Feasibility of Using Rideshare Transportation to Reduce Barriers to Participating in a Clinic-based Food Insecurity Intervention.

BACKGROUND: Few clinic-based food insecurity interventions address transportation barriers to utilizing food resources. OBJECTIVES: We assessed the feasibility of using free rideshare-based transportation to reduce barriers to participating in an ongoing clinic-based food insecurity intervention. METHODS: Our multi-methods pilot study used patient surveys (n = 155), focus groups with clinic and program staff (n = 10), and rideshare usage data. RESULTS: Of the 95 (61.2%) survey respondents who reported transportation barriers, only 34 (21.9%) used rideshare. More than 80% of rideshare users rated their experience as good or excellent. Clinic and program staff reported that the service allowed patients a greater sense of control over their time and health and emphasized the need for staffing and program-level infrastructure. CONCLUSIONS: Free rideshare may address transportation barriers for some patients but multiple options for support and adjustments to how we offer transportation solutions are needed to successfully meet the needs of all program participants experiencing transportation barriers.

An ethnographic study exploring factors that minimize lunch waste in Tokyo elementary schools.

OBJECTIVE: To explore factors that minimize lunch waste in Tokyo elementary schools and to consider how such factors can be modified and applied in US schools. DESIGN: Focused ethnographic study using interviews, observation, participant observation and document review. Data were analysed using thematic analysis. SETTING: Tokyo, Japan. PARTICIPANTS: Five school dietitians participated in the study. Data collection methods included in-depth interviews, observation of nutrition education lessons, participant observation of school lunchtime and review of relevant school documents (e.g. lunch menus, food waste records). RESULTS: Five themes emerged from the analysis: (i) reinforcement of social norms to eat without waste; (ii) menu planning to increase exposure to unfamiliar and/or disliked foods; (iii) integration of food and nutrition education into the school curriculum; (iv) teacher lunchtime practices related to portion sizes, distributing leftover food and time management; and (v) engagement of students in reducing school lunch waste. Practical and tangible applications to US schools include measuring and reporting lunch waste to influence social norms, teaching students about the importance of reducing food waste, offering flexible school lunch portion sizes and providing students with meaningful opportunities to contribute to solving the problem of school lunch waste. CONCLUSIONS: Japan offers a model for minimizing school lunch waste through a holistic approach that includes factors that operate at and interact across multiple levels of society. Modifying and applying such an approach in US schools is worth considering given the urgent need to address food waste in order to support healthy diets and sustainable food systems.

CSA Partnerships for Health: outcome evaluation results from a subsidized community-supported agriculture program to connect safety-net clinic patients with farms to improve dietary behaviors, food security, and overall health.

Safety-net clinic patients are at risk for food insecurity, which is associated with poor diet quality and negative health outcomes. Research on the impact of interventions addressing food insecurity in health care settings is limited. The primary aim of this study was to determine the preliminary effectiveness of Community-Supported Agriculture (CSA) Partnerships for Health, a 23 week grant-subsidized CSA program, in improving dietary behaviors, self-efficacy to eat vegetables, food security, and overall health among safety-net clinic patients. This single-group pretest-posttest study used interviewer-administered surveys. Study participants were 48 safety-net clinic patients. Outcomes included fruit and vegetable intake, frequency of dark green and orange vegetable intake, self-efficacy to eat vegetables, eating habits, food security status and ability to afford to eat healthy meals, emotional health, social health, and general health status. Differences in values at postintervention versus preintervention were examined using two-sided paired t-tests, McNemar's tests, and generalized estimating equation models. The difference between postintervention versus preintervention values was statistically significant for a number of outcomes, including vegetable intake (p = .030), orange vegetable intake (p = .004), eating habits (p = .039), food security (p = .039), ability to afford to eat healthy meals (p = .003), and general health status (p = .039). Generalized estimating equation models showed similar associations. CSA Partnerships for Health may have the potential to improve dietary behaviors, reduce food insecurity, and improve overall health among safety-net clinic patients.

Strengthening adolescents' connection to their traditional food system improves diet quality in remote Alaska Native communities: results from the Neqa Elicarvigmun Pilot Study.

