Protocol for the Support Application for Food PAntrieS trial: design, implementation, and evaluation plan for a digital application to promote healthy food access and support food pantry operations.

Introduction: Food-insecure households commonly rely on food pantries to supplement their nutritional needs, a challenge that was underscored during the COVID-19 pandemic. Food pantries, and the food banks that supply them, face common challenges in meeting variable client volume and dietary needs under normal and emergency (e.g., pandemic, natural disaster) conditions. A scalable digital strategy that has the capacity to streamline the emergency food distribution system, while promoting healthy food options, managing volunteer recruitment and training, and connecting to emergency management systems in times of need, is urgently required. To address this gap, we are developing a working mobile application (app) called the Support Application for Food PAntrieS (SAFPAS) and will evaluate its feasibility and impact on food pantry staff preparedness, stocking, and client uptake of healthful foods and beverages in two urban United States settings. Methods: This paper describes the protocol for a randomized controlled trial of the SAFPAS mobile application. We will conduct formative research in Baltimore, Maryland and Detroit, Michigan to develop and refine the SAFPAS app and increase scalability potential to other urban settings. Then we will test the app in 20 food pantries in Baltimore randomized to intervention or comparison. The impact of the app will be evaluated at several levels of the emergency food system, including food pantry clients (n = 360), food pantry staff and volunteers (n = 100), food pantry stock, and city agencies such as the local food bank and Office of Emergency Management. The primary outcome of the SAFPAS trial is to improve the healthfulness of the foods received by food pantry clients, measured using the Food Assessment Scoring Tool (FAST). Post-trial, we will conduct additional formative research in Detroit to prepare the app for scale-up. Discussion: We anticipate that SAFPAS will improve alignment in the supply and demand for healthy foods among food pantry clients, food pantries, and city agencies which supply food in Baltimore. Real-time, bidirectional communication between entities across the system allows for increased situational awareness at all levels during normal and emergency operations. By conducting formative research in Detroit, we hope to increase the scalability of the SAFPAS app to additional settings nationwide. Clinical trial registration: NCT87654321. https://classic.clinicaltrials.gov/ct2/show/NCT05880004.

Design of a Mobile App Interface That Engages Community Members in a Food System Pilot Study.

Supermarkets are scarce in many under-resourced urban communities, and small independently owned retail stores often carry few fresh or healthy items. The Baltimore Urban food Distribution (BUD) mobile application (app) was previously developed to address supply-side challenges in moving healthy foods from local suppliers to retailers. In-app opportunities for consumers to indicate demand for these foods are crucial, but remain absent. We sought to understand community members' perspectives on the overall role, function and features of a proposed consumer-engagement module (BUDConnect) to expand the BUD app. A series of initial high-fidelity wireframe mockups were developed based on formative research. In-depth interviews (n = 20) were conducted and thematically analyzed using ATLAS.ti Web. Participants revealed a desire for real-time crowd-sourced information to navigate their food environments safely and effectively, functionality to help build community and social networks among store owners and their customers, opportunities to share positive reviews and ratings of store quality and offerings, and interoperability with existing apps. Rewards and referral systems resulting in the discounted purchasing of promoted healthy items were suggested to increase adoption and sustained app use. Wireframe mockups were further refined for future development and integration into the BUD app, the program and policy implications of which are discussed.

Sources of Stress and Coping Strategies Among Urban African American Adolescents: A Qualitative Study of Child and Caregiver Perspectives.

Early adolescence is a critical point for intervention to protect against negative consequences of stress on the developing brain. This study aimed to gather perspectives on stress from adolescents and their caregivers living in under-resourced Baltimore City neighborhoods. Nine African American adolescents and their caregivers (n = 18 total) participated in qualitative interviews exploring neighborhood environments, sources of stress, and coping behaviors. Neighborhood social cohesion was described as a strength of participants' communities, despite concerns about neighborhood safety. Caregivers were highly aware of their child's stressors and coping behaviors. School-related pressure was a prevalent source of stress emphasized by adolescents, along with social stress due to disrupted routines during the COVID-19 pandemic. Adolescents described frequent use of electronics to cope with stress, as well as self-care and relaxation techniques. Themes identified from these data can be used to inform future adolescent stress-reduction interventions and stress-prevention efforts in this priority population.

