Mixed-Methods Research in Nutrition and Dietetics

Student and caregiver acceptability of a school-based intervention to improve sugar-sweetened beverage behaviors: a mixed methods study

Kids SIPsmartER is a 6-month behavioral and health literacy intervention effective at reducing sugar-sweetened beverage (SSB) intake among middle school students and their caregivers in the rural Appalachian region. This exploratory mixed methods study utilized a convergent parallel design to assess participant acceptability of a school-based curriculum for students and a text messaging program for caregivers. Acceptability was assessed using surveys (873 students and 453 caregivers), five focus groups (34 students) and telephone interviews (22 caregivers). Quantitative data were analyzed descriptively, and qualitative data were content coded. On a 5-point scale, average quantitative survey acceptability ratings ranged from 2.7 to 3.3 among three student-rated questions and 4.1 to 4.2 among four caregiver-rated questions. Qualitative focus group findings suggested that students preferred curricular activities that were hands-on and involved social interaction, while caregiver interview results showed high acceptability of the text messaging program's design, including usability, content messages and personalization. Students and caregivers reported similar program benefits: increased knowledge of SSBs and health risks, increased awareness of SSB behaviors and support to make beverage behavior changes. Results from this study can be used to understand Kids SIPsmartER's effectiveness data, communicate the intervention's acceptability with stakeholders and plan for future implementation studies.

Universal School Meals During the Pandemic: A Mixed Methods Analysis of Parent Perceptions From California and Maine

BACKGROUND

In response to the COVID-19 pandemic, the US Congress authorized the US Department of Agriculture to waive a variety of school meal regulations and funded school meals daily for all students at no charge regardless of family income. Because federal Universal Free School Meals (UFSM) ended with the 2021-2022 school year, several states, including California and Maine, adopted state-level UFSM policies.

OBJECTIVE

This study aimed to understand parent perceptions of school meals and the federal and new state UFSM policies in California and Maine, including potential challenges and benefits to students and households.

DESIGN

A mixed methods study design was used. A quantitative cross-sectional survey was administered, and semi-structured interviews were conducted in English and Spanish during the 2021-2022 school year.

PARTICIPANTS/SETTING

The quantitative survey was administered to parents of students in elementary, middle, and high schools in rural, suburban, and urban communities in California (n = 1110) and Maine (n = 80). Qualitative interviews were then conducted with a subset of these parents in California (n = 46) and Maine (n = 20) using Zoom (Zoom Video Communications). Most survey participants (708 of 1190 [59.5%]) and interviewees (40 of 66 [60.6%]) were parents of students who were eligible for free or reduced-price meals.

MAIN OUTCOME MEASURES

Parents' perceptions of UFSM, school meal quality, and experiences applying for free or reduced-price meals were examined.

ANALYSES PERFORMED

Tests of proportions were used to analyze survey data. Using grounded theory, interview transcripts were analyzed qualitatively by 2 trained research assistants, applying principles of content analysis to identify themes and domains. Inter-rater reliability was conducted.

RESULTS

Parents perceived that school meals and UFSM saved families money and time, as parents had fewer meals to purchase and prepare for their children. In addition, UFSM reduced parents' stress and reduced stigma for children and for parents, who described feelings of embarrassment when they previously filled out paperwork for free or reduced-price meals. Although parent perceptions of school meal quality and healthfulness were mixed, most parents reported feeling grateful for school meals.

CONCLUSIONS

Parents had mixed opinions on the quality and healthfulness of school meals, but believed UFSM saved them money and time and reduced their stress. Parents also felt UFSM reduced stigma for families.

Explanatory sequential mixed-methods approach to understand how registered dietitians implemented computed tomography skeletal muscle assessments in clinical practice

BACKGROUND

There is a need to adopt valid techniques to assess skeletal muscle (SM) in clinical practice. SM can be precisely quantified from computed tomography (CT) images. This study describes how registered dietitians (RDs), trained to quantify SM from CT images, implemented this technique in clinical practice.

METHODS

This was an explanatory sequential mixed-methods design with a quantitative and a qualitative phase. RDs collected data describing how they implemented CT SM assessments in clinical practice, followed by a focus group exploring barriers and enablers to using CT SM assessments.

RESULTS

RDs (N = 4) completed 96 CT SM assessments, with most (94%, N = 90/96) taking <15 min to complete. RDs identified reduced muscle mass in 63% (N = 45/72) of men and 71% (N = 17/24) of women. RDs used results of CT SM assessments to increase protein composition of the diet/nutrition support, advocate for initiation or longer duration of nutrition support, coordinate nutrition care, and provide nutrition education to patients and other health service providers. The main barriers to implementing CT SM assessments in clinical practice related to cumbersome health system processes (ie, CT image acquisition) and challenges integrating CT image analysis software into the health system computing environment.

CONCLUSION

Preliminary results suggest RDs found CT SM assessments positively contributed to their nutrition care practice, particularly in completing nutrition assessments and in planning, advocating for, and implementing nutrition interventions. Use of CT SM assessments in clinical practice requires innovative IT solutions and strategies to support skill development and use in clinical nutrition care.

Using Focus Groups to Explore Older Black Men's Perception of Dietary Interventions

Older Black men are underrepresented in research despite being disproportionately affected by Alzheimer's disease (AD) and cardiovascular (CV) risk factors related to AD compared with non-Hispanic Whites. Although dietary interventions have shown promise to reduce modifiable CV risk factors related to AD, Black Americans have lower adherence likely due to lack of cultural considerations. Using a noninterventional convergent parallel mixed-methods approach, this study examined the cultural contexts that inform perceptions of dietary interventions among older Midwestern Black men. All participants completed an online demographic and dietary habit survey prior to focus group discussions. Two focus group discussion sessions were conducted with a total of 10 cognitively normal Black men aged 55 years and older. Survey data were analyzed using a frequency analysis and qualitative data were analyzed using a six-step thematic analysis process. Most men indicated having hypertension (N = 7, 77.8%) and currently not following a dietary eating pattern (N = 8, 88.9%). Emerging themes identified included (1) knowledge of dementia, (2) perceptions of dietary interventions, (3) barriers impacting participation in dietary interventions, and (4) overcoming barriers to engage Black men in dietary interventions. Findings from this study should inform the design of future dietary interventions for AD prevention to enhance participation among older Black men.

Learning What Works: A Mixed-Methods Study of American Self-identified Food Conservers

OBJECTIVE

Identify psychosocial factors influencing food waste mitigation and explore motivations and strategies for successful conservation among self-identified food conservers.

METHODS

Mixed-methods study consisting of an online survey estimating food waste production and psychosocial factors and a focus group to explore waste mitigation strategies and motivations.

RESULTS

Sampled 27 self-identified conservers (female, aged 18-30 years, White/Asian). Mean household food waste was 6.6 cups/wk (range, 0.0-97.9 cups/wk; median 1.3 cups). Reported waste mitigation strategies include proactive mitigation and adaptive recovery measures in each phase of the food management continuum. Conservers reported various intrinsic and extrinsic motivations to reduce food waste and viewed barriers as manageable.

CONCLUSIONS AND IMPLICATIONS

Food conservers act on high intentions to reduce waste by consistently employing both proactive waste mitigation and adaptive food recovery measures. Future research is needed to determine if these findings hold in larger, more diverse samples and link specific behaviors to waste volume.

A collaborative approach to designing an online nutrition education program for people with multiple sclerosis

PURPOSE

People with multiple sclerosis (pwMS) want disease-specific dietary advice to reduce the confusion around diet. This study used co-design principles to develop an online nutrition education program for pwMS.

METHODS

Mixed-methods (multiphase sequential design). Phase 1: online survey (n = 114 pwMS) to explore preferred content and characteristics of a nutrition program and develop a draft program. Phase 2: feedback on the draft program from stakeholders (two meetings; n = 10 pwMS and multiple sclerosis (MS) health professionals) and pwMS (two workshops; n = 6) to produce a full program prototype. Phase 3: cognitive interviews (n = 8 pwMS plus 1 spouse) to explore acceptability and ease of comprehension of one module of the program, analysed using deductive content analysis.

RESULTS

Preferred topics were included in the program, which were further developed with consumer feedback. Cognitive interviews produced four themes: (1) positive and targeted messaging to motivate behaviour change; (2) "not enough evidence" is not good enough; (3) expert advice builds in credibility; and (4) engaging and appropriate online design elements are crucial.

CONCLUSIONS

Positive language appears to improve motivation to make healthy dietary changes and engagement with evidence-based nutrition resources. To ensure acceptability, health professionals can use co-design to engage consumers when developing resources for pwMS.IMPLICATIONS FOR REHABILITATIONCo-designed nutrition education programs can help people achieve high-quality diets in line with recommendations, but very few programs exist for people with multiple sclerosis (MS), and none were co-designedThe participatory research in this study was instrumental in ensuring that important information regarding program acceptability was identifiedCo-design can ensure that the language is appropriate for the target audience, and positive language appeared to improve motivation in people with MS to engage with the online nutrition education programWhere practical and feasible, health professionals should collaborate with MS consumers when developing resources, and use positive, empowering language.

