Participant Perceptions of the Double Up Food Bucks Program at Oregon Farmers’ Markets

ObjectiveTo explore perceptions of program impact among Double Up Food Bucks participants in Oregon.MethodsData were collected from 1,223 Double Up Food Bucks participants at 42 Oregon farmers’ markets. Chi-square tests of independence and logistic regressions were used to examine associations among key variables.ResultsMost participants reported buying more fruits and vegetables (FVs) (91.0%), trying new FV types (82.2%), eating less processed food (69.8%), having more food available at home (81.1%), and perceiving improvements in health (87.9%). Perceptions of affordability were higher among younger adults (P < 0.001) and households with 3–5 people (P = 0.02), with children (P < 0.001), and without chronic disease (P = 0.003). Perceptions of increased FV purchases were higher in households with children (P = 0.009) and reported overall health improvements were higher among non-White participants (P = 0.04). Perceptions of increased FV purchases and affordability were associated with other positive program outcomes.Conclusions and ImplicationsParticipants may perceive barriers to purchasing FVs from farmers’ markets, which are not fully addressed by the increased purchasing power from a FV incentive. Targeted redesign, outreach, and education may improve program experiences among groups with less positive perceptions. Further research to identify explanations for variation in program experience is needed.     

A Qualitative Exploration of Predominantly White Non-Hispanic Tennessee WIC Participants’ Food Retail and WIC Clinic Experiences During COVID-19

BackgroundThe novel coronavirus disease 2019 (COVID-19) has widened many existing nutrition disparities. In response, federal nutrition assistance programs have introduced flexibility waivers in programs, including the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), to rapidly respond to support the nutritional health status of income-eligible participants during COVID-19. Waivers were approved that permitted flexibilities in the WIC food package, WIC vendor guidelines, and WIC clinic experience. The impact of these waivers on WIC participants’ retail and clinic experiences remains unknown.ObjectivesOur aims were to understand the experiences of WIC participants in food retail settings and with WIC clinics during the COVID-19 pandemic and to explore WIC participants’ perceptions of the impact of COVID-19 on their family’s overall health, well-being, and daily lives.DesignWe conducted semi-structured phone interviews between April 30 and May 7, 2020.Participants/settingParticipants were 24 adults in WIC-enrolled families residing in Tennessee.AnalysisUsing grounded theory as the analytical framework, 2 coders completed an iterative, data-driven analytic process within NVivo, version 12. Hierarchical maps, coding matrices, and concept maps were used to aid direct content analysis for theme detection.ResultsFive primary themes emerged, including shopping barriers (existing compounded with new), coping strategies, impact on mental and emotional health, social comparison, and unintended consequences of COVID-19 on WIC families.ConclusionsCOVID-19 created additional barriers to food security among WIC families and negatively affected their health and well-being. To meet the needs of this vulnerable population during and beyond the pandemic, the carryover of WIC flexibilities (ie, physical presence and food package substitution waivers) after COVID-19 may improve the ease of overall program participation.     

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.     

‘They say God punishes people with HIV’: experiences of stigma and discrimination among adults with HIV in Dili,Timor-Leste

Abstract

Little is known about the experiences of people with HIV in the small island nation of Timor-Leste. This study explored the HIV-related stigma experiences of adults aged between 18 and 40 living with HIV in Dili, Timor-Leste. Participants were interviewed on topics related to living with HIV, both as key informants describing the experience of others with HIV known to them, and also with respect to their own personal experiences. Findings suggest that people with HIV in Timor-Leste face stigma and discrimination in various contexts. In this predominantly Catholic country, perceptions of HIV and attitudes towards people with HIV appear to be commonly shaped by religious beliefs. In families and communities, participants encountered gossip, social exclusion and threats of violence. In health settings, participants experienced discrimination from health providers in the form of failing to maintain confidentiality and inappropriate treatment. The impact of stigma was profoundly negative and influenced participants’ decision to disclose their status to others. Participants attributed stigma to a lack of information about HIV among the general public. Unless stigma reduction interventions also address the Church’s role in shaping perceptions of HIV, education campaigns are unlikely to be effective in reducing HIV-related stigma.     

