Fifteen community residents participated in the community-based SMA program; all chose to participate in the research study. The majority of participants were older adult, African American women (Table 1). Half the participants reported living with high blood pressure, one-third with diabetes, and one-fifth with sleep apnea. Most reported having health insurance and a primary care doctor. While almost all the participants reported feeling confident in meal preparation with vegetables, there were varied responses to healthful food availability and food security. All participants attended the 10 weekly sessions of the SMA program, which was facilitated by the Community Relations staff providing phone call reminders. One participant died about 2 months after program completion.
Participant Focus Group and Stakeholder Interview Themes
All FFL Community study participants joined in the first focus group after the SMA program. The majority reported by survey that they did not have a hard time following the nutritional recommendations, incorporating the lifestyle changes, taking the supplements, and/or eating the food delivery meals of the SMA program. Themes were grouped into three categories: 1) education and health changes due to the SMA program; 2) program preferences; and, 3) thoughts about future state.
Education and Health Changes
Participants shared several health changes as a result of the community-based SMA program. These included a greater understanding of food as medicine and inflammatory foods, more water intake, improved gut function, more mindful eating practices, and improved energy levels. Participants discussed the connection between program activities and function:
My thing is that it allows me to function, and function better. By eating the right foods, taking supplements, being mindful of what and when I eat. (Female participant)
Eat slowly. I ate so fast, they taught me to place fork down, and chew food thoroughly never used to chew, my food, and I’m enjoying the flavors in the food. (Female participant)
The routines help your body to feel better, more energy, I started jogging. (Female participant)
Several factors influenced the uptake of the community-based SMA program recommendations. Participants appreciated the time for and method of explanation given for nutrition choices, test results, and use of dietary supplements. A few commented that this was different than their current experience with medical care.
Most places don’t explain why you shouldn’t eat something, just to not eat it. (Female)
I liked the cardio metabolic testing they did. If you were to go to your doctor, they wouldn’t do that… [The SMA program staff] tell you what to focus on. No doctor has every mentioned that. (Female)
Community-based SMA participants appreciated the in-kind resources of meal delivery, dietary supplements, and laboratory testing. They especially liked the curriculum and delivery of the program, including the cooking demonstration session. The value of the group support was also discussed.
I like the way you focus on how’s and whys, why you do something. The group support was a main reason. We supported each other on things. (Female)
Participants’ preferences for changes to the program included more variety in food choices, even more individualized support, and more cooking demonstrations. Possible additions to the program included adding a physical activity component and ensuring an affordable program if supplements and food were not covered.
SMA participants had two main thoughts on next steps. The first was that they had received enough information to be in control of their health journey. The second was concern about continuing the habits without the group and the meal delivery/food component due to time and budget constraints. In response to the concerns, the Community Relations team provided health activities that would facilitate group members meeting and being accountable to their goals.
In learning what foods to eat to help blood pressure and cholesterol, we knew this, but being in group helped so much. I have been on millions of diets, and this is the first time I was able to lose weight, lower blood pressure, and cut my high blood pressure medicine. And now, I know where to go. (Female)
The program is not a piece of cake, you have to get off the couch. We have done healthy challenges, so this part wasn’t too difficult for us. But, with diet, it’s very hard because you have to pass a bunch of fast food restaurants when you’re getting from place to place, think about grabbing this grabbing that. You have to work at diet to stick with it. (Male)
A second focus group with eight participants was conducted 3 months after the completion of the community-based SMA program. All maintained several aspects of the program, including increased healthful food and water consumption. Barriers to maintenance stemmed from the loss of weekly sessions and the loss of prepared food (meal delivery) to support portion size and food choices.
Well one thing about being by myself, is that I don’t cook that much. Like if I do cook something, and I cook a big amount, it is all gone. Those dinners helped me a lot with the portion. Then when I tried to figure out what was too much by using the palm of my hand, I realized I had two pieces of chicken. I really have to work on that. It’s really hard. But the meals were helpful. (Female)
Facilitators for maintenance included preparing meals in advance, recalling learnings from the SMA program, receiving positive feedback on health, and sharing health education with family and friends.
I actually got a little lazier after the program because we were receiving the meals and we did not have to cook. It was really time saving. I ended up getting the meals again because I thought that was the easiest for me and the easiest way out. It isn’t difficult though. This Sunday I cooked three different things that would last for the week. Which I could’ve been doing; saving that Sunday to do all the time but it was football season at the time. (Male)
When I went to the hairdresser, they told me that my hair got stronger and that there was more hair. (Female)
I went to my regular doctor and they told me that whatever I’m doing, I should keep doing. They said I am in excellent shape and to continue doing what I’ve been doing. (Female)
Table 4 illustrates key themes for implementation as discussed with SMA program stakeholders. Barriers to sustainability include heavy time and personnel resources to carry out the program and need to adapt the program to community participants with significant medical and socioeconomic needs. Facilitators to implementation included enthusiastic clinical staff who were familiar with the content and could adjust to a lower health literacy group than seen in clinically-based SMAs, partnership with a trusted community organization, and ability to obtain in-kind resources to support participants’ full engagement in the program.
Stakeholder interviews findings on the implementation of community-based SMA program
What are the organizational resources to carry out the FFL Community program?
• Existing program adapted to community setting
• FTE support for multidisciplinary team - dietician, health coach, clinician, and administrative teams to deliver the program
• Ability to obtain in-kind donations for meal delivery, dietary supplements, laboratory testing, and printed health education material
• Existing community health activities and team that facilitated the selection of participants
What are the staff experience and capacity to carry out FFL Community?
• Significant clinical staff experience and passion to adapt the SMA program for a group with more health and socioeconomic needs than usual patients who may not have financial or environmental barriers
• Cultural competency and authenticity of providers
What are the potential barriers to implementing FFL Community?
• Significant time preparation for those that delivered the program content to meet participants’ health literacy and morbidity level (e.g., most participants did not have computers or wifi access so all materials needed to be printed)
• Large group as there was no attrition among the participants
• Lack of space in community setting made one-on-one sessions challenging for physical exam or lab review
• Lack of staff knowledge about local community resources - unsure if enough tools provide for participants to continue program on their own given environment and health conditions
• Sustainability and scaling limited as program was resource intense and non-revenue generating; dependent on philanthropic support
• Distrust between community residents and healthcare system
What are the potential facilitators to implementing FFL Community?
• Ongoing communication and engagement between the clinical and community teams for planning, flexible execution, and evaluation
• Weekly reminder calls to participants from the community team
• Participants were familiar with each other, health activities, and the community site which facilitated group engagement
• Meal delivery facilitated nutrition; unclear if sustainable
What potential modification to FFL Community would need to be made to maximize implementation?
• Better understanding of community members’ needs and assets to adapt program content
• More experiential learning, such as cooking demonstrations and grocery store shopping on food vouchers
• Develop and incorporate activities for longer support of participants