Leveraging Implementation Science in the Public Health Response to COVID-19 : Child Food Insecurity and Federal Nutrition Assistance Programs

Position of the Society for Nutrition Education and Behavior: The Importance of Emergency-Related Food and Nutrition Education Before, During, and After a Disaster

It is the position of the Society for Nutrition Education and Behavior that for effective recovery from and resilience to disasters, it is essential that impacted individuals and communities have access to safe, nutritious, and culturally and contextually appropriate foods and beverages, and receive emergency-related food and nutrition education before, during, and after a disaster. Despite the increasing number, duration, and intensity of disasters worldwide, there is relatively limited guidance for research, policy, and practice about addressing the emergency-related food and nutrition needs of affected populations. Although nutrition emergencies tend to be understudied, emerging efforts are working to advance food and nutrition security during disaster response and recovery. To help elevate the importance of emergency-related food and nutrition education before, during, and after a disaster, Society for Nutrition Education and Behavior, which represents the unique professional interests of nutrition educators worldwide, summarizes the relevant literature and puts forth recommendations for all those who are engaged in this work in the following 4 key areas: (1) improving communication and outreach, (2) fostering community engagement and locally-driven preparedness, (3) building the evidence base and translating the evidence into action, and (4) training current professionals and the next generation of public health leaders. Altogether, before, during, and after a disaster, those who engage in this work, among other allies, can help elevate the importance of nutrition education and other strategies to promote healthy eating behaviors through research, policy, and practice.

Studying the impact of COVID-19 mitigation policies on childhood obesity, health behaviors, and disparities in an observational cohort: Protocol for the COVID-19 Family Study

BACKGROUND

COVID-19 pandemic control policies, including school closures, suspended extra-curricular activities, and social distancing, were introduced to prevent viral transmission, and disrupted children's daily routines, health behaviors, and wellness. This observational cohort study among 697 families with children or adolescents, based on the Family Stress Model, aims to: 1) evaluate pre- to during-pandemic changes in child health behaviors (diet, physical activity, sleep) and weight gain, 2) identify mechanisms explaining the changes, and 3) determine projected healthcare costs on weight gain and obesity. Each aim includes an examination by racial and ethnic, socioeconomic, and geographic disparities.

METHODS

The study employs a mixed methods design, recruiting children and their caregivers from two obesity prevention trials halted in 2020. Enrolled participants complete annual surveys to assess child health behaviors, family resources, routines, and demographics, and home environment in 2020-2022. Height and weight are measured annually in 2021-2022. Annual semi-structured interviews are conducted within a subsample to understand mechanisms of observed changes. Multilevel mixed models and mediation analyses are used to examine changes in child health behaviors and weight gain and mechanisms underlying the changes. Qualitative data are analyzed within and across time points and integrated with quantitative findings to further explain mechanisms. Markov models are used to determine healthcare costs for unhealthy child behaviors and weight gain.

CONCLUSION

Findings from this study will aid in understanding pandemic-related changes in child health behaviors and weight status and will provide insights for the implementation of future programs and policies to improve child and family wellness.

Challenges and Opportunities for Equity in US School Meal Programs: A Scoping Review of Qualitative Literature Regarding the COVID-19 Emergency

The emergency school meals program provided free meals to children in the United States (US) during COVID-19-related school closures. This scoping review aims to synthesize the existing qualitative empirical evidence published between March 2020 and January 2023 on the operations and utilization of emergency school meal programs during the pandemic. Qualitative, US-based peer-reviewed literature was collected from three sources: (1) parent review of all federal nutrition assistance programs; (2) systematic search of four databases; and (3) manual search of grey literature. Identified scientific articles and grey literature reports (n = 183) were uploaded into Covidence and screened for duplicates and inclusion/exclusion criteria. Our final sample included 21 articles/reports, including 14 mixed methods and seven qualitative-only projects. Articles spanned all U.S. states. Articles had similar research questions to understand school meals and/or general food access during COVID-19, with an emphasis on long-term policy implications. Hybrid deductive/inductive analytic coding was used to analyze data, utilizing domains from the Getting to Equity Framework (GTE). GTE considers multi-level factors that influence nutrition behavior while centering more equitable pathways to improve nutrition security and reduce adverse health. Findings were sorted into two categories: operational challenges during the pandemic and solutions to address inequities in school meal distribution during and after the pandemic, particularly during school closures such as summers or future emergencies. Key challenges related to supply chain issues, safety, and balancing families' needs with limited staff capacity. Programs addressed equity by (a) reducing deterrents through federally issued waivers and increased communications which allowed the serving of meals by programs to families who previously did not have access, (b) building community capacity through collaborations and partnerships which allowed for increased distribution, and (c) preparing and distributing healthy options unless barriers in supply chain superseded the effort. This review highlights the importance of emergency school meal programs and provides insights into addressing challenges and promoting equity in future out-of-school times. These insights could be applied to policy and practice change to optimize program budgets, increase reach equitably, and improve access to nutritious meals among populations at highest risk for nutrition insecurity.

