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Abstract

Introduction/Objectives:

Adults with food insecurity (FI) face barriers to hypertension management, including difficulty adhering to diet recommendations. Few community health worker (CHW) interventions focus on diet to improve blood pressure. This qualitative study elicited patient and CHW perspectives on healthy eating and a future CHW nutrition intervention for patients with hypertension.

Methods:

Twenty-five patients with hypertension and FI and 5 CHWs participating in a hypertension health coaching program from 5 Boston-area health centers participated in semi-structured interviews from July to September 2023. Interviews were audio recorded, transcribed, and analyzed using the Framework Method.

Results:

Themes included: 1) Variable patient knowledge about dietary patterns for hypertension management and low confidence in interpreting nutrition labels; 2) Culture influenced healthy food perception; and 3) Barriers to healthy eating included cost, limited cooking abilities/supplies, and competing demands. Patients and CHWs favored simple nutrition education materials (e.g., traffic light nutrition ranking, healthy meals on a budget). Patients had mixed opinions about CHW-accompanied supermarket visits.

Conclusions:

This study identified culture, knowledge gaps, and budget constraints as factors influencing diet among patients with hypertension and FI. A CHW-delivered intervention could include simplified nutrition education, strategies for healthy eating on a budget, and linkage to community-based food programs.

Keywords

hypertension food insecurity nutrition insecurity community health worker qualitative research

Introduction

Food insecurity, defined as limited or uncertain access to food, is associated with increased risk of diet-sensitive chronic conditions and disproportionately affects people with hypertension compared to normotensive individuals.^1,2 Dietary modification is part of first-line, nonpharmacologic therapy for hypertension management, but following a healthy diet can be difficult, especially for people experiencing food insecurity, due to higher cost of healthier foods.^3
-5

Nutrition security, a related but distinct concept, emphasizes not only availability and access to food, but also the intake and stability of nutritious food over time.⁶ Although the US Preventive Services Task Force recommends that all adults with cardiovascular risk factors including hypertension be offered or referred to behavioral counseling to promote a healthy diet,⁷ nutrition counseling rarely occurs during primary care visits for hypertension, largely due to time constraints, competing demands,^8
-13 and inadequate nutrition education training for physicians.¹⁴ Furthermore, research has shown that primary care clinicians seldom or never refer patients with hypertension to registered dietitians,¹⁵ and referral rates may be even lower for low-income populations given that Medicaid coverage of nutrition services varies by state.^16,17 Integrating community health workers (CHWs) trained in nutrition into care teams is a promising strategy for hypertension management, as team-based care models that include CHWs have been shown to improve blood pressure in underserved populations and are promoted by the American Heart Association.^18,19

While existing studies of CHW interventions for hypertension management in the US have demonstrated improvement in self-monitoring behaviors, medication adherence, and appointment keeping,^20
-25 few have integrated diet interventions to improve blood pressure and cardiovascular risk. The objective of this qualitative study was to explore patient and CHW perspectives on healthy eating among low-income community health center patients with hypertension, and to elicit participants’ opinions on a potential CHW-delivered nutrition intervention to improve diet for adults experiencing nutrition insecurity.

Methods

Study Design, Setting, and Participants

This study used a qualitative descriptive design, which was chosen for its ability to help researchers produce a rich but straightforward description of complex factors that contribute to a phenomenon²⁶ and gather information needed to develop or refine an intervention.²⁷ Semi-structured interviews were conducted with community health center patients and CHWs between July and September 2023 to explore sociodemographic and behavioral factors that impact dietary choices, and to obtain participants’ opinions on a potential nutrition-focused CHW intervention. Patients were recruited over the telephone from LiveWell, a cohort study (N = 1056) designed to evaluate a Massachusetts Medicaid program that provides accountable care organizations (ACOs) with funding to address participants’ food and housing insecurity.²⁸ LiveWell enrolled English and Spanish-speaking adults 21 to 62 years old who had Medicaid or commercial ACO insurance and at least 2 visits in the prior 2 years at 1 of 5 health centers within Mass General Brigham (MGB), a large integrated health system in eastern Massachusetts. LiveWell participants were followed over 3 years with annual surveys which collected data on various demographic, behavioral, and psychological measures, as well as health-related social needs such as food security status as measured by the USDA 10-item Adult Food Security Survey Module.²⁹ For this study, we purposively sampled LiveWell patients with hypertension who had marginal, low, or very low food security at least once during the 3 years prior to this study (N = 234) to gather perspectives on healthy eating and feedback on a potential nutrition intervention from patients at high risk of having low diet quality. Twenty-five patients approximating the racial/ethnic composition of LiveWell were included, a sample size generally sufficient to achieve data saturation.^30,31 Five CHWs who served racially and ethnically diverse patients in an MGB hypertension health coaching program were recruited via email per the recommendation of their manager. Study procedures were approved by the MGB institutional review board on November 8, 2022. All participants provided verbal informed consent for participation. Patients were remunerated $50 and CHWs were provided a meal for participation.

