
==== Front
Perm J
tpj
tpj
The Permanente Journal
1552-5767
1552-5775
The Permanente Press

39075979
10.7812/TPP/24.062
TPJ-24-062
Brief Report
Community-Specific Video Training for Primary Care Settings: Increasing Capacity and Motivation to Address Food Insecurity
http://orcid.org/0000-0003-4121-4278
Nederveld Andrea MD, MPH 1
Jantz Kathryn MPH, MSW 2
Brennan Margery MA 1
Skalecki Macharnie 3
Broaddus-Shea Elena PhD 1
1 University of Colorado School of Medicine, Department of Family Medicine, Aurora, CO, USA
2 HealthBegins, Burbank, CA, USA
3 Rocky Vista University, Parker, CO, USA
Andrea Nederveld, MD, MPH andrea.nederveld@cuanschutz.edu
2024
30 7 2024
28 3 152156
© 2024 The Authors.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Published by The Permanente Federation LLC under the terms of the CC BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

Abstract

Background

Food insecurity (FI) is the most common health-related social need (HRSN) and is frequently identified in primary care through screening and referral. However, health care workers often do not have the knowledge, motivation, capability, or opportunity necessary to discuss FI with patients in patient-centered ways.

Methods

An educational module for health care workers on FI was created using user-centered design and tested with health care workers, using the COM-B model as an evaluation framework.

Results

Watching the module’s video increased participant knowledge, capability, and motivation to address FI with patients.

Discussion

This preliminary pilot study suggests that simple training modules could help with the effectiveness of efforts to address HRSNs, such as FI, by increasing health care workers’ capacity to discuss, screen, and refer patients. Findings warrant expanded studies to assess the effectiveness of such modules on patient-level outcomes.

Conclusion

This type of educational module on FI or other HRSNs holds promise as a time- and cost-efficient strategy for improving screening and referral processes, ultimately alleviating FI for more patients and improving health outcomes.

Keywords:

food insecurity
primary care
video training
COM-B
screening and referral
==== Body
pmcIntroduction

Social determinants of health are the conditions in which people are born, grow, work, live, and age, as well as the wider set of forces and systems shaping the conditions of daily life.1 Social determinants of health result in health-related social needs (HRSN), such as food insecurity (FI), defined as the lack of consistent access to enough food for every person in a household to lead an active, healthy life.2 FI is the most common HRSN and is associated with development of chronic disease.3–5 Emerging evidence shows improved health outcomes when FI is ameliorated, and FI screening and referral to resources is now occurring in primary care.6,7

Through screening or conversations with patients, health care workers often learn that patients are facing FI, but they are not always familiar with food assistance resources or comfortable discussing FI,8–10 especially when they are not able to connect people with resources.8,10 These barriers may diminish the effectiveness of efforts to identify and address FI in primary care populations.

To better address FI in Mesa County, Colorado, the authors employed user-centered design—a method in which the end users of an intervention lead the design process11,12—to create a 40-minute training video for health care workers. A group of patients with lived experience of FI, health care workers, food resource agency staff, and other local leaders participated in the development and filming of the training video that described the causes of FI, resources available in the community, barriers to resource access, and strategies for identifying FI and connecting people with resources. The authors then conducted an evaluation to determine the video’s preliminary efficacy. Evaluation outcomes were guided by the COM-B Model of Behavior,13,14 which theorizes that an individual’s likelihood of engaging in a given behavior is determined by their capability, opportunity, and motivation to do so.

Methods

Evaluation participants were health care workers (clinicians, clinical staff, administrators, and others) from 2 safety-net primary care practices in Mesa County. We emailed potential participants a link via the REDCap data collection system that connected them first to a pre-video survey, then to the training video, and then to a post-video survey. Both the pre- and post-video surveys required < 10 minutes each to complete. Participants were offered a $25 supermarket gift card as a thank-you for completing the evaluation. The Colorado Multiple Institutional Review Board reviewed and approved this protocol.