Parenting Practices Are Associated With Adolescent Food Choices During Independent Eating Occasions

BACKGROUND

Frequency of independent eating occasions (iEOs) has been linked to intake of unhealthy foods and overweight or obesity among adolescents. Parenting practices involving modeling healthy food intake and making healthy foods available have been associated with healthy food intake among adolescents; however, little is known about these associations during iEOs.

OBJECTIVE

To determine whether parenting practices involving structure (monitoring, availability, modeling, and expectations), lack of structure (indulgence), and autonomy support reported by adolescents or parents were associated with adolescent iEO intake of junk foods, sugar-sweetened beverages (SSBs), sugary foods, and fruit and vegetables.

DESIGN

Cross-sectional study measuring parenting practices and adolescent iEO food choices via an online survey and adapted food frequency questionnaire.

PARTICIPANTS/SETTING

Parent/adolescent dyads (n = 622) completed surveys (November-December 2021) using a national Qualtrics panel database. Adolescents were 11 to 14 years of age and had iEOs at least weekly.

MAIN OUTCOME MEASURES

Primary measures included parent- and adolescent-reported frequency of food parenting practices and adolescent-reported iEO intake of junk foods, sugary foods, SSBs, and fruits and vegetables.

STATISTICAL ANALYSES PERFORMED

Multivariable linear regression models were used to examine associations between parenting practices and iEO intake of foods/beverages, adjusting for adolescent's age, sex, race and ethnicity, iEO frequency, parent's education and marital status, and household food security status. Bonferroni multiple comparison corrections were conducted.

RESULTS

More than half of parents were female (66%) and 35 to 64 years of age (58%). Adolescents/parents identified as White/Caucasian (44%/42%), Black/African American (28%/27%), Asian (21%/23%), and Hispanic ethnicity (42%/42%). Positive associations were observed among adolescent-reported and parent-reported autonomy support, monitoring, indulgence and expectations parenting practices, and adolescent-reported daily iEO intake frequencies of junk foods, sugary foods, and fruits and vegetables (P < 0.001).

CONCLUSIONS

Structural and autonomy support parenting practices were positively associated with both healthy and unhealthy iEO food intake by adolescents. Interventions to improve adolescent iEO intake could promote positive practices associated with healthy food consumption.

Post-Migration Changes in Dietary Patterns and Physical Activity among Adult Foreign Residents in Niigata Prefecture, Japan: A Mixed-Methods Study

The migrant population of Japan is gradually increasing, but it is not well known how and why diet and physical activity (PA) change post-migration. Therefore, this study used a mixed-method approach to investigate the changes in dietary patterns and PA through a web- and paper-based survey (n = 128) and understand the contextual factors for those changes through semi-structured interviews (n = 21). Descriptive and thematic analyses of quantitative and qualitative data were conducted, respectively. The majority of survey (57.8%) and interview (66.7%) participants were female, and the mean duration of stay in Japan was 5 and 3.6 years, respectively. The survey revealed an increased consumption of foods attached to Japanese culture, frozen and microwavable food, and a reduced consumption of fruits. We identified environmental (availability, accessibility, and affordability of foods; food safety and diet-related information; and climate), individual (living status; post-migration lifestyle; and food preferences and limitations), or socio-cultural (relationships with Japanese people; cultural differences; and religious influences) factors that impact diet changes. Language proficiency and the duration of stay shape dietary behaviors. Determinants of PA changes were climate, lifestyle, and the influence of Japanese culture. In conclusion, immigrants in Japan experience post-migration diet and PA changes, and this study adds knowledge about how and why such changes occur.

Priorities, barriers, and facilitators for nutrition-related care for autistic children: a qualitative study comparing interdisciplinary health professional and parent perspectives

Introduction

Children with autism spectrum disorder often face nutrition-related challenges, such as food selectivity, gastrointestinal issues, overweight and obesity, and inadequate nutrient intake. However, the role of routine nutrition-related screening or care by interdisciplinary health professionals is not well understood. This study aimed to compare the beliefs of health professionals with those of parents of autistic children regarding high-priority nutrition-related challenges, barriers and facilitators to care, and desired education and resources related to nutrition for autistic children.

Participants

Interdisciplinary health professionals (n = 25) (i.e., pediatricians, occupational therapists, speech-language pathologists, board certified behavior analysts, registered dietitians) and parents of autistic children (n = 22).

Methods

The study used semi-structured phone interviews, which were recorded, transcribed, verified, and double-coded using the Framework Method.

Results

Thematic analysis of transcripts revealed that while health professionals and parents of autistic children shared some perspectives on nutrition-related challenges and care, they also had distinct viewpoints. Parents emphasized the importance of addressing food selectivity, behavioral eating challenges, sensory issues, and sleep disturbances affecting appetite. Both groups acknowledged the need for tailored support, access to an interdisciplinary care team, and reasonable expectations. Some health professionals perceived parents as lacking motivation or the ability to make changes. In contrast, many parents felt that health professionals lacked the knowledge and motivation to take nutrition or growth concerns seriously. Health professionals acknowledged that their lack of knowledge or capacity to provide nutrition education or referrals was a common barrier to care, particularly given limited community resources.

Discussion

Health professionals who serve autistic children are motivated to address nutrition-related challenges but lack resources related to nutrition. To promote better health outcomes for autistic children, professionals should identify and support parent motivations around nutrition-related care. Both groups expressed interest in accessing autism-specific resources for education, referral, and screening guidance. Future research could explore the development of healthcare training models that improve the competency of health professionals in providing nutrition care and referral for autistic children.

Better understanding determinants of dietary guideline adherence among Dutch adults with varying socio-economic backgrounds through a mixed-methods exploration

OBJECTIVE

Low dietary guideline adherence is persistent, but there is limited understanding of how individuals with varying socio-economic backgrounds reach a certain dietary intake. We investigated how quantitative and qualitative data on dietary guidelines adherence correspond and complement each other, to what extent determinants of guideline adherence in quantitative data reflect findings on determinants derived from qualitative data and which of these determinants emerged as interdependent in the qualitative data.

DESIGN

This mixed-methods study used quantitative questionnaire data (n 1492) and qualitative data collected via semi-structured telephone interviews (n 24). Quantitative data on determinants and their association with total guideline adherence (scored 0-150) were assessed through linear regression. Directed content analysis was used for qualitative data.

SETTING

Dutch urban areas.

PARTICIPANTS

Adults aged 18-65 years.

RESULTS

A range of determinants emerged from both data sources, for example higher levels of cognitive restraint (β 5·6, 95 % CI 4·2, 7·1), habit strength of vegetables (β 4·0, 95 % CI 3·3, 4·7) and cooking skills (β 4·7, 95 % CI 3·5, 5·9), were associated with higher adherence. Qualitative data additionally suggested the influence of food prices, strong dietary habits and the social aspect of eating, and for the determinants cognitive restraint, habit strength related to vegetables, food prices and home cooking, some variation between interviewees with varying socio-economic backgrounds emerged in how these determinants affected guideline adherence.

CONCLUSIONS

This mixed-methods exploration provides a richer understanding of why adults with varying socio-economic backgrounds do or do not adhere to dietary guidelines. Results can guide future interventions promoting healthy diets across populations.

Students' Perceptions of Their Student-Operated Restaurant Experience: A Qualitative Study

As there is a rapid increase in the consumption of food outside the home, it is essential that future foodservice managers are well prepared for their critical role in menu creation and nutrition care planning in a variety of foodservice establishments. Student-operated restaurants (SORs) are one method of experiential learning used to educate future foodservice managers. This study aimed to explore the students' perceptions of their SOR experience and the extent to which nutrition concepts were incorporated in their program. This is a research area that has not been explored previously. For this study, a total of eighteen students from four universities were recruited via email to participate in interviews. Results from the qualitative thematic analysis of interview data revealed the following three overarching themes related to students' SOR experience: (1) Interpersonal Relationships and Mentoring, (2) Assessment of Immediate Experience, and (3) Moving Forward, Added Value, and Growth. Regarding nutrition, while some students felt that nutrition principles were effectively addressed during their SOR experience, other students acknowledged a lack of nutritional emphasis in their SOR and expressed a desire for a greater application of the nutritional principles learned in other classes. The SOR experience described by students was rich as they developed a variety of relationships and skills.