Data Collection

Trained clinical research coordinators (KCF, AM, OB) conducted one-on-one telephone interviews with patient participants (average duration: 38 min); coordinators may have had prior telephone or email contact with patients when collecting LiveWell data. An endocrinology fellow physician (KDG) conducted hour-long, one-on-one interviews over virtual video meeting platform with 5 CHWs with whom she had no prior relationship. Interviews were conducted in English or Spanish (AM and OB). Patient semi-structured interview guides (Appendix) were developed with input from all study team members to target 4 main content areas: general nutrition knowledge and dietary habits, barriers and facilitators to healthy eating, opinions on 5 possible components of a CHW intervention, and anticipated barriers and facilitators to intervention participation. The proposed intervention components included simplified nutrition education about reading nutrition labels and using a traffic light labeling system to identify the healthfulness of foods^32,33; shopping for groceries on a budget;³⁴ preparing culturally-relevant healthy meals; supermarket visits accompanied by CHWs to reinforce healthy choices and food budgeting; and linkage to community-based food programs. CHW interview guides (Appendix) explored the same content areas and additional questions about their perceptions of patients’ nutrition knowledge and opinions about home visits.

Patient demographics were previously collected as part of the LiveWell study. Data on household size, dependents, employment status, use of food assistance programs (eg, Supplemental Nutrition Assistance Program, food pantries), duration of hypertension diagnosis, and hypertension medication use were collected during interviews. CHW demographic data collected during interviews included years of CHW experience, age, gender, race, and ethnicity.

Data Analysis

Descriptive statistics were used to analyze demographic data. Coding and analysis of qualitative data was conducted by KDG, KCF, AM, and OB following the Framework Method, a seven-step systematic procedure commonly used for thematic analysis of semi-structured interview transcripts. This method was chosen for its ability to reduce and organize data into a structured framework matrix based on defined categories and codes, which allows all team members, even those not directly involved with the technical aspects of coding, to engage with the data and offer input in the analysis.³⁵ Interviews were audio recorded and transcribed using online digital transcription service. Three transcripts were initially chosen for independent review by 2 to 3 coders per transcript. Coders established a list of codes based on interview guide content areas, complemented by inductive addition of codes to capture novel concepts from the initial transcripts. Coders then compared and discussed codes and definitions. Once consensus was reached, a working analytical framework of codes was entered into Dedoose software (version 9.2.006, SocioCultural Research Consultants, LLC) to facilitate coding. Using this software, 2 coders (KDG and KCF for English or AM and OB for Spanish transcripts) independently indexed excerpts from each remaining transcript into this coding framework. Throughout the process, the coders discussed progress and questions to ensure consistent code application and added novel codes to the framework as they arose; any discrepancies were resolved with input from principal investigator ANT. Upon completion of coding, the coding team generated a framework matrix organized by interviewee, code, and excerpt to facilitate analysis of the data for common characteristics and themes.

Results

Participant Characteristics

Twenty-five patients and 5 CHWs completed interviews. Median age (IQR) of patients was 49 (33, 63) years. More than half of patients were female (60%) and Hispanic (56%); 32% spoke Spanish as their primary language. Participants self-identified race including 32% percent Black or African-American, 4% “mixed” race, 24% “other” race, and 40% White. The majority (88%) resided in a household of 2 or more people. Most (68%) did not have children in the household, and about half reported being unemployed. About 3 quarters of participants reported using at least 1 food assistance program such as Supplemental Nutrition Assistance Program or food pantries. All patients reported taking at least 1 daily hypertension medication. CHW ages ranged from 26 to 63 years old and most were female (N = 4). CHWs identified as Black, White, and Latinx. All had at least 2 years of CHW experience.