Electronic dietary recording system improves nutrition knowledge,eating attitudes and habitual physical activity: A randomised controlled trial

ObjectiveThis study's objective was to investigate whether use of an electronic dietary recording system improves nutrition knowledge, eating attitudes and habitual physical activity levels compared to use of a food diary and no self-monitoring.MethodsSixty adults aged 20–60 with a body mass index ≥ 25 were recruited and randomly assigned to one of three groups: a group using an electronic system (EG), a group using a food diary (FD) and a control group using nothing (CG) to record food intake. All participants took part in three 60–90 nutrition seminars and completed three questionnaires on general nutrition knowledge, habitual physical activity levels and eating attitudes at the beginning and end of the 12-week study. The pre- and post-test scores for each questionnaire were analysed using a paired sample t-test.ResultsSignificant improvements in the domain of ‘dietary recommendations’ were found in the EG (p = 0.009) and FD groups (p = 0.046). Great improvements were found in ‘sources of nutrients’, ‘choosing everyday foods’ and ‘diet–disease relationships’ in EG and FD groups. EG group showed greater improvement in the work index and sport index.ConclusionAn electronic dietary recording system may improve eating and exercise behaviour in a self-monitoring process.     

Development of Reliable and Valid Questions to Assess Food Resource Management Behaviors in Adults With Limited Income

ObjectiveDevelop reliable, valid questions to assess changes in food resource management (FRM) behaviors in adults with limited incomes.DesignQuestionnaire development using a mixed-methods approach: content validity (subject matter and curricula), face validity, temporal reliability (test-retest), sensitivity to change, and exploratory factor analysis (EFA).SettingCommunity settings in 12 states.ParticipantsConvenience samples of English-speaking Expanded Food and Nutrition Education Program (EFNEP) or EFNEP-eligible adults: 105 (cognitive interviews), 181 (test-retest), 185 (sensitivity), and 389 (EFA) adults.Variables MeasuredBehaviors related to FRM skills: planning, shopping, and budgeting.AnalysisConsistency and agreement in cognitive interviews and temporal reliability; sensitivity at posttest (paired t tests, Wilcoxon signed-rank tests); internal consistency of scales identified in EFA (Cronbach α). P < 0.5.ResultsAll questions had acceptable temporal reliability ranges for the intraclass correlation coefficient (0.48–0.74) and Spearman rank-order correlation (0.48–0.73). All questions were sensitive to change at posttest (P < 0.001). Planning and saving scales, revealed by EFA, demonstrated internal consistency (> 0.80 Cronbach α).Conclusions and ImplicationsThe 9 FRM behavior questions have acceptable temporal reliability and content and face validity and can be used nationally by EFNEP to assess participants’ self-reported behavior changes. Other nutrition programs with similar audiences and content could use these questions to measure changes in FRM behaviors.     

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.     

Implementation of Federal Waivers for Feeding Children in Early Care and Education During the COVID-19 Pandemic

ObjectiveTo capture Child and Adult Care Food Program (CACFP) state directors’ experiences implementing federal waivers for feeding children in early care and education (ECE) settings during coronavirus disease 2019.DesignQualitative semistructured interviews.SettingVirtual interviews with state CACFP directors.ParticipantsChild and Adult Care Food Program directors from 21 states from December 2020 to May 2021.Phenomenon of InterestImplementation of state-level waivers.AnalysisQualitative thematic analysis.ResultsState directors reported that the coronavirus disease 2019 waivers allowed ECE programs to continue feeding children despite being closed or having limited enrollment. The meal pattern, noncongregate feeding, parent/guardian meal pick-up, and monitoring waivers were most frequently used by states. Challenges included maintaining integrity to CACFP meal pattern requirements, addressing the limited capacity of ECE to produce and distribute noncongregate meals, and adapting technology for virtual reviews. Suggested improvements included streamlined communication from the US Department of Agriculture, standing waivers for emergencies, ongoing flexibilities for feeding children, and strategies to increase CACFP enrollment and reduce financial viability requirements for ECE.Conclusions and ImplicationsResults indicate the need for the US Department of Agriculture to consider issuing and extending waivers, increasing ECE participation in CACFP, and ensuring timely communication and guidance on waiver tracking.     

