“Food engages people, as we know”: health care and service providers’ experiences of using food as an incentive in HIV care and support in British Columbia, Canada

ABSTRACT

Food insecurity is widely documented among people living with HIV (PLWH) worldwide, and it presents significant challenges across the spectrum of HIV care and support. In North America, the prevalence of food insecurity among PLWH exceeds 50%. In the province of British Columbia (BC), it exceeds 65%. It comes as no surprise that food has become an essential tool in supporting and engaging with PLWH. Over the past decade, however, a shift has taken place, and food has become an incentive to boost uptake and outcomes of prevention, testing, treatment, and support. To explore this practice, we drew on a qualitative case study of incentives in the care and support of PLWH. This paper presents the findings of a targeted analysis of interviews (N = 25) that discuss food incentives and explores two main themes that shed light on this practice: (1) Using food to engage versus to incentivize and (2) Food is more beneficial and more ethical. Providers perceived food more positively than other incentives, despite the goal remaining somewhat the same. Incentives, such as cash or gift cards, were considered ethically problematic and less helpful (and potentially harmful), whereas food addressed a basic need and felt more ethical.

KEYWORDS:

• Food
• HIV
• incentive
• providers
• case study

Introduction

Food insecurity¹ is widely documented among people living with HIV (PLWH), and it presents significant challenges across the spectrum of HIV care and support, from prevention to treatment adherence and retention in care (Anema, Fielden et al., 2014; McKay et al., 2017). In North America, the prevalence of food insecurity among PLWH in urban settings exceeds 50% (Bekele et al., 2018). In the province of British Columbia (BC), it ranges from 66% to 73% (Anema et al., 2011; Anema, Kerr et al., 2014; Anema et al., 2016; Koehn et al., 2020). In recent years, food has become an essential tool in supporting and engaging with PLWH who are food insecure in BC (Miewald et al., 2018). Food has also become an incentive to boost uptake and outcomes of prevention, testing, treatment, and support (Gagnon et al., 2020). To explore this practice, we draw from a case study of incentives in the care and support of PLWH in BC (Gagnon et al., 2020) and offer some insights into the use of food more specifically.

Methods

We conducted semi-structured interviews with health care and service providers (N = 25) (Table 1). Each interview was audio-recorded, transcribed, and analyzed using Applied Thematic Analysis (Guest et al., 2011). For this paper, we extracted food-related data from these interviews, developed a coding matrix with nine codes. We used the codes to develop preliminary themes that were then compared and contrasted.

Table 1. Sample characteristics.

What year were you born?
1950s–1960s	4
1970s–1980s	15
1990s	6
How would you describe yourself?
Man	5
Woman	19
Non-binary	1
What is your highest level of education?
High School	2
College	6
Undergraduate	16
Graduate	1
What is your position?
Registered Nurse	15
Social Worker	2
Community Worker	3
Peer Worker	5
How long have you worked in this position?
<5 years	6
5–10 years	14
>10 years	5
How long have you worked with people at risk or living with HIV?
<5 years	6
5–10 years	15
>10 years	4

Results

Participants discussed three types of food incentives: (1) prepared meals, (2) purchased items in fast-food restaurants, but not full meals due to costs, and (3) snacks and coffee. During our analysis, we identified two recurrent themes: Theme 1. Using food to engage versus to incentivize and Theme 2. Food is more beneficial and ethical (Table 2).

Table 2. Key themes and selection of quotes.

Theme 1

Participant 24: Like, you know, even chatting and then bringing up the concerns that we were having. And they’ll want to go for coffee with you or they want to go get a [name of restaurant] or a burger or whatever, you know? But using those kind of things as tools in your pocket helped us to definitely get people to engage with us, for sure. Participant 17: So, a big part of our job, most of our job, is almost just the engagement, building the relationships and having an incentive like going for coffee is a huge thing. But yes, it certainly is helpful. I will get some people before I even have a conversation with them ask “Oh, could we go get a coffee?” or “I’m really hungry, I haven't eaten all day. Can I get a piece of pizza?” Participant 8: It was always, it would be if you, you know, say we did have someone that was challenging to go get their blood work done, it would be like, “Okay, if you go do your blood work today, we can go for coffee after. Or we can go for lunch.” Participant 19: Well, we have a small budget to help build rapport and therapeutic relationships with our clients and get them to trust us. We can take them out for coffee, you know, before an appointment or something. Or buy them a burger from [name of restaurant], that kind of thing. Participant 6: But you know, I have different opinions on the type of incentives. Like I like the juice and granola bar. Like why not? You know? Would I even call it an incentive? I guess it is, but I just feel like food, food I have, I’m more, like I just felt I wanted to be a part of the food part of things.

