How does eligibility for GusNIP produce prescriptions relate to fruit and vegetable purchases and what factors shape the relationship? A protocol for a secondary analysis of nationally representative data in the USA.

INTRODUCTION: US Department of Agriculture (USDA) Gus Schumacher Nutrition Incentive Programme (GusNIP) produce prescription programme (PPR) 'prescriptions' provide eligible participants with low income, risk for diet-related chronic disease and food insecurity a healthcare issued incentive to purchase lower to no cost fruits and vegetables (FVs). However, GusNIP requirements specify that PPR prescriptions can only be redeemed for fresh (not frozen, canned or dried) FVs. This requirement may prevent participants from fully engaging in or benefiting from GusNIP PPR, given communities with lower healthy food access may have reduced fresh FV accessibility. METHODS AND ANALYSIS: We will use the nationally representative 2012-2013 National Household Food Acquisition and Purchase Survey (FoodAPS) and complementary FoodAPS Geography Component data in a secondary data analysis to examine how household GusNIP PPR eligibility relates to the quantity and variety of fresh, frozen, canned and dried FV purchases and to what extent individual, household and food environment factors shape the relationship. FoodAPS data include household food purchasing and acquisition information across a 7 day period from 14 317 individuals among 4826 households and was collected between April 2012 and January 2013. The FoodAPS Geography Component provides information about the local community/environment relative to FoodAPS households. This study will examine the correlation or association of selected variables between different quantities and varieties of fresh, frozen, canned and dried FVs, as well as correlations among multilevel predictors. ETHICS AND DISSEMINATION: We are following data integrity standards as outlined by agreements with the USDA Economic Research Service. All results of analyses will undergo a thorough disclosure review to ensure no identifiable data are shared. Results will be disseminated to research, practice and policy communities using an Open Access peer-reviewed manuscript(s), scientific and practice presentations, and a public facing report and infographic.

E-health Dietary Interventions for Participants of SNAP and WIC: A Systematic Review.

The migration of federal assistance services to online platforms during the COVID-19 pandemic sparked interest in digital nutrition education for individuals participating in the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs. With federal government investing in the modernization of the nutrition education components of both programs, there is a need to identify science-backed electronic health (e-health) dietary interventions to improve health outcomes in this population. Therefore, the objective of this systematic literature review was to summarize the effectiveness, acceptability, and feasibility of e-health dietary interventions among individuals participating in WIC or SNAP. Keyword searches were performed in Google Scholar, PubMed, and Science Direct. The search included peer-reviewed literature from 2014 to 2023 and a few articles offering context about interventions used long-term by the nutrition assistance programs. PRISMA guidelines were followed to conduct this systematic literature review, which resulted in 36 articles eligible for extraction. The studies evaluated e-health (52.8%), short message service/text messaging (27.8%), and smartphone application interventions (19.4%) delivered to WIC or SNAP participants. The interventions identified aimed to modify food choice, eating behavior, and dietary intake among SNAP participants, SNAP-eligible adults, and WIC participants. Most interventions were developed using content delivery and health behavior theoretical frameworks (77.8%) and evidence-based nutritional recommendations (59.3%). Review findings show a high level of acceptability and feasibility for e-health and mobile health dietary interventions among WIC and SNAP participants but varying levels of effectiveness. Level of engagement, dosage, retention, and adherence were strong predictors of positive dietary behavior change regardless of the mode of intervention delivery. Future studies need to prioritize health equity by recruiting samples representative of food nutrition assistance participants and addressing digital health literacy as a potential barrier to intervention effectiveness, as none of the present studies measured literacy among participants.

"We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities.

Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.

Implementation and Impact of Perinatal Food Is Medicine Programs: A Qualitative Research Study.