Qualitative Exploration of Cultural Influence on a Rural Health-Promotion Initiative

ObjectiveTo develop a conceptualization of cultural influence on perceptions of a rural food and physical activity policy, systems, and environmental (PSE) change project to inform public health research and practice.DesignBasic qualitative research design, semistructured phone interviews with community health coalition members.SettingFive rural Southern counties (obesity prevalence > 40%).ParticipantsThirty-nine community coalition members.InterventionThe Centers for Disease Control and Prevention High Obesity Program. PSE initiatives to increase access to healthy food and physical activity opportunities through a community coalition model.Phenomenon of InterestSocial norms and cultural influences surrounding community members’ food preferences, physical activity behavior, and future hopes for community development.AnalysisAbductive content analysis.ResultsMajor categories on food social norms (subcategories: physical health, eating habits, and food preference), race relations, generational factors, physical activity social norms, and hopes for the community (subcategories: increased engagement, health, awareness, cohesion, and inspiration) were discussed in relation to the progress of PSE initiatives.Conclusions and ImplicationsBecause of community member perceptions, PSE initiatives became associated with factors beyond food and fitness, such as race relations, generational differences, and community cohesion. A focus on increased youth and church involvement, community values, relationship building, and input from diverse voices can be foundational to culturally-appropriate PSE efforts in rural settings.     

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.     

Teachers’ Experience and Perspectives of Traditional Breakfast and Breakfast in the Classroom

ObjectiveTo understand teachers’ perceptions about Breakfast in the Classroom and traditional breakfast.DesignAn electronic survey was sent to teachers across the state of Utah. Teachers responded to an open-ended question exploring what they liked and/or disliked about Breakfast in the Classroom and traditional breakfast.SettingSchools across the state of Utah.ParticipantsKindergarten through grade 12 teachers who were members of the Utah Education Association.Phenomenon of InterestTeachers’ opinions regarding Breakfast in the Classroom and traditional school breakfastAnalysisResearchers independently coded all responses and then grouped codes into themes. Themes were reviewed recursively over time.ResultsThe 3 overarching themes were food and nutrition, administration of school breakfast, and student outcomes. Aspects most commonly disliked were the nutrition or quality of food, the mess created, the time required, coordination and logistical issues, behavioral issues, and waste. Aspects most commonly liked were breakfast being available to all students, students being fed or not hungry, coordination and logistics, and student learning and academics.Conclusions and ImplicationsTeachers liked and disliked aspects of Breakfast in the Classroom and traditional breakfast. Schools could potentially increase efforts to garner support and feedback from teachers to create buy-in and identify best practices. Future research could focus on identifying the effect that the School Breakfast Program model has on teachers’ perceptions as well as confirming results with a larger and more diverse population.     

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.     

Child Involvement in Choosing a Recipe,Purchasing Ingredients,and Cooking at School Increases Willingness to Try New Foods and Reduces Food Neophobia

ObjectiveTo investigate the effect of involving children in their feeding process (choosing a recipe, purchasing the ingredients, and cooking) on their lunch food choice in a school environment.DesignQuasi-experimental.SettingTwo schools in Bilbao, Spain.ParticipantsA total of 202 children (aged 8–9 years) participated in the study (43% girls), with 99 in the nutrition education (NE) group and 103 in the hands-on (HO) group.InterventionThree 1-hour workshops (1 workshop/wk), different for each group: HO, cooking-related activities, and NE, healthy habits promotion through nutrition education activities.Main Outcome MeasuresFood neophobia, diet quality, cooking self-efficacy and attitudes toward cooking, and food intake and selection of the experimental lunches.AnalysisChi-square test of independence, ANCOVA, and t tests were performed.ResultsStudents from the HO group selected and ate more spinach/broccoli (P < 0.001 and P = 0.02, respectively) for the first lunch; and selected more spinach/broccoli (P = 0.04) for the second lunch. After the intervention, improvements were observed for spinach liking and neophobia for the HO group and cooking self-efficacy and KidMed score for both groups.Conclusions and ImplicationsBoth interventions succeeded in improving children's diet quality, but only the HO group reduced food neophobia levels. Therefore, involving children in choosing a recipe, purchasing ingredients, and cooking may promote changing eating behaviors toward healthy habits such as increasing vegetable consumption.     

