Journey Maps to Understand Veterans' Experiences with Food Insecurity

Food insecurity is a socio-economic condition that affects approximately 1 in 5 Veterans. Veterans who are food insecure are more likely than their civilian counterparts to reduce their food intake or skip meals. Food insecurity is also associated with depression and suicidal ideation. Thus, assisting Veterans who are food insecure is critical to supporting their health and well-being.

Current solutions to help those who are food insecure primarily focus on federal programs like the Supplemental Nutrition Assistance Program (SNAP) and/or charitable food distributions. However, relatively little is known regarding Veterans' experiences with finding and using these resources. Thus, to understand and support Veteran-centered solutions, the HSR-funded study, Seeking Food Assistance: Food Insecure Veterans' Experiences Navigating through Systems, engaged Veterans who were food insecure to learn what they experienced as they navigated their way to food assistance.

"We're trained to survive… On the outside, we wouldn't look like people who struggle" - Veteran study participant

In the data collection portion of the study, investigators at the Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) at the Michael E. DeBakey VA Medical Center in Houston, TX used qualitative methods to construct a journey map of Veterans' experiences seeking food assistance.

Journey maps are visual representations of actions people go through, touchpoints they encounter, and emotions they feel as they navigate a task. During the design phase of the study, principal investigator Nipa Kamdar, PhD, worked closely with a small team of Veterans to draft and test a journey map template using the Veterans' own lived experiences with seeking food assistance. This template, along with the corresponding interview guide, allowed researchers to standardize interviews. Veteran participants were asked the same core questions about their experiences seeking nutritional security, allowing researchers to later assess response data for patterns and deviations.

The template consisted of three major columns reflecting Veterans' phases of food insecurity and food-seeking. The first phase explored Veterans' initial experiences with food insecurity such as in childhood or early adulthood. The second phase focused on identifying food insecurity in the healthcare setting. The third phase focused on connecting to food assistance resources. Additionally, to depict Veterans' emotions and reactions, three face icons were included: one in green and smiling, one neutral in yellow, and one frowning in red.

A draft of this template was tested with three Veterans who had experienced food insecurity but did not participate in interviews. Two were consultants to the project and the third was a Veteran peer navigator at the local VA hospital. They piloted the template as Veterans with their own food insecurity journeys to determine if it was broad enough to encompass the range of experiences the research team aimed to collect. Ultimately it was determined that filling out the template during qualitative interviews was too cumbersome, so a blank copy was provided to Veteran participants to help guide them, and the investigators completed the template post-interview.

Example of an initial Journey Map template of Veterans' food insecurity¹

After analyzing and coding interview transcripts, study researchers organized codes into the four phases in the original journey map template, and iteratively updated categories to better reflect Veterans' responses, resulting in the updated Journey Map template below:

1. Prior experiences with food insecurity became contributing circumstances
2. Inadequate food supply became recognizing food insecurity
3. Port of entry for assistance became recognizing food insecurity
4. Steps to seeking food assistance became finding help

The green, yellow, and red facial expression icons were replaced with descriptive terminology and short quotes from the qualitative interviews.

The revised Journey Map better chronicles Veterans' food insecurity experiences.

Over the course of the study, the research team learned several lessons about the process of journey mapping. Perhaps the most significant was the difficulty in following and completing a template during interviews. Study investigators suggest using a second team member to record responses where appropriate, while allowing for the interview to take a natural, conversational path. Additionally, regarding food insecurity, Veterans' journeys are seldom linear and often cyclical, necessitating flexibility in mapping. The inclusion of emotions and pain points helped to facilitate empathy in the research team and to help other Veterans who were not part of the study to identify their journeys, leading to discussion about successfully seeking help. Lastly, this study exemplified the importance of being prepared to share information to help Veterans with the subject being studied. For example, one interviewer was able to connect a Veteran participant with immediate-need housing resources and another with food pantries and something to eat during the interview.

"I didn't really feel like a human being. I felt more like an ant… and when you feel small like that… it's hard to even ask"

"I'm still in limbo" - Veteran study participants

This study was conceptualized through the course of a conversation with Veterans who shared their lived experiences with food insecurity. Investigators and Veterans were sitting together and discussing results from a prior study when insights the Veterans shared led to the question of what other Veterans may be experiencing as they navigate the various systems in search of help. The Veterans who inspired the current research read portions of the study's grant proposal and helped construct the journey map template. Once funded, they served as paid consultants on the study and continued to help with study recruitment, followed by interpretation and dissemination of results. Engagement with them and other Veterans early and often in this and subsequent studies has helped to keep the research Veteran-centered and serve their needs.

This study was the discovery phase of the human-centered design framework. The insights learned from the journey mapping research were used with funding through the HSR Career Development Program to support the development and pilot of an intervention to support Veterans who are struggling to meet food and other basic needs (e.g., housing, transportation). The results of the pilot are currently under analysis and will be disseminated soon. Some opportunities to improve care and services for Veterans who need food assistance can be done relatively quickly with leadership and staff support. Others, like policy change, will require more effort.

Opportunities to improve care for Veterans who are food-insecure²

References

1. Haltom TM, Kamdar N. Exploring Journey Maps as Products From Qualitative Research: Application Through Food Insecure Veterans' Experiences. Qualitative Health Research. October 4, 2024; online ahead of print.

1. Kamdar N, True G, Lorenz L, et al. Getting Food to the Table: Challenges, Strategies, and Compromises Experienced by Low-Income Veterans Raising Children. Journal of Hunger & Environmental Nutrition. 2022;17(1):32-52.

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