Ecological risk and protective factors for food insufficiency in Los Angeles County during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic increased food insufficiency: a severe form of food insecurity. Drawing on an ecological framework, we aimed to understand factors that contributed to changes in food insufficiency from April to December 2020, in a large urban population hard hit by the pandemic.

DESIGN

We conducted internet surveys every 2 weeks in April-December 2020, including a subset of items from the Food Insecurity Experience Scale. Longitudinal analysis identified predictors of food insufficiency, using fixed effects models.

SETTING

Los Angeles County, which has a diverse population of 10 million residents.

PARTICIPANTS

A representative sample of 1535 adults in Los Angeles County who are participants in the Understanding Coronavirus in America tracking survey.

RESULTS

Rates of food insufficiency spiked in the first year of the pandemic, especially among participants living in poverty, in middle adulthood and with larger households. Government food assistance from the Supplemental Nutrition Assistance Program was significantly associated with reduced food insufficiency over time, while other forms of assistance such as help from family and friends or stimulus funds were not.

CONCLUSIONS

The findings highlight that during a crisis, there is value in rapidly monitoring food insufficiency and investing in government food benefits.

In-Store Marketing and Supermarket Purchases: Associations Overall and by Transaction SNAP Status

INTRODUCTION

In-store placement promotions are used widely in supermarkets, but their effects on customer purchases remain largely unknown. This study examined associations of supermarket placement promotions with customer purchases overall and by Supplemental Nutrition Assistance Program (SNAP) benefit use.

METHODS

Data on in-store promotions (e.g., endcaps, checkout displays) and transactions (n=274,118,338) were obtained from a New England supermarket chain with 179 stores from 2016 to 2017. Product-level analyses examined multivariable-adjusted changes in products' sales when they were promoted (versus not) across all transactions and stratified by whether the transaction was paid for with SNAP benefits. Food group-level analyses examined the extent to which a 20% increase from the mean number of weekly promotions for a food group (e.g., increasing the number of candy promotions from 17.0 to 20.4) was associated with total food group sales. Analyses were conducted in 2022.

RESULTS

Across stores, the mean (SD) number of promotions per week was highest for sweet/salty snacks (126.3 [22.6]), baked goods (67.5 [18.4]), and sugar-sweetened beverages (48.6 [13.8]) and lowest for beans (5.0 [2.6]) and fruits (6.6 [3.3]). Product sales were between 16% (low-calorie drinks) and 136% (candy) higher when promoted versus not promoted. In 14 of 15 food groups, associations were stronger among transactions made with SNAP benefits than among those not made with SNAP benefits. The number of in-store promotions was generally not associated with total food group sales.

CONCLUSIONS

In-store promotions, which were mostly for unhealthy foods, were associated with large product sales increases, particularly among SNAP purchasers. Policies limiting unhealthy in-store promotions and incentivizing healthy promotions should be explored.

The Association of Supplemental Nutrition Assistance Program Participation and Food Insufficiency among Households with Children in the United States during COVID-19

BACKGROUND

As the expansion of Supplemental Nutrition Assistance Program (SNAP) benefits and pandemic emergency assistance programs ended in late 2021, little is known about subsequent trends in food insufficiency (FI) among households with children.

OBJECTIVES

This research examined the association between SNAP participation and FI among households with children in the United States, particularly non-Hispanic Black (Black) and Hispanic households.

METHODS

This cross-sectional analysis used Household Pulse Survey data collected from December 2021 to May 2022. Spatial analysis was conducted to visualize FI and SNAP participation rates across 50 states. With state SNAP policy rules as exogenous instruments and sociodemographic factors as control variables, 2-stage probit models were utilized to assess the SNAP and FI association among all (n = 135,074), Black (n = 13,940), and Hispanic households with children (n = 17,869).

RESULTS

Approximately 13.9% [95% confidence interval (CI): 13.85%, 13.99%] of households experienced FI, and 20.4% (CI: 20.35%, 20.51%) received SNAP benefits. Among Black and Hispanic households, higher rates were observed, with 23.3% (CI: 23.12%, 23.4%) and 20.8% (CI: 20.61%, 20.95%) experiencing FI and 36.3% (CI: 36.1%, 36.5%) and 26.9% (CI: 26.61%, 27.13%) receiving SNAP benefits. These rates varied across states, ranging from 8% (Utah) to 21.1% (Mississippi) for FI and from 8.8% (Utah) to 32.7% (New Mexico) for SNAP participation. SNAP participants demonstrated a 12% lower likelihood of FI than nonparticipants (CI: -0.18, -0.05, P < 0.001). Among Black households, SNAP participants had a 29% lower likelihood of FI than nonparticipants (CI: -0.54, -0.03, P < 0.001). However, SNAP participation was not significant among Hispanic households (P = 0.99), nor did it narrow the FI gap between Hispanic and non-Hispanic households (P = 0.22).

