State Implementation of SNAP Waivers and Flexibilities During the COVID-19 Pandemic: Perspectives From State Agency Leaders

ObjectiveTo describe state agencies’ implementation of the Supplemental Nutrition Assistance Program (SNAP) during the first year of the coronavirus disease of 2019 (COVID-19) pandemic, barriers and facilitators to SNAP implementation, and recommendations to improve SNAP implementation.DesignQualitative methodology guided by Bullock's determinants of policy implementation framework using 7 semistructured, virtual focus groups in April 2021.SettingTwenty-six states representing all 7 US Department of Agriculture Food and Nutrition Service regions.ParticipantsFour focus groups with state-level SNAP administrators and 3 focus groups with state-level SNAP supportive services (Supplemental Nutrition Assistance Program-Education, Employment & Training, and Outreach) supervisors (n = 62).Phenomenon of InterestSupplemental Nutrition Assistance Program implementation during the COVID-19 pandemic.AnalysisThematic analysis using a phronetic iterative approach.ResultsSix primary themes emerged: the policy response, technology needs, collaboration, participant communication, funding realities, and equity. Implementation challenges included the design of waivers in the early pandemic response, inadequate federal guidance and funding, outdated technology, and prepandemic regulations limiting state authority. Modernized technology systems, availability of virtual programming, partnerships, and enhanced benefits facilitated SNAP implementation.Conclusions and ImplicationsSupplemental Nutrition Assistance Program administrators adapted their programs to deliver services virtually during the COVID-19 pandemic. These experiences highlighted the importance of certain policy determinants, such as modernized technology and streamlined application processes, to improve outcomes for SNAP participants and staff.     

Identification of a Framework for Best Practices in Nutrition Education for Low-Income Audiences

To promote effective low-income nutrition education programs, an expert panel of nutrition education and public health researchers built consensus around 28 best practices grouped into 5 domains (Program Design, Program Delivery, Educator Characteristics, Educator Training, and Evaluation) targeting direct delivery of nutrition education. These best practices can be used to assess program strengths, promote fidelity in delivery and evaluation, and design research to strengthen programs’ evidence base. A survey of Supplemental Nutrition Assistance Program–Education nutrition education leaders helped identify staff development needs and interest relative to specific best practices. Best practices can be used to identify staff development needs among frontline educators, supervisors, and program leaders in Supplemental Nutrition Assistance Program–Education, Expanded Food and Nutrition Education Program, and other programs targeting low-income audiences.     

Household Supplemental Nutrition Assistance Program Participation is Associated With Higher Fruit and Vegetable Consumption

ObjectiveExamine whether differences were present by Supplemental Nutrition Assistance Program (SNAP) participation in dietary patterns, achievement of dietary recommendations, and food security for children (aged 7–18 years) receiving free/reduced-price school meals.MethodsCross-sectional study. Caregiver–child dyads at a pediatric clinic completed validated surveys. Food security, dietary patterns, and achievement of dietary recommendations were compared between child SNAP participants/nonparticipants.ResultsAmong 205 caregivers, 128 (62.4%) reported SNAP participation. Percentages of child SNAP participants/nonparticipants meeting recommendations were largely nonsignificantly different and overwhelmingly low. Supplemental Nutrition Assistance Program participants reported higher mean daily servings of vegetables (P = 0.01) and fruits (P = 0.01) than nonparticipants. Caregiver-reported household food security was not significantly different between SNAP participants and nonparticipants (P = 0.44).Conclusions and ImplicationsIn this study, child-reported fruit/vegetable intakes were significantly higher among SNAP participants than nonparticipants, suggesting child SNAP participants may experience small but noteworthy benefits related to fruit/vegetable consumption. Additional supports are needed to achieve dietary recommendations.     