The Impact of the COVID-19 Pandemic on the Experiences and Operations of Sponsors of the Summer Food Service Program in Maryland, USA: A Multiphase Mixed Methods Study

During the COVID-19 pandemic, the Summer Food Service Program (SFSP) was allowed to operate in untraditional non-summer months to ensure children did not lose access to free and reduced-priced nutritious meals when schools were mandated to close in the United States. This study assessed the impact of the pandemic on the operations and experiences of Summer Food Service Program (SFSP) sponsors in the state of Maryland during the COVID-19 pandemic in 2020 (Phase I) and 2021 (Phase II). This study used a multiphase explanatory sequential mixed methods design with qualitative prioritization. Maryland SFSP sponsors completed an online survey (Phase I: n = 27, Phase II: n = 30), and semi-structured in-depth interviews were conducted with a subset of sponsors who completed the survey (Phase I: n = 12, Phase II: n = 7). Inductive and deductive analyses were used for qualitative data, and descriptive statistics were used for quantitative data. The COVID-19 pandemic caused SFSP sponsors to change their operations. Sponsors were primarily concerned about staff safety/burnout and decreased participation. Sponsors perceived waivers implemented by the United States Department of Agriculture to be crucial in enabling them to serve meals to children during the pandemic. The findings from our study support advocacy efforts to permanently implement waivers and provide free school meals for all children.

A Comparison of Experiences with Factors Related to Food Insecurity between College Students Who Are Food Secure and Food Insecure: A Qualitative Study

BACKGROUND

Previous research has reported negative health consequences and poor academic achievement among college students who are food insecure. It is unknown if students with food insecurity's experiences qualitatively differ from students who are food secure.

OBJECTIVE

To qualitatively evaluate experiences of students who are food secure and food insecure with internal and external factors related to food insecurity.

DESIGN

Trained interviewers conducted in-person qualitative interviews from February to August 2018 to gain insights about eating patterns, food environment, financial situation, and ideas for addressing food insecurity on college campuses with students who are food secure and food insecure.

PARTICIPANTS AND SETTING

Students from three universities in the western United States (N = 58) who were classified as food secure (n = 28) and food insecure (n = 30) using the US Department of Agriculture's 6-item Food Security Module participated in this study.

STATISTICAL ANALYSES PERFORMED

Interviews were recorded and transcribed verbatim. Data were analyzed using a conventional content analysis. A random sample of transcripts were independently coded to determine interrater reliability. Researchers divided transcripts for final coding and overarching themes were discussed. Descriptive statistics were used.

RESULTS

Students who were both food secure and food insecure obtained food from similar sources (eg, grocery stores); had unexpected expenses that led to financial constraints; indicated transportation barriers altered the amount or package size of food purchased; and reported similar knowledge, attitudes, use, and familial history of food assistance. Students with food insecurity uniquely reported prioritizing rent or other living expenses over food, and when funds were low, reducing food intake, experiencing a variable food supply throughout the month, or using strategies like donating plasma or selling possessions to enhance financial stability.

CONCLUSIONS

This study helps nutrition and dietetics practitioners better understand how college students' experiences with factors related to food insecurity differ by food security status. Future quantitative research is needed to confirm the coping strategies identified among students with food insecurity in this study.

Why context matters when changing the diet: A narrative review of placebo, nocebo, and psychosocial context effects and implications for outcome research and nutrition counselling

Placebo (PE) and nocebo effects (NE) have been subjects of systematic research in medicine and psychotherapy for many decades to distinguish between the (specific) pharmacological effect of medication and the (unspecific) effect of the context. Despite this significant research, the awareness, operationalisation, and reflection of the multiplicity of PE, NE, and psychosocial context effects (PSCE) is currently limited when researching outcomes of diet changes in studies without randomisation and placebo control. This neglection is critical as it could systematically influence outcomes by moderating and mediating them and thus reducing the validity and evidence base of these studies. Therefore, we performed a (non-systematic) narrative review (NR) on the following objectives: (1) present a concise overview about the relevance of PE, NE, and PSCE in medicine and nutrition research; (2) review the current state of research on reflecting context effects when studying diet changes; (3) provide useful theoretical foundations via consideration and integration of micro- and macro context effects; (4) operationalise as hypotheses the potential PE, NE, and PSCE which are specific for researching diet changes; and (5) derive their impact for future research as well as for nutrition counselling. The electronic search in this NR for objective (2) identified N = 5 publications and for objective (4) we found N = 61 articles retrieved in the first round of search, additional references were identified by a manual and snowball search among the cited references resulting finally in N = 37. This NR offers a synoptical basis to foster awareness and operationalisation of a variety of PE, NE, and PSCE. Interdisciplinary research teams should monitor these factors using, e.g., qualitative, mixed-method studies, process evaluation, item bank approaches, moderator and mediator analysis that might reveal substantially new insights, and outcomes of relevance to science and nutrition counselling. Nevertheless, the present NR has several limitations, especially as it is non-systematic, because it is a very heterogeneous field of research, in which the topic we are investigating is usually regarded as marginal and subordinate. Therefore, future research should conduct systematic reviews and particularly theory-based primary studies (experimental research) on hypotheses of PE, NE, and PSCE in outcome research in diet changes.

Community-based nutrition education and hands-on cooking intervention increases farmers' market use and vegetable servings

OBJECTIVE

The objective of the current study was to evaluate the impact of the Market to MyPlate (M2MP) program on participants' reported farmers' market (FM) attitudes and shopping behaviours, frequency of serving vegetables to their families, food resource management behaviours and food security. A secondary objective was to identify facilitators and barriers to shopping at FM and food waste reduction techniques used by low-income families.

DESIGN

The current study used a mixed methods evaluation embedded within a cluster randomised trial of the M2MP intervention.

SETTING

The 7-week M2MP program was delivered at Extension offices and community centres in central Illinois.

PARTICIPANTS

Participants included 120 adults and their families. Class cohorts were randomly assigned to one of three treatment groups: (1) nutrition education and cooking classes with produce allocations (PAE, n 39); (2) nutrition education and cooking classes only (EO, n 36) or (3) control group (n 45).

RESULTS

Compared with control participants, PAE participants were significantly more likely to report shopping at FM (P = 0·029) and reported serving more vegetables to their families (P = 0·010) (EO participants did not differ from the control group on any outcomes). There were no differences between conditions in survey-based measures of food security or food resource management behaviours. Interview results describe facilitators and barriers to shopping at FM and a variety of food waste reduction techniques (including food placement and food resource management).

CONCLUSIONS

These findings suggest that fresh produce provision coupled with nutrition and culinary education can positively impact shopping and dietary behaviours.

Addressing Food Insecurity: A Qualitative Study of Undergraduate Students' Perceptions of Food Access Resources

Food insecurity has emerged as a leading health care problem in the United States, impacting college students' health, well-being, and academic performance. The aims of this study were: (1) to assess the prevalence of food insecurity, (2) to identify college students' perceptions about food access resources, and (3) to explore students' expressed needs from the university in improving food security status. A mixed-methods approach was used to assess the quantitative and qualitative aspects of the study aims. An online survey to gather demographic information and assess food security status using the 6-item version of the US Household Food Security Scale Module (HFSSM) was administered. Next, qualitative focus groups with subsets of participants was conducted to gain further insight into the perceptions, coping mechanisms, and resource utilization issues related to food insecurity. This study found 34.1% of undergraduate college students to be food insecure and demonstrates that students with a meal plan are less likely to be food insecure (p = 0.012; OR = 0.68; 95% CI = 0.489, 0.918). Qualitative data identified key influencers of food insecurity: (1) personal beliefs, (2) life skills, and (3) the university. The results of this study contribute to the literature focused on food insecurity prevalence in college students and presents insight from the college student perspective. Findings may support the development of relevant interventions that are congruent with students' needs, enhancing resource utilization to increase food security status among college students.

Preparing Future Foodservice Managers: Operational and Educational Characteristics of Student-Operated Restaurants

OBJECTIVE

To study operational, management, and educational experiences of student-operated restaurants (SOR) through the perspective of SOR managers across the US.

METHODS

Qualitative semistructured interviews were conducted with 19 SOR managers. Qualitative case study procedures were used for analysis.

RESULTS

Three themes emerged: (1) objectives and processes in SORs, (2) support received by SORs, and (3) individual experiences in SORs. Within these themes, participants described various methods and designs used to operate SORs. However, participants ultimately perceived that SORs were successful in helping students gain foodservice management skills and be better prepared to be future foodservice managers.

CONCLUSIONS AND IMPLICATIONS

Foodservice managers can connect nutrition principles to practice for consumers. Strong foodservice education through SORs can play a role in students being more competent and prepared for foodservice management careers. Findings provide ideas for foodservice educators as they initiate or refine the use of SORs.

