge about nutrition, and demographic
factors. Stimulus characteristics include information about the content and format of the
nutritional information. Due to the fact that the content and format of food supplement were
not taken into account in this study, stimulus characteristics have not been researched.
In the study of Moorman (1990), motivation to process information was measured by
the use of statements about how interested consumers were in looking for information about
different products. Because this current research only looked at food supplements, questions
instead of statements, regarding how interested consumers were in looking up information
about food supplements and if they had the intention to look up information, were asked. An
example of such a question is: ‘Are you interested in looking up or reading information about
food supplements and why?’
Furthermore consumer characteristics also include the knowledge about nutrition and
in this study food supplements. Therefore, it was asked how participants received information
about what is or is not healthy for them. Also three statements about health hazards were
translated into questions based on the research of Moorman (1990). Instead of a 7-point
Likert-scale the statements were translated into questions in order to gain as much views,
opinions, and ideas as possible. An example of such a question is: ‘Do you try to prevent
health hazards before you feel any symptoms, why or why not?’ Moorman (1990) also used
other statements regarding the curative orientation, which explains to which extend health
problems are dealt with after the appearance of symptoms. However, since in-depth
interviews were held, only the statements about health hazards were translated into questions.
This was done in order to get more depth and avoid confusion among the participants, as
multiple scales could be experienced as overlapping during an interview.
Because the semi-structured approach allows the researcher to cover a list with
specific topics (Britten 1995; Jarratt 1996), the two subtopics ‘interest’ and ‘health hazards’
were created in accordance with the literature of Moorman (1990) mentioned above. These
subtopics were created in order to create a clear overview and to make sure all relevant
subtopics were discussed in each interview.
nutritional intake, also used subtopics in their semi-structured interviews. The following
subtopics were used by Wylie, Copemann, and Kirk (1999): shopping, budget for food, food
storage and cooking facilities, home helps, physical disabilities and loneliness, and
bereavement. These subtopics were divided into the main topics motivation, opportunity and
ability. No suitable topics were found for motivation. The subtopics concerning opportunity
were ‘shopping’ and ‘budget for food’, since these subtopics represent the environmental
mechanisms that constitutes opportunity. This is in accordance with research of Bos et al.
(2015), who used subtopics as ‘physical availability’ and ‘financial’ to research the
opportunities of consumers to choose low calorie snack foods and beverages. Physical
availability means whether consumers know where to find products and financial opportunity
means whether the products are financial attractive (Bos et al. 2015).
The subtopics focusing on ability were ‘home helps’ and ‘physical disabilities’, since
these topics represent to what extend participants have the internal skills and capacities
needed to implement a healthy behavior. These subtopics are also in accordance with the
previous mentioned research of Bos et al. (2015), who used ‘skills’ and ‘knowledge’ to
investigate the abilities of consumers to choose for specific products.
The main questions regarding opportunity and ability and the corresponding subtopics
were based upon an interview with Dr. Martine Assié, Market Manager Food at Avebe.
Dependent on how the interviews went and what unexpected factors and perspectives came
forward, further questions were developed. Examples of these questions are: ‘Do you
experience difficulties while shopping?’ and ‘Do you receive help with the preparation of
food by, for example, ‘Tafeltje Dekje’ or family?’ An overview of the main questions can be
found in appendix II.
prevention focus, the scale of Gomez et al. (2013) to determine which focus is pursued had
been used. The scale of Moorman (1990) did not make this distinction. Both scales, of Fried
et al. (2001) and Gomez et al. (2013), were asked on paper as closed questions. The scales can
be found in appendix II.
5.5 Data analysis and interpretation
The transcribed interviews were coded according to the quantification method. This
method was chosen because it is a suitable method to test predetermined hypotheses and to
obtain improved insights in qualitative data (Schmidt 2010). The interviews were coded on
the basis of predefined concepts, which were motivation, opportunity and ability. The
qualitative data analysis software Atlas.ti 8.2.1, 2018 was used during the process of coding.
The first step was looking for codes related to the three predefined concepts. The documents
were analyzed line by line in order to identify relevant quotes from participants regarding the
predefined concepts. After coding the first two interviews it became clear that sub-concepts
were needed in order to create a clear overview. The second step was analyzing the first four
interviews in order to enrich the predefined concepts with sub-concepts. The codes made out
of those first four interviews were used throughout analyzing the remaining interviews. The
quotes by participants were immediately split into frail and not frail codes. In this way every
sub-concept got two codes. For example, code ‘M:NF:Interest’ stands for the main concept
motivation, a not frail participant, with interest as sub-concept and the code ‘A:F:Difficulties’
stands for the main concept ability, a frail participant, who mentioned difficulties observed in
their life. An overview of the transcribed interviews can be found in appendix III and an
overview of the coded quotations can be found in appendix IV.