Theme 2

Participant 25: Well I think for me as a care provider, definitely food felt like a cleaner transaction. But, yeah, like it felt more aligned with my values as like a [name of the position] to be, you know, nourishing people's bodies, giving them something that their medications can kind of absorb into. Participant 13: I was trying to think of kind of incentives that they provide there. They also offered food, but that's more of just a kind of stabilization and helping with absorption for HIV medications and a lot of antibiotics and that kind of thing (…) And a lot of people who start at the program are really, like they’re people who don't have access to food. Sometimes people come in and it's their only meal of the day. Participant 4: And I think part of it is this idea of like, there are certain things that we can do to, yeah, to address those basic needs that we have at our disposition. Like, for example, a snack because you know that you can't really have a conversation with someone if they’re stomach is growling and they’re, you know, starving. Participant 11: Sometimes we do buy people a snack and meals out of our own pocket because there's no money in the program to do that. I think all of us has kind of made that decision because we knew that this is the last dot that will connect us with the client who is very difficult to engage. You know what I mean? Participant 16: So we would really try hard to like kind of make sure that everybody's needs were met. But also, at the same time, sometimes that did require limiting and rationing of the resources that we do have. From a therapeutic perspective, that's tough when a person is legitimately hungry and they want two sandwiches.

Using food to engage versus to incentivize

The nuance between engagement and incentivization was the most common theme discussed by participants. They described engagement as a process whereby food is used to foster trust, build a rapport and a therapeutic relationship, connect with clients, start a conversation, and provide support. Participants compared food to having a “tool in your pocket” to engage with clients who would not otherwise engage. In other words, they saw it as a relational tool that can break through barriers in the provision of HIV care and support, not so much a carrot at the end of a stick. This was an interesting finding because participants described using food to reward clients for participating in outreach, doing blood tests, taking HIV medications, going to clinic appointments. They also acknowledged that without food, clients would not show the same level of engagement and would likely not engage at all. Food motivated them to engage.

Increased perceived reward and heightened motivation are two classic characteristics of incentives – and are the main reasons they work, especially with people who need them the most. Yet, we found that participants pushed back against the view that food is “just an incentive.” Three main factors can explain this. First, food felt different from other incentives and generated a different experience for both providers and clients. Compared to a ten-dollar gift card, for example, food feels more relational and less transactional. Second, food was more flexible than other types of incentives. For example, taking someone out for coffee and a meal makes sense when establishing a new therapeutic relationship with a client. However, it may not be useful and possible every time you encounter that client. Participants considered that a food incentive was akin to having a relational tool in their pocket. Finally, we noted that participants who worked in programs where food was provided in a more structured way shared a similar view and described the provision of meals as an appropriate extension of HIV care and support.

Food is more beneficial and more ethical

The second theme emerging from the interviews is the special status of food compared to other types of incentives. Participants explained that, unlike money, gift cards, and prize draws, food is inherently beneficial for two main reasons. Eating is a basic need, and as such, providing food to clients who are food insecure is an act of care and support even if this gesture is conditional upon them doing something (e.g., taking medications). Providing food is also part of promoting health, and for this reason, participants considered it a “cleaner incentive,” one that helps clients meet health goals and outcomes. Overall, feeding clients felt overwhelmingly beneficial and consequently more ethical. This practice was not without ethical tensions, however, and issues such as rationing food, budgetary constraints, and out-of-pocket spending by providers arose from the interviews.