CONCLUSIONS

SNAP participation was associated with lower levels of FI among households with children, particularly for Black households. However, there was no significant association between SNAP participation and FI among Hispanic households with children.

A Mixed-Methods Study of Perceived Implementation Challenges for WIC Online Ordering and Transactions

BACKGROUND

Federal food assistance programs are working towards online grocery shopping. Online ordering in Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is emerging following successful implementation in Supplemental Nutrition Assistance Program (SNAP).

OBJECTIVE

To identify anticipated challenges, potential solutions, and expected costs of WIC online ordering.

DESIGN

Cross-sectional, mixed-methods, web-based, survey research.

SUBJECTS AND SETTING

Data were collected from December 2020 to January 2021. Purposeful and snowball sampling included WIC stakeholders involved in developing processes and systems required for WIC online ordering. Respondents represented diverse geographic areas, levels of intraorganizational authority, and WIC benefit card types.

STATISTICAL ANALYSES PERFORMED

The research team used a rapid analysis and lean coding approach to identify emergent themes from open-ended survey responses. Descriptive statistics were used to describe the distribution of responses across themes and stakeholder types.

RESULTS

Respondents (n = 145) described 812 anticipated challenges within 20 themes grouped into five topic areas: rules and regulations; shopping experience; security, confidentiality, fraud, and WIC State agency processes; training, assistance, and education; and equitable access and buy-in. Addressing anticipated regulatory issues were among the few concrete potential solutions described. The two most frequent costs reported were increased staff time and start-up and ongoing technology costs.

CONCLUSIONS

This study identified several, critical anticipated challenges and considerations that will help prepare WIC state agencies for opportunities to expand online ordering to WIC participants.

Measuring Food Security in the United States for More Than 25 years: History, Methods, Findings, and Opportunities

This article sets the stage for the "25 Years of Food Security Measurement: Answered Questions and Further Research" conference, with support from the Economic Research Service of the US Department of Agriculture, by providing some history of federal food security measurement, summarizing notable findings, and reviewing selected special topics in analysis methods. The federal government uses food security surveys to monitor national progress toward reducing food insecurity and to evaluate federal nutrition assistance programs. For the monitoring purpose, there is a tension between focus (on a single authoritative measurement approach) and breadth (encompassing multiple tools or instruments suitable for diverse populations, contexts, and applications). For the program evaluation purpose, challenges include coordination with study designs capable of real causal estimation in the face of strong self-selection effects and tailored reference periods in survey questions that match the timing of program participation. Some analysis methods treat the food security survey items as distinct experiences of hardship, whereas others treat the food security survey items as windows on an underlying latent variable, a food insecurity score. The severity of food-related hardship may be assessed quantitatively by the number of distinct hardships reported, by the estimated value of a latent food insecurity score, or by the frequency of occurrence for sentinel hardships. Ongoing work investigates statistical approaches that are sufficiently simple for policy application and yet sufficiently flexible to accurately match the empirical survey evidence.

Examination of an Online Cooking Education Program to Improve Shopping Skills, Attitudes toward Cooking, and Cooking Confidence among WIC Participants

The present study examined if adapting the Cooking Matters (CM) curriculum to be used in an online format would improve participants' shopping skills, attitudes toward cooking, and feelings of cooking confidence, similar to the traditionally offered method, which is conducted in person. Results from factor analyses indicated that the online CM program demonstrated construct and content reliability compared to in-person (Cronbach's α ≥ 0.70). Repeated-measures ANOVA revealed a decrease in shopping skills overall (F = 5.91; p ≤ 0.05), consistent across age groups (F = 3.2; p ≤ 0.05) and food security status (F = 7.48; p < 0.01), with larger impacts on the food insecure (FI). Positive cooking attitudes increased with income (F = 2.86; p ≤ 0.05), especially among the <$20,000 and $30-39,000 income brackets. Cooking confidence increased post-intervention (F = 27.2, p < 0.001), with an interaction effect for food security status (F = 7.45; p ≤ 0.01), with greater improvement for households with food insecurity. These findings provide evidence to program and policymakers that virtual nutrition and cooking education services for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) should continue to be supported beyond the pandemic as they reduce barriers to receiving program benefits, nutrition education, and may lead to reductions in household food insecurity.