Patient and CHW Perceptions of Nutrition, Health, and Barriers to Healthy Eating

Table 1 presents themes surrounding patient and CHW perceptions of nutrition and eating habits with representative quotes. Patients and CHWs had general knowledge of healthy and unhealthy foods, but there were some inaccuracies (eg, cooking with butter is healthier than oil). Culture influenced eating habits and the perception of which foods were considered healthy; for example, Hispanic and Latinx patients and CHWs emphasized rice as a dietary staple but had mixed opinions on its healthfulness. While many patients and all CHWs understood the connection between diet and health, some patients were unsure of specific dietary recommendations for hypertension. When asked about nutrition labels, patients and CHWs referenced various items found on food packaging, including different aspects of the nutritional facts label (eg, serving size, calories), ingredient lists, expiration dates, brand labels, and price of food. Many patients expressed low confidence in interpreting these labels. Patients and CHWs reported receiving nutrition information from a variety of sources, including the internet, social media, television, family or friends, and healthcare professionals. However, patients had mixed attitudes about the reliability of nutrition information from healthcare professionals. While cost was identified as the primary barrier to healthy eating, other important barriers included concerns related to food preparation (ie, limited cooking abilities, lack of supplies or appliances, food spoilage), work and neighborhood food environments, time constraints and competing demands, and stigma related to use of food assistance programs.

Table 1.

Patient and CHW Perceptions of Nutrition, Health, and Barriers to Healthy Eating With Representative Quotes.

Topic/code	Theme	Patient quotes	CHW quotes
Nutrition knowledge and dietary habits	Most had general knowledge of healthy and unhealthy foods, but some knowledge gaps were identified	• “I don’t fry food no more. I don’t deal with oil. I use butter.” • “Well, the foods that I consider to be healthy is fruits and vegetables, but I eat steak and chicken, so I guess those are healthy, I hope.	• “I would say anything that’s cooked home is healthy.”
Nutrition knowledge and dietary habits	Culture influenced eating habits and perception of healthfulness of foods	• “My culture, we eat a lot of rice and beans. And when you go to family functions, there’s always rice and beans and pork.” • “The rice is healthy. Beans are healthy.”	• “I’m from a Latinx culture, so rice is super important to us, and trying to find ways and alternative foods to rice can be sometimes a challenge.”
Diet and health	Most participants understood the general connection between diet and health, but some patients were unsure of specific dietary recommendations for hypertension	• “If I suffer from high blood pressure and eat a lot of salt and not as healthy, it probably raises your blood pressure.” • “I assume [my diet] affects my blood pressure, but I don’t really know.”	• “Almost every patient I had is, on some levels, generally aware of how their diet affects their health. And this might be because they already talked to their PCP or their care team, and those conversations come up. There’s always at least a little bit of general awareness, always at least a little bit of it. How in-depth they know and how— it really depends, right? Patients know that salt is bad for you, but they don’t necessarily know that salty things—I mean, it’s the same as salt.”
Nutrition labels	Participants referenced various aspects of food packaging when discussing nutrition labels; many expressed low confidence in label interpretation	• “I might check out the ingredients list, take a quick glance at the nutritional values. But to be honest with you, a lot of that doesn’t really mean anything to me.”	• “It’s really convenient to look at something and see—for example, comparing the, ‘serving size’, you can get a jar of pasta sauce, and I’ll say the calories is 150 calories per serving. But when you look at its serving size and you realize it’s like one-eighth of the jar, and realistically, you’re going to use at least maybe like a third for each serving.” • “In the ingredient list, if it’s more so—if salt’s the first thing on the list, you know that, okay, that one has more.”
Sources of nutrition information	Participants receive nutrition information from a variety of sources	• “I Google what’s in stuff.” • “I have had the information from my doctors, who are more reliable from my point of view.” • “Doctors don’t know jack about nutrition . . . They don’t know what they’ve been told and taught. So I don’t require—I only go to social media to get information, which you think might be bad, but it’s worked out pretty good for me so far.” • “My friend and I sit around talking about what we eat, what our meds are.”	• “Social media definitely has influenced a lot my take on what is healthy eating. I followed a lot of Instagram blogs on easy-tofollow meals that are still healthy, so yeah, definitely. And good old Google is also really good.”
Barriers	Several barriers to healthy eating were identified by patients and CHWs	• Cost: “Food prices. Yeah, because if you want a healthy food, it’s expensive. If you want to buy organic stuff and fresh stuff, it’s more expensive than the other.” • Cooking-related barriers: “Yeah, definitely kitchen supplies and cooking skills. I have limited supplies as far as utensils go, pots and pans specifically. And then, yeah, I have never been taught to cook. I just read recipes and do my best.” • Work and neighborhood environment: “I try to avoid fast food, but obviously, sometimes that’s all that’s available to me depending on what time of night it is. In terms of restaurants, there aren’t many restaurants in my neighborhood that I frequent, which is another issue because sometimes I’m hungry and I don’t feel like driving anywhere.” • Time constraints: [Interviewer: “Do you have enough time to prepare meals?”] “I really don’t. The meal really require a lot of time, and so that’s the reason why I like to eat whatever I can find quickly.”	• Competing demands: “This is the hardest demographic of patients who exist because you know they’re in need in financial assistance. They just don’t qualify for government programs. I always try to get them to go to food pantries. And there’s lists I compile with times and opening dates and how often it can go, but they’re working. They’re driving Uber. They’re working night shifts, multiple shifts. And they’re not going to go to the pantry in time for distribution.”