Dollar store policy opportunities in Baltimore City: community member and policy maker perspectives.

Introduction: There are currently over 50 dollar stores in Baltimore City, Maryland. Community perceptions of over-saturation and resulting neighborhood impacts have garnered recent attention. A Maryland State Senate Bill required further study of dollar stores in Baltimore City to inform future policy. Therefore, the over-arching goal of this study was to generate community-informed policy recommendations for the Baltimore City Council. Methods: Three methods of data collection were used: (1) in-depth interviews with community members, retail staff/owners, dollar store staff, and policy makers; (2) an online survey of Baltimore City residents; and (3) workshop with community members and one with policy makers. Triangulation across data sources, discussion amongst the research team, and member checking were used to generate the top four policy options: a conditional use ordinance, a community benefits agreements, a dispersal ordinance, and a staple foods ordinance. Results: There was strong support for policies that encourage dollar stores to better align with community priorities (e.g., improving store cleanliness and appearance, increasing availability of healthy foods), as opposed to closing or banning dollar stores entirely. There was also strong support for policies that would empower communities to participate in determining the role of dollar stores in their neighborhoods, for example through a conditional use ordinance or community benefits agreement. Key concerns included policy enforcement, given the additional funding required, and current limited capacity at the city government level. Strategies to address such challenges were generated including implementing business licenses at the city level, linking new ordinances to dollar store leases and permits, and encouraging dollar store participation in federal and local programs to more feasibly stock healthier food items (e.g., fresh produce). Dissatisfaction was expressed regarding a lack of policy options to address the existing dollar stores, not just new dollar stores entering the City. Discussion: This study is the first of its kind to assess community support for dollar store policies at the local level, and serves to inform policies that improve dollar stores. A report of these findings was provided to Baltimore City Council to inform new, community-supported dollar store policies.

Federal Food Assistance Accessibility and Acceptability Among Indigenous Peoples in the United States: A Scoping Review.

The purpose of this scoping review was to determine the extent to which accessibility and acceptability of federal food assistance programs in the United States have been evaluated among indigenous peoples and to summarize what is currently known. Twelve publications were found that examine aspects of accessibility or acceptability by indigenous peoples of 1 or more federal food assistance programs, including the supplemental nutrition assistance program (SNAP) and/or the Food Distribution Program on Indian Reservations (n = 8), the Special Supplemental Nutrition Program for Women, infants, and children (WIC) (n = 3), and the national school lunch program (n = 1). No publications were found to include the commodity supplemental food program or the child and adult care food program. Publications ranged in time from 1990-2023, and all reported on findings from rural populations, whereas 3 also included urban settings. Program accessibility varied by program type and geographic location. Road conditions, transportation access, telephone and internet connectivity, and an overall number of food stores were identified as key access barriers to SNAP and WIC benefit redemption in rural areas. Program acceptability was attributed to factors such as being tribally administered, providing culturally sensitive services, and offering foods of cultural significance. For these reasons, Food Distribution Program on Indian Reservations and WIC were more frequently described as acceptable compared to SNAP and national school lunch programs. However, SNAP was occasionally described as more acceptable than other assistance programs because it allows participants autonomy to decide which foods to purchase and when. Overall, little attention has been paid to the accessibility and acceptability of federal food assistance programs among indigenous peoples in the United States. More research is needed to understand and improve the participation experiences and health trajectories of these priority populations.

Design of an innovative digital application to facilitate access to healthy foods in low-income urban settings.

Background: Under-resourced urban minority communities in the United States are characterized by food environments with low access to healthy foods, high food insecurity, and high rates of diet-related chronic disease. In Baltimore, Maryland, low access to healthy food largely results from a distribution gap between small food sources (retailers) and their suppliers. Digital interventions have the potential to address this gap, while keeping costs low. Methods: In this paper, we describe the technical (I) front-end design and (II) back-end development process of the Baltimore Urban food Distribution (BUD) application (app). We identify and detail four main phases of the process: (I) information architecture; (II) low and high-fidelity wireframes; (III) prototype; and (IV) back-end components, while considering formative research and a pre-pilot test of a preliminary version of the BUD app. Results: Our lessons learned provide valuable insight into developing a stable app with a user-friendly experience and interface, and accessible cloud computing services for advanced technical features. Conclusions: Next steps will involve a pilot trial of the app in Baltimore, and eventually, other urban and rural settings nationwide. Once iterative feedback is incorporated into the app, all code will be made publicly available via an open source repository to encourage adaptation for desired communities. Trial Registration: ClinicalTrials.gov NCT05010018.

