Strengthening Primary Care Through Project ECHO ® : Pilot Study on Nutrition,Brain Health,and Clinician Self-Efficacy

Abstract

Objectives:

Primary care clinicians are mostly the initial point of contact in providing patient care; however, many clinicians report inadequate training and a lack of confidence in promoting brain health among their patients from a nutrition perspective. This participatory mixed-methods study evaluated the impact of a Project ECHO® pilot program on clinicians’ perceived self-efficacy in promoting brain health through nutrition among Latino older adults in South Texas.

Methods:

Employing an explanatory sequential design, a training curriculum was designed for primary care clinicians using the Project ECHO® model. Four virtual sessions were provided once a week on nutrition-related topics through the videoconferencing platform Zoom. Quantitative data were collected via pre- and post-program surveys (N = 13) and analyzed using the Wilcoxon signed-rank test in GraphPad Prism Version 10.6.0 to inform subsequent qualitative interviews. Thematic analysis was conducted to examine the transcripts from individual interviews with 4 of the 13 participating clinicians using Taguette (Version 1.3, Open-Source Software).

Results:

Data indicated a statistically significant increase in mean self-efficacy scores among clinicians following program participation (P < .005). Participant satisfaction with the program exceeded 90%, and clinicians intended to integrate nutrition into brain health counseling with patients. Thematic analysis of individual interviews identified 3 key themes, including perceived training outcomes, evaluation of the study design, and suggested areas for program improvement.

Conclusions:

Findings suggest that the Project ECHO^® Nutrition and Brain Health program is a feasible intervention for improving clinician self-efficacy in delivering nutrition-based brain health care to Latino older adult populations. Future research should examine whether enhanced self-efficacy translates into practice change and improved patient outcomes.

Keywords

primary care geriatrics nutrition education brain health clinician self-efficacy underserved communities

Introduction

It is estimated that about 7.2 million older adults in the United States aged 65 and above are currently living with Alzheimer’s disease (AD), with a projected increase to 13.8 million by the year 2060.¹ According to the Centers for Disease Control and Prevention (CDC), older Black Americans are twice as likely, while older Hispanic Americans are 1.5 times more likely compared to older non-Hispanic White Americans to develop dementia.² In the state of Texas, 11.9% of individuals aged 65+ are reported to be living with AD, which exceeds the national average of 10.9% in the United States.³ This rate is particularly higher in South Texas, where over 14% of older adults are affected by AD, and 13.6% are classified as food insecure (limited access to quality food).³ Aging is the greatest contributing risk factor for developing AD, which disproportionately affects minority populations.² Other contributing factors include low socioeconomic status and higher prevalence of chronic diseases.² Lack of access to resources, poor nutritional status, inadequate medical care, prevailing health disparities⁴ can have a significant impact on older adults, leading to poor brain health outcomes.⁵

Nutrition is a modifiable risk factor for dementia, yet most older adults in the U.S. fail to meet their recommended needs.^6,7 According to the 2024 Lancet Commission Report on Dementia, about 45% dementia cases can be prevented by addressing modifiable risk factors, of which poor diet quality is an important one.⁸ The Healthy Eating Index (HEI) is a validated tool used to assess overall diet quality.⁹ Among older adults especially in the southern United States, HEI scores have remained consistently low at 59.5,¹⁰ with less than 2% meeting the recommended score of 80 out of 100 indicating poor diet quality.¹¹ Studies indicate that improved diet quality are associated with a significantly lower risk of dementia.^12,13 Additionally, the incorporation of culturally tailored nutrition programs can promote healthy eating patterns leading to better brain health; however, there is a dearth of programs that target minoritized populations.^14-16 The Worldwide Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), a large randomized controlled trial, demonstrated that lifestyle intervention focusing on dietary improvements, increased physical activity, cognitive training, and management of cardiovascular risk factors can significantly reduce the risk of cognitive decline and potentially delay the onset of dementia in at risk older adults.¹⁷ Similarly, another program in a Finnish long-term care facility aimed at improving nutrition for older adults with dementia trained primary care practitioners to assess nutritional status and enhance care. By integrating reflective learning models, clinicians tested new practices and learned from the outcomes. The program led to significant improvements, including increased caloric intake and key nutrients like calcium and folic acid for residents.¹³

Primary care clinicians are usually the initial point of contact in the care management domain and play an important role in proactive guidance and care for older adults.^18,19 Programs that improve clinicians’ skills and self-efficacy to apply evidence-based methods can address community needs and improve healthcare systems.^20,21 However, clinicians are often not equipped with adequate training to support nutrition-based lifestyle changes among their patients, specifically for the promotion of brain health and reduction of dementia risk.^22-26 Clinicians often lack self-efficacy in discussing nutrition, especially for marginalized populations.²⁷ Our pilot study created a Project ECHO^® program to increase their ability to promote brain health in older adults through effective nutrition guidance.