Experiences and Perceived Outcomes of Low-Income Adults During and After Participating in the British Columbia Farmers’ Market Nutrition Coupon Program: A Longitudinal Qualitative Study

BackgroundThe British Columbia Farmers’ Market Nutrition Coupon Program (FMNCP) is a farmers’ market food subsidy program that provides low-income households with coupons valued at $21/wk for 16 weeks to purchase healthy foods at participating BC Association of Farmers’ Markets members’ markets.ObjectiveThis study aimed to explore changes, differences, and similarities in participants’ experiences and perceived short-term outcomes during and after participating in the FMNCP.DesignA longitudinal qualitative research approach was used to conduct a recurrent cross-sectional analysis. Data generation and analysis were guided by Freedman et al’s theoretical framework of nutritious food access. Data generation occurred during 2019 FMNCP program (time 1) and 4 to 7 weeks after (time 2) the program year ended. Data at each time point were analyzed separately using directed content analysis, followed by a comparative analysis to identify changes, differences, and similarities between time points.ParticipantsTwenty-eight adult participants were interviewed during the program; 24 were re-interviewed post program.SettingThree communities in British Columbia, Canada.ResultsThree themes were generated: temporary relief and engagement; lasting experiences and outcomes; enhancing participant experiences and outcomes. The first theme related to how participants’ experiences and perceived outcomes, such as increased financial support and improved diet quality and health, were temporary. The second theme reflected positive lasting experiences and outcomes from participating in the FMNCP, including increased food and nutrition knowledge and enhanced social ties. The third theme focused on enhancing participants’ program experiences and outcomes, including increasing the duration of food subsidies.ConclusionThe FMNCP temporarily enhanced access to nutritious foods and had lasting positive effects on participants’ nutrition-related knowledge and social outcomes. Nevertheless, participants struggled to maintain healthy eating practices post program due to financial constraints. Expanding farmers’ market subsidy programs may improve access to nutritious foods; maintain positive dietary, social, and health outcomes for participants; and reach more low-income households.     

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.     

A community-based evaluation of disability resources and inclusion practices in rural Botswana

BackgroundCommunity-based approaches to enhance the inclusion of persons with disabilities have proven effective; however, not much is known about cultural and contextual factors that influence the capacity of policy implementation and inclusion practices in rural Botswana.ObjectiveThe study evaluated local disability education and health resources in rural Botswana to develop a deeper understanding of cultural and contextual factors impacting inclusion practices.MethodResearchers used socio-demographic and qualitative research methods to conduct a comprehensive community-based needs assessment. Sampling techniques included maximum variation and snowball sampling. Thirty-two individuals participated in the study. Data were collected between June and August of 2019 through participant observation, in-depth interviews, and focus group discussions. An inductive thematic analysis was conducted by examining participants’ attitudes, perceptions, and experiences of community members with disabilities.ResultsFour primary themes emerged identifying factors that affect people living with disabilities in the rural community: (1) culture of vulnerability, (2) determinants of disability, (3) educational resources for persons with disabilities, and (4) effective systems integration. Findings suggested that while policies associated with disability at the government level are in place, disparities among rural communities’ hindered local responses to managing the needs of persons with disabilities.ConclusionsSocial, environmental, and physical barriers prevent the full implementation of policies that advocate for the rights of persons with disabilities in Botswana's rural settings. Increasing awareness of cultural and contextual factors may help community stakeholders facilitate inclusive practices in Botswana.