Use of Survival Analysis to Predict Attrition Among Women Participating in Longitudinal Community-Based Nutrition Research

ObjectiveTo identify participant characteristics and study methodology that influenced the completion of a 15-month community-based longitudinal study evaluating the impact of the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program.DesignObservational longitudinal 15-month study across 12 data collection timepoints. Sociodemographic characteristics were collected with a paper-based survey at baseline.SettingFive counties across central and southern Illinois.ParticipantsWomen, aged 18 to 65 years (n = 297), recruited at sites likely to serve families eligible for the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program (housing departments, child care centers, etc).Main Outcome MeasuresPredictors of participant attrition during the study duration.AnalysisCox proportional hazard models.ResultsNinety-seven participants were retained across the full study. In unadjusted models, greater income and education levels were significantly related to lower attrition; however, this relationship did not persist in a multivariate model. When adjusted for other characteristics, larger household size was the only measured variable significantly related to greater odds of attrition (odds ratio = 1.09; 95% confidence interval = 1.02, 1.17).Conclusions and ImplicationsSeveral characteristics predicting attrition in other settings were not significant in this study. Future attrition analyses that evaluate social support, transportation capacity, and type of phone in longitudinal nutrition education studies are warranted.     

COVID-19 Benefits and Dietary Behaviors Among Mothers From Low-Income,Food-Insecure Households

ObjectiveTo examine the dietary behaviors of mothers from very low food security (VLFS) households following the availability of coronavirus disease 2019 (COVID-19) unemployment and Supplemental Nutrition Assistance Program benefits.MethodsDiet and food security status were obtained from 2,584 California mothers during Federal Fiscal Year 2020. Fruits, vegetables, and 100% fruit juice (FV100%FJ), sugar-sweetened beverages, and water intake, and Healthy Eating Index-2015 scores, were compared across 4 groups (before vs after COVID-19 benefits by VLFS vs non-VLFS households) with race/ethnicity and age as covariates.ResultsBefore COVID-19 benefits, VLFS was associated with fewer cups of FV100%FJ (P = 0.010), more fluid ounces of sugar-sweetened beverages (P = 0.004), and poorer diet quality (P = 0.003). After COVID-19 benefits, mothers from VLFS vs non-VLFS households reported similar dietary outcomes. VLFS mothers reported 0.96 (95% confidence interval, 0.53–1.38) more cups of FV100%FJ after COVID-19 benefits.Conclusions and ImplicationsCoronavirus disease 2019 benefits may have reduced dietary inequities among low-income families. Associations between increased Supplemental Nutrition Assistance Program and unemployment benefits and decreased costs associated with the negative health outcomes linked to food insecurity and poor diets would be of value.     

Effectiveness of Expanded Food and Nutrition Education Program in Changing Nutrition-Related Outcomes Among Adults With Low Income: A Systematic Review

ObjectiveTo review the effect of the Expanded Food and Nutrition Education Program (EFNEP) in changing nutrition-related outcomes.MethodsRelevant research conducted before December 2020 was identified using PubMed, Web of Science, Google Scholar, and the EFNEP Research Database. The methodological quality of each eligible study was assessed.ResultsOf the 406 studies found, 30 were eligible; 26 studies were on EFNEP, and 4 included both EFNEP and Supplemental Nutrition Assistance Program Nutrition Education (SNAP-Ed). The sample sizes ranged from 35 to 122,961. Outcome measures included consumption of food groups, nutrients, other nutrition-related behaviors, and food security. At least 1 immediate behavior change (P < 0.05) was reported in each study, but long-term maintenance of behavior change was not evident.DiscussionThis review found a consistent, immediate improvement in nutrition behaviors after program participation but poor retention over time. Overall, variation in programming and outcome measures, incomplete reporting, and generally low study quality by modern standards precluded strong conclusions.Implications for Research and PracticeThis review identified the need for control groups, improved reporting of program protocols, theory-based curriculum, and measurement of long-term outcomes.     