Opinions on CHW-Delivered Intervention Components

Table 2 displays participants’ attitudes towards potential intervention components and barriers to participation in a CHW-delivered nutrition intervention for hypertension management. Simplified education about nutrition label reading and the traffic light labeling system received positive feedback from most patients and CHWs; many patients expressed interest in learning about the best dietary choices for their health conditions. Patients and CHWs generally favored resources to guide them in shopping for healthy groceries on a budget, and patients expressed particular interest in learning how to create shopping lists, use coupons, compare prices, and purchase a variety of foods. Patients and CHWs also favored resources to prepare culturally-relevant meals. While patients were especially interested in healthy recipe ideas, food substitutions, and food preparation methods, 1 CHW expressed concern about certain cultures being less inclined to measuring ingredients, making them less likely to view recipe resources favorably.

Table 2.

Patient and CHW Opinions on CHW Nutrition Intervention Components and Barriers to Program Participation.

	Patient and CHW quotes
Intervention components
Simplified nutrition guidance (e.g., traffic light labeling)	• “I think the traffic light for foods is a great way to go about it, and it’s an easier thing that can help patients who are visual learners.” -CHW • “Yes, that would be useful because then it would teach me how to read the labels, because actually sometimes I don’t understand it.” -Patient
Shopping on a budget	• “Because we have a limited budget. If they teach us how to [buy healthy foods on a budget], that would be ideal. For me it’s a good idea. I like it.” -Patient • “Yes, of course, yes, because sometimes there are some things in the supermarket that we think are cheap and maybe there is another place in the supermarket that is cheaper than this one.” -Patient
Preparing culturally-relevant healthy meals	• “It would be great to see recipes, new recipes, even if it’s something like videos on YouTube that show you how to make good food. You know what I mean? That kind of thing would be really good just to see new and different ways to do things with spices, with condiments, with cooking in general. Different ways to prepare things that are healthier than the way we were taught how to cook. Just throw butter in a pan and then throw the food in.” -Patient • “I think anything that’s in tune with their culture [patients] be open to.” -CHW
Supermarket visits with CHWs	• “I just think if people are getting the advice where they shop and when they shop, it’s going to be easier for them to remember it. They can say, oh, I remember when I was here and we did this.” -Patient • “Somebody that would go to the supermarkets with them, I don’t think would be very welcome. I feel like people would feel like it would be an invasion of their privacy. I feel like, I mean, being a SNAP recipient too, imagine somebody walking behind you while you’re shopping and you really want that and you don’t care what the nutrition label says and they’re chirping in your ear. Because you’re already feeling bad enough knowing that you have to shop carefully and you’re doing that . . .” -Patient • “Supermarket visits would be great, especially if the CHW feels confident and are well-trained enough to assess nutrition information. I think going to the supermarket with patients and seeing what they have access to is great.” -CHW
Linkage to community-based food programs	• “I think that [assistance locating or connecting with community resources] would be super helpful because I don’t know where—I didn’t even know they existed in my neighborhood.” -Patient • “I think food pantries might be fine because at least my stepdad [the primary food shopper] would still be able to use them occasionally. He doesn’t like going there in person because when he goes food shopping, it’s usually after work. He’d be wearing his uniform and he would be embarrassed.” -Patient • “I guess just having more programs that offer that, even if they do have the stipulations, just having different stipulations that meet the patient’s needs. It could just be that they’re—if they’re homeless, have a place they can go and have a meal as opposed to mailing it out, like a particular place that will offer. I guess just having the available resources mainly, is what I’m trying to get out there.” -CHW