Improving Fecal Immunochemical Test Return Rates: A Colorectal Cancer Screening Quality Improvement Project in a Multisite Federally Qualified Health Center

The goal of this quality improvement project was to improve colorectal cancer (CRC) screening rates in a multicenter federally qualified health center (FQHC) within the Central Appalachian region of rural, southwestern Virginia. Guided by the Plan-Do-Study-Act (PDSA) cycle, the objectives were to (1) evaluate implementation processes and effectiveness of an automated electronic medical record patient reminder system to promote fecal immunochemical test (FIT) completion, compared with live telephone reminders delivered by a care coordinator (i.e., usual care), and (2) explore staff perceptions related to improving CRC screening rates. In total, 119 FITs were distributed with 59 assigned to usual care and 60 to the automated groups. In the usual care group, 79% patients with completed protocol returned their FIT; 9% were positive. In the automated reminder group, 76% patients with completed protocol returned their FIT; 10% were positive. There was no significant difference in the number of contacts per patients between the usual care (2.0, SD = 0.82 contacts/patient) and automated (1.8, SD = 0.98 contacts/patient) groups (p = .248). In total, the usual care and automated groups required 56 and 17 live calls, respectively. Overall, FQHC system-wide CRC screening rates increase from 30.5% to 47.3%. Ten staff interviews revealed perceptions of CRC screening, the QI project, and organizational change processes that may inform future cancer control projects. Researcher and practitioners should consider PDSA quality improvement projects as an initial step to build capacity and improve CRC screening rates, especially when working in FQHC with limited resources to engage in large complex research projects.

Mixed-methods implementation study of a home garden intervention in rural Guatemala using the RE-AIM framework

BACKGROUND

Home gardening is a strategy to improve nutrition and food security. More information is needed about optimizing gardens in different contexts.

OBJECTIVE

The aim was to identify implementation barriers and facilitators for a home gardening intervention in rural Guatemala and inform future larger-scale interventions in the region.

DESIGN

A mixed-methods implementation study using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework was conducted from January 2019 to July 2020.

PARTICIPANTS/SETTING

Families (n=70) in rural Guatemala participated in the intervention. Staff (n=4), families (n=6) and community stakeholders (n=3) participated in interviews or focus groups.

INTERVENTION

Participating households received seeds and seedlings for 16 crops, garden construction materials, agronomist-delivered education and assistance, and a standard-of-care nutrition program.

MAIN OUTCOME MEASURES

Implementation data were collected from program records and observations, participant surveys, and interviews and focus groups. Crop count and nutritional functional diversity of home gardens were assessed.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics were calculated for quantitative outcomes. Qualitative data were double-coded and organized into over-arching themes.

RESULTS

Reach: Ninety percent of eligible households participated. Child nutritional eligibility criteria was a barrier to reach.

EFFECTIVENESS

Participants and stakeholders felt the intervention improved access to diverse foods. Cultivated crops increased an average of 5 species (95% CI 4-6) at 6 months, although not all were consumed. Adoption: The main community adoption barrier was water sourcing for garden irrigation.

IMPLEMENTATION

Raised beds were the most common gardening method, with good adoption of agricultural best practices. Gray water filters and flexible implementation were important for participation. Maintenance: Crops failure rates were low. Seed availability was a sustainability challenge. Direct costs were 763 USD per household.

CONCLUSIONS

Interest and engagement with a home garden intervention in Guatemala were high. Gaps between garden production and consumption, access to water, and seed sourcing should be addressed in future work.

A qualitative exploration of the impact of COVID-19 on food decisions of economically disadvantaged families in Northern Ireland

Background

The first UK-wide lockdown to prevent the spread of COVID-19 had a serious financial impact on low-income households, a population already in higher risk of food insecurity and poor dietary choices. Qualitative data on the impact of COVID-19 lockdown on food decisions of UK families are scarce. This study aimed to explore how the measures to control the spread of COVID-19 influenced the food-related decisions of socioeconomically deprived families in Northern Ireland.

Methods

A qualitative study captured data from online individual interviews. Participation was open for parents of children 2–17 years old living on a tight budget in urban and rural areas of Northern Ireland. A sampling matrix enabled equal representation of single- and two-parent households, as well as parents of younger children (<12y) and adolescents (≥12y). Data were collected by using the methods of Photovoice and mapping exercise. Data were analysed through a thematic approach.

Results

Twelve online interviews were conducted and five distinct themes were identified reflecting families’ food-related decisions that were affected by the COVID-19 lockdown: 1) food planning; 2) food purchasing; 3) meal preparation; 4) eating and feeding behaviours and 5) eating food prepared outside the house.

Conclusions

The restrictions put in place to inhibit the spread of COVID-19 influenced all aspects of dietary decisions of low-income families. Changes observed during this period included frequent consumption of homemade meals, but also increased unhealthy snacking. Infrequent food shopping encouraged good meal planning, but was also a barrier to securing adequate fresh food. Food-related support including school meal assistance contributed to families’ food security, particularly those of single parents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12307-1.

Specificity Matters: Unpacking Impact Pathways of Individual Interventions within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India

BACKGROUND

To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring.

OBJECTIVES

This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package.

METHODS

We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling.

RESULTS

Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%).

CONCLUSIONS

Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.

Pointers and Pitfalls in Interpreting Nutrition and Dietetics Research: The Importance of Statistical and Clinical Significance

This monograph focuses on understanding statistical and clinical significance and is one of a research and statistics series published by the statistical team of the Journal of the Academy of Nutrition and Dietetics. The content covers the research questions, the definition of clinical significance, hypothesis testing, p-values, effect sizes, sample sizes, confidence intervals, power analyses, minimal clinically important differences, and validity. This monograph concludes with a summary of the importance of clinical and statistical results, for nutrition professionals to consider when assessing statistical and clinical significance. The assessment will help readers make subjective clinical judgements in the application of research findings based on their experience.

Using Qualitative Interviews to Better Understand Differences in How Local Health Departments Inspect School Share Tables

ABSTRACT

Environmental and health advocates are increasingly promoting food donations to reduce landfilled food waste and feed hungry people. Share tables are locations where students can put unwanted school food or beverage items, allowing their uneaten food items to be "shared" with other students and providing food donation opportunities for the 4.9 billion lunches served annually in the U.S. National School Lunch Program. The purpose of this qualitative study was to identify differences in health inspector interpretations of the Food Code as it relates to share table operations and risk mitigation techniques preferred by inspectors for preventing foodborne illness from recovered food. A snowball sampling technique was used to identify Illinois health inspectors (n = 13) engaged in share table inspections. Telephone interviews were audio recorded and transcribed verbatim. The transcripts were coded using a hybrid process of deductive and inductive content analysis. Participants considered contamination, rather than temperature abuse, to be the primary risk factor for foodborne illness. Those participants with permissive Food Code interpretations considered contamination risk in the context of the overall school environment. Participants had the lowest degree of consensus on whether to allow whole apple recovery via a share table. Participants also lacked consensus on reuse of unclaimed share table items in future meal programs (reservice). This lack of consensus indicates that further research is needed to develop data-driven strategies to assess and manage the microbial risks associated with share tables and ultimately to facilitate increased food recovery.

HIGHLIGHTS

Community-based culinary and nutrition education intervention promotes fruit and vegetable consumption

OBJECTIVE

The main objective of this study was to evaluate the impact of the Market to MyPlate (M2MP) program on fruit and vegetable consumption and cooking behaviours. Secondary objectives were to examine factors that affected participant retention and program completion, and analyse program feedback provided by participants.

DESIGN

This study conducted a mixed methods evaluation embedded within a cluster randomised controlled trial of the M2MP intervention. Adult participants completed a pre- and post-program survey reporting on their fruit and vegetable consumption and cooking behaviours. A subsample participated in structured interviews, providing feedback about M2MP and the impact of the program.

SETTING

Seven weekly classes took place in community centres and extension offices in central Illinois.

PARTICIPANTS

120 adults and their families participated. Class cohorts were randomly assigned to one of three treatment groups: (1) nutrition education and cooking classes with produce allocations (PAE, n 39); (2) nutrition education and cooking classes only (EO, n 36) or (3) control group (n 45).

RESULTS

Compared to control, PAE participants reported larger increases from pre- to post-intervention in fruit (P = 0·001) and vegetable consumption (P = 0·002), with no differences in cooking frequency. Interview analyses identified key themes in behaviour changes due to M2MP, including reported increases in dietary variety, cooking self-efficacy and children's participation in cooking.

CONCLUSIONS

PAE participants who received an intervention that directly increased their access to fresh produce (via produce allocations) increased their reported fruit and vegetable consumption. Though participants' cooking frequency did not change, interviewees reported increased variety, cooking confidence and family participation in cooking.

Advancing engagement and capacity for rural cancer control: a mixed-methods case study of a Community-Academic Advisory Board in the Appalachia region of Southwest Virginia

BACKGROUND

The objectives are to: 1) describe engagement processes used to prioritize and address regional comprehensive cancer control needs among a Community-Academic Advisory Board (CAB) in the medically-underserved, rural Appalachian region, and 2) detail longitudinal CAB evaluation findings.