Policy approaches to nutrition-focused food banking in industrialized countries: a scoping review

OBJECTIVE

This review aims to synthesize the literature describing policy approaches to nutrition-focused food banking in industrialized countries, spanning the period 2000 to October 2021.

BACKGROUND

The charitable food system provides food assistance to increasing numbers of people experiencing food insecurity in industrialized countries. Calls to improve the nutrition quality of foods provided by foods banks, pantries, and shelves have increased, yet little is known about the challenges faced when initiating policy in this setting.

METHODS

A protocol based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews Guidelines was developed and registered with Open Science Framework. Four electronic databases (MEDLINE [Ovid], Global Health, ProQuest, and Scopus) were searched for peer-reviewed articles published in English. A gray literature search was conducted using Google Advanced Search.

RESULTS

Of 642 peer-reviewed articles screened, 15 were eligible for inclusion. In addition, 24 gray literature documents were included. These 39 papers were assessed against the Iron Triangle of Hunger Relief and the Campbell et al framework of organizational factors. Six themes were identified: (1) there is a moral imperative to take action to ensure the provision of appropriate and nutritious food for vulnerable clients; (2) nutrition policies are unlikely to be formalized; (3) the unpredictability of donated food is a barrier to providing healthy foods; (4) reliance on donations affects the sector's willingness to reduce the unhealthy inventory for fear of losing donors, and the challenges of managing donor relationships were emphasized; (5) organizational capacity (volunteer workforce, executive leadership support) must be considered; (6) the existing measure of success is a weight-based metric that does not support food banks' prioritizing of healthy foods. These, and other characteristics, were incorporated into an adapted framework.

CONCLUSION

There is a need and opportunity for nutrition-focused food banking. A priority action area is the adoption of an outcome metric that is based on nutritional quality, to reorient the charitable food system.

Familial sources of encouragement and breast-feeding practices among women participating in the US Special Supplemental Nutrition Programme for Women, Infants and Children

OBJECTIVE

To explore how sources of familial encouragement are associated with breast-feeding initiation and duration among a national sample participating in the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

This study uses the 2013-2015 WIC Infant and Toddler Feeding Practices Study 2 (WIC ITFPS-2) data. Breast-feeding initiation was measured at the first month, while duration was derived from a composite of the first 13 months. The analysis used logistic and linear regression to explore the association between encouragement sources and breast-feeding outcomes.

SETTING

A nationally representative sample of WIC participants in the USA.

PARTICIPANTS

WIC participants who completed the 13-month interview of the WIC ITFPS-2 (n 2807).

RESULTS

Encouragement was significantly associated with both initiation and duration. Each source of encouragement was associated with a 3·2 (95 % CI 2·8, 3·8) increase in odds of initiating breast-feeding in the unadjusted model and 3·0 (95 % CI 2·5, 3·6) increased odds, controlling for age, education, nativity, poverty status, race and ethnicity (<0·0001). When predicting log duration, each percent increase in source of encouragement was associated with an increasing duration on average by 0·003 d (95 % CI 0·2, 0·3, <0·0001). When controls were added, it was associated with an increase of an average of 0·002 d (95 % CI 0·2, 0·3) per percent increase in encouragement source (<0·0001).

CONCLUSIONS

Women who receive encouragement appear to be more likely to breastfeed. Additional work is needed to explore sources of encouragement and how to include them in intervention work.

Acceptability and Ease of Use of an Educational Website among Women, Infants, and Children Program Participants in Puerto Rico: A Pilot Study

OBJECTIVE

To evaluate a website for an educational intervention among participants of the Baby-Act Trial. Baby-Act is a community-based intervention to prevent infant obesity by promoting physical activity, sleep, and healthy eating behaviors in Women, Infants, and Children (WIC) program participants in Puerto Rico. The intervention was designed to be delivered through a mobile application, but after the study was launched, participants reported many difficulties, and an alternative educational platform was developed.

METHODS

Participants of the WIC program completed a face-to-face structured interview consisting of several open-ended questions. After completing the interview, they were instructed on how to access the newly developed webpage and completed the lessons found therein. Then followed a survey that explored the overall experience.

