Integrating Human-Centered Design Methods Into a Health Promotion Project: Supplemental Nutrition Assistance Program Education Case Study for Intervention Design.

BACKGROUND: Human-centered design, or design thinking, offers an extensive toolkit of methods and strategies for user-centered engagement that lends itself well to intervention development and implementation. These methods can be applied to the fields of public health and medicine to design interventions that may be more feasible and viable in real-world contexts than those developed with different methods. OBJECTIVE: The design team aimed to develop approaches to building food skills among caregivers of children aged 0-5 years who are eligible for a federal food assistance program while they were in the grocery store. METHODS: They applied 3 specific human-centered design methods-Extremes and Mainstreams, Journey Mapping, and Co-Creation Sessions-to collaboratively develop intervention approaches to enhance Supplemental Nutrition Assistance Program Education (SNAP-Ed) reach and impact across food retail settings. Extremes and Mainstreams is a specific kind of purposive sampling that selects individuals based on characteristics beyond demographics. Journey Mapping is a visual tool that asks individuals to identify key moments and decision points during an experience. Co-Creation Sessions are choreographed opportunities for individuals to explicitly contribute to the design of a solution alongside research or design team members. RESULTS: Ten caregivers with diverse lived experiences were selected to participate in remote design thinking workshops and create individual journey maps to depict their grocery store experiences. Common happy points and pain points were identified. Nine stakeholders, including caregivers, SNAP-Ed staff, and grocery store dieticians, cocreated 2 potential intervention approaches informed by caregivers' experiences and needs: a rewards program and a meal box option. CONCLUSIONS: These 3 human-centered design methods led to a meaningful co-design process where proposed interventions aligned with caregivers' wants and needs. This case study provides other public health practitioners with specific examples of how to use these methods in program development and stakeholder engagement as well as lessons learned when adapting these methods to remote settings.

Nutrition interventions addressing structural racism: a scoping review.

African Americans experience high rates of obesity and food insecurity in part due to structural racism, or overlapping discriminatory systems and practices in housing, education, employment, health care and other settings. Nutrition education and nutrition-focused policy, systems and environmental changes may be able to address structural racism in the food environment. This scoping review aimed to summarise the available literature regarding nutrition interventions for African Americans that address structural racism in the food environment and compare them with the 'Getting to Equity in Obesity Prevention' framework of suggested interventions. An electronic literature search was conducted with the assistance of a research librarian encompassing six databases: MEDLINE, PyscINFO, Agricola, ERIC, SocINDEX and ProQuest Dissertations & Theses. A total of thirty sources were identified detailing interventions addressing structural barriers to healthy eating. The majority of nutrition interventions addressing structural racism consisted of policy, systems and/or environmental changes in combination with nutrition education, strategies focused on proximal causes of racial health disparities. Only two articles each targeted the 'reduce deterrents' and 'improve social and economic resources' aspects of the framework, interventions which may be better suited to addressing structural racism in the food environment. Because African Americans experience high rates of obesity and food insecurity and encounter structural barriers to healthy eating in the food environment, researchers and public health professionals should address this gap in the literature.

Evaluation of a Healthy Checkout Lane "Nudge" on Grocery and Convenience Store Sales of a Price-Promoted Nutritious Food.

Grocery store intervention trials, including trials testing behavioral economics "nudges," may change food-purchasing behaviors and improve diet quality. This study aimed to design and evaluate a grocery store healthy checkout lane "nudge" intervention on sales of a targeted healthy item. We conducted a randomized controlled trial based on the behavioral economic concept of cognitive fatigue and the marketing concept of impulse buying. Six grocery stores from one North Carolina-based chain were randomized to the intervention (n = 3) or control (n = 3) condition. Researchers tested a 4-week healthy checkout lane intervention, in which intervention stores moved 6-ounce cans of peanuts to the cash registers. Cashiers were instructed to upsell the peanuts to all shoppers at checkout. While not a component of the intervention, the retailer decreased the price of the peanuts from $1.99 to $1.50 during the first 2 weeks of the intervention. Fidelity to the checkout display was high. Fidelity to the upsell was low. The main outcome measure was aggregated store-level sales of the promoted peanuts for 4 weeks before the intervention and during the 4-week intervention period. On average, sales increased by 10 units/week in intervention stores (5.83 vs. 15.83 units, p = .04) with no significant change in control stores (1.42 vs. 1.17 units, p = .64). The difference (10 vs. -0.25 units, p = .02) was likely due to displaying the peanuts at checkout combined with the price promotion. Larger randomized controlled trials should examine whether healthy checkout lane interventions are effective "nudges" for promoting purchases of healthier foods in grocery stores.