METHODS

This three-year case study (2017-2020) used a convergent parallel, mixed-methods design. The approach was guided by community-based participatory research (CBPR) principles, the Comprehensive Participatory Planning and Evaluation process, and Nine Habits of Successful Comprehensive Cancer Control Coalitions. Meeting artifacts were tracked and evaluated. CAB members completed quantitative surveys at three time points and semi-structured interviews at two time points. Quantitative data were analyzed using analysis of variance tests. Interviews were audio recorded, transcribed, and analyzed via an inductive-deductive process.

RESULTS

Through 13 meetings, Prevention and Early Detection Action Teams created causal models and prioritized four cancer control needs: human papillomavirus vaccination, tobacco control, colorectal cancer screening, and lung cancer screening. These sub-groups also began advancing into planning and intervention proposal development phases. As rated by 49 involved CAB members, all habits significantly improved from Time 1 to Time 2 (i.e., communication, priority work plans, roles/accountability, shared decision making, value-added collaboration, empowered leadership, diversified funding, trust, satisfaction; all p < .05), and most remained significantly higher at Time 3. CAB members also identified specific challenges (e.g., fully utilizing member expertise), strengths (e.g., diverse membership), and recommendations across habits.

CONCLUSION

This project's equity-based CBPR approach used a CPPE process in conjunction with internal evaluation of cancer coalition best practices to advance CAB efforts to address cancer disparities in rural Appalachia. This approach encouraged CAB buy-in and identified key strengths, weaknesses, and opportunities that will lay the foundation for continued involvement in cancer control projects. These engagement processes may serve as a template for similar coalitions in rural, underserved areas.

A Systems Examination of Food Packaging and Other Single-Use Item Waste in School Nutrition Programs

OBJECTIVE

Identify types of food packaging used in school nutrition programs and competing priorities, barriers, and facilitators for sustainable packaging waste use and recovery.

DESIGN

Qualitative interviews (n = 20) and structured kitchen observations were conducted.

SETTING

Data were collected from 3 school districts in Northern Colorado.

PARTICIPANTS

Three nutrition program directors, 14 kitchen managers, and 3 sustainability staff.

PHENOMENON OF INTEREST

Barriers and facilitators for sustainable food packaging waste practices among school nutrition programs.

ANALYSIS

Interviews were recorded and transcribed, followed by inductive content analysis to identify themes.

RESULTS

Commonly used food packaging included cardboard, aluminum, paper, plastic, and styrofoam. Four competing priorities were identified as impacting school nutrition programs' ability to reduce or recover food packaging: serving line speed, labor, food quality, and cost. One key barrier was that school staff had difficulty understanding the total system impact of their food packaging use and recovery decisions.

CONCLUSIONS AND IMPLICATIONS

Food packaging is commonly used in school nutrition programs, and participants felt that its use offered key benefits, such as facilitating faster serving lines. More research is needed to quantify the direct and indirect impacts of packaging waste reduction and recovery in school nutrition programs.

Foodservice Management Educators' Perspectives on Nutrition and Menu Planning in Student-Operated Restaurants

OBJECTIVE

Explore how student-operated restaurant (SOR) managers consider and apply nutrition principles and menu planning in SORs.

DESIGN

Nineteen SOR managers in the US were recruited to complete an online survey and participate in a 30-60-minute interview. Interviews were conducted via video conference and explored the menu and nutritional characteristics of the SOR at each facility.

SETTING

SORs across the US.

PARTICIPANTS

Managers of SORs.

PHENOMENON OF INTEREST

Menu and nutrition characteristics and their use in SORs.

ANALYSIS

Demographic data were analyzed using SPSS. Thematic analysis was conducted using NVivo software.

RESULTS

Thematic analysis revealed nutrition in practice, nutrition philosophy, and menu planning as the 3 major themes. Nutrition in practice captured the role of nutrition in menu planning, special diets, and healthy options. Nutrition philosophy subthemes explored issues such as the purpose of the SOR experience and instructor perspective on nutrition. Menu planning subthemes addressed issues regarding the menu development process, including menu planning that was student-driven and faculty-driven.

CONCLUSIONS AND APPLICATIONS

Approaches to menu planning had varying degrees of student involvement. Although nutrition was stated as a consideration in menu planning, most programs did not include formalized nutrition criteria as part of the SOR curriculum.

Dietary Supplement Use in US Army Personnel: A Mixed-Methods, Survey and Focus-Group Study Examining Decision Making and Factors Associated With Use

BACKGROUND

Dietary supplement (DS) use by Army personnel is high and is a safety and readiness issue.

OBJECTIVE

Our aim was to examine factors motivating use of DSs among US Army personnel and preferred safety education strategies.

DESIGN

This mixed-method study used a validated DS questionnaire and subsequent focus groups that were formed based on questionnaire-identified demographic characteristics. An embedded qualitative dominant design was used.

PARTICIPANTS/SETTING

Data were collected from April to July 2015 from active duty soldiers at 3 military installations in the United States.

MAIN OUTCOME MEASURES

A self-report questionnaire (n = 289) provided data on demographic characteristics, health, exercise, detailed use, and attitudes regarding DS safety and efficacy. Fourteen focus-group sessions (n = 129) examined factors motivating DS use, education strategies, and identified themes and DS-related behaviors.

STATISTICAL ANALYSIS PERFORMED

Descriptive statistics and χ² analyses were conducted.

RESULTS

Of the soldiers who completed questionnaires, 83% were male, 60% were enlisted, and 40% were officers; mean age ± standard deviation was 27.6 ± 0.36 years and 75% used at least 1 type of DS per week: 52% used protein/amino acids, 47% used multivitamins/minerals, and 35% used a combination of products. Focus groups indicated reasons for use included physical appearance, fitness, peer endorsement, ease of access, limited availability of healthy food, occupational demands, and health. Participants requested education from an expert on safe use that was not focused on dangerous products.

CONCLUSIONS

Soldiers are high DS users, especially products marked for purported performance enhancement. Motivating factors for DS use are fitness/appearance and occupational demands, but soldiers lack knowledge of DS regulatory requirements and safety/efficacy. Soldiers wished to receive education on DSs from trusted health care professionals, such as registered dietitian nutritionists, that was not focused on dangerous products. Study findings suggest guidance and education should occur before periods of high DS use, such as deployment.

Understanding Mothers' Perceptions of Food Skills: A Qualitative Study

BACKGROUND

Food skills are behaviors surrounding the planning, purchasing, and preparing of food. Food skills have been identified as important for promoting diet quality. Little work has investigated specific food skills perceived by parents to promote a healthy diet or parents' perceived barriers to implementing food skills.

OBJECTIVE

Our aim was to determine current food skills that parents identify as helpful behaviors for consuming a healthy diet and the perceived barriers to implementing food skills.

DESIGN

We conducted a qualitative study using focus groups with mothers (18 years or older) who reported being primarily responsible for acquiring and preparing food.

PARTICIPANTS/SETTING

Thirty mothers with at least 1 child under the age of 18 years were asked to attend 1 of 5 focus groups held in a university setting.

MAIN OUTCOMES

Outcomes included emergent themes and subthemes within the domains of food skill behaviors identified as helpful and perceived barriers to implementing food skills.

ANALYSIS

Focus groups were audio-recorded and transcribed. Thematic analysis was used to analyze transcripts and descriptive statistics were used to characterize participant demographics.

RESULTS

Food skill themes identified as helpful behaviors for consuming a healthy diet included mothers' resourcefulness, overall planning behaviors, and child involvement and influence. Themes for barriers to implementing food skills included limited time, cooking for multiple needs and tastes, exposure to food and sales while shopping, and food cost.

CONCLUSIONS

Qualitative findings indicated that mothers need behavior strategies for time management, meeting multiple family needs, dealing with exposure to food and sales, and food resource management rather than being provided solely with education. These findings can inform future behavior-based interventions to improve the diet quality of families.

Wisconsin School Wellness Policies after Federal Legislation Change: Understanding Key Mechanisms of Policy Improvement

BACKGROUND

The Final Rule of the Healthy Hunger Free Kids Act, published in 2016, required school districts participating in the federal Child Nutrition Programs to update their local wellness policies to reflect the more stringent requirements effective June 30, 2017.

OBJECTIVE

Our aim was to investigate whether Wisconsin school wellness policies (SWPs) were updated after the Final Rule, measure policy quality change, and describe mechanisms of successful policy change.

DESIGN

From 2016 through 2018, an explanatory sequential mixed-methods study examined change in SWP quality before and after the Final Rule was published. SWPs were collected in 2 waves reflecting policies written before and updated after the July 21, 2016 publication of the Final Rule. Semi-structured key-informant interviews were conducted with districts that demonstrated significant policy improvement.

PARTICIPANTS/SETTING

Quantitative analysis examined 442 Wisconsin school districts' SWPs. Semi-structured interviews were conducted with 14 school districts that demonstrated significant change between waves.

MAIN OUTCOME MEASURES

WellSAT 2.0 strength and comprehensiveness scores measured SWP quality among districts that updated their policies. Themes from interviews were identified using framework analysis.