RESULTS

Nine participants were interviewed; they all agreed that the website was easy to access, registration was simple, and the webpage was clear; 8 were able to complete at least 1 lesson (1 participant had a very poor signal), and all 9 reported being confident in using the webpage and stated they would use it again.

CONCLUSION

The study participants found this website to be user-friendly and a viable alternative for future educational intervention delivery to WIC participants.

Food banks: Understanding their role in the food insecure population in the UK

The present paper reviews the growing body of literature on food insecurity and food bank use in the UK. It provides an overview of food insecurity in this context, followed by a description of the emergence of food banks, highlighting how any role that food banks play in the food insecure population is limited. Data on food insecurity and food bank use suggest many people experiencing food insecurity do not receive help from food banks. To better understand the factors influencing the relationship between food insecurity and food bank use, a conceptual framework is outlined, suggesting the relationship is far from straightforward and contingent on many factors. The nature and availability of food banks and other local support services and individual-level factors influence the likelihood of food banks being used in the context of food insecurity. Then, the extent to which food banks can impact food insecurity is also dependent on the quantity and quality of food distributed, as well as other support services offered from food banks. Closing reflections highlight rising living costs and food banks reporting that they do not have capacity to cope with increasing demand, underscoring the need for policy interventions. Reliance on food banks to respond to food insecurity may ultimately impede formulation of effective policy interventions to reduce food insecurity, giving the illusion of widespread available support, whilst food insecurity persists among those receiving help from food banks and those who experience food insecurity but do not use food banks.

Evaluation of a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) State Agency's Vendors to Comply With Regulatory Competitive Price Requirements

OBJECTIVES

The Inter Tribal Council of Arizona, Inc (ITCA) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition services for families by partnering with local vendors. In 2009, the US Department of Agriculture (USDA) instituted the WIC Vendor Cost Containment Final Rule, which required WIC programs to group vendors with similar characteristics. USDA issued guidance for evaluating and constructing vendor peer grouping systems in 2017. We constructed vendor peer groups using USDA recommended methods.

METHODS

We used ITCA WIC vendor and redemption data to construct composite variables for mean food basket cost as the outcome in linear models using the following predictors: business model, Supplemental Nutrition Assistance Program (SNAP) store type, WIC total sales, number of Universal Product Codes (UPCs) redeemed, number of cash registers, store square footage, rural-urban commuting area codes, 2010 Frontier and Remote (FAR) area codes, distance to the closest interstate in miles, and urban or nonurban location. We developed an ITCA WIC vendor peer group system.

RESULTS

We examined 146 ITCA WIC vendors. Final complete vendor peer groups for ITCA WIC in linear regression models included SNAP store type (P < .001), number of cash registers (P < .017), and FAR codes (P < .001). FAR codes were important, while other geography measures were not.

CONCLUSIONS

Using vendor peer groups can improve cost containment measures and the integrity of WIC services. Other WIC programs can use FAR codes as a USDA-required geography measure for local vendor peer group evaluations.

Differences in mobile food market customer outcomes between 2019 and 2021

OBJECTIVES

To evaluate the outcomes of increasing mobile market service from mostly biweekly in 2019 to weekly in 2021.

DESIGN

Repeated, cross-sectional customer intercept surveys.

SAMPLE

Mobile market customers in Summers 2019 (N = 302) and 2021 (N = 72).

INTERVENTION

Mobile food markets bring affordable, high-quality foods to communities that lack such access.

MEASURES/ANALYSIS

Outcomes included food security, fruit/vegetable intake, and food-related characteristics and behaviors. General linear and logistic regression models were used to assess associations between outcomes and survey year and length of mobile market shopping. Models were adjusted for economic assistance use, race, and ethnicity.

RESULTS

No outcomes were significantly different between 2019 (with mostly biweekly service) and 2021 (with weekly service). Length of mobile market shopping (e.g., >2 years, 1-2 years, etc.) was positively associated with affordable, quality food access (β = 0.20, SE = 0.10, p = .03) and fruit/vegetable intake (β = 0.28, SE = 0.08, p < .001) as well as lower odds of food insecurity in the last 12 months (aOR = 0.79, 95% CI = 0.64, 0.99).

CONCLUSIONS

Despite COVID-19 interrupting scheduled market service, the length of time that a survey respondent identified as a full-service mobile market customer was associated with higher food access and fruit/vegetable intake and reduced food insecurity odds. These findings suggest promise and encourage further evaluation.