African Americans' perceptions of nutrition interventions: a scoping review.

Nutrition education and policy, systems and environmental (PSE) change interventions may be able to address food insecurity and obesity, conditions which are disproportionately experienced by African Americans. Work that seeks to address these disparities and advance social justice should uplift and learn from participant voices, particularly from marginalised groups. This scoping review aimed to summarise the available literature describing African Americans' perceptions of and experiences participating in nutrition interventions. We conducted an electronic literature search with the assistance of a research librarian which encompassed six databases (MEDLINE, PyscINFO, Agricola, ERIC, SocINDEX and ProQuest Dissertations & Theses) and identified thirty-five sources meeting our inclusion criteria. The majority of studies assessing African Americans' satisfaction with interventions examined educational interventions alone, and about half of the included studies assessed satisfaction through quantitative methods alone. The only studies which found participants to be dissatisfied with interventions used qualitative methods and examined interventions providing education alone. Future work should evaluate African Americans' experience with nutrition-focused PSE changes, interventions which may be better able to address racial disparities in obesity and food insecurity. Nutrition educators working with African Americans should also consider evaluating future interventions using qualitative inquiry, to obtain an in-depth understanding of participant experiences with interventions.

A qualitative analysis of SNAP and minimum wage policies as experienced by workers with lower incomes.

Work-related policies, including minimum wage and food assistance work requirements, can affect food security for people with lower incomes. This study conducted 112 qualitative interviews to understand participant policy experiences in two contexts (Raleigh, North Carolina and Minneapolis, Minnesota). Participants experienced frequent, destabilizing changes to their United States Department of Agriculture Supplemental Nutrition Assistance Program benefits, which they identified as part of a broader safety net. Raleigh workers described an unsupportive policy environment; Minneapolis workers reaped few benefits from an ongoing wage increase. Many workers face complex financial tradeoffs; more sophisticated evaluations should consider broader policy contexts and long-range effects.

Evaluating the Benefits of a SNAP-Ed-Funded Community Garden Intervention Using Ripple Effect Mapping.

In North Carolina, rural communities experience high rates of chronic illness due to health inequities exacerbated by the decline of major industries. Community gardens increase access to fresh produce and opportunities for physical activity and may offer additional benefits. These benefits can be difficult to measure as they are often unplanned or unintended. This article describes how we utilized Ripple Effect Mapping (REM), a participatory approach for evaluating complex interventions, to understand the impact of a SNAP-Ed-funded program. We purposively selected six community gardens to participate in 2-hour, facilitated REM sessions. On average, 15 people participated in each session. Participants developed a map of benefits using Appreciative Inquiry, mind mapping, and consensus-building methods. The map organized benefits across three levels: first ripple (individual), second ripple (interpersonal), and third ripple (community). In addition, participants coded benefits using the Community Capitals Framework. After the sessions, the research team extracted identified impacts into a matrix, aligned them with the SNAP-Ed Evaluation Framework, and developed digitized maps. These data corroborated findings from previous evaluations and offered insight into community-identified benefits not previously documented, including other types of capital generated by community gardens in rural communities. In addition, REM was an effective approach to measure and report several SNAP-Ed evaluation indicators, including LT11: Unexpected Benefits. Ultimately, the research team found REM to be an effective community-engaged method for understanding a complex intervention's benefits while centering participant community voices and transferring ownership of the data to community partners, a key principle in equitable evaluation.

Recruitment of Low-wage Workers for a Time-Sensitive Natural Experiment to Evaluate a Minimum Wage Policy: Challenges and Lessons Learned.

Natural experiments are often used for answering research questions in which randomization is implausible. Effective recruitment strategies are well documented for observational cohort studies and clinical trials, unlike recruitment methods for time-sensitive natural experiments. In this time-sensitive study of the impact of a minimum wage policy, we aimed to recruit 900 low-wage workers in Minneapolis, Minnesota and Raleigh, North Carolina. We present our recruitment strategies, challenges, and successes for participant screening and enrollment of a difficult-to-reach population.

Coping with diabetes stress among adults in rural Dominican Republic: "I don't think about it".

