Abstract
Introduction: The purpose of this research is to explore how dietitians can identify and support people who are food insecure. The thesis contains two feasibility studies. The first study is mixed method design and tests the feasibility and acceptability of implementing a brief intervention for identifying food insecure individuals in dietetic practice and referring on to available food aid support. The second study explores the practicalities and experiences of implementing a healthy diet skills programme in a foodbank setting. This is the first time a brief intervention for food insecurity has been tested in UK dietetic practice and the first time a nutrition education programme delivered in a UK foodbank by a dietitian has been formally evaluated. Both the interventions are novel in design and pioneering in the UK. The research undertaken in this thesis demonstrates a clear commitment to improving dietetic practice and provision on issues of food insecurity.Food insecurity is not having physical access to enough nutritious food to eat well for good health. It is known that the prevalence of food insecurity is increasing and the COVID-19 pandemic has further accelerated this. Food insecurity can lead to negative health outcomes; for example, obesity and depression and is an increasing concern in the UK and around the world. Mothers who are food insecure are twice as likely to report mental health problems. Adults living with diabetes who are food insecure are more likely to have poorer health outcomes due to the impact food insecurity can have on adherence to medical recommendations. Much food insecurity goes undetected and insufficient support is available. The use of foodbanks in the UK is rising exponentially but this reveals further problems and a ‘more than food’ approach has emerged aiming to improve health and wellbeing, reduce reliance on external support and advance social circumstances.
The PhD aims were to conduct two unique studies:
1. Test the feasibility and acceptability of implementing a brief intervention for food insecurity in dietetic practice
2. Evaluate a healthy diet skills programme delivered by a dietitian in a foodbank setting.
Study 1:
A feasibility study of a brief intervention for food insecurity (BIFI) using the ‘Ask, Advise, Act’ model was conducted by dietitians. A dietitian used a validated 2-item screening tool to identify food insecurity (Ask), if identified the dietitian describes the impact of this on health (Advise) and provides literature (eat well spend less and local food aid support), signposts to local help and refers to a foodbank as appropriate (Act). This was a mixed methods study design, feasibility was measured through quantitative procedures investigating recruitment and response rates and acceptability was explored by an embedded qualitatively study using semistructured interviews and focus groups with dietetic service users and dietitians.
5 dietitians and 47 dietetic service users consented and were eligible to take part in the study. 26% (n=12) of participants were identified as food insecure. 5 accepted a foodbank voucher, of which 4 attended, all accepted a copy of the ‘eat well, spend less’ leaflet, all but one accepted a copy of the local food support leaflet. The dietetic service user analysis revealed two themes: providing important and accessible help and room for improvement. The dietitian analysis revealed five themes: A new area of assessment and a worthwhile intervention; Improve training provision to increase confidence and knowledge and reduce challenges faced; Time and work pressures will always be a factor in the delivery and engagement of the intervention; Building rapport and providing understanding and sensitivity to food insecurity is key to helping patients and Alternative modes of delivery.
This study is unique in its contribution to the field. It is the first UK study reporting it is feasible and acceptable for a dietitian to screen for food insecurity in dietetic practice using a brief intervention that uses the model - ask, advise, act. The intervention was able to detect food insecure dietetic service users and connect them to community food-aid. Having standardised food insecurity screening was important for dietitians and dietetic service users to address food insecurity, reducing the sense of awkwardness and stigma. The simplicity and brevity of the BIFI enables it to be integrated into clinical practice with universal application thereby reducing the risk of unmet needs when clinician-triggered screening is undertaken. Dietitians are suitably placed to undertake the BIFI because it fits with their scope of practice; however, there is an opportunity for this to be rolled out more widely to other health care professionals in a variety of settings. A randomized control trial is required, it would be useful to explore changes in health outcomes and food insecurity status.
Study 2:
A feasibility study of a two-week nutrition education and cooking intervention delivered in the foodbank. The intervention involved 2 x 2hour sessions, split into one-hour nutrition education and one hour cooking fresh vegetable soup. Pre and post intervention measures assessed change in nutritional knowledge, dietary choice and confidence in healthy food preparation. Feasibility was measured through client’s uptake and attendance rates at the programme. This was a feasibility study with a quantitative design and a researcher reflection.
42 foodbank clients completed the healthy diet skills intervention, and there were 2-4 foodbank clients on each course. There was a low dropout rate between week 1 and week 2 of the intervention with only 2 foodbank clients (5%) not completing the intervention. Improvements were noted in nutrition knowledge and confidence. Following the intervention there was an increase in clients’ knowledge of the recommendations for physical activity (55%) and The Eatwell Plate (40%). Confidence was identified as the most improved measured variable. Across all variable’s confidence increased with statistical significance, for example ‘How confident do you feel in planning meals?’ (P<0.001).
The study reported a dietitian delivering a cooking and nutrition course is a worthwhile delivery option for a UK Foodbank. The intervention makes an important contribution to the ‘more than food’ approach. The study has successfully contributed to the growing evidence base that foodbanks are effective locations for nutrition education programmes. The three pre and post intervention measures: dietary knowledge, dietary confidence and dietary choice have all produced positive findings. More research is needed over a longer period of time to assess whether the behaviours that were planned were followed through. On the spot interventions may work better instead of asking clients to return on a future date. This explorative piece of research has begun to emphasise the importance of interventions of this kind embedded within a developed community food-aid network. It provides a unique contribution to the field, being the first UK study of its kind.
Conclusion:
Until a fairer society and more stable world exists, with improved national and international policies to alleviate food insecurity, dietitians require mechanisms to identify and support food insecure individuals and families. The BIFI study in clinical practice screens, identifies and directs people to available food-aid support in the community where the healthy diet skills programme is located. Although further testing is needed it is prudent that screening is adopted. The healthy diet skills programme has been shown as a worthwhile intervention in a foodbank. The COVID-19 pandemic and other world events highlighting the vast growing need for such support.
| Date of Award | Jun 2023 |
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| Original language | English |
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| Supervisor | Deborah Lycett (Supervisor), Anne Coufopoulos (Supervisor) & Andy Turner (Supervisor) |