Description of the sample
People who took part were aged from 26 to 83 years of age (mean age = 53). All but one reported having multiple conditions with 16 participants reporting they were living with three or more conditions. All were on medication and in most cases, multiple types of medication. Thirteen participants were retired or were unable work due to ill-health with the remainder either in paid or voluntary work. Table 1 provides a full account of the participants’ profile.
Study participant profile
Gender
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Age Range (in years)
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Ethnicity
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Self-Reported Health Condition(s)
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Employment Status
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Self-Rated Health Status
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Male
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70 -79
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White Scottish
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Stroke, mobility issues, left-sided weakness
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Permanently sick or disabled
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Good
|
Male
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80 - 89
|
Other British
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Heart problems, circulation issues, stomach issues
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Permanently retired from work
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Fair
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Female
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70 - 79
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White Scottish
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COPD, osteoporosis, stomach ulcer, back and leg pain, mobility issues
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Permanently retired from work
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Fair
|
Male
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50 - 59
|
White Scottish
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Angina, heart problem, asthma, sciatica, mobility issues
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Permanently sick or disabled AND looking after family
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Very Bad
|
Female
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70 - 79
|
White Scottish
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COPD, osteoporosis, asthma, fibromyalgia, heart blockage
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Other – volunteer
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Bad
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Female
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40 - 49
|
White Scottish
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Under-active thyroid, stress following family bereavement
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Unemployed and seeking work (volunteer)
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Fair
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Female
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30 -39
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White Scottish
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Polycystic kidney - kidney failure, depression and anxiety
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Unable to work due to illness
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Bad
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Female
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60 -69
|
White Scottish
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Fibromyalgia, osteoarthritis, spondylitis, asthma, diverticulitis
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Unable to work due to illness
|
Bad
|
Female
|
50 -59
|
Irish
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COPD, IBS, anxiety and depression
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Unable to work due to illness
|
Bad
|
Male
|
40 - 49
|
White Scottish
|
Lower back pain, various injuries to feet and ankles, psoriasis, mental health problems and anxiety, severe migraines, suicidal thoughts, self-harm. Previous history of drug misuse
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Permanently sick or disabled
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Fair
|
Male
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60 - 69
|
White Scottish
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"Horseshoe” kidneys (low kidney function), anxiety, IBS, digestive problems, high blood pressure and cholesterol
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Unemployed and seeking work (volunteer)
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Fair
|
Male
|
60 - 69
|
White Scottish
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COPD, agoraphobia, fibromyalgia
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Unable to work due to illness AND Permanently sick or disabled
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Bad
|
Male
|
50 - 54
|
White Scottish
|
Arthritis and depression
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Unable to work due to short-term illness or injury
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Fair
|
Female
|
30 - 39
|
White Scottish
|
type 1 diabetes, anorexia, depression, anxiety
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Employed part-time
|
Fair/ Bad (varies)
|
Male
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50 - 59
|
White Scottish
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depression, arthritis, high blood pressure, stomach problems
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Unemployed
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Fair
|
Male
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20 - 29
|
White Scottish
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Type 1 diabetes
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Employed part-time and volunteer
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Good
|
Male
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40 - 49
|
White Scottish
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Type 1 diabetes, strokes and depression
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Other - volunteer
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Fair
|
Female
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50 - 59
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Other British
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Lupus SLE, underactive thyroid, arthritis, tendonitis, MH issues, endometriosis, irritable bladder, irritable bowel
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Employed full-time
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Bad
|
Female
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30 - 39
|
White Scottish
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Anxiety and depression, asthma, arthritis
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Permanently sick or disabled
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Fair
|
Male
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50- 59
|
White Scottish
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Depression, history of substance misuse. Previous Hepatitis C
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Unemployed & Seeking Work AND Unable to work due to short-term illness or injury
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Good
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Our analysis generated four key themes which included: 1. food practices - compromises and trade-offs that related to economic constraints and lack of choice; 2. food scarcity and illness experience as they related to participants’ physical and mental ill-health; 3. the (in)visibility of economic vulnerability in the context of health care consultations: 4. participants’ notions of useful health care professional support in relation to their health condition self-care practices and life circumstance challenges.