In remote Alaska Native communities, traditional foods are inextricably linked to health and food security. Degradation of the traditional food system over the past several decades has resulted in a shift in dietary patterns that have contributed to increased rates of chronic diseases and food insecurity among Alaska Native People. Interventions are needed to address this. Our objectives were to evaluate the preliminary efficacy of a school-based intervention-Neqa Elicarvigmun or the Fish-to-School Program-on diet quality, fish intake, and attitudes and beliefs around traditional foods (specifically fish) using a pre-post comparison group design with data collection occurring at three time points. Study participants were 76 middle and high school students in two remote Alaska Native communities (population <900) in southwestern Alaska. We used a participatory approach to design the school-based, multilevel intervention that included activities in the cafeteria, classroom, and community. Multilevel analyses showed that students in the experimental community showed significant improvements in diet quality compared to the comparison community (Beta = 4.57; p < .05). Fish intake, measured using the stable nitrogen isotope ratio of hair, a validated biomarker, also increased significantly in the experimental community (Beta = 0.16; p < .05). Leveraging the cultural and physical resources of the traditional food system for the Neqa Elicarvigmun program represents a strength-based approach that improves diet quality, increases adolescents' connection to their traditional culture, and by promoting the local food system supports food security. Embedding the program into the local culture may result in faster adoption and greater sustainability of the program.

Feasibility of Using a Community-Supported Agriculture Program to Increase Access to and Intake of Vegetables among Federally Qualified Health Center Patients.

OBJECTIVE: This study explored the feasibility of using a 23-week subsidized community-supported agriculture program to increase access to and intake of vegetables among Federally Qualified Health Center patients. METHODS: Outcomes were measured using pre-post intervention surveys (n = 9). Process data were collected in post-intervention surveys and focus groups (n = 15). RESULTS: Most participants (77%) indicated that the program improved their health and all (100%) reported that they were eating a greater variety of vegetables because of their participation in the program. Three themes emerged from the focus groups: increased access to fresh and/or organic vegetables, improved diet quality, and the importance of social support during the program. CONCLUSIONS AND IMPLICATIONS: Linking subsided community-supported agriculture programs with Federally Qualified Health Centers has the potential to increase access to and intake of vegetables among low-income patients. However, further research is needed with a larger sample size and a more robust study design.

A Cooking Intervention to Increase Vegetable Consumption by Parents With Children Enrolled in an Early Head Start Home Visiting Program: A Pilot Study in Portland, Oregon, 2013-2014.

INTRODUCTION: Cooking interventions may improve diet quality. Most cooking interventions are delivered in group settings. Home visiting programs may be an appropriate mechanism for delivering such interventions to low-income families with young children. We conducted a pilot study to test the feasibility of using a cooking intervention delivered by home visitors to improve attitudes and behaviors related to vegetable consumption by low-income parents with children enrolled in a home visiting program. METHODS: We invited 121 parents with children enrolled in an Early Head Start Home Visiting program in Portland, Oregon, to participate. During 2013-2014, each month for 8 months, home visitors (n = 14) implemented 1 cooking activity plus 1 complementary activity focused on 12 vegetables. We collected pre- and post-intervention data on participants' cooking confidence and whether they tried and liked the selected vegetables. We also measured fidelity to protocol and home visitors' perception of intervention usability. RESULTS: Of 104 participants, 58 provided pre- and post-intervention data. We observed a significant increase in confidence in baking, roasting or grilling vegetables; cooking 6 of 10 vegetables; and trying 7 of 12 vegetables. Nearly all respondents participated in the monthly cooking activity (96%) and complementary activity (94%). Twelve of 14 home visitors reported that the intervention was acceptable, feasible, and easy to understand, and needed systems supports to implement. CONCLUSION: Cooking interventions may be a feasible approach to improving attitudes and behaviors related to vegetable consumption by low-income families with young children. Additional research is needed to assess the impact of such interventions on vegetable consumption.

Food-related practices and beliefs of rural US elementary and middle school teachers.