Home visits	• “Visualizing the food environment is, I think, a really good strategy because then when you’re helping patients, you already know what’s in their kitchen or what tends to be in their kitchen.” -CHW • “If my patients are in the nearby area, I will drive to their houses. I have done that. But if they’re really far out, then it could be a potential issue just because of getting from one place to another and stuff like that.” -CHW
Barriers to participation in a CHW intervention
Barriers	• Time: “I mean, because sometimes you got two jobs. You got to run here, run there, and it makes it a little challenging [to participate].” -Patient • Stigma: “It’s not—the idea of somebody going to the grocery store with you and helping you pick nutritious meals and all that is wonderful. The problem that complicates that is because we’ve been stigmatized for so long, we’re going to be feeling like they’re there to watch us and judge us because the watching and judging has been going on for so long and nobody’s cared.” -Patient • Motivation: “I think complacency would be the main obstacle, whether I would want to participate in a program like this. I would be like, ‘It’s fine the way it is. So why not leave it?’” -Patient • Transportation: “It depends on the transportation because certain places I do drive, but certain places I won’t drive to.” -Patient

The idea of supermarket visits with CHWs was met with mixed attitudes. Many patients were interested in assistance with reading nutrition labels and choosing healthy, affordable options when shopping, but some patients described concerns about potential stigma associated with shopping with a CHW. Several patients and CHWs expressed worry about logistical challenges (eg, lack of transportation, scheduling conflicts). Similarly, patients provided mixed feedback on assistance connecting with community-based food programs, such as food pantries. While some patients expressed concern about quality of food provided at pantries, many patients expressed interest in a consolidated guide to food resources in their neighborhood that could accommodate their primary language, food preferences, and physical limitations. Some CHWs viewed home visits as an opportunity to provide tailored nutrition support while others expressed concerns about travel time and scheduling. Both patients and CHWs suggested that lack of time, motivation, or transportation, and stigma related to participation, could be possible barriers to enrolling in this type of intervention.

Discussion

This qualitative study of low-income community health center patients with hypertension and CHWs with hypertension coaching experience identified not only high cost of healthy food as a primary barrier to healthy eating but also several other factors that influenced dietary choices (eg, neighborhood and work environment, time constraints, competing demands, stigma surrounding the use of community food resources). Overall, patients and CHWs favored the development of a CHW nutrition intervention and were particularly interested in simplified education on healthy food choices using strategies such as traffic light labeling system to identify healthier food options^32,33 and reading nutrition labels, as well as approaches to shop for healthy food on a budget.³⁴

In addition to health professionals, family and friends were important source of nutrition information for patients. Since CHWs typically reside in the communities they serve,³⁶ they can leverage their position as trusted community members to deliver evidence-based nutrition counseling. CHWs can relate to patients through shared ethnicity, language, socioeconomic status, and life experiences,^37,38 empowering them with a nuanced understanding of their patients’ health needs and the ability to provide culturally appropriate health counseling. In their role, CHWs are typically trained in the navigation of community-based food resources, which was highlighted in the interviews as an important component of nutrition counseling.