OBJECTIVES: As type 2 diabetes prevalence increases across Latin America, understanding local approaches to coping with diabetes stress is essential to providing care that incorporates patients' values and preferences. This study explored a local phenomenon, "no le doy mente" (I don't think about it), used by adults with type 2 diabetes in the Dominican Republic to cope with diabetes stress. METHODS: We conducted 19 qualitative in-depth interviews with adults with type 2 diabetes (10 men, 9 women) recruited from one rural clinic. Using an inductive analytic approach including iterative coding, memos, and matrices, we identified reasons, strategies, and perceived benefits of not thinking about type 2 diabetes among participants. RESULTS: Participants described not thinking about diabetes as an active process to maintain a sense of normalcy despite significant life changes following diagnosis. They avoided thinking about diabetes by staying busy, proactively managing type 2 diabetes through diet and medication, and turning to their faith. Participants perceived that enacting no le doy mente helped to protect their overall health and well-being. DISCUSSION: Future research should investigate provider perceptions of no le doy mente to align patient and provider communication and mindfulness-based stress reduction as a way to support people with type 2 diabetes avoid dwelling on negative thoughts about diabetes.

Interventions to Enhance Patient and Family Engagement Among Adults With Multiple Chronic Conditions: A Systematic Scoping Review.

PURPOSE: In the United States, 42% of adults, and 81% of adults over 65 years of age live with multiple chronic condition (MCC). Current interventions to facilitate engagement in care focus primarily on the patient; however, many individuals with MCC manage and live with their conditions within the context of their family. This review sought to identify interventions used to facilitate patient and/or family engagement among adults with MCC. METHODS: We adhered as closely as possible to PRISMA guidelines and conducted a systematic scoping review using a modified approach by Arksey and O'Malley. We searched PubMed, Web of Science, and Scopus using terms related to MCC, patient and family engagement, and intervention. We included articles that: (1) were published in English; (2) were peer-reviewed; (3) described an engagement intervention (with or without a comparator); and (4) targeted individuals with MCC. We abstracted data from included articles and classified them using the Multidimensional Framework for Patient and Family Engagement in Health and Health Care, and the Classification Model of Patient Engagement. RESULTS: We identified 21 discrete interventions. Six (29%) were classified as having the highest degree of engagement. Eighteen (85%) focused on engagement at the direct care level. Only one was specifically designed to engage families. CONCLUSIONS: Many engagement interventions currently exist for adults with MCC. Few of these interventions foster the highest degree of engagement; most focus on engagement at the level of direct care and do not specifically target family member involvement.

Novel Sales Tracking Method to Evaluate a Healthy Corner Store Intervention.

This article describes a Supplemental Nutrition Assistance Program-Education-funded (SNAP-Ed) healthy corner store intervention and novel evaluation method for tracking sales of promoted foods in two corner stores in North Carolina. The healthy corner store intervention was designed to encourage the purchase of healthy foods among SNAP participants. Stickers were placed on eligible foods to highlight healthy options as well as assist with tracking the sales of those products. Store staff removed the sticker and placed it on a tracking sheet that recorded the date, number of healthy foods purchased, whether the purchased item(s) contained a fruit or vegetable, and the type of payment. Storeowners were interested in participating and remained engaged throughout the program; however, there were challenges with fidelity to the intervention and its evaluation using the sticker method to track sales. Additional research on methods for evaluating healthy retail interventions that are simple, low cost, and feasible for retailers that do not have electronic sales data is needed.

Evaluation of three behavioural economics 'nudges' on grocery and convenience store sales of promoted nutritious foods.

OBJECTIVE: To evaluate the association between three behavioural economics 'nudges' and store sales of promoted healthier foods. DESIGN: Multiple interrupted time series. SETTING: Two predominantly rural counties in central North Carolina, USA. PARTICIPANTS: Aggregated store transaction data from two grocery stores (one intervention, one control) and two convenience stores (one intervention, one control) were analysed using ANOVA to examine the association between three 'nudges' and store sales of promoted items. The nudges included: a 'cognitive fatigue' experiment, in which floor arrows guided customers to the produce sections; a 'scarcity' experiment, in which one sign in one area of the produce section portrayed a 'limited amount' message; and a 'product placement' experiment, where granola bars were moved into the candy bar aisle. RESULTS: In convenience stores, there were no significant differences between sales of the promoted items during the intervention period for any of the nudges when implemented individually. However, compared with baseline sales, implementation of all three nudges simultaneously was associated with an increase in sales during the intervention period based on proportional computations (P = 0·001), whereas no significant changes in sales were observed in the control convenience store. Among the grocery stores, there were no significant differences in sales during the intervention period for any of the nudges or the combined intervention compared with baseline sales. CONCLUSIONS: Implementing three nudges concurrently in a convenience store setting may increase sales of promoted items. However, before stores consider implementing these nudges to increase sales of nutritious foods, additional research is warranted.