INTRODUCTION: Childhood obesity disproportionately affects rural populations; therefore, promoting healthy eating among rural children is essential. Teachers are important role models for children and can influence children's eating behaviors through their own behaviors and beliefs about food. This study examined the food-related practices and beliefs of rural elementary and middle school teachers. METHODS: Data were used from the SNACZ study, a school- and community-based trial conducted in rural Oregon. Kindergarten through eighth-grade teachers (n=87), teaching students usually aged 5-14 years, from eight rural school districts completed a baseline survey in November 2012 concerning their classroom food practices, eating behaviors at school, beliefs about the school food environment, and nutrition knowledge. Frequencies of responses to each item were calculated. RESULTS: Nearly all teachers (97.6%) agreed that a healthy school food environment is important, but fewer agreed that teachers' behaviors and the foods available at school influence students' eating behaviors (71.0% and 67.0%, respectively). Nearly 86% of teachers used candy as a reward for students, while 78.2% consumed unhealthy snacks and 42.5% consumed sweetened beverages in the classroom. CONCLUSIONS: The results suggest that most rural teachers recognize that having a healthy school food environment is important, but are less aware of factors within the school that influence students' eating behaviors - including their own eating behaviors and classroom food practices - and, perhaps for this reason, many rural teachers engage in classroom practices and behaviors that do not promote healthy eating. Teacher training and expanded school policies that focus on teacher behavior may be needed to ensure a healthier rural school food environment.

Formative Evaluation to Increase Availability of Healthy Snacks and Beverages in Stores Near Schools in Two Rural Oregon Counties, 2013.

INTRODUCTION: Children living in rural areas are at greater risk for obesity than their urban counterparts. Differences in healthy food access may contribute to this disparity. Most healthy food access initiatives target stores in urban areas. We conducted a formative evaluation to increase availability of healthy snacks and beverages in food stores near schools in rural Oregon. METHODS: We assessed availability of healthy snacks and beverages in food stores (n = 15) using the SNACZ (Students Now Advocating to Create Healthy Snacking Zones) checklist and conducted in-depth interviews with food store owners (n = 6). Frequency distributions were computed for SNACZ checklist items, and interview data were analyzed by using applied thematic analysis. RESULTS: Overall, availability of healthy snacks and beverages in study communities was low. Four interrelated themes regarding store owner perspectives on stocking healthy snacks and beverages emerged from the interviews: customer demand, space constraints, vendor influence, and perishability. CONCLUSION: In addition to working with food store owners, efforts to increase availability of healthy snacks and beverages in rural areas should engage young people, food buyers (eg, schools), and vendors as stakeholders for identifying strategies to increase demand for and availability of these items. Further research will be needed to determine which strategies or combinations of strategies are feasible to implement in the study communities.

Harvest for Healthy Kids Pilot Study: Associations between Exposure to a Farm-to-Preschool Intervention and Willingness to Try and Liking of Target Fruits and Vegetables among Low-Income Children in Head Start.

BACKGROUND: Most US children do not meet recommendations for daily fruit and vegetable intake. OBJECTIVE: Our aim was to evaluate the hypothesis that at post-intervention, children exposed to the Harvest for Healthy Kids pilot study will have greater willingness to try and liking of target foods vs children in the comparison group, controlling for baseline differences. DESIGN: We conducted a quasi-experimental pilot study with comparison, low-intervention, and high-intervention groups. Pre- and post-intervention survey data were collected. PARTICIPANTS/SETTING: The intervention period was October 2012 to May 2013. The analysis sample was 226 children within the higher-level unit sample of five participating Head Start centers (Portland, OR); 231 children dropped out of or enrolled in Head Start mid-year, were absent during or refused to participate in the assessments, or were missing covariates. INTERVENTION: The comparison group received no intervention components; the low-intervention group received foodservice modifications; the high-intervention group received foodservice modifications and nutrition education. MAIN OUTCOME MEASURES: Willingness to try and liking of target foods were tested and analyzed as binary variables. STATISTICAL ANALYSES PERFORMED: McNemar's tests were used to assess differences between pre- and post-intervention scores by intervention group. Fixed slope, random intercept multilevel logistic models were used to assess associations between intervention group and post-intervention scores controlling for covariates, adjusting for baseline values, and accounting for center level clustering. RESULTS: The difference between pre- and post-intervention willingness to try and liking of target foods was statistically significant for a variety of foods; for example, 44.2% of children liked rutabaga pre-intervention compared with 78.1% post-intervention (P=0.004). Multilevel modeling indicated similar associations. CONCLUSIONS: The Harvest for Healthy Kids pilot study suggests a positive association between the intervention and willingness to try and liking for target foods among study participants. Additional research is needed to assess the impact of the program on fruit and vegetable intake.