Military Eligibility for the Supplemental Nutrition Assistance Program: Simulating the Exemption of the Basic Allowance for Housing from Gross Income

BACKGROUND

Twenty-four percent of active-duty service member households experienced food insecurity in 2020; however, limited data have suggested that few participate in the Supplemental Nutrition Assistance Program (SNAP). A potential reason for low SNAP participation among active-duty military households is that the basic allowance for housing (BAH) is considered countable income for SNAP eligibility determination.

OBJECTIVES

This study explores how many more service members' households, referred to as "SNAP units" (that is, a group of individuals who live together and regularly buy food and prepare meals together), would become eligible for SNAP benefits if the BAH is excluded from countable income in deciding eligibility.

METHODS

This study used 2016-2020 American Community Survey 5-y estimates to construct a sample of active-duty military households combined with data on military pay and allowances to simulate changes to SNAP eligibility and poverty status with a BAH exemption as well as impacts on federal spending on SNAP.

RESULTS

Eligibility for SNAP among military SNAP units increases from 0.4% to 1.5% (263% increase) if a service member's BAH was exempted from their gross income. The increase was driven by SNAP units whose highest-ranking service member was from the noncommissioned officer ranks without dependents. As more military SNAP units became eligible and chose to participate, annual SNAP disbursements (that is, amount of funds spent on SNAP) for the whole program increased by up to 1.3%, compared with FY16-20 SNAP disbursements. With an increase in SNAP participation, the poverty rate among military SNAP units decreases from 8.7% to 1.4% (83.9% decrease).

CONCLUSIONS

Exempting service members' BAH from their gross income would likely increase SNAP eligibility and participation among military households and, in turn, reduce poverty.

Policy Opportunities and Legal Considerations to Reform SNAP-Authorized Food Retail Environments

CONTEXT

There is an invigorated national interest in nutrition security, with emphasis on the Supplemental Nutrition Assistance Program (SNAP) playing a key role.

OBJECTIVE

To support healthy food purchasing, several strategies have emerged to modify the food retail environment. However, the legal feasibility of several such policy options has not been established.

DESIGN

Research was conducted using Lexis+ to evaluate statutes, regulations, and case law to determine the legal feasibility of requiring retail-based SNAP signage and nutrition disclosures, healthy endcaps and checkout aisles, and tying advertising restrictions to the licensing of SNAP retailers.

SETTING

US in-store and online food retail retailers.

MAIN OUTCOME MEASURE

Legal feasibility.

RESULTS

Requiring retailers that designate certain foods or locations as SNAP-eligible to consistently do so in all SNAP-eligible pages/locations is likely feasible. If properly drafted to focus on the nutritional quality of food, healthy checkout and endcap restrictions are legally feasible. It is of unclear legal feasibility to require retailers (especially in-store) to disclose nutrition-related labeling, shelf tags, or nonfactual symbols indicating the relative healthfulness of products. Restricting or banning advertising is not legally feasible even if the government ties the restrictions to retail licensing requirements.

CONCLUSIONS

Entities seeking to support healthy food retail should not seek to restrict advertising or compel retailers to convey messages against their interests. The government can license retailers and require them to abide by laws and other requirements that do not violate their constitutional rights. The government can also use its own speech through public service announcements, billboards, and transit advertising to encourage healthy food consumption for all shoppers including those who use SNAP. Additional research is warranted into online retail practices to evaluate variations in online checkout pages and to determine whether online retailers treat SNAP participants differently from non-SNAP participants.

County- and state-level immigration policies are associated with Supplemental Nutrition Assistance Program (SNAP) participation among Latino households

The purpose of this study was to investigate the association between county- and state-level immigrant criminalizing and integrating policies and Latino household participation in the largest safety net program against food insecurity in the U.S., the Supplemental Nutrition Assistance Program (SNAP). Our outcome, county-level proportion of SNAP-participating Latino households, and county-level covariates were obtained from the American Community Survey 1-year county files (N = 675 counties) for 13 years (2007-2019). Our exposures were county-level presence of sanctuary policies and a state-level immigrant friendliness score, created based on 19 immigrant criminalizing and integrating state-level policies obtained from the Urban Institute's State Immigration Policies Resource. We classified every county in the sample as 1) sanctuary policy + immigrant friendly state, 2) sanctuary policy + immigrant unfriendly state, 3) no sanctuary policy + immigrant friendly state, and 4) no sanctuary policy + immigrant unfriendly state. Using multivariable generalized linear models that adjusted for poverty levels and other social composition characteristics of counties, we found that county-level SNAP participation among Latino households was 1.1 percentage-point higher in counties with sanctuary policies (B = 1.12, 95%CI = 0.26-1.98), compared to counties with no sanctuary policies, and 1.6 percentage-point higher in counties with sanctuary policies in immigrant friendly states (B = 1.59, 95%CI = 0.33-2.84), compared to counties with no sanctuary policy in immigrant unfriendly states. Local and state immigration policy, even when unrelated to SNAP eligibility, may influence SNAP participation among Latino households. Jurisdictions which lack sanctuary policies or have more criminalizing and less integrating policies should consider adopting targeted outreach strategies to increase SNAP enrollment among Latino households.