Methods

Study Design

This study utilized an explanatory sequential design with 3 phases (Figure 1). In the first phase, pre- and post-intervention self-efficacy measures and weekly questionnaires were collected and analyzed. The pre-intervention self-efficacy survey was completed at enrollment and prior to the first Project ECHO^® session. Weekly questionnaires collected feedback from participants about the session’s pace, achievement of weekly objectives, feedback on the instructor, and the intent to apply the session information in practice. The post-intervention survey was completed after the last session. The results from the self-efficacy survey guided the development of a semi-structured interview guide for the second phase, where individual interviews with clinicians were conducted online and thematically analyzed. The final phase integrated both quantitative and qualitative findings for interpretation of the outcomes.

Figure 1.

Mixed methods study design.

Project ECHO^® (Extension for Community Healthcare Outcomes) is an education model that aims to bridge the knowledge gap between healthcare practitioners and those with limited access to healthcare resources. The model utilizes videoconferencing, didactic presentations, and interactive case-study discussion between subject matter experts and participating clinicians.^28,29 We incorporated the Project ECHO^® model to create an evidence-based curriculum around nutrition and brain health for primary care clinicians who predominantly serve Latino older adults in South Texas.

Ethical Approval

The study protocol was reviewed, and all materials were approved by the University Institutional Review Board (IRB) (Protocol # 00000552) and determined to be exempt from full review in accordance with federal regulations. Prior to enrollment, all participants received information about the pilot study and provided informed consent, acknowledging that participation was voluntary and that they could withdraw at any time without consequence.

Development of the Project ECHO^® Nutrition and Brain Health Model

A participatory approach was used to ensure that diverse perspectives informed the development of the program and the study materials used for its evaluation. A community-academic working group was established that included the study lead, program facilitator, coordinator, two clinicians who work with diverse patient populations, and a community health worker with dementia training. The study lead, an expert in dietetics and nutrition, coordinated and facilitated the working group meetings. Through these meetings, the curriculum, program materials, recruitment flyers, surveys, and interview guides were developed. This collaboration supported the cultural adaptation of weekly presentation materials, informational brochures, recipes, and grocery list examples to better meet the needs of primary care clinicians managing the care of older adults in South Texas.

Participant Recruitment

Prior to conducting the study, a community assessment survey was administered to eligible clinicians at partner networks, to assess their educational interests, prior training, and perceived gaps in knowledge related to nutrition and brain health. Clinicians were asked if they were willing to be contacted to enroll in the program once developed. Seventeen clinicians initially completed the survey; however, 1 respondent was a dentist who did not meet the inclusion criteria, and 1 was a duplicate entry.

To facilitate recruitment, a flyer was shared with partner clinic networks, various listservs within the university, and community contacts such as Practice Based Research Networks (PBRNs), and hospitals. Inclusion Criteria: Clinicians that included Doctor of Medicine (MDs), Doctor of Osteopathic Medicine (DOs), Nurse Practitioners (NPs), Physician Assistants (PAs), Doctor of Pharmacy (PharmDs), within our partner networks could participate if (1) they were licensed in the state of Texas, (2) they practiced within the partner networks, and (3) if they were able to commit to attending at least 3 of the 4 sessions and complete all study activities. Exclusion criteria: (1) inability to read and speak English, and (2) inability to access/utilize videoconferencing technology.

Program Intervention

The program used the Project ECHO® model to deliver a four-session curriculum on nutrition and brain health. The “hub” team consisted of a facilitator, subject matter experts (a registered dietitian and a geriatrician), a coordinator, and technical support staff. Clinicians were participants and not members of the “hub” team. Each 90-minute session was conducted through the videoconferencing platform Zoom (Version 6.0, Zoom Communications, Inc., San Jose, CA, April 2024) and included a didactic lecture (30–45 min) and case-based discussions presented by participants. Curriculum topics included: (1) Introduction to Nutrition and Brain Health, (2) Evidence-Based Diets to Promote Brain Health, (3) Nutrition Resources for Patients, and (4) Practical Strategies for Primary Care. Didactic content incorporated examples tailored for Latino older adults, with emphasis on culturally relevant dietary practices, recipes, shopping lists, and local nutrition assistance resources.