STATISTICAL ANALYSIS PERFORMED

First, we calculated the proportion of Wisconsin school districts participating in federal Child Nutrition Programs for which SWPs were obtained at both waves of policy collection (n = 192 districts, 43.4%). Among districts that updated SWPs in wave II, repeated-measure analysis of variance tests described policy quality and policy quality change, respectively.

RESULTS

Among the 192 districts that updated their SWPs, policy quality increased overall and for 5 of 6 domains. Nutrition education scores did not show significant change. Interviewees commonly cited wellness leadership, support and resources, and buy-in and culture change as key components of policy improvement.

CONCLUSIONS

Fewer than half of Wisconsin school districts updated their policies in the 10 months after the Final Rule was published. SWP from these districts showed policy quality improvement in most areas. Interviews with successful districts indicate the common need for empowered leaders and supportive environments to facilitate culture change around student wellness.

A Multilevel Approach to Understand the Context and Potential Solutions for Low Colorectal Cancer (CRC) Screening Rates in Rural Appalachia Clinics

PURPOSE

To explore system/staff- and patient-level opportunities to improve colorectal cancer (CRC) screening within an 11-clinic Federally Qualified Health Center (FQHC) in rural Appalachia with CRC screening rates around 22%-30%.

METHODS

Using a convergent parallel mixed-methods design, staff (n = 26) and patients (n = 60, age 50-75, 67% female, 83% <college, 47% Medicare, 23% Medicaid) were interviewed about CRC-related screening practices. Staff and patient interviews were guided by the Consolidated Framework for Implementation Research and Health Belief Model, respectively, and analyzed using a hybrid inductive-deductive approach.

RESULTS

Among staff, inner setting factors that could promote CRC screening included high workplace satisfaction, experiences tracking other cancer screenings, and a highly active Performance Improvement Committee. Inner setting hindering factors included electronic medical record inefficiencies and requiring patients to physically return fecal tests to the clinic. Outer setting CRC screening promoting factors included increased Medicaid access, support from outside organizations, and reporting requirements to external regulators, while hindering factors included poor social determinants of health, inadequate colonoscopy access, and lack of patient compliance. Among patients, perceived screening benefits were rated relatively higher than barriers. Top barriers included cost, no symptoms, fear, and transportation. Patients reported high likelihood of getting a stool-based test and colonoscopy if recommended, yet self-efficacy to prevent CRC was considerably lower.

CONCLUSIONS

Contextualized perceptions of barriers and practical opportunities to improve CRC screening rates were identified among staff and patients. To optimize multilevel CRC screening interventions in rural Appalachia clinics, future quality improvement, research, and policy efforts are needed to address identified challenges.

Perceived Benefits of a Standardized Patient Simulation in Pre-Placement Dietetic Students

The purpose of this study was to evaluate the effect of a simulation-based learning (SBL) experience on perceived confidence in monitoring and evaluation, as part of the delivery of nutrition care of pre-placement dietetic students, and to describe their perceived value of the learning experience post-placement. A mixed method explanatory sequential study design was used. A confidence appraisal scale was developed and completed by students before (n = 37) and after (n = 33) a low fidelity simulation using a volunteer patient in an acute care setting. Two semi-structured focus group discussions with post-placement students (n = 17) were thematically analysed, grounded in phenomenology. Overall perceived confidence in monitoring and evaluating, as part of nutrition care, improved after the simulation [pre-SBL: 74 (62–83) vs. post-SBL: 89 (81–98.5), p = 0.00]. Two factors emerged to modulate confidence, namely (i) structure and (ii) authentic learning. Structure in turn was modulated by two key factors; safety and process. A low fidelity simulation using a standardised patient can improve students’ perceived confidence in monitoring and evaluation, and a well-structured authentic learning experience was valued and positively perceived by most dietetic students.

Implementation of a Multi-Component School Lunch Environmental Change Intervention to Improve Child Fruit and Vegetable Intake: A Mixed-Methods Study

Nudge interventions are widely used to promote health in schools, yet implementation metrics are seldom used to understand intervention outcomes. A multi-component intervention consisting of cafeteria decorations, creative names, social norming taste tests, and flavor station components was implemented in three rural elementary school cafeterias by school nutrition services (SNS) and extension staff. Selection and consumption of fruits and vegetables at lunch were measured through monthly plate waste assessments over eight months (n = 1255 trays). Interviews were conducted with SNS staff (n = 3) upon completion of the intervention to assess implementation outcomes using validated acceptability and feasibility metrics. Consumption findings were generally inconsistent across schools and time points, yet fruit consumption increased at School 1 (p < 0.05) during the taste test and flavor station intervention months and School 2 (p < 0.001) during the creative names intervention months compared to baseline. Odds of selecting a vegetable at School 3 were three times higher than baseline during the taste test intervention months (odds ratio (OR), 3.0; 95% confidence interval (CI), 1.3–6.5). Cafeteria decorations and taste tests had higher reported implementation metrics for acceptability and feasibility than other interventions. Thematic analysis underscored the facilitating role of extension support, as well as systems factors, which served as facilitators and barriers across schools and interventions. These findings suggest that nudge interventions are a promising strategy to improve vegetable selection and fruit consumption in school meal programs.

Developing National Conceptual Understanding to Describe Entry-to-Practice Dietetics Competence

OBJECTIVE

Develop consensus on entrustable professional activities (EPAs) and milestones for students, practice educators, and academics that need shared understanding to assess entry-level competence in dietetics.

DESIGN

An iterative, pragmatic, 3 key-phase approach involving workshops, a consensus survey with job description and consultation.

SETTING

Australia.

PARTICIPANTS

A total of 58 academics and 43 practitioners with expertise in competency-based assessment in dietetics were purposefully selected to participate in 4 national workshops. Of those selected, 36 completed a survey that sought consensus on the EPAs and milestones drafted at the workshops (36% response rate).

PHENOMENON OF INTEREST

Support for competency-based assessment.

ANALYSIS

Level of agreement on the survey was set at ≥70%. These comments were triangulated with content analysis from 98 entry-level job descriptions.

RESULTS

Consensus on 4 key tasks of the profession with associated descriptions of the level of performance were included to implement a nutrition intervention; facilitate a food, nutrition, and/or lifestyle conversation; perform professional activities and projects; and work as part of a team.

CONCLUSIONS AND IMPLICATIONS

Identification of the key minimum tasks of a dietitian upon entry-to-practice, together with developmental descriptors of performance, provides clarity in the expected progression and end point of assessment. This resource will support competency-based assessment decisions. The international transferability of this warrants further investigation.

Adapting the "Resist Diabetes" Resistance Training Intervention for Veterans

PURPOSE

The Resist Diabetes trial demonstrated that twice-per-week resistance training reduced prediabetes prevalence and improved strength among older adults with prediabetes. Our objective was to determine initial perceptions of patients and care providers in a Veterans Affairs Medical Center (VAMC) regarding Resist Diabetes (RD), and ultimately, inform adaptations to improve uptake of RD in the Veterans Health Administration.

METHODS

A mixed-methods approach was utilized. Care providers (n=20) and veterans with prediabetes (n=12) were recruited to gauge perceptions of the RD program and identify barriers and facilitators to the program referral process and program implementation. Care provider perceptions of the acceptability, appropriateness and feasibility were determined using a validated survey. Open-ended questionnaires and interview guides, based upon the Consolidated Framework for Implementation Research, were utilized to determine major and minor themes within the provider and veteran responses. To identify the dissemination potential of RD, the availability of onsite fitness facilities at VAMC facilities nationally (n=159) was assessed.

RESULTS

Providers rated (scaled 1-5; 1=completely disagree, 5=completely agree) the RD program as appealing (4.8+/-0.1), appropriate (4.8+/-0.0), and feasible (4.6+/-0.2). Providers reported that prediabetes/diabetes is a significant problem in the VAMC, and that different prevention programs will appeal to different types of VAMC patients. Patients (n=12; 58% female; aged 65+/-10yrs; BMI 34+/-6 kg/m²; HbA1c 5.7+/-1.8%) expressed interest in an exercise-focused diabetes prevention program and defined key barriers: travel, transportation, and time constraints. Among the responding national VAMC sites, 85% (97/114) reported having an onsite fitness facility.

CONCLUSION

Salem VAMC care providers and veteran patients demonstrated positive perceptions of the Resist Diabetes program. Program adaptations are needed to address barriers to patient participation including travel, transportation and time constraints.

Development of Parent and Adolescent Questionnaires to Assess Food Parenting Practices That Address Adolescent Consumption During Independent Eating Occasions

OBJECTIVE

To develop and test parent and early adolescent questionnaires to assess food parenting practices that influence early adolescent food consumption during independent eating occasions (iEOs).

METHODS

Cross-sectional online questionnaires were completed by 206 and 62 low-income parent/early adolescent (11-14 years) dyads at Time 1 and 2, respectively, recruited via a Qualtrics (Provo, UT) US national panel database. Principal component analyses, internal consistency, and test-retest reliability checks were performed.