When the coding was completed, the quotations and answers were analyzed and put
into tables as much as possible. It is noteworthy that not every participant gave a clear answer
to every question. This is due to (1) some participants joined the interview halfway, but gave
relevant information on the remaining questions and therefore it was decided to also include
these participants into the analysis, (2) some participants gave a vague answer, which was not
reliable enough to include into the analysis. One participant was called afterwards to make
clear whether or not he used food supplements, since this question was relevant for the
research. Another participant took the initiative to e-mail some more information regarding
the topics afterwards.
6. Results
6.1 Utilization food supplements
The majority of the participants made use of food supplements and only four out of the
18 participants do not use the products. Two of them are frail and the other two are not
perceived as frail. One participant told that she only used a food supplement once in her life,
during her pregnancy. The majority (n=10) of the participants pointed out that they use
vitamin supplements; such as vitamin B and vitamin D. Three out of the food supplements
users indicated that they also use other food supplements besides vitamins. 70% of the
participants who are not frail use food supplements and 75% of the participants who are frail
use the products. Lastly, two participants drink every day a bottle from Nutricia.
Age Frailty level Frail (F) / Not frail (NF)
Reason why or why not to use food supplements
89 NF “Do not want to use, that is not the right word. But, we do not get around, we do not figure it out anymore or we do not see that anymore. We also do not get the doctor’s advice. Then you do not do it. It is more convenience.”
77 NF “Glucosamine against osteoarthritis. And the rest to stay healthy. Preventive.”
67 NF “I do not think I need it. I think you only need food supplements when your diet itself, what you usually get, is not enough.”
66 NF “If my energy improves as a results and my resistance improves as a result, then I am open for it.”
67 F “Because we eat fresh vegetables every day. And then you get enough vitamins. That is unnecessary. That is my opinion.”
70 F “I had some troubles with my nails. Now, I press an orange every dag, but I always was a very bad fruit-eater. And that is why I had it, but also for my nails. That is going well now. But, that is also the only thing I use.”
82 F “Also to ensure that you stay well. And for the gout, then you have no more gout. He always had gout, that is over now.”
The table above shows some statements of the participants, in order to see what drives
consumers to use or not to use food supplements. The reasons why or why not consumers use
food supplements vary widely. Some participants indicated that they use food supplements in
order to stay healthy or because the doctor said so. Other participants indicated that they do
not use food supplements because they do not have the knowledge about the products or they
already eat healthy enough. In the next paragraphs the relationship between motivation and
utilization of food supplements will be further examined.
6.2 Motivation
As stated before, health motivation includes the goal-directed ambition of someone to
engage in health prevention behavior (Moorman and Matulich 1993).
6.2.1 Differences between the health promotion focus and health prevention focus
The distinction between participants pursuing the health promotion or health
prevention focus is based on the scale of Gomez et al. (2013). The first step was checking
whether this existing scale is strong enough to use in this research. In order to test the internal
consistency between the items a reliability test was conducted. The reliability test showed that
the items, for the health promotion focus, all measure the same underlying dimension
(Cronbach’s Alpha = 0.733). When one question will be removed the Cronbach’s Alpha will
become lower, indicating that all questions measure the same. However, when doing the
reliability test for the health prevention focus Cronbach’s Alpha was nearly 0.6 (Cronbach’s
Alpha = 0.568). Concluding, the health promotion and health prevention scales seemed to be
strong enough to be used in this research.
health promotion focus and health prevention focus for participants who use and do not use
food supplements. Therefore, both hypothesis 1a and 1b cannot be supported.
6.2.2 Differences between frail and not frail elderly and the utilization of food
supplements
Most participants indicated that they do not worry or do not want to worry about the
health risks that might come in the future. As one non-frail participant of 83 years old said: “I
do not want to think about that all the time. It happens to you. When you think about that all
the time, then… I understand everything, this can happen to you and that… But, I do not want
to think about it all the time. That might be a bit stupid.” Another frail woman of 70 years old
states: “Well, I have learned not to look too far ahead and enjoy the day. Do not worry about
what you think that might happen to you and then ultimately does not happen. …. It ruins
your life. It will always go differently and then you have ruined your life.” However, one
participant indicated that he worries about the future and one participant might think about the
health problems that may come in the future, see table 3. The difference between frail and
non-frail participants is small with 10% (n=1) of the non-frail participants who worries about
the future.
Most participants do not worry about the health problems that might come in the
future. Or participants do not want to think about these problems that might come. But, on the
contrary, eight participants took preventive actions in order to stay healthy. It seems that
non-frail participants took more preventive actions to stay healthy (60% vs. 25%). Participants
indicated that they do this by taking the flu shot, exercise, trying to eat healthy and some take
vitamins to prevent their health from external risks. However, some participants indicated that
they think news about how to stay healthy changes a lot. Resulting in that they do not believe
all of it: “I often find that nonsense stories. I still have the tendency that this kind of things are
a trend that suddenly comes up.”