Preconception Maternal Mentoring for Improved Fetal Growth among Indonesian Women: Results from a Cluster Randomized Controlled Trial.

The prevalence of stunting in young children is associated with poor growth during the prenatal and early postnatal periods. A maternal mentoring program was developed for Indonesian women to improve birth outcomes. A cluster-randomized controlled trial (CRCT) was conducted in three sub-districts of the Special Region of Yogyakarta, Indonesia. A total of 384 eligible participants were randomly allocated to either an intervention (received the maternal mentoring program and standard care; n = 189) or control (received standard care only; n = 195) group. The maternal mentoring program provided preconception health education; health monitoring; and text message reminders for preconception women. Fetal growth was measured between gestational weeks 27 and 30 using the estimated fetal weight generated from ultrasonographic measurements. Birth weight was measured within 24 h of birth. A structured questionnaire captured women's demographics, pregnancy readiness, and body mass indexes (BMIs). After adjustment, fetal weight was 14% (95% CI: 5.1-23.0) higher in the intervention group than in the control group, and the average weight-for-length Z-score at birth was 0.16 (95% CI: 0.04-0.30) higher in the intervention group than in the control group. The maternal mentoring program was associated with improved fetal growth and birth weight in this population and should be considered for scale-up to other settings, nationally and globally.

Food access narratives as told by consumers and retailers engaging in a COVID-19-stricken urban food system: A brief report.

Small food retail ("corner") stores in many underserved urban settings face challenges to stocking healthy, affordable foods. The food supply chain is considered one of the most important sectors of the economy and has suffered recent negative impacts due to the Coronavirus disease 2019 (COVID-19) pandemic, from farm to consumer. As part of the larger Baltimore Urban food Distribution (BUD) Study, we examine corner store owner and consumer perceptions of the impact of COVID-19 on navigating an urban food environment using a brief, reflective, semi-structured oral interview framed as "storytelling." Open-ended responses are documented, transcribed, and analyzed for key themes. Presently, we discuss initial key findings in hopes of helping to ensure sufficient value added for corner store owners and consumers who will interact with the BUD mobile application as part of a full-scale trial being implemented in Baltimore, Maryland.

Our Voice NOLA: Leveraging a Community Engaged Citizen Science Method to Contextualize the New Orleans Food Environment.

OBJECTIVE: We employed the Our Voice citizen scientist method using a mobile application (app) to identify and contextualize neighborhood-level features influencing food access and wellbeing in New Orleans, Louisiana. DESIGN: A three-phase, multi-method study comprised of: (1) a researcher-assisted tag-a-long neighborhood walk (referred to as a 'journey') with the Discovery Tool (DT) app to document neighborhood-level features via geo-coded photos and audio-recorded narratives; (2) a post-journey interview to enable citizen scientists to share their lived experiences; and (3) a community meeting with citizen scientists and local stakeholders. SETTING: Various neighborhoods in New Orleans, Louisiana, USA. PARTICIPANTS: Citizen Scientists (i.e., residents) aged 18 years and older. MAIN OUTCOME MEASURE(S): Features that influence food access and health behaviors. ANALYSIS: Descriptive statistics and a thematic content analysis were conducted to assess survey and app data. RESULTS: Citizen scientists (N = 14) captured 178 photos and 184 audio narratives. Eight major themes were identified: safety; walkability; aesthetics; amenities; food; health services; neighborhood changes; and infrastructure/city planning. The post-journey interview provided insights around the abovementioned themes. The community meeting demonstrated the willingness of citizen scientists and stakeholders to convene and discuss issues and relevant solutions. CONCLUSIONS AND IMPLICATIONS: Findings demonstrate the ability of technology and citizen science to help better understand the complexities of New Orleans' past, present and distinct culture-and implications for food access and wellbeing in the context of trauma in an urban ecosystem.

Balancing Mission and Margins: What Makes Healthy Community Food Stores Successful.