Data Collection

Data were collected utilizing REDCap (Research Electronic Data Capture).³⁰ Participants completed both pre- and post-program surveys designed specifically for this study to evaluate clinician self-efficacy. The self-efficacy survey was developed ad hoc³¹ and comprised of 8 items rated on a 5-point Likert scale, ranging from “0 = not at all confident” to “4 = very confident” summed to a total score (0–32), with higher scores indicating a higher level of self-efficacy. The underlying construct measured was clinicians’ self-efficacy in delivering nutrition and brain health guidance. Pre-surveys were linked to enrollment forms that gathered demographic information and were administered prior to the commencement of the program. Post-surveys included questions regarding session attendance, which were verified through weekly attendance logs maintained by the study team. Participants received a $25 electronic gift card upon the successful completion of both the pre- and post-surveys. After a preliminary analysis of the survey data, the hub team drafted a semi-structured interview guide to further investigate key findings. Semi-structured interviews followed a guide that included 5 open-ended questions on overall experiences with the program, cultural relevance of the content, and recommendations for improvement. Interviewers (program facilitator and coordinator) had prior training and experience in qualitative interviewing and conducted the sessions via Zoom. Participants that engaged in the interviews received a $20 electronic gift card as compensation for their time.

Data Analysis

Data were analyzed using NCSS 2020, showing high internal consistency (Cronbach’s alpha = 0.95) for the self-efficacy survey. Wilcoxon signed rank was used to assess pre- and post-program scores using GraphPad Prism Version 10.6.0. All qualitative data were audio-recorded, transcribed, and de-identified. Thematic analysis was used to examine the transcripts using Taguette (Version 1.3, Open-Source software).³² Open coding was conducted by two reviewers to identify initial concepts, with codes subsequently refined and grouped into broader themes and subthemes.

Results

Of the 15 enrolled clinicians, 13 (87%) attended at least 3 sessions and completed both pre- and post-surveys. The majority were women (n = 11), aged 46 to 55 (n = 5), with over 10 years of practice (n = 8) in Family Medicine (n = 10). Most had dementia training (n = 11), but only 5 clinicians received prior training in nutrition and brain health (Table 1). Two clinicians were only able to attend 1 or 2 sessions and did not complete the post-survey due to scheduling conflicts. Their demographic characteristics did not differ meaningfully from those of participants that completed the study.

Table 1.

Demographic Characteristics of Project ECHO® Nutrition and Brain Health Pilot Study Participants (N = 13).

Measurement	Enrolled (N = 13)
Age in years ± SD	55 ± 3.38
Female (%)	85%
Practicing for more than 10 years (%)	62%
Practicing in family medicine (%)	77%
Received prior training in nutrition	38%
Doctor of medicine (MD)	54%

Self-efficacy surveys

A total of 13 participants completed the self-efficacy pre- and post-survey. Wilcoxon signed-rank tests indicated significant pre–post improvements across all self-efficacy items (all P < .005). Effect sizes were above 1.5, indicating large improvements (Table 2).

Table 2.

Self-Efficacy Scores from Pre- and Post-Surveys Completed by Participating Clinicians in the Nutrition and Brain Health Pilot Study.

Self-efficacy	M (±SEM) Pre-survey (N = 13)	M (±SEM) Post-survey (N = 13)	P value	Cohen’s d
Understand the connection between nutrition and brain health.	1.8 ± 0.3	3.7 ± 0.1	<.005	2.28
Describe strategies to lower the potentially modifiable risk factors in dementia.	2.2 ± 0.3	3.7 ± 0.3	<.005	1.56
Describe ways to manage symptoms and progression of dementia.	1.9 ± 0.4	3.4 ± 0.7	<.005	1.31
Recommend evidence-based diets that promote nutrition and brain health in older adults.	1.7 ± 0.4	3.8 ± 0.4	<.005	2.12
Describe the impact of food insecurity on brain health in older adults.	1.5 ± 0.3	3.7 ± 0.6	<.005	2.23
Can discuss culturally inclusive nutritional recommendations with patients.	1.1 ± 0.2	3.8 ± 0.4	<.005	4.53
Can discuss culturally inclusive with patients’ nutritional recommendations.	1.2 ± 0.3	3.5 ± 0.1	<.005	3.07
Able to use screening questions to assess patients’ nutritional status to improve brain health.	1.4 ± 1.1	3.6 ± 0.2	<.005	2.56

N = number of participants. M (±SEM) = M (±standard error of mean)

Pre–post differences were analyzed using the Wilcoxon signed-rank test. All comparisons were statistically significant at P < .005. Effect sizes are reported as Cohen’s d to indicate the magnitude of change.