Mothers as insurance: Family spillovers in WIC

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a widely used program. Previous research shows that WIC improves birth outcomes, but evidence about impacts on older children and their families is limited. We use a regression discontinuity leveraging a loss of benefits at age five when children become ineligible for WIC and examine nutritional and laboratory outcomes for adults and children. We find little impact on children who aged out of the program. But caloric intake falls and food insecurity increases among adult women, suggesting that mothers protect children by consuming less themselves. We find no effect on others in the household.

Perspective: Food and Nutrition Insecurity in Europe: Challenges and Opportunities for Dietitians

In recent years, the interest in food and nutrition insecurity in high-income countries has skyrocketed. However, its recognition in Europe is still developing. This perspective summarizes the evidence on food and nutrition insecurity across Europe in terms of prevalence, consequences, and current mitigation strategies, with the aim of outlining the challenges and opportunities for dietitians. Prevalence in the general population ranges between 5% and 20%, with higher rates identified in women, children, older adults, single-parent households, those with low educational attainment, and on low or unstable income and/or employment. In users of food aid, the prevalence of food insecurity is above 70%. Responses to food and nutrition insecurity include welfare policies and food assistance programs at regional and national levels. However, most current strategies are not successful in tackling the structural drivers of food and nutrition insecurity, nor do they guarantee diet quality. Despite limited involvement to-date, dietitians can play an important role in addressing food and nutrition insecurity across Europe. This narrative identifies 4 areas: 1) create awareness of the existence and severity of food and nutrition insecurity, 2) advocate for comprehensive, robust data on the determinants and prevalence, 3) partner with diverse stakeholders, social assistance providers, local authorities, and nongovernmental organizations in a comprehensive, intersectoral, and integrated manner, 4) participate in the development of political instruments and interventions that ensure equitable access to high-quality safe food.

Client experience of food assistance programs among adults in the United States: a qualitative evidence synthesis protocol

Introduction

Policymakers, health practitioners, and other key partners are increasingly focused on ensuring that clients of food assistance programs have positive experiences, a key aspect of high-quality programming. The objectives of this review are to describe the experiences of clients participating in food assistance programs in the United States (US) and to identify ways that these programs promote or hinder positive experiences.

Methods and analysis

We will conduct a qualitative evidence synthesis with partners from food security organizations and community members. Peer-reviewed literature will be systematically searched in Scopus, CINAHL, and AGRICOLA. To identify grey literature, we will use Google's programmable search engine. This review will consider sources that present results of primary qualitative studies that focus on at least one food assistance program in the US and explore the perspectives of adult clients. Only sources published in English or Spanish from 2007 onward will be included. Multiple reviewers will screen articles for inclusion and extract data from articles that meet the inclusion criteria, using a structured data extraction tool. Thematic synthesis or meta-ethnography may be appropriate approaches for synthesizing the extracted data. The final selection of synthesis method will be determined once the set of primary qualitative studies to be included in the review is complete and the type of data presented in these studies is known. We will assess the methodological quality of the included studies using the CASP (Critical Appraisal Skills Programme) tool for qualitative studies and assess the confidence in the review findings using the GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach.

Discussion

The findings of this review will inform the development of measures to assess client experience and quality improvement efforts.

SNAP Participation and Medication Adherence Among Older Black Medicaid-Insured Individuals Living With Hypertension

BACKGROUND

Black people are more likely to be diagnosed with hypertension and to experience food insecurity and antihypertensive medication non-adherence compared to White people in the U.S. The Supplemental Nutrition Assistance Program (SNAP)-a means-tested program that targets food insecurity has been shown to affect health outcomes. This study analyzed the relationship between SNAP participation and antihypertensive medication adherence among older Black Medicaid-insured individuals.