The pre-video survey collected demographic information and baseline measures for knowledge, capability, and motivation to address FI. The post-video survey collected end line measures for the same, as well as assessments of the module. All measures were developed by the study team, as no previously validated brief pragmatic measures for the domains of interest were available. The authors measured knowledge using 4 multiple-choice questions about food resources and FI. Correct responses were summed to generate a score (range: 0–4). Capability and motivation were measured using scales consisting of 4 items each. Respondents used a sliding bar to indicate their level of agreement with each item, with responses scored from 0 to 100. Responses across items were averaged to generate an overall score for each scale. We also measured subjective assessments of the module by asking respondents to rate their agreement with a series of 10 statements.

We calculated descriptive statistics for participants’ demographic characteristics and for all survey items and generated knowledge index and capability and motivation scale scores for each respondent at each time point. Due to the small sample size and nonnormality of distributions, we used a Wilcoxon signed-rank test (a nonparametric test of equivalence for paired data) to test the significance of pre- and post-video changes in knowledge, capability, and motivation. A significance threshold of p < 0.05 was used. Analyses were conducted in STATA 12 (StataCorp LLC, College Station, TX).

This study was approved by the Colorado Multiple Institutional Review Board.

Results

Of the 41 health care workers who received invitations to participate in the evaluation in January 2021, 19 (46%) completed the pre- and post-video surveys. Table 1 describes their characteristics.

Table 1: Survey respondent characteristics (N = 19)

Characteristics	Medical staff, n (%)	
Gender	
 Female	14 (74)	
Age, y	
 ≤ 20	1 (5)	
 21–40	9 (48)	
 41–60	6 (32)	
 ≥ 60	3 (16)	
Race/ethnicity a	
 White	16 (84)	
 Latinx/Hispanic	3 (16)	
 Black	1 (5)	
 American Indian or Native American	1 (5)	
 Prefer not to say	1 (5)	
Current professional role	
 Clinician	5 (26)	
 Clinical staff (eg, MA, RN)	6 (32)	
 Clinic admin (eg, office manager or front desk staff)	5 (26)	
 Other medical staff role	3 (16)	
Currently screening for food insecurity at practice	
 Yes	15 (79)	
 No	2 (11)	
 I don’t know	2 (11)	
a Sums to more than 100%; respondents selected all race/ethnicity categories with which they identified.

MA, master of arts; RN, registered nurse.

As shown in Table 2, the average number of knowledge questions that respondents answered correctly increased significantly after watching the training video. Average capability and motivation scale scores also increased significantly.

Table 2: Pre- and post-assessment responses on knowledge, capability, and motivation (N = 19)

Questions	Pre-video	Post-video	
Knowledge questions—respondents answering each question correctly, n (%)	
 What percent of people living in Mesa County are food insecure? (10%–11%)	8 (42)	11 (58)	
 What percent of people are eligible but not enrolled in SNAP in Mesa County? (40%–49%)	5 (26)	5 (26)	
 What percent of families with children are food insecure in Mesa County? (13%–14%)	1 (5)	10 (53)	
 What is the average amount of money that a SNAP participant receives per month? ($200–$300)	12 (63)	16 (84)	
 Average number of questions answered correctly	1.4	2.2 a	
Capability questions—average score by item (0–100 slide bar)	
 I know how to assess whether patients are experiencing food insecurity. (1–100 from “strongly disagree” to “strongly agree”)	60	80	
 I feel comfortable talking with patients about food insecurity. (1–100 from “strongly disagree” to “strongly agree”)	59	73	
 I know a lot about the resources and programs available for patients experiencing food insecurity. (1–100 from “strongly disagree” to “strongly agree”)	47	76	
 I am confident in my ability to help connect food insecure patients with resources. (1–100 from “strongly disagree” to “strongly agree”)	66	78	
 Average capability score	58.1	76.5 a	
Motivation questions—average score by item (0–100 slide bar)	
 To what degree do you think food insecurity is linked to health conditions? (1–100 from “not at all linked” to “very closely linked”)	85	93	
 How important is it to address food insecurity in your professional setting in relation to other priorities? (1–100 from “not at all important” to “extremely important”)	81	86	
 How likely are you to initiate a conversation about food insecurity with a patient/family in the next two weeks? (1–100 from “very unlikely” to “very likely”)	65	72	
 How likely are you to help connect a food insecure patient/family with resources in the next two weeks? (1–100 from “very unlikely” to “very likely”)	68	77	
 Average motivation score	74.7	81.9 a	
a Significant increase (p < 0.01).