Food practices - compromises and trade-offs
Eating was commonly described as an erratic and solitary activity, which provided little enjoyment, or the nutritional balance necessary for good health. Choice and agency over food consumed was severely limited. This dictated not only what participants said they were able to buy or were given to eat by the food bank, but also where and when they were able to eat. For example, this participant talks about being advised by his doctor to stay off work for a few days, which he ignored to acquire to milk for his tea:
...cause the worst-case scenario is I run out of milk, for my tea…But, er, that's happened a couple of times and all, and I'm like, right, I know I'm no feeling well, and say the doctor's telt me to stay off work for a couple of days, I'll just come into work, just for the sheer fact I get milk...but I'll do a full day's work just to get that milk, do you know what I mean? (Keith, 48).
Few participants ate three meals a day. Most reported eating one meal a day or going without food for several days and living on beverages such as tea and coffee during those times. Some viewed this pattern as their normal, illustrated by this example where the participant talked about his daily routine which was characterised by a lack of predictability of there being food in the house to make even one meal in the day:
I get up in the morning, maybe have a cup of tea, depending .., sit about, maybe wait to supper time, maybe throw something in the microwave or the oven, if there's something there, and that's it (Pete, 44).
Others thought their diet fell short of what they thought should and wanted to be eating. Jimmy talks here for example, about having to buy and eat cheap, carbohydrate-based food that he wouldn’t ordinarily choose to eat:
To make it [money] spread further cause you're buying, you're buying food you don't usually, we don't want to eat, you use it, like pies and things, we'll three, four in a packet, or cheap pizza which is, you get one for a pound, that's a meal in itself basically, and er, just cheap kind of loaf… (Jimmy, 61).
The example above illustrates a coping strategy commonly described across the sample involving the maximising (stretching out) their household food resources by buying cheap or quick and easy to prepare foods.
Other coping strategies described, included cooking from scratch using inexpensive ingredients (such as cheaper cuts of meat which tend to be higher in fat, described in the following quote) and/ or food hoarding for times when money and food may be scarce:
I tend to do like a, a, a tinned shop. I'll buy like all the, the beans and spaghetti and pasta and stuff, you know, the dry stuff, I'll buy all of that sort of monthly and then the rest is kind of weekly, cause I don't know what money I'm going to have for the month and I don't know what's going to happen and, who's going to need what or, whatever, so it tends to be just weekly picking up, you know, maybe a pack of mince but, we would, like a pound of mince would do maybe three meals for the two of us so, you know, and we would just, I've got like packets of mince in the freezer, like half a pack or a third of pack, tend not to, you know, spread things out rather than bulking things up with the mince (Heather, 54).
It was also evident that people had a clear system of prioritising other family members’ food needs were prioritised above their own. In particular, mothers described ensuring that their children’s nutritional needs were satisfied first. This practice applied to both adult children, as well as dependent, young children:
…obviously I've got to feed the kids. They still are my main priority ... (Julie, 37).
Additionally, bills, such as housing costs and heating were prioritised and paid for first. Food assumed lesser status as an area of spending and was often minimised to accommodate other necessary household expenditure:
...and, with my budget, I think food is basically the bottom of the list...pay for everything and then, then it's food shopping and generally there's just not really a lot of money for food shopping (Heather, 54).
All participants expressed appreciation for the support they received from the food bank or food pantry. Both organisations were described as a key source of basic foods (such as tea, coffee, sugar, pasta, jars and tinned foods), as well as fresh produce (including fruit, vegetables, some meat and fish), that would otherwise be out of reach due to budget constraints. They found that both organisations could not always meet all of their dietary needs. That experience was tempered with low expectations that their needs could be met at all. This appreciation for and perception (and acceptance) of food supply constraints is illustrated here where one participant with lactose intolerance maintained:
They're (food bank) quite good. If there's any soya milk, that sort of thing, they keep it back for me…they do a sterling job, yeah… (Tom, 61).