Weekly Questionnaires

Weekly surveys (N = 13 per session) showed >90% satisfaction with session quality and content, with participants intending to integrate nutrition into brain health counseling. These findings support the strong relevance and acceptability of the curriculum.

Individual Interviews

All 13 participating clinicians were contacted via email to assess interest in individual interviews regarding their feedback on the training program. Of those, 4 clinicians agreed to participate in the interviews, of whom only 1 had received prior training in nutrition and brain health. Among those interviewed, all were female; 1 was a nurse practitioner and 3 were practicing in family medicine. Emerging codes from individual interviews transcripts were organized around 2 main themes regarding the perceived training outcomes, and evaluation of the study design. While no new codes emerged by the end of the 4th interview, limited sample size may restrict the range of perspectives.³³ Themes, Subthemes, and illustrative quotes, are presented in Supplementary Material 1.

Perceived Training Outcomes

Enhanced self-efficacy: Most of the clinicians reported a significant improvement in their self-efficacy when discussing nutritional and lifestyle changes that promote brain health. Many of the clinicians did not receive prior training with regards to nutrition and its impact on brain health.

Sensitivity to individual dietary needs: Most of the clinicians reported adopting a proactive approach to addressing nutrition with their patients allowing them to engage in detailed discussions about the importance of nutrition in brain health.

Evaluation of the Study Design

Course modality: All interviewees found the model beneficial due to its blend of lectures and interactive case studies focused on improving brain health through nutrition. This format encouraged collaboration and learning from each other’s experiences. Interviewees shared that the evening sessions supported their participation after clinic hours.

Practical application: The didactic lectures provided a variety of information and focused on practical applications. Among all the sessions, the one dedicated to identifying nutrition resources available within the community stood out as particularly beneficial.

Mixed-Methods Integration

Supplementary Material 2 presents the interpretation of data collected from participant interviews and self-efficacy assessments. Qualitative data collected from individual interviews provided deeper insights into the survey findings from the first phase of this study. Findings suggest that clinicians self-efficacy to promote brain health through nutrition may have improved due to previously limited resources. Taken together, quantitative and qualitative findings suggest that the program met clinicians needs to improve their knowledge of nutrition and community resources and in doing so, enhanced their self-efficacy to promote brain health with their patients. Themes identified through interviews explain the quantitative findings and are consistent with an explanatory sequential mixed-methods study design, illustrating how higher self-efficacy scores were reflected in clinicians’ practice intentions.

Discussion

This pilot study demonstrated that participation in the Project ECHO^® Nutrition and Brain Health program may improve self-efficacy among clinicians to promote brain health in their patients from a nutrition focus. Weekly evaluations also indicated high levels of satisfaction and intent to apply program content in clinical practice, supporting the effectiveness of this approach. Our findings align with previous research indicating that Project ECHO^® can build provider capacity in resource-limited settings and equip them with the tools and resources needed to incorporate nutrition focused care in dementia prevention, particularly in underserved populations.^34-36 The curriculum was developed in response to feedback from a working group that was designed to address gaps in nutrition knowledge. The curriculum aimed to enhance clinicians’ self-efficacy by providing evidence-based information and strategies to support nutrition and brain health among older adults. The model was overall well-received by participating clinicians who felt the online format allowed them to obtain important information they would otherwise not have had access to due to their busy practice schedules despite the initial challenges experienced during recruitment.³⁷

Communities with limited resources would likely benefit from a program that equips clinicians’ with knowledge around preventative strategies and tips to leverage existing resources.^38,39 As pharmacological interventions are being developed, they remain inaccessible for many communities impacted by dementia;⁴⁰ however, programs that promote self-efficacy among clinicians can serve as a preventative strategy to help improve brain health among marginalized communities. While clinician practice change and improved patient outcomes are the preferred endpoints of educational interventions, Project ECHO^® recommends prioritizing the evaluation of program effectiveness in achieving its immediate objective such as in this study of enhancing clinician self-efficacy. This pilot was designed to address that foundational step and gap in knowledge, with future studies aimed at assessing translation into practice behaviors and patient outcomes.