Mission-driven, independently-owned community food stores have been identified as a potential solution to improve access to healthy foods, yet to date there is limited information on what factors contribute to these stores' success and failure. Using a multiple case study approach, this study examined what makes a healthy community food store successful and identified strategies for success in seven community stores in urban areas across the United States. We used Stake's multiple case study analysis approach to identify the following key aims that contributed to community store success across all cases: (1) making healthy food available, (2) offering healthy foods at affordable prices, and (3) reaching community members with limited economic resources. However, stores differed in terms of their intention, action, and achievement of these aims. Key strategies identified that enabled success included: (1) having a store champion, (2) using nontraditional business strategies, (3) obtaining innovative external funding, (4) using a dynamic sourcing model, (5) implementing healthy food marketing, and (6) engaging the community. Stores did not need to implement all strategies to be successful, however certain strategies, such as having a store champion, emerged as critical for all stores. Retailers, researchers, philanthropy, and policymakers can utilize this definition of success and the identified strategies to improve healthy food access in their communities.

The Baltimore Urban Food Distribution (BUD) App: Study Protocol to Assess the Feasibility of a Food Systems Intervention.

Low-income urban communities in the United States commonly lack ready access to healthy foods. This is due in part to a food distribution system that favors the provision of high-fat, high-sugar, high-sodium processed foods to small retail food stores, and impedes their healthier alternatives, such as fresh produce. The Baltimore Urban food Distribution (BUD) study is a multilevel, multicomponent systems intervention that aims to improve healthy food access in low-income neighborhoods of Baltimore, Maryland. The primary intervention is the BUD application (app), which uses the power of collective purchasing and delivery to affordably move foods from local producers and wholesalers to the city's many corner stores. We will implement the BUD app in a sample of 38 corner stores, randomized to intervention and comparison. Extensive evaluation will be conducted at each level of the intervention to assess overall feasibility and effectiveness via mixed methods, including app usage data, and process and impact measures on suppliers, corner stores, and consumers. BUD represents one of the first attempts to implement an intervention that engages multiple levels of a local food system. We anticipate that the app will provide a financially viable alternative for Baltimore corner stores to increase their stocking and sales of healthier foods, subsequently increasing healthy food access and improving diet-related health outcomes for under-resourced consumers. The design of the intervention and the evaluation plan of the BUD project are documented here, including future steps for scale-up. Trial registration #: NCT05010018.

Forms of Community Engagement in Neighborhood Food Retail: Healthy Community Stores Case Study Project.

Community engagement is well established as a key to improving public health. Prior food environment research has largely studied community engagement as an intervention component, leaving much unknown about how food retailers may already engage in this work. The purpose of this study was to explore the community engagement activities employed by neighborhood food retailers located in lower-income communities with explicit health missions to understand the ways stores involve and work with their communities. A multiple case study methodology was utilized among seven retailers in urban U.S. settings, which collected multiple sources of data at each retailer, including in-depth interviews, store manager sales reports, store observations using the Nutrition Environment Measures Survey for Stores, public documents, and websites. Across-case analysis was performed following Stake's multiple case study approach. Results indicated that retailers employed a wide variety of forms of community engagement within their communities, including Outreach, Building Relationships through Customer Relations, Giving Back, Partnering with Community Coalitions, and Promoting Community Representation and Inclusiveness. Strategies that built relationships through customer relations were most common across stores; whereas few stores demonstrated community inclusiveness where members participated in store decision making. Findings provide a more comprehensive view of the ways local food retailers aim to develop and sustain authentic community relationships. Additional research is needed to evaluate the impact of community engagement activities on improving community health.

Food-Seeking Behaviors and Food Insecurity Risk During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: Food insecurity risk increases among disaster-struck individuals. The authors employed the social determinants of health framework to (1) describe the characteristics and food-seeking behaviors of individuals coping with the coronavirus disease 2019 pandemic and (2) evaluate the relationship between these factors and food insecurity risk. DESIGN: A cross-sectional Qualtrics survey was administered May 14-June 8, 2020. PARTICIPANTS: Adults living in New York were recruited online (n = 410). MAIN OUTCOME MEASURE: Food insecurity risk. ANALYSIS: Logistic regression analyses were conducted using a model-building approach. RESULTS: A total of 38.5% of the sample was considered food insecure after the coronavirus disease 2019 outbreak. The final model revealed that not knowing where to find help to acquire food, reporting that more food assistance program benefits would be helpful, being an essential worker, having general anxiety, and being a college student were risk factors for food insecurity regardless of demographic characteristics. CONCLUSIONS AND IMPLICATIONS: With more individuals experiencing food insecurity for the first time, there is a need for enhanced outreach and support. The findings complement emerging research on food insecurity risk during and after the pandemic and can help to inform food assistance programs and policies.