The Impact of ABAWD Time Limit Reinstatement on SNAP Participation and Employment

ObjectiveEstimate the impact of the Supplemental Nutrition Assistance Program (SNAP) time limit for able-bodied adults without dependents (ABAWD) on SNAP participation, employment, and earnings.DesignA quasi-experimental study using state administrative SNAP and earnings data to compare outcomes for SNAP participants before and after the time limit went into effect.ParticipantsSupplemental Nutrition Assistance Program participants in the study cohorts in Colorado, Missouri, and Pennsylvania (N = 153,599).Main Outcome MeasuresMonthly SNAP participation, quarterly employment, annual earnings.AnalysisLogistic and ordinary least squares multivariate regression models.ResultsTime limit reinstatement reduced SNAP participation by 7 to 32 percentage points in the 12th month of time limit reinstatement but did not generate evidence of improved employment or annual earnings (1 year after time limit reinstatement, employment decreased by 2 to 7 percentage points and annual earnings decreased by $247 to $1,230).Conclusions and ImplicationsThe ABAWD time limit reduced SNAP participation but did not improve employment and earnings. SNAP may provide helpful support to participants as they seek to enter or re-enter employment, and removing this support may be detrimental to their employment prospects. These findings can inform decisions about requesting waivers or pursuing changes to ABAWD legislation or regulations.     

Evaluation of a Policy,Systems, and Environmental-Focused Faith-Based Health Promotion Program

ObjectiveThis study assessed the impact and lessons learned from implementing policy, systems, and environmental (PSE) changes through Faithful Families Thriving Communities (Faithful Families), a faith-based health promotion program, in 3 southern states.MethodsFaithful Families classes and PSE changes were implemented through a coordinated effort between the Expanded Food and Nutrition Education Program (EFNEP) and Supplemental Nutrition Assistance Program–Education (SNAP-Ed). Changes were measured using a faith community assessment, site reports, and annual reporting.ResultsThirteen faith communities participated in the intervention. A total of 34 PSE changes were implemented across the 3 states, affecting 11 faith communities with 4,810 members across sites.Conclusions and ImplicationsPrograms such as Faithful Families can allow EFNEP and SNAP-Ed to coordinate to implement PSE changes in community settings. However, these types of coordinated programs to support faith communities require time for relationship building and trust, adequate training, and strong support for faith-based lay leaders as they carry out this work.     

Training Needs of Nutrition Educators Engaged in Policy,Systems, and Environmental Approaches

ObjectiveAssess training needs of nutrition educators incorporating policy, systems, and environmental (PSE) approaches into their obesity prevention efforts, to identify content for online training.MethodsConducted a national, online survey of state and local Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program Education professionals engaged in PSE efforts.ResultsRespondents (n = 601) rated the importance of 24 training topics related to planning, implementing, and evaluating PSE approaches. Most (21) topics were rated very important or essential, confirming the need for a comprehensive approach. Paired-sample t tests found significant differences (P <0.001) in some training needs between local and state staff (eg, training in evaluation rated higher for state staff). Training needs did not differ by program, region, or length of employment. The top 5 settings for PSE efforts were schools, farmers’ markets, food banks/pantries, community gardens, and after-school programs.Conclusions and ImplicationsResults informed the development of an online training for program implementers. Future research will be needed to assess and refine training needs further, which will evolve as nutrition educators gain more experience in PSE approaches.     

Plate Waste in School Lunch: Barriers,Motivators, and Perspectives of SNAP-Eligible Early Adolescents in the US

ObjectiveTo determine barriers, motivators, and perspectives regarding plate waste reduction of early adolescents.DesignTrained interviewers conducted audio-recorded individual interviews with adolescents.SettingElementary schools implementing the National School Lunch Program in Hawai‘i, Montana, and Virginia.ParticipantsEarly adolescents (n = 47, aged 9–13 years) from families receiving or eligible to receive Supplemental Nutrition Assistance Program benefits were recruited to participate.Phenomenon of InterestFactors influencing plate waste among adolescents and potential plate waste reduction strategies.AnalysisCoders analyzed content and thematic data to identify code categories and themes.ResultsMain barriers to reducing school lunch plate waste were unsupportive school policy, undesirable food quality, satiation, and social influences. Key motivators to reducing school lunch plate waste were supportive school policy, including allowing students to share food with peers and save food to eat later; and social influences. Participants found it acceptable to throw away disliked food and unacceptable to throw away wanted food; they perceived that their peers did not care whether food was thrown away; and they thought their parents disliked wasting food.Conclusion and ImplicationsResults suggest that several factors might allow for minimization of school lunch plate waste in the National School Lunch Program, including improvements in food quality, food policy, and social influences. Under these important themes, strategies to employ may include improving food preparation and taste, allocating more time for students to finish lunch, allowing students to self-select food lunch items, and permitting them to share and save their leftover food.     