BACKGROUND: Improving social determinants of health, such as access to nutritious food, is crucial for achieving health equity. Nutrition insecurity, especially during pregnancy and postpartum, can lead to poor maternal and birth outcomes. Food is Medicine (FIM) programs, which integrate food into the health care system to prevent or manage disease, have the potential to improve nutrition insecurity, but research about perinatal FIM programs is limited. OBJECTIVE: The purpose of this study was to explore perceptions of public health impacts of perinatal FIM programs from the perspectives of both program implementers and program supporters and implementation strategies used to enhance program adoption, implementation, and maintenance. DESIGN: Qualitative data were collected through semi-structured interviews. The interview guide was based on the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. PARTICIPANTS/SETTING: Program implementers (n = 16) and program supporters (n = 20) were recruited across the United States through purposive sampling in 2022 and 2023. ANALYSIS: Data were analyzed using deductive thematic analysis and an iterative feedback loop with the project partner. RESULTS: Interviews were completed with program implementers and program supporters and generated meaning units (n = 1,942), which were coded into themes aligned with each Reach, Effectiveness, Adoption, Implementation, Maintenance dimension. Perinatal FIM programs reached multiple priority populations who were mainly recruited through health care systems. Effectiveness measures typically included nutrition patterns and practices, as well as return on investment. Motivations for adopting programs primarily included partnerships and connections, financing, and policies and laws. Program components varied and were adapted to meet participants and setting needs. Policy, evidence, funding, and partnerships could lead to program maintenance. Implementation strategies applied by the program supporters included financial strategies and infrastructure changes. CONCLUSIONS: There is a need to identify the core functions and adaptable forms of perinatal FIM programs, which could lead to identification of standard evaluation metrics. This could result in greater uptake by potential delivery agents, increased funding and policy support, and enhanced benefits for perinatal population experiencing health disparities.

Which Program Implementation Factors Lead to more Fruit and Vegetable Purchases? An Exploratory Analysis of Nutrition Incentive Programs across the United States.

Background: Nutrition incentive (NI) programs help low-income households better afford fruits and vegetables (FVs) by providing incentives to spend on FVs (e.g., spend $10 to receive an additional $10 for FVs). NI programs are heterogeneous in programmatic implementation and operate in food retail outlets, including brick-and-mortar and farm-direct sites. Objective: This study aimed to explore NI program implementation factors and the amount of incentives redeemed. Methods: A total of 28 NI projects across the United States including 487 brick-and-mortar and 1078 farm-direct sites reported data between 2020 and 2021. Descriptive statistics and linear regression analyses (outcome: incentives redeemed) were applied. Results: Traditional brick-and-mortar stores had 0.48 times the incentives redeemed compared with small brick-and-mortar stores. At brick-and-mortar sites, automatic discounts had 3.47 times the incentives redeemed compared with physical discounts; and auxiliary services and marketing led to greater redemption. Farm-direct sites using multilingual and direct promotional marketing had greater incentives redeemed. Conclusions: To our knowledge, this is the first national study to focus on NI program implementation across sites nationwide. Factors identified can help inform future programming and research.

How the Gus Schumacher Produce Prescription Program Works: An Adaptation of a Nutrition Incentive Theory of Change.

The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports nutrition incentive (NI) and produce prescription programs (PPRs). PPRs allow healthcare providers to "prescribe" fruits and vegetables (FVs) to patients experiencing low income and/or chronic disease(s) and who screen positive for food insecurity. We developed a Theory of Change (TOC) that summarizes how and why PPRs work, identifies what the programs hope to achieve, and elucidates the causal pathways necessary to achieve their goals. We created the PPR TOC through an iterative, participatory process that adapted our previously developed GusNIP NI TOC. The participatory process involved food and nutrition security experts, healthcare providers, PPR implementors, and PPR evaluators reviewing the existing NI TOC and suggesting modifications to accurately reflect PPRs. The resulting TOC describes the mechanisms, assumptions, rationale, and underpinnings that lead to successful and equitable outcomes. Modifications of the NI TOC centered around equity and focused on inclusion of healthcare as an additional partner and the importance of health and healthcare utilization as outcomes. The TOC describes how the GusNIP PPR program reaches its goals. This understanding will be useful for PPR developers, implementers, funders, and evaluators for describing the pathways, assumptions, and foundations of successful PPRs.

Food Insecurity in the Rural United States: An Examination of Struggles and Coping Mechanisms to Feed a Family among Households with a Low-Income.