Participants found themselves in situations where they had to ration food, and this was particularly difficult given the severity of the food insecurity experienced by clients. For example, some participants described situations in which clients were asking for more food. They had to justify not providing more or, alternatively, bending the rules to provide more. The main ethical dilemma faced by participants was that of rationing food to ensure fairness or making exceptions to meet the individual needs of particular clients who may be more hungry that day. Budgetary constraints also posed a challenge to participants and resulted in an overreliance on “cheap” food, especially fast-food restaurants. The rationing of food and budgetary constraints pushed some participants to pay out-of-pocket, albeit reluctantly. Using their own money seemed more ethical than denying food to a client. However, this practice did not sit well with participants who had to absorb the expenses and manage boundaries.

Discussion

Our findings highlight three important points. First, food provision transforms health care and service providers into food providers. From the perspective of clients who engage in daily survival provision and consumption of food, this shift can effectively change how they perceive (and welcome) interactions with providers. For example, these interactions may be assigned more value and higher priority. They may also lead to more compliance given the conditional offer of food. Second, providers act as new access points in complex “geographies of survival” (Miewald et al., 2017). Miewald and colleagues have documented these “geographies of survivals” by mapping how PLWH “shuffle” from one food access point to another every day (Miewald et al., 2017, 2018, 2019). Interactions with providers thus become part of that daily survival “shuffle.” Third, food is an effective tool when engaging clients who experience high rates of food insecurity. Interestingly, providers believed that providing food to hungry clients in return for engagement was ethically different from offering cash to (the same) low-income clients in return for (the same) engagement. When providers used food incentives, they did so in this context and within existing structures and relations of power. This point was clearly illustrated in our general findings (Gagnon et al., 2020) but less so in this targeted analysis. One reason for this could be that focusing on engagement and benefits allowed participants to create a depoliticized and neutralized account of their practice. Alternatively, it offered a lesser evil type of narrative that positioned food as more ethical than other incentives. Our findings suggest that relationality is central to how providers used food incentives. In other words, they used food within the context of their relationships with clients by fostering trust, rewarding behaviors, and keeping clients engaged. However, unlike other charitable food providers, they differed in that they expected something in return. They provided food to make it more appealing and rewarding for the most “at-risk” clients to engage – knowing that they would not otherwise.

Providers perceived food more positively than other incentives, despite the goal remaining somewhat the same. Food felt more ethical. This distinction is interesting and worth interrogating. Historically, programs and services that provide food to low-income communities have been described as “spaces of care” (Miewald et al., 2019). The provision of food, as participants pointed out in this analysis, is an act of care and support. However, we question if this holds when the provision of food is contingent upon meeting with a provider, going for a blood test, taking medications, attending a clinic appointment, and so forth. One could argue that health care and service providers are engaging in this practice because they care. However, this rationale is paternalistic and does not address why clients struggle in the first place. We also find issues with the type, quantity, and quality of food offered. Providing these incentives may feel more ethical and beneficial. But are they?

Conclusion

Our findings provide critical insights into the use of food as incentive. They also confirm the importance of exploring better ways of caring for and supporting PLWH who experience food insecurity. Tackling food insecurity and its impact on health outcomes requires community-based, low-cost, and self-sustaining approaches that can generate quality and diverse food in sufficient quantities to meet the needs of PLWH, provide opportunities to cook and store food safely and foster mutual support. It requires an approach rooted in food justice.

Authors’ contributions

MG, AG, and VB designed the case study. MG conducted the interviews. AP extracted the food-related data and led the literature review. AP completed the initial coding of the data and worked with MG to finalize the themes. MG wrote the manuscript. AP, AG and VB revised the manuscript and contributed to the discussion. All authors read and approved of the final version.

Ethics and consent to participate

This study was reviewed and approved by the Research Ethics Board of the University of Victoria and the University of Windsor.

Availability of data and materials

In order to protect the confidentiality and anonymity of participants, the data (transcripts) will not be shared.

Acknowledgements

We would like to thank all the providers who contributed to the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was funded by the Canadian Institutes of Health Research, Grant # 159826.

Notes

1 Food insecurity is the experience of lacking “physical, social, and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life” (Anema, Fielden et al., 2014, p. 478).