Institute of Epidemiology & Health Care


Promoting Independence and well-being in later life


The HomeHealth Trial

With age, people often develop an increasing number of health conditions that affect how they feel and their ability to remain independent. Some may struggle with decreased energy levels, low appetite, lower muscle strength and difficulty with household tasks such as shopping and cooking.

However, few health services currently exist to help. We designed the HomeHealth service in 2014-2015 in partnership with older people, carers, health and social care professionals and experts. It aims to help people aged 65+ who are starting to find everyday activities more difficult to stay independent and healthy for as long as possible. 

We are carrying out a national randomised controlled trial to test whether the HomeHealth service makes a significant difference to the people who use it, and if it proves to be good value if it were to be commissioned by the NHS. Please see our website www.ucl.ac.uk/home-health-trial for more information.



The WISH study evaluated a Multi-dimensional Risk Assessment in Older people (MRAO) expert system encompassing health, social, economic and environmental domains. It considered the potential effectiveness of the MRAO as a tool to promote self-care and foster cross sector working to promote community well-being.

An evaluation of the feasibility of using the MRAO system was conducted in two localities (urban London, semi-rural Hertfordshire).

The MRAO intervention is a self-assessment system to identify health, social, economic and environmental needs and promote well-being among older people. The MRAO includes a questionnaire for older people that asks about their health, social and environmental circumstances. Software analyses answers and generates personalised advice on problems needing attention, lifestyle changes and useful local services. A copy of this advice is sent to each participant, and also to their GP practice, who arranges a consultation for follow-up if needed. In our feasibility study we asked lead practice nurses to read the reports and arrange follow-up for anyone they felt had new and complex or concerning needs. A local profile of needs of the older people participating can be created for each practice and/or local area.

We conducted an evaluation, including collecting data on feasibility and costs, needs, well-being and quality of life before and after implementation and a qualitative study including 52 interviews with key stake-holder and participating older people.

The project was funded by the Medical Research Council

Primary care interventions to improve nutrition in later life: a systematic review

Project Title: Exploring the views of primary care and community professionals on managing malnutrition in frail older people


Team: Cini Bhanu, Kalpa Kharicha, Christina Avgerinou

Project co-applicants and collaborators: Kate Walters, Jennifer Rea, Helen Croker

Patient and Public Involvement (PPI): Maggie Kirby-Barr, Jane Hopkins


Start date: 1/5/2018

Finish date: 31/12/2019


Background: Malnutrition is associated with increased morbidity and mortality, and is very common in frail older people. However, we know little about how weight loss in frail older people can be managed in primary care.

Aims: To a) explore the views and practices of primary care and community professionals on the management of malnutrition in frail older people; b) identify components of potential primary care-based interventions for this group; c) identify training and support required to deliver such interventions.

Design and setting: Qualitative study; primary care and community settings.

Methods: Seven focus groups and an additional interview with general practice (GP) teams, frailty

multi-disciplinary teams (MDT) and community dietitians in London and Hertfordshire, UK (n=60

participants). Data were analysed using thematic analysis.

Results: Primary care and community health professionals perceived malnutrition as a multifaceted problem. There was an agreement that there is a gap in care provided for malnutrition in the community. However, there were conflicting views regarding professional accountability. Challenges commonly reported by primary care professionals included overwhelming workload and lack of training in nutrition. Community MDT professionals and dietitians thought that an intervention to tackle malnutrition would be best placed in primary care and suggested opportunistic screening interventions. Education was an essential part of any intervention, complemented by social emotional and/or practical support for frailer or socially isolated older people.

Conclusions: Future interventions should include a multi-faceted approach. Education tailored to the needs of older people, carers and healthcare professionals is a necessary component of any intervention.


