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.

A qualitative study of independent fast food vendors near secondary schools in disadvantaged Scottish neighbourhoods.

BACKGROUND: Preventing and reducing childhood and adolescent obesity is a growing priority in many countries. Recent UK data suggest that children in more deprived areas have higher rates of obesity and poorer diet quality than those in less deprived areas. As adolescents spend a large proportion of time in school, interventions to improve the food environment in and around schools are being considered. Nutrient standards for school meals are mandatory in the UK, but many secondary pupils purchase foods outside schools at break or lunchtime that may not meet these standards. METHODS: Qualitative interviews were conducted with fast food shop managers to explore barriers to offering healthier menu options. Recruitment targeted independently-owned shops near secondary schools (pupils aged c.12-17) in low-income areas of three Scottish cities. Ten interviews were completed, recorded, and transcribed for analysis. An inductive qualitative approach was used to analyse the data in NVivo 10. RESULTS: Five themes emerged from the data: pride in what is sold; individual autonomy and responsibility; customer demand; profit margin; and neighbourhood context. Interviewees consistently expressed pride in the foods they sold, most of which were homemade. They felt that healthy eating and general wellbeing are the responsibility of the individual and that offering what customers want to eat, not necessarily what they should eat, was the only way to stay in business. Most vendors felt they were struggling to maintain a profit, and that many aspects of the low-income neighbourhood context would make change difficult or impossible. CONCLUSIONS: Independent food shops in low-income areas face barriers to offering healthy food choices, and interventions and policies that target the food environment around schools should take the neighbourhood context into consideration.

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.

Shared Perceptions on Upstream Factors that Influence Water and Sugar-Sweetened Beverage Consumption Among Hispanic Families in the Greater Washington, DC, Metro Area: Qualitative Results From Focus Group Discussions.

BACKGROUND: Hispanics in the United States are among those with highest consumption of sugar-sweetened beverages (SSBs) and lowest consumption of water. These dietary disparities are rooted in systemic influences that must be identified and addressed. OBJECTIVE: The study aimed to describe how Hispanic parents currently living in the greater Washington, DC, metro area and born outside of the United States, perceived upstream factors that influenced their current beverage choice. DESIGN: Six qualitative focus groups were conducted in Spanish in 2021. PARTICIPANTS/SETTING: Hispanic parents (n = 31) of children enrolled in Early Head Start in the greater Washington, DC, metro area were recruited (all women, born outside the United States, and spoke Spanish as a first language). STATISTICAL ANALYSIS: Verbatim transcripts were analyzed deductively using the Community Energy Balance Framework. RESULTS: The five key findings were: Growing up (in their countries of origin in Central America and Mexico) participants were used to drinking water, often gathered it from the source, and liked its flavor. Relatives passed down their knowledge about potabilization of water, the health benefits of drinking water, and health consequences of drinking SSBs. Growing up, prepackaged SSBs were not as accessible compared with where they now live in the United States. Participants perceived that sociocultural hospitality norms dictated that guests should be served SSBs and not water. Participants noted that messages regarding juice and water across US public health programs and policies were not aligned. CONCLUSIONS: These findings suggest there are opportunities for public health messaging and procurement of safe, palatable drinking water in lieu of SSBs and juice.

Dietary Outcomes of a Multilevel, Multicomponent, Cluster Randomized Obesity Intervention in 6 Native American Communities in the Upper Midwest and Southwest United States.

Background: Impacts of colonization on dietary intake have led to high rates of obesity and noncommunicable diseases among Native American adults. Multilevel, multicomponent (MLMC) interventions may improve dietary intake. Objectives: To assess the impact of a MLMC obesity intervention, OPREVENT2 (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans 2; clinicaltrials.gov NCT02803853), on dietary intake in Native American adults in Intervention versus Comparison communities. Methods: A cluster-randomized controlled trial was performed among participants in 6 communities randomized to Intervention (n = 3 and Comparison (n = 3). Adults aged 18 to 75 were recruited from tribal communities in the Southwest and upper Midwest United States from September 2016 to May 2017 (n = 601). This analysis included participants who completed baseline and follow-up surveys (82% retention), reported dietary intake between 500 and 7000 kcal/d, and had no missing data for outcomes of interest (n = 446). The intervention was implemented from May 2017, to November 2018. OPREVENT2 integrated individual, environmental, social, and structural factors and was implemented in food stores, worksites, schools, and community media outlets in Intervention communities. Activities included taste tests, cooking demonstrations, and stocking healthier items in food stores and were reinforced by a social m)edia campaign, posters, brochures, and booklets focused on nutrition. Individual-level dietary intake among participating Native American adults was assessed via modified Block food-frequency questionnaire at preintervention and postintervention. Multilevel mixed-effects linear regression, with clustering at the community level, was performed. Results: Between-group effects were significant (P < 0.05) for intake of carbohydrates (-23 g/d), total fat (-9 g/d), saturated fats (-3 g/d), and monounsaturated fats (-4 g/d), with greater decreases in Intervention communities. Between-group effect for total sugar (-12 g/d in Intervention communities) was not statistically significant. Conclusions: This MLMC intervention was associated with significantly improved carbohydrate, total fat, and saturated fat intake among Native American adults. These changes are important for improving health within this population.