METHODS

This is a retrospective cohort study using linked 2006-2014 state of Missouri Medicaid and SNAP administrative claims data. Analyses were restricted to older (≥60 years) Black individuals who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60 years with at least one pharmacy claim (n = 10,693). Our outcome measure is a dichotomous measure of antihypertensive medication adherence defined using the Proportion of Days Covered (≥80% PDC = 1). The exposure variables are four measures of SNAP participation.

RESULTS

A higher proportion of SNAP participants were adherent to their antihypertensive medications compared to non-SNAP participants (43.5% vs. 32.0%). On multivariable analyses, compared to non-SNAP participants there was an increased likelihood of antihypertensive medication adherence among SNAP participants (prevalence ratio [PR] = 1.25; 95% confidence interval [CI] = 1.16-1.35). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of antihypertensive medication adherence among those who were enrolled for 10-12 months (PR = 1.41; 95% CI = 1.08-1.85).

CONCLUSIONS

Medicaid-insured older Black adults who were SNAP participants had a higher likelihood of antihypertensive medication adherence compared to non-SNAP participants.

Associations Between Ending Supplemental Nutrition Assistance Program Emergency Allotments and Food Insufficiency

This cross-sectional study evaluates associations between changes in Supplemental Nutrition Assistance Program emergency allotments and food insufficiency, a severe form of food insecurity characterized by recent food inadequacy.

Supplemental Nutrition Assistance Program Emergency Allotments and Food Security, Hospitalizations, and Hospital Capacity

Importance

Understanding how social policies shape health is a national priority, especially in the context of the COVID-19 pandemic.

Objective

To understand the association between politically motivated changes to Nebraska's Supplemental Nutrition Assistance Program (SNAP) policy and public health measures during the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional study used synthetic control methods to estimate the association of Nebraska's decision to reject emergency allotments for the SNAP with food security and hospital capacity indicators. A counterfactual for Nebraska was created by weighting data from the rest of the US. State-level changes in Nebraska between March 2020 and March 2021 were included. Data were acquired from the Census Bureau's Household Pulse Survey on individual food security and mental health indicators and from the US Centers for Disease Control and Prevention on hospital-level capacity indicators. Data analysis occurred between October 2022 and June 2023.

Intervention

The rejection of additional SNAP funds for low-income households in Nebraska from August to November 2020.

Main Outcomes and Measures

Food insecurity and inpatient bed use indicators (ie, inpatient beds filled, inpatient beds filled by patients with COVID-19, and inpatients with COVID-19).

Results

The survey data of 1 591 006 respondents from May 2020 to November 2020 was analyzed, and 24 869 (1.56%) lived in Nebraska. Nebraska's population was composed of proportionally more White individuals (mean [SD], 88.70% [0.29%] vs 78.28% [0.26%]; P < .001), fewer individuals who made more than $200 000 in 2019 (4.20% [0.45%] vs 5.22% [0.12%]; P < .001), and more households sized 1 to 3 (63.41% [2.29%] vs 61.13% [1.10%); P = .03) compared with other states. Nebraska's rejection of additional funding for SNAP recipients was associated with increases in food insecurity (raw mean [SD] difference 1.61% [1.30%]; relative difference, 19.63%; P = .02), percentage of inpatient beds filled by patients with COVID-19 (raw mean [SD] difference, 0.19% [1.55%]; relative difference, 3.90%; P = .02), and percentage of inpatient beds filled (raw mean [SD] difference, 2.35% [1.82%]; relative difference, 4.10%; P = .02).

Conclusions and Relevance

In this cross-sectional study, the association between social policy, food security, health, and public health resources was examined, and the rejection of emergency allotments in Nebraska was associated with increased food insecurity. Additionally, this intervention was associated with an increased rate of hospitalizations for COVID-19 and non-COVID-19 causes.