SNAP, Supplemental Nutrition Assistance Program.

Finally, health care workers also responded positively to the video assessment questions. All participants either agreed or strongly agreed that the information in the video was clear, engaging, and would be useful in their work. All also agreed or strongly agreed with the statements that, “I feel better equipped to communicate with patients/families about food insecurity after watching this video,” and “I feel better equipped to help connect food insecure patients/families with resources after watching this video.”

Discussion

Providing a simple training explaining the lived reality of FI along with issues such as stigma, local resource availability, and communication approaches increased knowledge about FI, comfort, confidence, and intention to discuss FI with patients. Participants reported that the video was clear, engaging, and useful.

These results are important as we know that behaviors, like communicating about and arranging referrals for FI, are more likely when people have the knowledge, motivation, and capability to do so. In the COM-B model, opportunity to enact a behavior refers to both “physical” and “social” opportunities, meaning moments in the clinical visit process when FI can be addressed and times when it is socially acceptable.15 Training aimed at increasing knowledge and empathy about and for people living with FI may help to address the social acceptability of these conversations. Simple approaches to increasing knowledge and capability may be best, as primary care practices are adding HRSN screening and referral to already overburdened workflows.16 Video modules have been used successfully for education of health care workers,17–19 and this could be an avenue to offer education about FI, and possibly other HRSN in a flexible and convenient manner.

Ultimately, we need to develop effective and efficient systems for addressing FI that support local community knowledge, as well as support the capability, opportunities, and motivation to address it. The findings of this pilot study suggest that community-specific training videos could be one step in the right direction for health care workers. Further and more in-depth study is necessary to evaluate whether the increased knowledge and sense of capability would indeed lead to change in health care workers’ communication and behaviors related to addressing patients’ experience of FI and the impact of those behaviors on patients. Sustained improvement will require more scalable and systematized approaches.

LIMITATIONS

This evaluation was performed with a small convenience sample of health care workers in one geographic area and, therefore, is not generalizable. Participants self-selected into the study by responding to an email request and, thus, the population may not represent the larger health care worker population. The low response rate may indicate that shorter training opportunities would be better received. Evaluation measures were unvalidated due to a lack of existing measures to assess the outcomes of interest. Future work should be aimed at addressing these shortcomings and evaluating the behavior of health care workers and impacts on patients.

Conclusions

An educational video increased knowledge, capability, and motivation to address FI with patients, enabling behavior to change as opportunities to do so surface in clinical care. This promising preliminary work lays the groundwork for future confirmatory studies assessing behavior change and clinical outcomes.

Author Contributions: Andrea Nederveld, MD, MPH, developed and executed the study and analysis plan and created the video training. Elena Broaddus-Shea, PhD, developed and executed the study and analysis plan and provided feedback on the video training. Kathryn Jantz, MPH, MSW, contributed to the introduction and discussion and provided feedback on the manuscript overall. Macharnie Skalecki assisted with data collection and manuscript preparation. Margery Brennan, MA, assisted with manuscript preparation.

Conflicts of Interest: None declared

Funding: This work was funded by the Colorado Evaluation and Action Lab at the University of Denver.

Data-Sharing Statement: This study's underlying data are available upon request. Readers may contact the corresponding author to request the underlying data.
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