References
mistakes, allergies, Confusion, diabetes
RECRUITMENT, RECRUITMENT, ALLERGIES, EVENTS, DIABETES
Recruitment Flow Diagram, November 2021–February 2023.Participant Class Engagement Metrics After Re-Design by Study Arm and Preferred Language (Comparison of Study Arms with respect to the Role of the Facilitator, Setting, Requirements, Content, and Educational Approach.Original Design with Stakeholder Feedback and Description of Changes.Participants who miss DBC food pick-up cannot sign consent and do not pick up supplies (eCM arm).Participants cannot carry the full two-week supply of food distribution at DBC to the bus stop.Scheduling and coordinating food distribution pick-ups at DBC is cumbersome for the study team and distracts from primary recruitment tasks.Switch to a well-known, more accessible location (their clinic) for participants to meet with study staff.Change to phone-based opt-in for food assistance picks up at community organizations rather than an opt-out model.Allow participants who wish to continue going to DBC to pick up on a weekly basis to scale down the amount of food they must carry.Work with food assistance leaders (Crossroads, Sharing Life, and DBC) to provide a Food Assistance Resource List specific to ZIP code to decentralize efforts and allow participants to choose resources closer to them.DBC location is inconvenient, and participants expressed unfamiliarity/uncertainty with the process of using services.Participants who attend classes are highly motivated by individual benefits and find a way to make it happenEmphasize individual benefits of the class with enrolled participants during the notification calls and reiterate during in-person Orientation meetings (eCM only).Lack of internet-connected devices leading to exclusion of many patientsTarget recruitment to those with email addresses or MyChart access as a proxy for internet connectivity ^.Participants asking MNT staff about food pick up or asking study-specific questionsMeet periodically with RDs to ensure they are aware of study procedures and how to handle study-related questions.Introduce MNT staff RDs to DBC staff and set up a facility tour to familiarize them with local food assistance resources.High level of familiarity and relationship development with nutritionist, dedicated staff with recognizable interaction style (“patient visit”)Easier for participants to join due to flexibility (WebEx link via text, 1:1 scheduling, in-person, or virtual, unlimited reminders), but limited to working hoursGood feedback from participants, which did not require any redesign.Use this visit model to frame the redesign changes for the culinary medicine arm, including permanent instructor staffing, consistent/familiar relationship building with participants, ability to schedule make-up sessions (i.e., rescheduling), participant communication via text message, and texting the link to the class sessions.Not ready to cook when joining the class and prefer to “watch” video rather than cook in class.Would prefer to cook with their family members or friends in the class.Concerns about cooking at home and possible distractions (kids, pets, messy, etc.)Confusion about what to expect (missed pick up of supplies), what culinary medicine is, why, and how they should join.Unfamiliar with teacher/classmates, class format, timid about joining the class.Internet-connected device they have available to them is too small to see a video screen; or their internet service and/or connection is not strong enough for videoconferencing.Add a “watch only” option for the first class for those who are not ready to cook and open classes to peer and family attendance.Send video testimonials from other diabetes patients encouraging participants to do the classes ^.Revise info sheet and call scripts for clear and consistent messaging about the study goals, benefits, and expectations.Meet each participant in-person at a familiar location (i.e., their clinic) to conduct in-depth eCM Orientation meetings.Develop eCM Orientation Checklist to assess comfort level, identify household barriers, establish rapport and importance of class attendance, emphasize individual benefits and socialization, discuss comfort level with the first recipe (Tacos), and deliver a “tech module” for personalized app installation and teach-back learning of Zoom platform.Develop a Chef Biography and persona that participants can get excited to cook with and can relate to.Select “Sous Chefs” to assist with class and model desired behavior for participants, for example, asking questions, making mistakes, having messy kitchens, etc.Purchase participant tablets to ensure everyone has a large viewing screen for class participation ^.Share public library resource info sheet for internet hotspot rental program.Initial class attendance low. Participants experience events day-to-day that prevent them from joining the class, even when the day before, they voiced that they were planning to join.Time in between monthly classes is vast, and a lot can happen.Personal touch is important to participants before, during, and after intervention.Add personalized “check-in” calls in between classes to ask how they are doing, reiterate class material, see if they have attempted the recipe again, encourage them to submit a photo of the meal to share with the class, and ensure they are prepared for the upcoming class. Use this opportunity to discuss food preferences and substitutions for upcoming classes on a 1:1 basis outside of the group setting.Text the direct link with more engaging messaging: “Class starts in 2 h! Let us get cooking!—Chef Miguel”.Use WhatsApp or WebEx as more familiar platforms ^.Include a copy of the shopping list for the next class along with the grocery stipend they receive by mail to make sure they are prepared to cook and know what we are making.The written material presents a food literacy concern for participants, especially Spanish speakers, who are unfamiliar with recipes, cooking utensils, terminology.Contract bilingual, culturally competent RD for consistency across English and Spanish groups and for the duration of the class (6 months).Provide pictures of the finished meal in addition to the step-by-step recipes and ingredients list ^.Use in-person Orientation meetings to review each ingredient in the shopping list together with the participants in their native language to identify what they already have at home vs. what they need to buy before the class. Discuss their baseline understanding of the first recipe and potential obstacles to joining the class or preparing the ingredients (e.g., allergies, cheese affordability and preferences, etc.).* DBC = Dallas Bethlehem Center, our community-based partner for food pantry distribution. ^ Concepts that were suggested by stakeholders but were not implemented.Participant Characteristics at Baseline by Study Arm (* Self-Reported during baseline survey.