Connecting Families at Risk for Food Insecurity With Nutrition Assistance Through a Clinical-Community Direct Referral Model

ObjectiveTo assess the feasibility of a clinical-community direct referral model to enroll eligible households in the Supplemental Nutrition Assistance Program (SNAP).MethodsPediatric clinics screening for food insecurity (n = 27) invited families experiencing food insecurity to participate in a direct referral to a local organization that assists with SNAP applications. A food stamp specialist telephoned participants to determine SNAP eligibility, assist with the application, and/or provide other supports. Referrals, eligibility determination, enrollment, and estimated benefits were tracked.ResultsA total of 486 families were referred to the community partner; 72% (n = 351) were successfully contacted by a food stamp specialist, with 17% (n = 83) applying for SNAP benefits. Another 16% (n = 79) were already enrolled in SNAP but received an additional service.Conclusions and ImplicationsThis referral model was feasible and increased the number of families who received nutrition assistance. This approach could be adapted for other health-related social needs.     

Developing an online certification program for nutrition education assistants

ObjectiveTo develop an online certification program for nutrition education paraprofessionals to increase knowledge and confidence and to overcome training barriers of programming time and travel expenses.DesignAn online interactive certification course based on Supplemental Nutrition Assistance Program-Education and Expanded Food and Nutrition Education Program core competencies was delivered to employees of both programs. Traditional vs online training was compared. Course content validity was determined through expert review by registered dietitians. Parameters studied included increase of nutrition knowledge and teaching technique/ability, educator satisfaction, and programming costs related to training.SettingUtah State University Extension.ParticipantsTwenty-two Supplemental Nutrition Assistance Program-Education and Expanded Food and Nutrition Education Program educators in Utah.Main Outcome MeasuresKnowledge and skills were measured using pre/posttest statistics. Participant satisfaction was measured with a survey.AnalysisPaired t test; satisfaction survey.ResultsThe change in paraprofessional knowledge score was statistically significant (P < .001). Forty percent of paraprofessionals strongly agreed and 60% agreed they were better prepared as nutrition educators because of the training. An estimated $16,000 was saved by providing the training online as compared to a face-to-face training.Conclusions and ImplicationsThis interactive online program is a cost-effective way to increase paraprofessional knowledge and job satisfaction.     

Can the introduction of a full-service supermarket in a food desert improve residents' economic status and health?

PurposeTo estimate the impacts of a new supermarket in a low-income desert, on residents' economic status and health.MethodsWe surveyed a randomly selected cohort in two low-income Pittsburgh neighborhoods before and about 1 year following the opening of a supermarket. We used difference-in-difference approach to test changes across the two neighborhoods in residents' food security, United States Department of Agriculture Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women Infant and Children participation, employment, income, and self-reported health/chronic disease diagnoses.ResultsWe observed declines in food insecurity (−11.8%, P < .01), Supplemental Nutrition Assistance Program participation (−12.2%, P < .01), and fewer new diagnoses of high cholesterol (−9.6%, P = .01) and arthritis (−7.4%, P = .02) in the neighborhood with the new supermarket relative to residents of the comparison neighborhood. We also found suggestive evidence that residents' incomes increased more ($1550, P = .09) and prevalence of diabetes increased less in the neighborhood with the supermarket than in the comparison neighborhood (−3.6%, P = .10).ConclusionsLocating a new supermarket in a low-income neighborhood may improve residents' economic well-being and health. Policymakers should consider broad impacts of neighborhood investment that could translate into improved health for residents of underserved neighborhoods.     