Funded by: NIHR School for Primary Care Research (SPCR) FR13 (award number 407)


Contact details: Christina Avgerinou c.avgerinou@ucl.ac.uk


Project links and documents: https://www.spcr.nihr.ac.uk/projects/407-exploring-the-views-of-primary-care-and-community-professionals-on-managing-malnutrition-in-frail-older-people


Managing malnutrition in later life: a qualitative study

Project Title: Managing malnutrition in later life: exploring the views and dietary practices of older people at risk of malnutrition and their carers


Chief investigators: Christina Avgerinou & Kalpa Kharicha


Start date: 1st June 2017

Finish date: (if applicable): 28th February 2019



Malnutrition is a serious condition that occurs when a person’s diet lacks the amount of nutrients they need. It is a common problem in older people that can lead to weight loss, weakness and fatigue. If left unchecked, it can cause older people to become underweight, and more prone to severe illness and hospitalisation. Malnutrition can go unnoticed in the early stages as it can be difficult to recognise, and General Practitioners or practice nurses may not have the time or have received training on how to deal with this condition. Currently, little is known about the dietary choices made by older people at risk of malnutrition, how it is recognised and acted upon, and how it can be improved.

In this study, we interviewed older people who were underweight or at risk of malnutrition and friend/family carers of older people who needed help to prepare their meals. We explored the decisions they made about the food they buy and eat, their knowledge about dietary needs in later life, the advice and support they might need and the best place to seek support. We also asked older people and their carers for their views on how primary care could support nutritional and healthy eating advice.


What did we do in this study?

We spoke to 24 older people and 9 informal carers (people who help them buy or prepare food and drink regularly) about the kind of support that would prove helpful in eating and drinking well and if the NHS could play a role.


What did we discover?

Most people followed a familiar routine in their meal patterns, often eating 2-3 times a day. This generally comprised of one main meal and 1-2 smaller ones. Most avoided eating in between meals or ‘snacking’ as they considered it an ‘unhealthy’ habit. Some of the factors that influenced their pattern of eating habits were the following:


Patient and Public Involvement (PPI): Jane Hopkins, Maggie Kirby-Barr


Funded by: NIHR School for Primary Care Research (SPCR) FR13 (award number 377)



Contact details: Christina Avgerinou c.avgerinou@ucl.ac.uk


Project links and documents: https://www.spcr.nihr.ac.uk/projects/managing-malnutrition-in-later-life-exploring-the-views-and-dietary-practices-of-older-people-at-risk-of-malnutrition-and-their-carers


Publication: Avgerinou C, Bhanu C, Walters K, Croker H, Liljas A, Rea J, Bauernfreund Y, Kirby-Barr M, Hopkins J, Appleton A, Kharicha K. Exploring the views and dietary practices of older people at risk of malnutrition and their carers: a qualitative study. Nutrients 2019 Jun 5; 11(6). pii: E1281. doi: 10.3390/nu11061281.




Project co-applicants and collaborators: Kate Walters, Jennifer Rea, Amber Appleton, Helen Croker

Most of the people did not consider low weight to be ‘a problem’. Some had been slim all their lives whereas others had lost weight over recent months or years. However, the majority felt that their appetite and size of portions had grown smaller over time. Their understanding of ‘healthy eating’ primarily focused on the greater intake of fruit and vegetable and selection of low-fat items. Various reasons were given for not wanting to gain weight – avoiding the need and expense of buying new clothes, not seeing it as a necessity, low appetite and financial constraints. Whilst others were more open to the prospect of gaining weight, most of our participants were not keen on altering their eating habits. Although most would not bother to seek support from services for their weight loss, many were open to dietary advice if well justified or recommended by a doctor. Our study participants rarely asked their GP about diet but a number had spoken to a dietitian when they were referred for a specific diet related to a health condition (e.g. diabetes, coeliac disease). None of them had received advice about increasing their protein intake or gaining weight. The carers held different perspectives and most expressed concern about weight loss in the older person they cared for. Even though they provided assistance with shopping and meal preparation, they were often not provided with any helpful and trusted guidance on how to help meet the older person’s dietary needs. The majority of our older people and carers were open to advice on improved nutrition although held distinct preferences about the professional background and identity of who was best placed to deliver such a service (e.g. doctor, nurse, dietitian or other trained professionals). Approachability and ‘people skills’ ranked higher than formal qualifications for some participants and many preferred a ‘tailored’ approach that better reflected their needs. Who they currently lived with (e.g. changes such as separation or widowhood influenced motivation to cook when living alone) Early life experiences (e.g. dietary patterns established earlier in life, rationing during and after the war) Health-related factors (e.g. irritable bowel syndrome, depression, diabetes) Memory problems that affected their ability to shop and cook independently Financial constraints that meant they could buy what they could afford