RESULTS

Six parallel components were identified for parents and early adolescents with acceptable internal consistency and test-retest reliability. Scales included autonomy support, monitoring, availability, indulgence, expectations, and modeling. All except indulgence were positively correlated with importance of helping early adolescents make healthy choices during iEOs.

CONCLUSIONS AND IMPLICATIONS

Additional research is needed to test the questionnaires' validity regarding relationships between parenting practices and early adolescent consumption during iEOs. Findings could inform development of interventions to improve consumption during these occasions.

Diabetes-related nutrition knowledge and dietary adherence in patients with Type 2 diabetes mellitus: A mixed-methods exploratory study

Aim:

The aim of the study is to gain insights into the relationship between diabetes-related nutrition knowledge (DRNK) and diet quality in Singapore.

Methods:

Forty-two participants were recruited from a tertiary hospital. DRNK and diet quality were ascertained with the DRNK questionnaire and Alternate Healthy Eating Index 2010, respectively. Twenty-one semi-structured interviews of perceived barriers and enablers to adherence to dietary guidelines were audio recorded, transcribed and analysed.

Results:

Participants had a poor mean percentage DRNK score of 39.7% (±17.7) and diet quality of 54.2% (±9.4). Pearson’s correlation tests revealed no correlation between DRNK and diet quality ( r –0.29; p=0.065) but suggest a moderate positive correlation between DRNK and psychosocial self-efficacy ( r 0.41; p=0.008). Thematic analysis revealed six barriers (obesogenic environment; lack of time; conflict between advice and personal values; stress from external sources; lack of personal motivation; gaps in DRNK) and four enablers (personal motivation to improve condition; fear of T2DM complications; sufficient DRNK; presence of social support) to adherence to dietary guidelines.

Conclusion:

DRNK may not correlate with adherence to dietary guidelines; multiple mediating factors are identified when translating DRNK to practice.

Factors associated with adherence to dietary prescription among adult patients with chronic kidney disease on hemodialysis in national referral hospitals in Kenya: a mixed-methods survey

Introduction

Adherence to dietary prescriptions among patients with chronic kidney disease is known to prevent deterioration of kidney functions and slow down the risk for morbidity and mortality. This study determined factors associated with adherence to dietary prescription among adult patients with chronic kidney disease on hemodialysis.

Methods

A mixed-methods study, using parallel mixed design, was conducted at the renal clinics and dialysis units at the national teaching and referral hospitals in Kenya from September 2018 to January 2019. The study followed a QUAN + qual paradigm, with quantitative survey as the primary method. Adult patients with chronic kidney disease on hemodialysis without kidney transplant were purposively sampled for the quantitative survey. A sub-sample of adult patients and their caregivers were purposively sampled for the qualitative survey. Numeric data were collected using a structured, self-reported questionnaire using Open Data Kit “Collect software” while qualitative data were collected using in-depth interview guides and voice recording. Analysis on STATA software for quantitative and NVIV0 12 for qualitative data was conducted. The dependent variable, “adherence to diet prescription” was analyzed as a binary variable. P values < 0.1 and < 0.05 were considered as statistically significant in univariate and multivariate logistic regression models respectively. Qualitative data were thematically analyzed.

Results

Only 36.3% of the study population adhered to their dietary prescriptions. Factors that were independently associated with adherence to diet prescriptions were “flexibility in the diets” (AOR 2.65, 95% CI 1.11–6.30, P 0.028), “difficulties in following diet recommendations” (AOR 0.24, 95% CI 0.13–0.46, P < 001), and “adherence to limiting fluid intake” (AOR 9.74, 95% CI 4.90–19.38, P < 0.001).

Conclusions

For patients with chronic kidney disease on hemodialysis, diet prescriptions with less restrictions and requiring minimal extra efforts and resources are more likely to be adhered to than the restrictive ones. Patients who adhere to their fluid intake restrictions easily follow their diet prescriptions. Prescribed diets should be based on the individual patient’s usual dietary habits and assessed levels of challenges in using such diets. Additionally, diet adherence messages should be integrated with fluid limitation messages. Further research on understanding patients’ adherence to fluid restriction is also suggested.

Healthy Planet, Healthy Youth: A Food Systems Education and Promotion Intervention to Improve Adolescent Diet Quality and Reduce Food Waste

Emerging evidence suggests a link between young people's interest in alternative food production practices and dietary quality. The primary purpose of this study was to examine the impact of a student-driven sustainable food systems education and promotion intervention on adolescent school lunch selection, consumption, and waste behaviors. Sixth grade science teachers at two middle schools (n = 268 students) implemented a standards-based curriculum on sustainable food systems, addressing the environmental impacts of food choices and food waste. The cumulating curriculum activity required the 6th grade students to share their food systems knowledge with their 7th and 8th grade counterparts (n = 426) through a cafeteria promotional campaign to discourage food waste. School-wide monthly plate waste assessments were used to evaluate changes in vegetable consumption and overall plate waste using a previously validated digital photography method. At baseline, the intervention students consumed significantly less vegetables relative to the control group (47.1% and 71.8% of vegetables selected, respectively (p = 0.006). This disparity was eliminated after the intervention with the intervention group consuming 69.4% and the control consuming 68.1% of selected vegetables (p = 0.848). At five months follow up, the intervention group wasted significantly less salad bar vegetables compared to the control group (24.2 g and 50.1 g respectively (p = 0.029). These findings suggest that food systems education can be used to promote improved dietary behaviors among adolescent youth.

Kids SIPsmartER, a cluster randomized controlled trial and multi-level intervention to improve sugar-sweetened beverages behaviors among Appalachian middle-school students: Rationale, design & methods

The intake of sugar-sweetened beverages (SSB) is disproportionately high in Appalachia, including among adolescents whose intake is more than double the national average and more than four times the recommended daily amount. Unfortunately, there is insufficient evidence for effective strategies targeting SSB behaviors among Appalachian youth in real-world settings, including rural schools. Kids SIPsmartER is a 6-month, school-based, behavior and health literacy program aimed at improving SSB behaviors among middle school students. The program also integrates a two-way short message service (SMS) strategy to engage caregivers in SSB role modeling and supporting home SSB environment changes. Kids SIPsmartER is grounded by the Theory of Planned Behavior and health literacy, media literacy, numeracy, and public health literacy concepts. Guided by the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance), this type 1 hybrid design and cluster randomized controlled trial targets 12 Appalachian middle schools in southwest Virginia. The primary aim evaluates changes in SSB behaviors at 7-months among 7th grade students at schools receiving Kids SIPsmartER, as compared to control schools. Secondary outcomes include other changes in students (e.g., BMI, quality of life, theory-related variables) and caregivers (e.g., SSB behaviors, home SSB environment), and 19-month maintenance of these outcomes. Reach is assessed, along with mixed-methods strategies (e.g., interviews, surveys, observation) to determine how teachers implement Kids SIPsmartER and the potential for institutionalization within schools. This paper discusses the rationale for implementing and evaluating a type 1 hybrid design and multi-level intervention addressing pervasive SSB behaviors in Appalachia. Clincialtrials.gov: NCT03740113.

Resources, Barriers, and Tradeoffs: A Mixed Methods Analysis of School Pre-Consumer Food Waste

BACKGROUND

Food waste is a global problem. School food waste before the point of purchase, pre-consumer waste, has been little studied.

OBJECTIVE

Our aim was to elicit a comprehensive assessment and understanding of pre-consumer food waste amounts, behaviors, policies, and attitudes.

DESIGN

This study used mixed methods, featuring a convergent parallel design using key respondent interviews (n=20) and 80 hours of structured kitchen observations, including food waste measurement.

PARTICIPANTS/SETTING

School and district kitchens (n=14) using stratified random sampling to ensure school level and kitchen type reflected the population of three Colorado school districts in 2016-2017. Kitchen managers, district-level nutrition services directors, and sustainability staff were interviewed.

STATISTICAL ANALYSES PERFORMED

Mean food waste volumes and percentages were calculated. Linear regressions were used to determine the relationship between school kitchen characteristics and food waste volumes. Interviews were coded to identify common themes.

RESULTS

Trim waste and overproduction contributed the most to overall pre-consumer food waste; substandard foods and overproduction were the most common reasons for edible waste. Several competing priorities conflicted with schools' and districts' waste reduction efforts: food safety, promoting diet quality, food choice, and customer satisfaction. Batch cooking, production record use, shallow salad bar pans, and other inventory management techniques facilitated waste reduction. Staffing, space, and time constraints made it more difficult to implement these strategies. Increased food choice options were positively associated with pre-consumer waste volume (β=49.5, P=0.04), and this relationship remained significant once regression models adjusted for district, salad bar use, and new menu items (β=70.3, P=0.05).