Few Changes in Food Security and Dietary Intake From Short-term Participation in the Supplemental Nutrition Assistance Program Among Low-income Massachusetts Adults

ObjectiveTo examine whether short-term participation in the Supplemental Nutrition Assistance Program (SNAP) affects food security and dietary quality among low-income adults recruited from a Massachusetts-wide emergency food hotline.MethodsA 3-month, longitudinal study was conducted among 107 adults recruited at the time of SNAP application assistance. Outcomes included household food security (10-item US Department of Agriculture Food Security Survey Module), dietary intake (eg, grains, fruit) and diet quality (modified Alternate Healthy Eating Index). Data were analyzed using paired t tests and multivariable linear regression.ResultsSupplemental Nutrition Assistance Program participation was not associated with improved household food security over 3 months (P = .25). Compared with non-participants, SNAP participants increased refined grain intake by 1.1 serving/d (P = .02), from baseline to follow-up. No associations were observed with other foods, nutrients, or dietary quality.Conclusion and ImplicationsPolicies that simultaneously improve household food security and dietary quality should be implemented to support the health of low-income Americans participating in this crucial program.     

SNAP-Ed Policy,Systems, and Environmental Interventions and Caregivers’ Dietary Behaviors

ObjectiveTo examine dietary behaviors and diet quality among caregivers of children regarding the number of policy, systems, and environmental (PSE) change interventions implemented in their neighborhoods.MethodsHouseholds with incomes ≤185% of the federal poverty level were randomly sampled throughout California. A validated 24-h dietary recall assessment tool was administered by telephone. The independent variable was the number of Supplemental Nutrition Assistance Program Education PSE change interventions per census tract where the caregivers lived.ResultsMost (69.1%) of the 2,222 caregivers were Latino. Policy, systems, and environmental reach predicted decreased intake of sugar-sweetened beverages (P = 0.022, Cohen d = −0.12) and added sugar (P = 0.014, Cohen d = −0.18), and increased Healthy Eating Index–2015 scores (P = 0.046, Cohen d = 0.18), regardless of race and/or ethnicity, age, or reach of Supplemental Nutrition Assistance Program Education direct education.Conclusions and ImplicationsReplication of these methods and findings, and comparisons of dietary outcomes in association with PSE change interventions with and without direct education activities aimed at the same population under study, are encouraged.     

Being Motivated by Nutrition Is Associated With Healthy Home Food Environment of Supplemental Nutrition Assistance Program (SNAP) Recipients

Objective

To examine the relationship between food shopping motivating factors and the home food environment (HFE).

Trauma-Informed Financial Empowerment Programming Improves Food Security Among Families With Young Children

ObjectiveTo determine how trauma-informed programming affects household food insecurity (HFI) over 12 months.DesignChange was assessed in HFI from baseline to 12 months in response to a single-arm cohort intervention. Measures were taken at baseline and in every quarter. Two participant groups were compared: participation in ≥4 sessions (full participation) vs participation in <4 sessions (low/no participation).SettingCommunity-based setting in Philadelphia, Pennsylvania.ParticipantsA total of 372 parents of children aged <6 years, participating in Temporary Assistance for Needy Families and the Supplemental Nutrition Assistance Program, recruited from county assistance offices and community-based settings.InterventionTrauma-informed programming incorporates healing-centered approaches to address previous exposures to trauma. Sixteen sessions addressed emotional management, social and family dynamics related to violence exposure and childhood adversity, and financial skills.Main Outcome MeasuresHousehold food insecurity, as defined by the US Department of Agriculture Household Food Security Survey Module.AnalysisMixed-effects logistic regression models were used to compare groups from baseline to 12 months, controlling for adverse childhood experiences, depression, and public assistance.ResultsThose with full participation had 55% lower odds of facing HFI compared with the low/no participation group (adjusted odds ratio = 0.45; 95% confidence interval, 0.22–0.90).Conclusions and ImplicationsTrauma-informed programming can reduce the odds of HFI and may reduce trauma-related symptoms associated with depression and poverty.