The study presents several limitations, most notably the small sample size and the potential for social desirability bias resulting from self-administered surveys. Additionally, the qualitative study interviewers were members of the ECHO hub team and may introduce response bias in the participants’ responses. Considering the very small sample size in the qualitative study, it is important to acknowledge that participants feedback and perspectives may not be representative of the overall study population. Participants were recruited from established community-academic partnerships. Specifically, these clinicians may already possess a strong motivation to enhance their knowledge regarding nutrition and brain health. Incentives provided in the form of gift cards may have affected clinicians’ interest in participating in the study. Although tailored to Latino populations, the curriculum was developed primarily by members of a working group who were experts, not community members; future adaptations must include involvement of patients and caregivers. While the curriculum concentrated on dietary practices tailored to the Latino population in South Texas, a few clinicians expressed the need for a broader approach. They suggested that incorporating an overview of nutritional guidelines from other cultures and locations could enhance their understanding of the role of nutrition in cognitive wellness. Future research should extend this work to populations in different geographic and cultural settings. The participants were only those who attended, and insights from dropouts could have provided more information on program feasibility.

Conclusion

As the incidence of AD and related dementia continues to rise, particularly in underserved regions, healthcare professionals in South Texas are facing significant challenges. This area is broadly characterized by persistent barriers to improving nutrition status in marginalized communities. This pilot study provides preliminary evidence that a Project ECHO^® program focused on nutrition and brain health can improve clinician self-efficacy in a primary care setting. Adapting this training curriculum for diverse populations in other regions could further enhance its effectiveness, ultimately improving support for more individuals affected by cognitive decline. However, the small sample size, lack of a control group, limited qualitative data, and potential biases restrict generalizability. Future work should strengthen the study design, co-design curricula with patients and caregivers to strengthen cultural tailoring and extend session duration to support development of a community of practice.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251388298 – Supplemental material for Strengthening Primary Care Through Project ECHO®: Pilot Study on Nutrition, Brain Health, and Clinician Self-Efficacy

Supplemental material, sj-docx-1-jpc-10.1177_21501319251388298 for Strengthening Primary Care Through Project ECHO®: Pilot Study on Nutrition, Brain Health, and Clinician Self-Efficacy by Vidya Sharma, Sara S. Masoud, Caitlin E. Sangdahl, Angelica E Davila, Richel Z. Avery and Cynthia De La Garza-Parker in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-2-jpc-10.1177_21501319251388298 – Supplemental material for Strengthening Primary Care Through Project ECHO®: Pilot Study on Nutrition, Brain Health, and Clinician Self-Efficacy

Supplemental material, sj-docx-2-jpc-10.1177_21501319251388298 for Strengthening Primary Care Through Project ECHO®: Pilot Study on Nutrition, Brain Health, and Clinician Self-Efficacy by Vidya Sharma, Sara S. Masoud, Caitlin E. Sangdahl, Angelica E Davila, Richel Z. Avery and Cynthia De La Garza-Parker in Journal of Primary Care & Community Health

Footnotes

ORCID iDs

Vidya Sharma

Sara S. Masoud

Caitlin E. Sangdahl

Ethical Considerations

The study protocol was reviewed and approved by the Institutional Review Board (IRB) at the University of Texas Health Science Center at San Antonio (Protocol # 00000552) and was determined to be exempt from full review.

Author Contributions

Conceptualization, Data Curation, Methodology: VS, SM, CS. Formal analysis: VS, SM, CS. Visualization: VS, SM, CS. Writing - original draft: VS. Writing - review: SM, CS, AD, RA.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this work was made possible through the Community Engagement Small Project Grant Award from the Institute for the Integration of Medicine & Science at UT Health San Antonio, Texas.

Declaration of Conflicting Interests

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

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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Strengthening Primary Care Through Project ECHO ® : Pilot Study on Nutrition,Brain Health,and Clinician Self-Efficacy

Abstract

Objectives:

Methods:

Results:

Conclusions:

Keywords

Introduction

Methods

Study Design

Ethical Approval

Development of the Project ECHO® Nutrition and Brain Health Model

Participant Recruitment

Program Intervention

Data Collection

Data Analysis

Results

Self-efficacy surveys

Weekly Questionnaires

Individual Interviews

Perceived Training Outcomes

Evaluation of the Study Design

Mixed-Methods Integration

Discussion

Conclusion

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251388298 – Supplemental material for Strengthening Primary Care Through Project ECHO®: Pilot Study on Nutrition, Brain Health, and Clinician Self-Efficacy

Supplemental Material

sj-docx-2-jpc-10.1177_21501319251388298 – Supplemental material for Strengthening Primary Care Through Project ECHO®: Pilot Study on Nutrition, Brain Health, and Clinician Self-Efficacy

Footnotes

ORCID iDs

Ethical Considerations

Author Contributions

Funding

Declaration of Conflicting Interests

Supplemental Material

References

Supplementary Material

Development of the Project ECHO^® Nutrition and Brain Health Model