Food scarcity and illness experience
All participants were dealing with one or more physical and/or mental health condition. Some participants reported they were living with conditions such as diabetes and bowel problems that required dietary monitoring and management. Diet (quantity and quality) was also a key issue in many other types of conditions because it played an instrumental role in medication regimes, and people’s overall health and well-being.
Those who reported having diabetes or a condition that required care and monitoring of their dietary intake, such as bowel conditions, indicated they had good knowledge of the sorts of foods they believed they should be eating to manage their condition. However, realising that knowledge was not always possible due to financial constraints. Some found affordability was a barrier to an appropriate diet on a regular basis, others, from time to time. Those participants described using a range of coping strategies to help them deal with fluctuations in their household food supplies. These included; skipping meals, cutting back on medication because of food scarcity, adopting a “trial and error” approach to eating potentially troublesome, but affordable foods, and, food hoarding during times when financial constraints were less severe, illustrated in the comments below:
I might eat something and I'll feel extremely bloated or extremely tired... (Mary, 53).
I could maybe go and buy and say, well, that’s maybe like £2 something, I'll try that, if it doesn't work, I'll know, I canna buy that again... (Patricia, 66).
what I try and do is, try and stock up a wee bit so, we've always got food in the cupboard, you know, even if it's tinned stuff...(Grant, 51).
All participants were taking some form of medication and in most cases, multiple types of medication. Some of those on oral medication, which needed to be taken with food, said it wasn’t always possible to do so because they didn’t always have enough food. Jenny discussed how she regularly missed a dose of her medication to avoid unpleasant gastric side effects:
my arthritis medication, I'm meant to take that three times a day but, I've to take it with food or it can make you quite sick...so I, find that I can only take those tablets twice a day. So, I'm not getting the good of them… (Jenny, 30).
Indeed, several of the participants appeared unclear about the dietary advice around taking their medication(s), specifically whether medication should be taken with food or on an empty stomach. Some participants questions during the interview concerning medication and dietary advice prompted reflection of the consequences of overlooking stated advice on taking medication.
…six months ago I was on like 34 tablets a day, ken…and there was only a couple of them I noticed that you've got to take with, with food or without food but, I never really look at that…maybe that's why I sometimes get a sore stomach and everything, ken, cause actually thinking about it (Pete, 44).
Commonly, people also described how lack of food, lack of choice over food, and/or unappetising food had an adverse effect on their mental health, as illustrated below:
Well, it definitely affects your health cause, if you have, erm, nothing in the fridge that you would consider nice then you're just going to not bother and you're going go back to bed and not eat anything... it will lower your mood… (Mary, 53).
Eleven of the 20 participants stated they were suffering from depression at the start of interview.
(In)visibility of economic vulnerability
We asked participants about their experiences of discussing their food access challenges with their health care professionals including their general practitioner (GP)[1]. We were struck by the extent to which their narratives revealed that this issue remained unspoken and seemingly invisible in those discussions. Most believed their GP was unaware of their struggle to put food on the table and commonly indicated it was not a subject that their GP raised with them during a consultation. Many considered GPs to be exclusively concerned with treating their presenting physical or mental illness, as Grant notes:
It's just, I get the impression if you go to the doctor, you're nae wanted there, ken what I mean? You just, you've to get in and get out as quick as possible…Well, they've got ten minutes to get you in and out and that's it... (Grant, 51).
This quote also represents a commonly expressed perception that GPs were working within tight time constraints as far as appointments were concerned, and this factor inhibited the opportunity to talk about any possible financial problems that might prevent them following any dietary advice given. GPs were viewed as extremely busy, as it was, to talk about this sort of issue:
the GPs aren't really interested, they've got enough to do that they're nae going to turn around and say, “well, have you had something to eat today?”… (Raymond, 56).
It was also notable that GPs were considered to lack the appropriate knowledge and understanding to assist them with this problem:
my first thought of that would be, do the GPs actually know what's out there, erm, I'm going to say no…I wouldn't go to my GP to ask...(Lucy, 31).