Households with a low-income in rural places experience disproportionate levels of food insecurity. Further research is needed about the nuances in strategies that households with a low-income in rural areas apply to support food security nationally. This study aimed to understand the barriers and strategies that households with a low-income in rural areas experience to obtain a meal and support food security in the United States. We conducted a qualitative study with semi-structured interviews among 153 primary grocery shoppers with a low-income residing in rural counties. A majority of family's ideal meals included animal-based protein, grains, and vegetables. Main themes included struggles to secure food and coping mechanisms. Ten categories included affordability, adequacy, accommodation, appetite, time, food source coordinating, food resource management, reduced quality, rationing for food, and exceptional desperation. These results can inform public health professionals' efforts when partnering to alleviate food insecurity in rural areas.

Produce prescription projects: Challenges, solutions, and emerging best practices - Perspectives from health care providers.

Produce prescription projects are becoming increasingly common. This study explores perspectives and experiences of a sample of health care providers throughout the United States participating in implementing produce prescription projects with funding from the United States Department of Agriculture. Surveys (N = 34) were administered to collect demographic and descriptive data. Subsequently, individual key-informant interviews with participating health care providers (N = 16) were conducted via videoconference. Participants in this study included physicians and clinical staff (e.g., nursing, nutrition, social work) who work at health care organizations that facilitate a produce prescription project. Interview transcripts were coded using thematic qualitative analysis methods. Four cross-cutting key themes emerged. First, interviewees shared operational challenges, including lack of time/staff, difficulty with provider/patient engagement (some related to COVID-19), steep "trial and error" learning curve, and formidable barriers related to data sharing and research-related requirements (e.g., Institutional Review Board approvals). Second, interviewees elucidated their solutions, lessons learned, and emerging best practices as a response to challenges (e.g., importance of having a full-time paid staff member to manage PPR within clinic). Third, interviewees expressed satisfaction with produce prescription projects, particularly related to positive patient experiences (e.g., improved clinical outcomes and improved food security). Fourth, interviewees also shared appreciation for rigorous program evaluation to establish sustained funding and advance policies. However, they contextualized this appreciation within challenges outlined regarding collecting and sharing patient-related data outcomes. Findings provide emergent best practices and inform additional resources that are needed to sustainably implement and rigorously evaluate produce prescription projects.

Disparities in dietary practices during the COVID-19 pandemic by food security status.

Little is known about the differences in dietary practices among food secure and food insecure populations during the early COVID-19 pandemic restrictions. The purpose of this study was to examine differences in dietary practices the early COVID-19 pandemic restrictions between adults reporting food security versus food insecurity. An online cross-sectional survey using validated measures was administered between April and September 2020 to explore both dietary patterns and practices and food security status among persons residing in five U.S. states from different regions of the country during the COVID-19 pandemic. Between-group differences (food secure versus food insecure) were examined for dietary practice outcomes using Pearson's Chi-Square test statistic, with Fisher's Exact test for cell counts less than five. There were 3,213 adult respondents. Food insecurity increased among the survey sample from 15.9% before the COVID-19 pandemic to 23.1% during the onset of the COVID-19 pandemic (p < 0.01). Compared to food secure respondents, those experiencing food insecurity reported more group gatherings for meals during the pandemic, decreased fruit and vegetable intake, and a need for more nutrition support resources than food secure respondents (p < 0.05). Food secure individuals reported increasing alcohol consumption, more frequent take-out or delivery ordering from fast food or restaurants, and more interest in supporting the local food system (p < 0.05). Results indicate a clear risk of disparities in dietary practices based on food security status during the early COVID-19 pandemic restrictions. Public health research, practice, and policy efforts should tailor specific efforts towards both food secure and food insecure groups.

A Case for Using Electronic Health Record Data in the Evaluation of Produce Prescription Programs.