Cardiometabolic risk among rural Native American adults in a large multilevel multicomponent intervention trial.

This cross-sectional analysis of the baseline evaluation sample of the Obesity Prevention and Evaluation of InterVention Effectiveness in Native Americans 2 (OPREVENT2) study included 601 Native American adults ages 18-75 living in rural reservation communities in the Midwest and Southwest United States. Participants completed a self-report questionnaire for individual and family history of hypertension, heart disease, diabetes and obestiy. Body mass index (BMI), percent body fat, and blood pressure were measured by trained research staff. About 60% of respondents had a BMI >30 kg/m2. Approximately 80% had a waist-to-hip ratio and percent body fat classified as high risk, and nearly 64% had a high-risk blood pressure measurement. Although a large proportion of participants reported a family history of chronic disease and had measurements that indicated elevated risk, relatively few had a self-reported diagnosis of any chronic disease. Future studies should examine potential connections between healthcare access and discordance in self-reported versus measured disease risks and diagnoses.

A Systems Approach to Identify Factors Influencing Participation in Two Tribally-Administered WIC Programs.

Native American populations experience highly disproportionate rates of poor maternal-child health outcomes. The WIC program aims to safeguard health by providing greater access to nutritious foods, but for reasons not well understood, participation in many tribally-administered WIC programs has declined to a greater extent compared to the national average decline in participation over the last decade. This study aims to examine influences on WIC participation from a systems perspective in two tribally-administered WIC programs. In-depth interviews were conducted with WIC-eligible individuals, WIC staff, tribal administrators, and store owners. Interview transcripts underwent qualitative coding, followed by identifying causal relationships between codes and iterative refining of relationships using Kumu. Two community-specific causal loop diagrams (CLDs) were developed and compared. Findings from interviews in the Midwest yielded a total of 22 factors connected through 5 feedback loops, and in the Southwest a total of 26 factors connected through 7 feedback loops, resulting in three overlapping themes: Reservation and Food Store Infrastructure, WIC Staff Interactions and Integration with the Community, and State-level Administration and Bureaucracy. This study demonstrates the value of a systems approach to explore interconnected barriers and facilitators that can inform future strategies and mitigate declines in WIC participation.

Sociodemographic and Psychosocial Factors Associated With Diet Quality in 6 Rural Native American Communities.

OBJECTIVE: To identify psychosocial and household environmental factors related to diet quality among Native Americans (NA). DESIGN: Analysis of baseline data from a community-randomized obesity prevention trial. SETTING: Six rural NA communities in the Midwest and the Southwestern US. PARTICIPANTS: A total of 580 tribal members, aged 18-75 years old (mean 45 years), 74% female, self-identified as the main household food purchaser. VARIABLES MEASURED: Diet quality (Healthy Eating Index-2015 [HEI]) was derived from a semiquantitative food frequency questionnaire. Sociodemographic, psychosocial, and home food environment factors were assessed via interviewer-administered questionnaires. ANALYSIS: One-way ANOVA, linear regression models, and 2-tailed t tests compared HEI scores among sociodemographic categories. Multiple linear regression models assessed the relationship between psychosocial factors, home food environment, and HEI. RESULTS: Prevalence of obesity was 59%. Mean HEI-2015 score was 49.3 (SD = 8.1). Average HEI scores were 3.0 points lower in smokers than nonsmokers (P < 0.001), and 2.2 points higher in females than males (P < 0.01). Higher self-efficacy (ß = 0.97; P < 0.001) and healthier eating intentions (ß = 0.78; P < 0.001) were positively associated with HEI. Healthier household food patterns score was associated with higher HEI (ß = 0.48; P < 0.01). CONCLUSIONS AND IMPLICATIONS: Psychosocial factors were associated with diet quality, a finding that supports the use of social-cognitive intervention approaches in rural NA communities in the Midwest and Southwest, and warrants evaluation in other locations. There remains a need to elucidate the association between the Food Distribution Program on Indian Reservations and diet quality.