Age Frailty level Frail (F) / Not frail (NF) Supplement Usage Yes (Y), No (N) Worries about future Yes (Y), No (N), Maybe (~) Preventive actions for health Yes (Y), No (N), Maybe (~) Interests in food supplements Yes (Y), No (N), Maybe (~) 89 NF Y N N 77 NF Y N Y N 65 NF Y N N 65 NF N ~ Y 67 NF Y N Y ~ 74 NF N 66 NF Y Y Y Y 85 NF Y N Y 83 NF Y N Y Y 94 NF N N Y N 85 F Y Y N 67 F N N ~ Y 70 F Y N N N 82 F Y N Y Y 84 F Y ~ ~ Y 86 F Y 97 F N 88 F Y N ~ Y
TOTAL: 13 x yes 1x yes 8x yes 7x yes
Percentages not frail and frail:
70% yes (NF) 75% yes (F) 10% yes (NF) 0% yes (F) 60% yes (NF) 25% yes (F) 30% yes (NF) 50% yes (F)
Table 3: Output motivation codes
Nevertheless, participants indicated that they are not interested in information about
food supplements, consumers might still read information about the topic: “No, not so much.
Of course you will read something, but I am not specifically looking for something.” On the
contrary some participants do look up how they can improve their health by the use of food
supplements, for example: “Yes, than I will look at that. On the computer for a moment.” No
big differences, between frail and non-frail participants, between the reasons of why or why
not to use food supplements were found in table 2.
supplements answered the question whether they are interested in food supplement. This
resulted in one participant that was interested and one participant that was not.
No big differences were found between frail and non-frail consumers. Only the
difference between the preventive actions taken by frail participants (60%) versus non-frail
participants (25%) is meaningful. It might be noteworthy that some elder participants above
80 years old indicated that they are too old to improve their health: “We no longer need to
improve our health. We are already so old. I am already 86.” (Frail participant); “Well, it is, I
am so old now. First, this is good and then it is no longer good and then you have to change
again. And then I think, with my age of 88 years, you take something tasty and you eat that.”
(Frail participant); “We do not find out that anymore and we do not see that anymore.” (Not
frail participant). Therefore, there might not be a difference in motivation between frail and
not frail consumers, but it may be about how old participants feel. Concluding that hypothesis
1c cannot be accepted and thus motivation does not play a bigger role for non-frail
consumers, compared to frail consumers, for the utilization of food supplements.
6.3 Opportunity
As mentioned before, opportunity includes the priorities and resources of consumers
that allow them to pursue goals, without any restrictions coming from the external
environment (Clark, Abela, and Ambler 2005; MacInnis et al. 1991). An overview of the
outcomes related to the opportunities for the participants can be found in table 4.
6.3.1 Effect opportunity on food supplement usage
Eleven participants do groceries by themselves and two participants do sometimes the
groceries. Five participants do not do groceries anymore and thus do not get the opportunity
to see food supplements in stores. Most participants perceived stores as the pharmacy (n=5),
Kruidvat (n=4) and drugstores (n=3) as stores where they could buy food supplements.
However, some participants knew where to buy them, but this does not indicate that they are
interested in actually buying them: “Yes, at the drugstore, pharmacy, Kruidvat. But no, I am
not just swallowing everything. Only medications from the doctor, I have enough of those.”
Also, some participants guessed where to buy food supplements: “No, maybe at the Kruidvat,
but I do not know. Look, if you do not use it and you are not interested in it, then I will not
learn about it where I can get it.”
one participant said she had to really be convinced by her doctor: “Well, I do not know. That
depends on his motivation. I have the feeling that I am already doing well. So, if I want to take
it, even if it is free, he should really convince me.”
Age Frailty level Frail / Not frail Supplement Usage Yes (Y), No (N) Do groceries? Yes (Y), No (N), Not always (~)
Willing to pay for food supplements Yes (Y), No (N), Maybe (~)
Points of sale food supplements 89 NF Y Y Aldi 77 NF Y Y Y 65 NF Y Y Kruidvat 65 NF N ~ Drugstore 67 NF Y ~ Y 74 NF N Y 66 NF Y N Y Pharmacy 85 NF Y N 83 NF Y Y Y Pharmacy 94 NF N Y Pharmacy 85 F Y N Pharmacy 67 F N Y ~ Kruidvat, De Tuinen 70 F Y
Y ~ Kruidvat, drugstore, Aldi,
Jumbo 82 F Y Y Naturopathic 84 F Y N Y Drugstore, Pharmacy, Kruidvat 86 F Y N 97 F N Y 88 F Y Y Y Naturopathic
TOTAL: 13 x yes 11x yes 6x yes 5x pharmacy, 4x Kruidvat, 3x drugstore, 2x Aldi, 2x Naturopathic, 1x Jumbo,
1x De Tuinen Percentages not
frail and frail:
70% yes (NF) 75% yes (F) 60% yes (NF) 62.5% yes (F) 40% yes (NF) 25% yes (F) 75% named a store (NF) 60% named a store (F)