The effect of a maternal mentoring program on the timing of first antenatal care visit among pregnant women in Bantul, Indonesia: Results of a cluster randomized trial.

Background: Antenatal care (ANC) is low in developing countries, with an estimated 20% of Indonesian women not initiating ANC during the first trimester. The present study sought to determine the impact of a mentoring program on the timing of the first ANC visit. Methods: This cluster randomized controlled trial was conducted in 3 subdistricts of the Bantul District, divided into 61 clusters per treatment arm, with a final sample size of 205 confirmed pregnant women. The mentoring program consisted of (1) health education, (2) monitoring, and(3) text-message reminders. The primary outcome was the timing of first ANC visit. A multilevel mixed-effect logistic regression model was used to measure the effect of the program on the likelihood of having an earlier first ANC visit, with statistical significance at α=0.05. Results: At the individual-level, the intervention group had a mean time of first ANC visit±2 days earlier than the control group (P<0.05). After adjusted for cluster and other covariates, the odds of starting the first ANC visit early (<39 days of gestation) was higher in the intervention group (adjusted odds ratio [AOR] 3.00; 95% confidence interval [CI] 1.17-7.72). Conclusion: Maternal mentoring can improve the timing of the first ANC visit. This program has the potential to be adopted by health care systems in settings where there is little education on the importance of ANC. Future research could extend the length of mentorship until delivery in order to better understand the relationship between mentorship and early ANC on pregnancy outcomes.

Feasibility of using mobile point-of-sale technology in Baltimore City corner stores tracking sales: A brief report.

Small food retail stores in many underserved urban settings keep no electronic records, making documentation of program impact on sales difficult to obtain. We examined the feasibility of introducing a point-of-sale tablet (POST) application to track sales of foods and beverages in Baltimore City corner stores. A sample of four geographically and ethnically diverse corner store owners were trained to use POST to track sales of 14 items for eleven days. Feasibility was documented via a structured survey and open-ended interviews. POST had high economic and cultural acceptability, operability, and perceived sustainability, regardless of language differences or familiarity with mobile technology. All store owners reported willingness to use POST again. It is feasible to train corner store owners to use a point-of-sale application for sales monitoring. An upcoming trial will help to ensure that POST provides sufficient value added for corner store owners.

The role of the school food environment in improving the healthiness of school canteens and the readiness to reopen post COVID-19 pandemic: A study conducted in Indonesia.

BACKGROUND: Indonesian school children spend one-third of their time in school, where they are exposed to a variety of foods at school canteens. However, the healthiness of school canteens is not yet well understood. This study was conducted to characterize the healthiness and quality of management of school canteens, and measure readiness of school canteens to reopen following COVID-19 closures. DESIGN AND METHODS: Mixed-methods were used to conduct a cross-sectional study. Data were collected from schools located in the Bantul District of Indonesia. Primary schools (n=152) were randomly selected, with a final sample size of 147. Data were collected using Google Forms, delivered via WhatsApp or email. School canteens were classified as healthy if they had a Healthy Canteen Score (HCS) >= 10, or unhealthy if they had a HCS < 10. RESULTS: Less than half (43.5%) of school canteens were deemed to be healthy. School canteens were more likely to be healthy if the canteen manager had a formal decision letter (OR=15.2; 95% CI=3.7-62.5); used print material messaging (OR= 3.2 to 4.6 times); or received inspection by external officers periodically (OR=2.8; 95% CI= 1.04-7.5). Readiness to reopen was 4.5 (OR=4.5; 95%CI: 1.1-17.9) times higher among schools that had their own canteen, and 4 (OR=3.9; 95% CI =1.1-13.8) times higher among schools located in rural areas, adjusting for the remaining variables. CONCLUSIONS: School canteen healthiness can be improved by implementing national food policy and healthy school canteen standards accompanied by the existence of good management practices within schools, particularly following the COVID-19 pandemic.