Produce prescription programs within clinical care settings can address food insecurity by offering financial incentives through "prescriptions" for fruits and vegetables to eligible patients. The electronic health record (EHR) holds potential as a strategy to examine the relationship between these projects and participant outcomes, but no studies address EHR extraction for programmatic evaluations. We interviewed representatives of 9 grantees of the U.S. Department of Agriculture's Gus Schumacher Nutrition Incentive Grant Program's Produce Prescription Projects (GusNIP PPR) to understand their experiences with and capacity for utilizing EHR for evaluation. Five grantees planned to use EHR data, with 3 main strategies: reporting aggregate data from health clinics, contracting with external/third party evaluators, and accessing individual-level data. However, utilizing EHRs was prohibitive for others due to insufficient knowledge, training and/or staff capacity; lack of familiarity with the Institutional Review Board process; or was inappropriate for select target populations. Policy support for produce prescription programs requires a robust evidence base, deep knowledge of best practices, and an understanding of expected health outcomes. These insights can be most efficiently and meaningfully achieved with EHR data, which will require increased financial support and technical assistance for project operators.

Successful Community Nutrition Incentive Program Data Collection during the COVID-19 Pandemic: A Case Study.

Background: The coronavirus 2019 (COVID-19) pandemic has complicated rigorous evaluation of public health nutrition programs. The USDA Gus Schumacher Nutrition Incentive Program (USDA GusNIP) funds nutrition incentive programs to improve fruit and vegetable purchasing and intake by incentivizing Supplemental Nutrition Assistance Program (SNAP) participants at the point of sale. GusNIP grantees are required to collect survey data (e.g., fruit and vegetable intake and food insecurity status) on a subset of participants. However, due to COVID-19, most GusNIP grantees faced formidable barriers to data collection. The Hunger Task Force Mobile Market (HTFMM), a Wisconsin-based 2019 GusNIP grantee, used particularly innovative methods to successfully collect these data (n > 500 surveys). Objectives: The aim was to explore HTFMM's successful participant-level data-collection evaluation during COVID-19. Methods: A single case study methodological approach framed this study. The case is the HTFMM in Milwaukee, WI, USA. Participants included HTFMM leadership (n = 3), evaluators (n = 2), staff (n = 3), volunteers (n = 3), and customers (n = 10). These teleconference interviews were recorded and transcribed verbatim. Transcripts were coded using thematic qualitative analysis methods with 2 independent coders. Results: Four salient themes emerged: 1) there were multiple key players with unique roles and responsibilities who contributed to personalized, proactive, and time-intensive, telephone-based proctored survey collection methods; 2) the importance of resources dedicated to comprehensive evaluation; 3) longstanding relationships rooted in trust and community-based service are key to successful program delivery, engagement, and evaluation; and 4) the COVID-19 data-collection protocol also serves to mitigate nonpandemic challenges to in-person survey collection. Conclusions: These findings provide guidance on how alternative methods for data collection during COVID-19 can be used and applied to other situations that may affect the ability to collect participant-level data. These findings contribute to a growing body of literature as to best practices and approaches to collecting participant-level data to evaluate public health nutrition programs.

A systematic review of trucking food, physical activity, and tobacco environments and tractor-trailer drivers' related patterns and practices in the United States and Canada, 1993-2021.

Truckers in the United States (U.S.) and Canada are at high risk for noncommunicable disease. Although trucking built environments have been highlighted for intervention, no systematic review has assessed aspects of trucking environments that may influence food, physical activity (PA), and smoking patterns/practices. The purpose of this systematic review was to characterize the state of the science on trucking food, PA, and tobacco environments and to examine truckers' food, PA, and tobacco patterns/practices. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Five databases were selected for searching in April 2020 and 2021 using key terms constructed by a librarian. Peer-reviewed research with data about U.S. and Canadian truckers' (i.e., drivers operating 18-wheelers or tractor trailers) food, PA, and/or tobacco environments and related patterns/practices were included. Quality was assessed using the Mixed Method Appraisal Tool. Thirty-eight studies were identified. Results included data from at least 16,600 truckers and 282 trucking settings in the U.S. (n = 32) and Canada (n = 6). Most studies were classified as quantitative descriptive and of poor quality (average score 3 of 7). The few studies (n = 4) that measured trucking food and PA environments characterized trucking sites as poor. Fifteen (47%) presented data about truckers' perceptions of food or PA environments and highlighted prominent environmental barriers. Truckers' food, PA, and smoking patterns and practices suggested poor diet quality, sedentary practices, and a high prevalence of smoking. The science of trucking food, PA, and tobacco environments is underdeveloped and requires much more focus using validated measures.