CHWs could help improve diet for patients with hypertension as part of a collaborative care model in which primary care clinicians partner with a team of clinical staff to improve chronic disease management.^22,39
-41 CHWs can serve as a natural extension to this model for populations experiencing health-related social needs; evidence suggests that patients with food insecurity have a high likelihood of being referred to CHWs by care managers.⁴² As screening for health-related social needs becomes more common and as more states authorize Medicaid reimbursement for CHW services,^43,44 primary care referrals to CHWs are likely to increase.⁴⁵

This study explored with patients and CHWs how a future CHW intervention to improve diet in patients with hypertension and nutrition insecurity could be designed. Another study similarly incorporated participant feedback to develop and implement a single-arm pilot of a nutrition-focused CHW intervention to improve food security for formerly homeless adults living in a permanent supportive housing community. The study developed CHW intervention components based on needs assessments of 83 community residents and qualitative resident feedback. Results of this study found that most participants reported improved food security scores at 90 days follow-up.⁴⁶

Given that cost was identified as the primary barrier to healthy eating in this study, a CHW intervention that provides strategies for shopping on a budget could directly address this barrier. Study participants also reported that factors such as culture and food preparation techniques and preferences impact dietary choices. CHWs could provide patients with simple and culturally-appropriate strategies to prepare healthy meals, such as basic cooking methods and meal planning guides.⁴⁷ Because CHWs often provide care in community-based settings such as homes, schools, local businesses, or community centers,⁴⁸ home and supermarket visits with CHWs may be effective components of a CHW intervention for people with hypertension and nutrition insecurity. Linkage to community-based food resources such as nutrition assistance programs or food pantries, a strategy employed by other CHW-delivered hypertension interventions,⁴⁹ may also be effective but must be designed to minimize perceived stigma.

There are several limitations of this qualitative study. While the primary objective was to inform the design of a CHW-delivered nutrition intervention to improve diet and blood pressure control in patients with hypertension and nutrition insecurity, the sample was drawn from a larger cohort study of low-income community health center patients who may not have been experiencing nutrition insecurity during the study period. In addition, the sample consisted primarily of younger and middle-aged adults with Medicaid or commercial ACO insurance and took place within an urban health system with an existing CHW program in the Northeastern US, which limits generalizability.

Conclusions

In summary, this study identified many barriers to healthy eating among low-income adults with hypertension. Nutrition counseling delivered by CHWs, including simplified nutrition education, strategies for healthy eating on a limited budget, and linkage to community-based food resources, could improve diet and hypertension control in adults with nutrition insecurity. A CHW intervention could extend the reach of nutrition counseling for hypertension management, which does not occur routinely in primary care visits, and could improve health equity in populations experiencing health-related social needs.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319241285855 – Supplemental material for Patient and Community Health Worker (CHW) Perspectives on a CHW-delivered Nutrition Intervention for Low-Income Adults with Hypertension: A Qualitative Study

Supplemental material, sj-docx-1-jpc-10.1177_21501319241285855 for Patient and Community Health Worker (CHW) Perspectives on a CHW-delivered Nutrition Intervention for Low-Income Adults with Hypertension: A Qualitative Study by Kristine D. Gu, Jessica Cheng, Ashlie Malone, Katherine C. Faulkner, Oldy Bejarano, Emily Gelsomin and Anne N. Thorndike in Journal of Primary Care & Community Health

Footnotes

Author Contributions

ANT was responsible for the study design and funding. All authors contributed to the development of qualitative interview guides. KDG was responsible for drafting the manuscript text. All authors contributed to manuscript revision and have approved the final version, and all those who are qualified to be authors are listed.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institutes of Health [K24HL163073 (ANT), T32DK007028 (KDG), T32HL098048 (JC), and R01DK124145 (ANT)].

Ethical Considerations

The study received ethical approval from the Mass General Brigham institutional review board on November 8, 2022.

Consent to Participate

All participants provided verbal informed consent for participation.

ORCID iDs

Kristine D. Gu

Ashlie Malone

Anne N. Thorndike

Supplemental Material

Supplemental material for this article is available online.

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