This was not a perception that was confined to GPs. Other types of health care professionals were cited as giving participants advice that was not economically feasible for them to follow either. This lack of awareness or understanding became apparent as people spoke about being advised to eat certain foods or follow a specific diet that was unattainable due to cost, illustrated below:
…it was like the renal nurse, she told me to try like joining Slimming World but, I can't afford it (Julie, 37).
In a few cases, participants described their health care professionals advising and directing them on food management practices they were not able to follow due to the debilitating symptoms and bodily experiences associated with their health conditions. One woman talked about her difficulties when her GP advised on cooking advice during a consultation:
he told me just like porridge but, make porridge from scratch and like, I don't have energy to do that... (Julie, 37).
While most participants did not think that healthcare professionals were aware of their patients’ financial struggles, most also admitted that they didn’t actively disclose or volunteer information about their financial issues or food insecurity to their GP or healthcare professional either.
Notions of useful health care professional support
When asked what sort of support they wished to receive from health care professionals in relation to being food insecure, most participants thought it would be helpful if those professionals were aware of this challenge. In some cases, participants thought that GPs and other relevant professionals should be aware when people were experiencing food insecurity. GPs in particular were viewed as being the first point of contact with primary care services, and thought to have an important role to play in supporting people affected by food insecurity. Some believed it was down to the individual person to reveal this problem, yet at the same time, held the view (along with other participants) that health care professionals should proactively probe to find out if people were struggling to cope. The following quotes illustrates the conundrum revealed by this discussion in the data. In this first example, Jenny talks about a perceived role for GPs signposting to a dietician that she thought might help her cope better with her situation. Initially, she indicates that she should raise the issue with the GP, but simultaneously asserts that this sort of support should be routinely offered by the GP as routine. The second quote also highlights the challenge that flagging financial struggles to health care professional represents to some people with mental health problems, with this participant concluding that there should be more obvious signals coming from the health care environment that this is an issue people can get help with:
I think that would be something [GP referral to dietician] I could ask for...and then, but it should be something that's offered (Jenny, 30).
and
if you have a certain type of mental health issue it's hard to do that, asking, the approaching, sometimes, oh, they're better off with not being here and, if that makes kind of sense so, it can be difficult. I think, I think there should be a lot more information for individuals saying, this is available for you, this is where you can go, this is who can help... (Susie, 49).
Some participants thought health care professionals themselves would find it difficult to raise the issue because they might be concerned not to offend their patients, illustrated here:
…they canna really say to someone cause they dinna want to hurt their pride… (Patricia, 66).
However, the dominant theme in the data was the notion that it should be the responsibility of the health care professional to enquire about financial challenges as it was a difficult topic for patients to raise. This perspective was thought to be due to feelings of shame, embarrassment and in some cases, exacerbated by their health condition, as discussed above.
One dimension of the perceived benefits of a health care professional knowing about a person’s financial struggle was the apparent comfort that would be derived from knowing the GP or health care professional was aware of their position. It seemed that health care professional-knowing (which we believe was something akin to having empathy with their position) would, for some, be sufficient and mentally therapeutic in itself, as explained here
.. at the end of the day it's, it all goes back to the same, if, if it gets it out of your head and somebody listened to you and they tell, kind of, it's just a different, somebody else's different, looking at it a different way (Raymond, 56).
The other dimension of this health care professional-knowing was the view that it would enable better access to food-based help and support. Health care professionals were viewed as important signposting or referral agents to services such as food banks, support groups, food pantries or social groups or specialist health and social care professionals and services. Those included dieticians, social workers, nurses, community psychiatric nurses and pharmacists. Participants’ expectations of health care professional support did not include their being able to help with or alleviate the financial challenges that has caused our participants to be food insecure in the first place.
[1] A general practitioner in the UK is a general medical practitioner that is based in the primary care setting, sometimes referred to as a family doctor in other national jurisdictions.