Measurement of Fruit and Vegetable Intake Incorporating a Diversity, Equity, and Inclusion Lens. Comment on Di Noia, J.; Gellermann, W. Use of the Spectroscopy-Based Veggie Meter® to Objectively Assess Fruit and Vegetable Intake in Low-Income Adults. Nutrients 2021, 13, 2270.

Disparities in fruit and vegetable intake (FVI) and diet-related diseases exist among low-income and racial/ethnic minority populations [...].

The UnProcessed Pantry Project (UP3): A Community-Based Intervention Aimed to Reduce Ultra-Processed Food Intake Among Food Pantry Clients.

Low-income populations are more likely to experience food and nutrition insecurity and suffer a greater burden of noncommunicable disease than the general population. The UnProcessed Pantry Project (UP3) is an intervention aimed to reduce ultra-processed food availability and consumption of food pantry clients accessing the emergency food system. The pilot study included nutrition education, food boxes, and social support for 16 weeks at 2 food pantries. Data collection included the ASA24 dietary recall to calculate Healthy Eating Index-2015 (HEI-2015) scores, biomarkers (hemoglobin A1c, total cholesterol, blood pressure, waist circumference, body mass index [BMI]), and a demographic and psychosocial survey. Dietary quality among 43 participants significantly (P < .05) improved as measured by the HEI-2015 for total HEI-2015, whole grains, total protein foods, and added sugars scores. BMI, total cholesterol, and waist circumference also significantly improved across study participants. Findings indicate that the emergency food system may be an effective access point to apply frameworks including UP3 to address ultra-processed food consumption, dietary quality, and noncommunicable chronic disease risk among food-insecure populations. Programs and policies that limit the amount of ultra-processed food in the emergency food system should be further tested and could be efficacious in addressing inequities among vulnerable populations.

Descriptive Characteristics of Nutrition Incentive Projects Across the U.S.: A Comparison Between Farm Direct and Brick and Mortar Settings.

The purpose of this study is to describe the programmatic characteristics of current nutrition incentive projects supported by the Gus Schumacher Nutrition Incentive Program (GusNIP). Specifically, implementation characteristics of nutrition incentive projects that were funded in 2019 were compared across brick and mortar (B&M) and farm direct (FD) sites in the United States. Across 10 nutrition incentive (NI) grantees, there were 621 sites that reported data from B&M (n = 156) and FD (n = 465) locations. Among B&M sites, the common food retail types included: large chain traditional supermarket (n = 49) and independent traditional supermarket (n = 46). Among FD sites, the most frequently reported food retail types were farmers markets (n = 371). For B&M sites, the most common financial instruments were loyalty cards (n = 67, 43.5%), followed by an automatic discount at the register (n = 41, 26.6%), and coupons (n = 29, 18.8%). FD sites frequently reported physical financial instruments including tokens (n = 272, 61.1%), followed by paper vouchers (n = 131, 29.4%). Supplemental Nutrition Assistance Program (SNAP) purchases that were eligible to trigger incentives included mainly "all fresh FVs" at B&M sites (n = 98, 48.5%) and "all SNAP eligible items" at FD sites (n = 417, 85.8%). FVs eligible for incentive redemption included mainly "all fresh FVs" for both B&M sites (n = 110, 65.5%) and FD sites (n = 370, 67.6%). In terms of incentive-to-SNAP level ratio, both B&M sites and FD sites reported that they commonly utilized a 1:1 incentive-to-SNAP level ratio (n = 106, 68.8% and n = 261, 94.9% respectively). This paper will provide foundational understanding of the heterogeneity of GusNIP NI projects-specifically between B&M and FD settings-in order to inform future national work and ultimately demonstrate the impact of NI projects on food security status and dietary quality.

Accelerating Evaluation of Financial Incentives for Fruits and Vegetables: A Case for Shared Measures.