Exposure to a Multilevel, Multicomponent Obesity Prevention Intervention (OPREVENT2) in Rural Native American Communities: Variability and Association with Change in Diet Quality.

The OPREVENT2 obesity prevention trial was a multilevel multicomponent (MLMC) intervention implemented in rural Native American communities in the Midwest and Southwest U.S. Intervention components were delivered through local food stores, worksites, schools, community action coalitions, and by social and community media. Due to the complex nature of MLMC intervention trials, it is useful to assess participants' exposure to each component of the intervention in order to assess impact. In this paper, we present a detailed methodology for evaluating participant exposure to MLMC intervention, and we explore how exposure to the OPREVENT2 trial impacted participant diet quality. There were no significant differences in total exposure score by age group, sex, or geographic region, but exposure to sub-components of the intervention differed significantly by age group, sex, and geographical region. Participants with the highest overall exposure scores showed significantly more improvement in diet quality from baseline to follow up compared to those who were least exposed to the intervention. Improved diet quality was also significantly positively associated with several exposure sub-components. While evaluating exposure to an entire MLMC intervention is complex and imperfect, it can provide useful insight into an intervention's impact on key outcome measures, and it can help identify which components of the intervention were most effective.

Individual- and household-level factors associated with fruit, vegetable, and dietary fiber adequacy among Native American adults in 6 reservation communities.

This study utilized baseline data collected in 2017 from the OPREVENT2 trial, which included 540 Native Americans in six Midwest and Southwest reservation communities. The objective was to identify correlates of fruit, vegetable, and dietary fiber adequacy among participants 18-75 years old who self-identified as the main food purchaser or preparer in their household. Mean daily servings of fruits and vegetables and grams of dietary fiber were quantified based on a 30-day semi-quantitative food frequency questionnaire. Participants consumed an average of 0.5 (±0.4) cup-equivalent servings of fruit, 2.5 (±1.8) cup-equivalent servings of vegetables, and 15.5 (±8.9) grams of fiber per day. <2% of the study population met the 2015-2020 Dietary Guidelines for Americans recommendations for fruit consumption, while 12 and 42% met recommendations for dietary fiber and vegetable consumption, respectively. Females had a prevalence ratio 1.4 times greater than males for adequate intakes of vegetables (p = 0.008) and over 6 times greater for dietary fiber (p < 0.001). Participants over the age of 30 were about twice as likely to meet dietary fiber recommendations (p = 0.031) compared to those 30 years and younger. Participants receiving food assistance from the USDA's Food Distribution Program on Indian Reservations (FDPIR) were nearly twice as likely as non-FDPIR recipients to meet recommendations for dietary fiber (p = 0.008). These findings can help guide the development of targeted interventions to improve diet quality; however, further work is needed to understand and address underlying reasons for low fruit consumption in these rural reservation communities.

Seven key investments for health equity across the lifecourse: Scotland versus the rest of the UK.

While widespread lip service is given in the UK to the social determinants of health (SDoH), there are few published comparisons of how the UK's devolved jurisdictions 'stack up', in terms of implementing SDoH-based policies and programmes, to improve health equity over the life-course. Based on recent SDoH publications, seven key societal-level investments are suggested, across the life-course, for increasing health equity by socioeconomic position (SEP). We present hard-to-find comparable analyses of routinely collected data to gauge the relative extent to which these investments have been pursued and achieved expected goals in Scotland, as compared with England and Wales, in recent decades. Despite Scotland's longstanding explicit goal of reducing health inequalities, it has recently been doing slightly better than England and Wales on only one broad indicator of health-equity-related investments: childhood poverty. However, on the following indicators of other 'best investments for health equity', Scotland has not achieved demonstrably more equitable outcomes by SEP than the rest of the UK: infant mortality and teenage pregnancy rates; early childhood education implementation; standardised educational attainment after primary/secondary school; health care system access and performance; protection of the population from potentially hazardous patterns of food, drink and gambling use; unemployment. Although Scotland did not choose independence on September 18th, 2014, it could still (under the planned increased devolution of powers from Westminster) choose to increase investments in the underperforming categories of interventions for health equity listed above. However, such discussion is largely absent from the current post-referendum debate. Without further significant investments in such policies and programmes, Scotland is unlikely to achieve the 'healthier, fairer society' referred to in the current Scottish Government's official aspirations for the nation.