A Qualitative Study to Compare Barriers to Improving Food Security among Households with Young Children in the U.S. as Perceived by Different Types of Stakeholders before and during COVID-19

This qualitative study aimed to determine the perceived barriers of different community stakeholders’ to providing resources for improving food security in households with young children in the U.S. Community stakeholders working with low-income families with children 0–3 years of age in Florida were recruited to represent healthcare (n = 7), community/policy development (n = 6), emergency food assistance (n = 6), early childhood education (n = 7), and nutrition education (n = 6) sectors. In 2020, one-on-one interviews were conducted with each stakeholder in via Zoom, using an interview script based on the PRECEDE–PROCEED model and questions to capture the impacts of COVID-19. The interviews were audio-recorded, transcribed verbatim, and analyzed using a deductive thematic approach. A cross-tab qualitative analysis was used to compare data across categories of stakeholders. Healthcare professionals and nutrition educators indicated stigma, community/policy development stakeholders indicated a lack of time, emergency food assistance personnel indicated a limited access to food, and early childhood professionals indicated a lack of transportation as the main barriers to food security prior to COVID-19. COVID-19 impacts included the fear of virus exposure, new restrictions, lack of volunteers, and a lack of interest in virtual programming as barriers to food security. As perceived barriers may vary with respect to providing resources to improve food security in families with young children and the COVID-19 impacts persist, coordinated policy, systems, and environmental changes are needed.

Pre-pandemic to early-pandemic changes in risk of household food insecurity among Maryland families with children

OBJECTIVE

The objective was to examine risk and protective factors associated with pre- to early-pandemic changes in risk of household food insecurity (FI).

DESIGN

We re-enrolled families from two statewide studies (2017-2020) in an observational cohort (May-August 2020). Caregivers reported on risk of household FI, demographics, pandemic-related hardships, and participation in safety net programs (e.g. CARES stimulus payment, school meals).

SETTING

Maryland, United States.

PARTICIPANTS

Economically, geographically, and racially/ethnically diverse families with preschool to adolescent-age children. Eligibility included reported receipt or expected receipt of the CARES stimulus payment or a pandemic-related economic hardship (n=496).

RESULTS

Prevalence of risk of FI was unchanged (pre-pandemic: 22%, early-pandemic: 25%, p=0.27). Risk of early-pandemic FI was elevated for non-Hispanic Black (aRR=2.1 [95% CI 1.1, 4.0]) and Other families (aRR=2.6 [1.3, 5.4]) and families earning ≤300% federal poverty level. Among pre-pandemic food secure families, decreased income, job loss, and reduced hours were associated with increased early-pandemic FI risk (aRR=2.1 [1.2, 3.6] to 2.5 [1.5, 4.1]); CARES stimulus payment (aRR=0.5 [0.3, 0.9]) and continued school meal participation (aRR=0.2 [0.1, 0.9]) were associated with decreased risk. Among families at risk of FI pre-pandemic, safety net program participation was not associated with early-pandemic FI risk.

CONCLUSIONS

The CARES stimulus payment and continued school meal participation protected pre-pandemic food secure families from early-pandemic FI risk but did not protect families who were at risk of FI pre-pandemic. Mitigating pre-pandemic FI risk and providing stimulus payments and school meals may support children's health and reduce disparities in response to pandemics.

Feeding Children and Maintaining Food Service Operations during COVID-19: A Mixed Methods Investigation of Implementation and Financial Challenges

The United States Department of Agriculture (USDA) National School Lunch and Breakfast Programs are critical for the health and food security of U.S. schoolchildren, but access to these programs was disrupted by COVID-19 pandemic-related school closures in spring 2020. While temporary policy changes to the programs enabled school food authorities (SFAs) to pivot towards distributing meals throughout their communities instead of within school buildings, SFAs faced complex challenges during COVID-19 with minimal external support. This mixed methods study investigates the implementation and financial challenges experienced by twelve of the largest urban SFAs in the U.S. during COVID-19. We conducted semi-structured interviews with SFA leaders and analyzed alongside quantitative financial data. We found that SFAs reconfigured their usual operations with nearly no preparation time while simultaneously trying to keep staff from contracting COVID-19, accommodate stakeholders with sometimes competing priorities, and remain financially solvent. Because student participation was much lower than during regular times, and revenue is tied to the number of meals served, SFAs saw drastic decreases in revenue even as they carried regular operating costs. For future crises, disaster preparedness plans that help SFAs better navigate the switch to financially viable community distribution methods are needed.

Longitudinal patterns of food insecurity, the home food environment, and parent feeding practices during COVID-19

Background

The economic impacts of the coronavirus disease 2019 (COVID-19) have drastically increased food insecurity in the United States. Initial data, collected a few months into the pandemic, showed that families, particularly those experiencing food insecurity, reported detrimental changes to their home food environment and parent feeding practices, compared to before COVID-19.

Objective

This follow-up study obtained longitudinal data from a sample of parents in the United States to quantify changes in food security status, the home food environment, and parent feeding practices, from before to across COVID-19 as the pandemic continued to persist.

Methods

Parents (N = 433) completed online surveys May (T1) and September (T2) 2020 during COVID-19. Food security, home food environment, and parent feeding practices were reported at each timepoint. At T1, parents also retrospectively reported on these factors pertaining to before COVID-19. Chi square analyses and repeated measure mixed models examined associations among study variables.

Results

Low or very low food security increased from before COVID-19 (37%) to T1 (54%) and decreased by T2 (45%). About 30% of families who became food insecure, and 44% who stayed food insecure from T1 to T2, reported a decrease in total food in their home; only 3%-6% who became/stayed food secure reported this decrease. Parents' concern for child overweight and use of monitoring increased from before COVID-19 to T1, and decreased by T2, but remained elevated above pre-COVID-19 values.

Conclusion

Rates of food insecurity remain high as this pandemic persists. Continued assessment of nutrition-related factors and increased economic supports are critical for families to endure COVID-19 and prevent long-term obesity and health risks.