Food insecurity, or lack of consistent access to enough food, is associated with low intakes of fruits and vegetables (FVs) and higher risk of chronic diseases and disproportionately affects populations with low income. Financial incentives for FVs are supported by the 2018 Farm Bill and United States (U.S.) Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) and aim to increase dietary quality and food security among households participating in the Supplemental Nutrition Assistance Program (SNAP) and with low income. Currently, there is no shared evaluation model for the hundreds of financial incentive projects across the U.S. Despite the fact that a majority of these projects are federally funded and united as a cohort of grantees through GusNIP, it is unclear which models and attributes have the greatest public health impact. We explore the evaluation of financial incentives in the U.S. to demonstrate the need for shared measurement in the future. We describe the process of the GusNIP NTAE, a federally supported initiative, to identify and develop shared measurement to be able to determine the potential impact of financial incentives in the U.S. This commentary discusses the rationale, considerations, and next steps for establishing shared evaluation measures for financial incentives for FVs, to accelerate our understanding of impact, and support evidence-based policymaking.

The Influence of the COVID-19 Pandemic on the Food Supply in the Emergency Food System: A Case Study at 2 Food Pantries.

BACKGROUND: The onset of the coronavirus disease 2019 (COVID-19) pandemic increased demand for emergency food assistance and has caused operational shifts in the emergency food system. OBJECTIVE: This research explored how the initial phase of the COVID-19 pandemic influenced the food supply of 2 food pantries. METHODS: A case study approach was applied to collect data during the initial phase of the COVID-19 pandemic. Food supply data were collected weekly at 2 food pantries in southwest Montana for 17 wk in 2020. Surveys and interviews were conducted with food pantry clients and staff, respectively. Descriptive statistics and inferential statistics were applied to analyze quantitative data. Food supply data were analyzed using the Healthy Eating Index (HEI)-2015, NOVA system, and Unprocessed Pantry Project (UP3) Framework. Thematic analysis was applied to qualitative data. RESULTS: The food boxes collected between the 2 food pantries (n = 43) had a mean (± SD) total HEI-2015 score of 76.41 ± 7.37 out of a possible score of 100. According to both the NOVA and the UP3 Framework, 23.4% of the total food distributed was ultra-processed food. Of the food distributed, 50.0% and 48.3% was fresh, unprocessed food according to NOVA and UP3 Frameworks, respectively. From staff interviews, 3 themes arose that describe the food pantry operations that experienced change during the COVID-19 pandemic, including food procurement, distribution preparation, and food distribution. Nine supporting subthemes describing the causes and consequences of the operational themes were identified. Staff perceived that the nutrient quality of the food boxes increased from food distributed previously to the COVID-19 pandemic, whereas over one-third (39.4%) of food pantry clients who responded to surveys preferred the food box model. CONCLUSIONS: The COVID-19 pandemic has caused enormous operational challenges within food pantries. Food pantries overcame these challenges by swiftly and effectively altering operations so as to continue to distribute nutritious food boxes to pantry clients.

Examining the relationship between physical activity and mental health during the COVID-19 pandemic across five U.S. States.

The objectives of this paper are to investigate: 1) how the COVID-19 pandemic influenced both physical activity practices and mental health status, and 2) to assess the relationship between the two. Our mixed-methods study draws on 4,026 online survey responses collected between April - September 2020 across five states (Louisiana, Montana, North Carolina, Oregon and West Virginia). Logistic regression models were run for two outcome variables (physical activity and mental health status (measured using the Kessler Psychological Distress scale)). Researchers controlled for race/ethnicity, household income/size, gender, urbanicity, education, employment, use of government assistance and presence of chronic health conditions. Qualitative analysis was applied to open-ended survey responses to contextualize quantitative findings. Household income was significant in predicting difficulty maintaining pre-pandemic physical activity levels; pre-pandemic physical activity levels were associated with increased psychological distress levels during COVID-19; and race/ethnicity, income status and urbanicity were significantly associated with deteriorating mental health status and physical activity levels during COVID-19. Data suggests that a bi-directional, cyclical relationship between physical activity and mental health exists. Policy implications should include physical activity promotion as a protective factor against declining mental health.