Application Status Among Women Enrolled in a Healthy Start Program in Arkansas for the Special Nutrition Program for Women and Children

This study aimed to examine the demographic characteristics of pregnant women in a Healthy Start program who are presumed eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), but who have not yet applied for WIC benefits. We used a cross sectional evaluation of data collected from pregnant women (n=203) participating in a Healthy Start program. Data came from surveys administered at enrollment in the Healthy Start program from July 15th, 2019 until January 14th, 2022. The primary outcome was WIC application status, which was determined by whether the woman had applied or was receiving benefits at the time of enrollment. Covariates included race/ethnicity, marital status, insurance, education, income, age, employment, and having previous children/pregnancies. Fisher exact tests and logistic regression were used to examine associations. Approximately 65% of women had not yet applied for WIC benefits. Marshallese women (80.9%) and other NHPI women (80.0%) had the highest need for assistance. In adjusted analyses, White women (p = 0.040) and Hispanic women (p = 0.005) had lower rates of needing assistance applying for WIC than Marshallese women. There were higher rates of needing assistance in applying for women with private insurance or with no insurance and for those with higher incomes. Nearly two out of every three pregnant women who were eligible for WIC had not yet applied for benefits. The findings highlight the need for outreach for all populations that may be eligible, particularly among racial/ethnic minorities and those with higher incomes.

Service Awareness Among Older Adults Experiencing Barriers to Food and Eating

OBJECTIVE

To explore (1) the services older adults use to address the barriers to food access they face and (2) how they found out about these services.

DESIGN

Semistructured, basic descriptive qualitative in-person interviews.

SETTING

Senior center and participants' homes.

PARTICIPANTS

A convenience sample of 24 older adults recruited from suburban and urban settings. Primarily Black females, living alone, and able to leave home without help.

PHENOMENON OF INTEREST

Financial and nonfinancial barriers to food access, awareness of services available.

ANALYSIS

Codes were assigned to portions of the text in which participants described how they learned about a service. These codes were categorized into one of the 3 larger themes that emerged: (1) intentionally sought by the participant, (2) intentional outreach by the service, and (3) encounters in daily life and environment.

RESULTS

Most connections to services were made through encounters in participants' daily life and environment; for example, word of mouth from family, friends or neighbors; connection through other services; referral from health care professionals; and seeing the service in their neighborhood.

CONCLUSIONS AND IMPLICATIONS

Robust social networks, medical screening, and referral may promote awareness of food assistance services. Future research and outreach should target those who are most isolated.

Food prescription pilots: feasibility, acceptability and affordability of improving diet through menu planning and grocery delivery

BACKGROUND

Lack of adherence is a primary reason people fail to maintain a healthy diet or lose weight. Multiple environmental factors, including aggressive marketing and convenience of nutrient-poor food, undermine people's best intentions. The aim was to assess the feasibility, acceptability and impact of food prescriptions in which participants' exposure to commercial food outlets is reduced, because the groceries are delivered with weekly menu plans and recipes.

METHODS

This is a series of pre-post pilot proof-of-concept studies. We recruited 37 members of Kaiser Permanente interested in improving their diet or losing weight. Weekly meal plans meeting more than 90% of recommended dietary allowances were designed to be low cost, in line with Supplemental Nutrition Assistance Program (SNAP) allowances. Five separate pilots targeted different populations. Participants were required to provide 24-h dietary recalls (ASA24) before and during the interventions. Weight management pilot participants had height, weight and blood pressure measured before and after 4-week pilots and followed sustainability guidelines, limiting meat and dairy.

RESULTS

Across pilots, the healthy eating index improved (+21.1 points; 95% CI [confidence interval] 15.9, 26.3). For the weight management pilots, most participants lost weight (average 10.3 lbs for men, 5.7 lbs for women; 95% CI -10.2, -5.4). The majority of participants liked the programme and considered it the easiest weight loss programme they ever tried.

CONCLUSIONS

These pilots suggest that meal planning and grocery delivery can be affordable and acceptable and could ultimately have a major impact on diet-related chronic diseases. Longer-term studies are needed to confirm how long compliance will endure.

Adoption Of Standard Medical Deduction Increased SNAP Enrollment And Benefits In 21 Participating States

The Supplemental Nutrition Assistance Program (SNAP) reduces food insecurity but is underused among many households. To increase SNAP participation, twenty-one states have adopted the standard medical deduction (SMD), which simplifies administrative requirements for eligible households (those with older adults or people with disabilities). However, to offset the costs of the SMD, states have reduced SNAP benefits elsewhere, raising concerns of negative spillover effects. Using national data from the period 2004-19 and a fixed-effects estimator, we found that the SMD was associated with increased SNAP participation among SMD-eligible households, in terms of aggregate household counts (20 percent) and as a share of households receiving SNAP (5 percentage points). Moreover, estimated annual SNAP benefits per state increased for SMD-eligible households but decreased (although not statistically significantly) for ineligible households. Offsetting SNAP costs may have benefited households with older adults and households with people with disabilities at the expense of others.