Leader Behaviors, Group Cohesion, and Participation in a Walking Group Program.

INTRODUCTION: Less than half of all U.S. adults meet the 2008 Physical Activity Guidelines. Leader behaviors and group cohesion have been associated with increased participation or adherence in sports team and exercise class settings. Physical activity interventions in community settings that encompass these factors may enhance intervention adherence. The purpose of this study is to examine the impact of Community Health Promoter leader behaviors and group cohesion on participation in a walking group intervention among racially/ethnically diverse adults in low to moderate-income communities in Detroit, Michigan. DESIGN: Data for the current study were drawn from the Walk Your Heart to Health (WYHH) data set. WYHH was a multisite cluster RCT with a lagged intervention and outcome measurements at baseline and 4, 8, and 32 weeks. Pooled survey data from both intervention arms were used for the current study. Data were analyzed between August 2013 and October 2014. SETTING/PARTICIPANTS: A total of 603 non-Hispanic black, non-Hispanic white, and Hispanic adults across five cohorts that began the 32-week WYHH intervention between March 2009 and October 2011. INTERVENTION: The intervention was a 32-week walking group program hosted by community- and faith-based organizations and facilitated by Community Health Promoters. Walking groups met three times per week for 90 minutes per session. To promote participation in or adherence to WYHH, Community Health Promoters used evidence-based strategies to facilitate group cohesion. Group members assumed increasing leadership responsibility for facilitating sessions over time. MAIN OUTCOME MEASURES: Participation in WYHH as measured by consistency of attendance. RESULTS: Community Health Promoter leader behaviors were positively associated with participation in WYHH. Social but not task cohesion was significantly associated with consistent participation. Social cohesion may mediate the relationship between leader behaviors and walking group participation. CONCLUSIONS: Providing leaders with training to build socially cohesive groups may help motivate individuals to continue participation in community-based physical activity programs.

Availability of healthy snack foods and beverages in stores near high-income urban, low-income urban, and rural elementary and middle schools in Oregon.

BACKGROUND: Food stores near schools are an important source of snacks for children. However, few studies have assessed availability of healthy snacks in these settings. The aim of this study was to assess availability of healthy snack foods and beverages in stores near schools and examine how availability of healthy items varied by poverty level of the school and rural-urban location. METHODS: Food stores were selected based on their proximity to elementary/middle schools in three categories: high-income urban, low-income urban, and rural. Audits were conducted within the stores to assess the presence or absence of 48 items in single-serving sizes, including healthy beverages, healthy snacks, fresh fruits, and fresh vegetables. RESULTS: Overall, availability of healthy snack foods and beverages was low in all stores. However, there was significant cross-site variability in availability of several snack and fruit items, with stores near high-income urban schools having higher availability, compared to stores near low-income urban and/or rural schools. Stores near rural schools generally had the lowest availability, although several fruits were found more often in rural stores than in urban stores. There were no significant differences in availability of healthy beverages and fresh vegetables across sites. CONCLUSIONS: Availability of healthy snack foods and beverages was limited in stores near schools, but these limitations were more severe in stores proximal to rural and low-income schools. Given that children frequent these stores to purchase snacks, efforts to increase the availability of healthy products, especially in stores near rural and low-income schools, should be a priority.

Inter-rater reliability of a food store checklist to assess availability of healthier alternatives to the energy-dense snacks and beverages commonly consumed by children.