CONCLUSIONS

School nutrition programs are complex, and a systems approach is warranted to reduce overall waste in the context of existing food safety and nutrition policies. More research is needed to elucidate the impact of food choice on overall food waste of the school meal system.

Socio-Economic Factors, the Food Environment and Lunchtime Food Purchasing by Young People at Secondary School

The aim of this paper is to report on the lunchtime food purchasing practices of secondary school students and some of the factors related to this purchasing, including the influence of socio-economic status (SES) and the food environment within and around schools. A mixed-methods study incorporating an online purchasing recall questionnaire and multiple qualitative methods was undertaken at seven UK secondary schools. The analysis shows that SES was intricately woven with lunchtime food practices. Three-quarters of participants regularly purchased food outside of school; those at low SES schools were more likely to report regularly leaving school to buy food. Young people’s perception of food sold in schools in areas of low SES was often negative and they left school to find “better” food and value for money. Taste, ingredients and advertisements were factors that mattered to young people at schools with low or mixed SES; health as a driver was only mentioned by pupils at a high SES school. For public health initiatives to be effective, it is critical to consider food purchasing practices as complex socio-economically driven phenomena and this study offers important insights along with suggestions for designing interventions that consider SES. Availability of food outlets may be less important than meeting young people’s desires for tasty food and positive relationships with peers, caterers and retailers, all shaped by SES. Innovative ways to engage young people, taking account of SES, are required.

A Participatory Process to Engage Appalachian Youth in Reducing Sugar-Sweetened Beverage Consumption

Children and adolescents consume excessive amounts of sugar-sweetened beverages (SSBs), which are associated with adverse health outcomes. We describe a yearlong participatory research study to reduce SSBs in Central Appalachia, where excessive consumption is particularly prevalent. This study was conducted in partnership with a community advisory board in Southwest Virginia. Nine "youth ambassadors," aged 10 to 13 years helped to systematically adapt SIPsmartER, an effective theory-based program for Appalachian adults, to be age and culturally appropriate and meet desired theoretical objectives. They then assisted with delivering the curriculum during a school-based feasibility study and led an advocacy event in their community. Satisfaction surveys and feedback sessions indicate that ambassadors found the program acceptable and important for other students. Validated surveys and focus groups suggested that theoretical objectives were met. Findings from these mixed methods sources informed curricular changes to further enhance acceptability and refine theoretical objectives. Participation in follow-up advocacy activities was tracked and described. Following the yearlong study, ambassadors reported having advocacy skills and motivation to continue reducing SSB intake in their community. Results, challenges, and lessons learned are presented to inform larger efforts to enhance acceptability of programs and inspire youth to take action to reduce health disparities in Appalachian communities.

Ethnography in Nutrition and Dietetics Research: A Systematic Review

Ethnography is a qualitative research approach used to learn about people and their culture. There is a need to explore the application and use of ethnographic methodology in nutrition and dietetics research to inform future research and practice. Our aim was to examine the extent, range, nature, and contribution of ethnographic methodology in nutrition and dietetics research. Eight electronic databases were searched using a defined search strategy until November 2017. No restrictions were placed on language, date, or study design of original research. Two authors independently assessed titles and abstracts, then full-text records, against inclusion criteria. Hand-searching of reviews identified in the database search was undertaken. Quality assessment was conducted using the Critical Appraisal Skills Programme checklist. Data were described narratively. A total of 2,185 records were identified, with 92 studies from public health nutrition (n=72), clinical nutrition (n=13), and foodservice (n=7) practice areas meeting inclusion criteria. Common research areas included infant/child feeding, food choice, diabetes, nutrition in schools and food insecurity. In addition to observation, frequently reported data collection techniques were interview (n=85), focus groups (n=17), and document analysis (n=10). Ethnographic research was most often reported from North America (n=31), Europe (n=16), and Australia/Oceania (n=13). This research approach was shown to inform dietetic research and practice by illuminating sociocultural factors that influence dietary beliefs and practices, practitioner training opportunities, evaluating nutrition education methods, informing programs and interventions, identifying nutrition policy and guideline focus areas, and the need for new approaches and communication strategies. Ethnography can increase understanding of complex food and nutrition-related health issues and their contributing factors across public health nutrition, foodservice, and clinical dietetic practice. It can be used to explain health inequalities, direct policy, and inform more effective intervention design and delivery. Wider uptake of this research approach as a stand-alone or complementary study design will advance efforts to improve health and wellbeing through food and nutrition.

HEROs: Design of a Mixed-Methods Formative Research Phase for an Ecocultural Intervention to Promote Healthy Eating and Activity Behaviors in Rural Families With Preschoolers

OBJECTIVE

To describe the mixed-methods formative research phase in the development of the Healthy Environments Study (HEROs), a technology-based, interactive family intervention to promote healthy eating and activity behaviors for young children in the home environment.

DESIGN

A mixed-method iterative approach, using ecocultural theory as a framework, will guide the development of both quantitative and qualitative formative research assessments.

SETTING

Rural eastern Colorado.

PARTICIPANTS

Low-income families (n = 200) with preschool-aged children enrolled at 6 Head Start/preschool centers.

MAIN OUTCOME MEASURES

Quantitative and qualitative methodologies will garner insights into 4 key topic areas: (1) food behaviors and environments (Remote Food Photography Method, parent focus group, and survey), (2) physical activity behaviors and environments (parent interview and survey), (3) mobile device use (parent survey and interview), and (4) daily life (ecocultural family interview and teacher/staff group discussions).

ANALYSIS

Results will be interpreted in combination to allow for a holistic understanding of participant behaviors, beliefs, attitudes and values related to each of the 4 topic areas. Collectively, outcomes will provide a comprehensive picture of preschoolers' daily life and inform intervention design and strategies to enhance preschoolers' eating and activity behaviors in the home environment.

Questioning the Dietary Acculturation Paradox: A Mixed-Methods Study of the Relationship between Food and Ethnic Identity in a Group of Mexican-American Women

BACKGROUND

Epidemiological studies have described an "acculturation paradox." Increased acculturation to the United States is associated with increased consumption of dietary fat and decreased consumption of fruits/vegetables.

OBJECTIVE

To expand understanding of the dietary acculturation paradox, this study examined how bicultural Mexican-American women construct ethnic identity and how these identities and identity-making processes relate to perceptions of health and nutrition.

DESIGN

We utilized embedded mixed methods (in-depth interviews; survey).

PARTICIPANTS/SETTING

We analyzed a purposive sample of English-speaking Mexican-American women aged 18 to 29 years (n=24) in rural California to assess ethnic identity and diet beliefs.

RESULTS

Participants described food as central to expressing cultural identity, usually in terms of family interactions. Mexican food traditions were characterized as unhealthy; many preferred American foods, which were seen as healthier. Specifically, Mexican-American women perceived Mexican patterns of food preparation and consumption as unhealthy. In addition, traditional Mexican foods described as unhealthy were once considered special-occasion foods. Among the participants who expressed a desire to eat healthfully, to do so meant to reject Mexican ways of eating.

CONCLUSIONS

This study raises questions about the nature of the "dietary acculturation paradox." While food-the eating of Mexican foods-is central to the maintenance of ethnic identity throughout acculturation, negative perceptions about the healthfulness of Mexican foods introduce tension into Mexican-American women's self-identification. This study suggests a subtle contradiction that may help to explain the dietary acculturation paradox: While previous research has suggested that as Mexicans acculturate to the United States they adopt unhealthy diets, this study finds evidence that they do so at least in part due to perceptions that American diets are healthier than Mexican diets. Implications for interventions to improve Latinos' diets include an emphasis on the family and use of Spanish linguistic cues. Finally, messages that simply advocate for "traditional" diets should be reconsidered because that message is discordant with perceptions of the healthfulness of such foods.

Self-reported and observed feeding practices of Rhode Island Head Start teachers: Knowing what not to do

PURPOSE

Through their feeding practices, adult caregivers play an important role in shaping children's eating behaviors. However, the feeding practices of child care teachers have received little attention. The purpose of this study was to compare child care teachers' self-reported feeding practices and observed feeding practices during a preschool meal.

METHODS

Rhode Island Head Start teachers (n = 85) were observed during breakfast and lunch where feeding practices were coded using a tool adapted from the Environmental Policy Assessment and Observation (EPAO) tool. Teachers completed a questionnaire adapted from the EPAO Self-Report to capture self-reported feeding practices. Agreement between reported and observed was compared by percent agreement.

RESULTS

Teachers were predominantly White (89%) and female (98%). There was a higher level of agreement among self-reported and observed controlling feeding practices (78.8-97.6% agreement) compared to healthful feeding practices (11.8-20.0% agreement).

CONCLUSIONS

Although self-report measures are typically used to capture feeding practices, there are inconsistencies between self-report and observation measures. The inconsistencies found among healthful self-reported and observed feeding practices have implications for future research protocols, measurement refinement, and training of child care teachers.