BACKGROUND: Food stores have gained attention as potential intervention targets for improving children's eating habits. There is a need for valid and reliable instruments to evaluate changes in food store snack and beverage availability secondary to intervention. The aim of this study was to develop a valid, reliable, and resource-efficient instrument to evaluate the healthfulness of food store environments faced by children. METHODS: The SNACZ food store checklist was developed to assess availability of healthier alternatives to the energy-dense snacks and beverages commonly consumed by children. After pretesting, two trained observers independently assessed the availability of 48 snack and beverage items in 50 food stores located near elementary and middle schools in Portland, Oregon, over a 2-week period in summer 2012. Inter-rater reliability was calculated using the kappa statistic. RESULTS: Overall, the instrument had mostly high inter-rater reliability. Seventy-three percent of items assessed had almost perfect or substantial reliability. Two items had moderate reliability (0.41-0.60), and no items had a reliability score less than 0.41. Eleven items occurred too infrequently to generate a kappa score. CONCLUSION: The SNACZ food store checklist is a first-step toward developing a valid and reliable tool to evaluate the healthfulness of food store environments faced by children. The tool can be used to compare availability of healthier snack and beverage alternatives across communities and measure change secondary to intervention. As a wider variety of healthier snack and beverage alternatives become available in food stores, the checklist should be updated.

A community-based participatory research approach to developing the Harvest for Healthy Kids curriculum.

BACKGROUND: A diet rich in fruits and vegetables is associated with reduced risk of diet-related chronic diseases. However, fewer than half of children in the United States consume the recommended amount. OBJECTIVES: This article describes the community-based participatory research (CBPR) process used to develop the Harvest for Healthy Kids curriculum. METHODS: Harvest for Healthy Kids is a intervention research project designed to increase access to and intake of fruits and vegetables among preschoolers enrolled in Head Start. The curriculum is composed of eight kits, each focusing on a different fruit or vegetable. RESULTS: The Harvest for Healthy Kids curriculum was developed through an iterative process in which Head Start teachers were highly involved. The final product reflects the teachers' experiences using the curriculum and their suggestions for improving. CONCLUSIONS: The CBPR process used to develop the Harvest for Healthy Kids curriculum led to a product that is grounded in theory and practice.

Neighborhood food environment role in modifying psychosocial stress-diet relationships.

Exposure to highly palatable foods may increase eating in response to stress, but this behavioral response has not been examined in relation to the neighborhood food environment. This study examined whether the neighborhood food environment modified relationships between psychosocial stress and dietary behaviors. Probability-sample survey (n=460) and in-person food environment audit data were used. Dietary behaviors were measured using 17 snack food items and a single eating-out-of-home item. Chronic stress was derived from five subscales; major life events was a count of nine items. The neighborhood food environment was measured as availability of large grocery stores, small grocery stores, and convenience stores, as well as proportion of restaurants that were fast food. Two-level hierarchical regression models were estimated. Snack food intake was positively associated with convenience store availability and negatively associated with large grocery store availability. The measures of chronic stress and major life events were generally not associated with either dietary behavior overall, although Latinos were less likely to eat out at high levels of major life events than African Americans. Stress-neighborhood food environment interactions were not statistically significant. Important questions remain regarding the role of the neighborhood food environment in the stress-diet relationship that warrant further investigation.

Inter-rater reliability of the food environment audit for diverse neighborhoods (FEAD-N).

Studies have shown that neighborhood food environments are important influences on dietary intake and may contribute to health disparities. While instruments with high reliability have been developed to assess food availability, price, and quality, few measures to assess items associated with the physical and social features of food stores have been developed. Yet, recent qualitative studies have documented aspects associated with such features of urban food stores that are barriers to food acquisition. We assessed the reliability of measures to assess multiple components of the food environment-including physical and social store features--in three geographically distinct and diverse communities in Detroit, Michigan, using the Food Environment Audit for Diverse Neighborhoods (FEAD-N). Using the FEAD-N, four trained observers conducted observations of 167 food stores over a 10-week period between October and December 2008. To assess inter-rater reliability, two trained observers independently visited, on the same day, a random subset of 44 food stores. Kappa statistics and percent agreement were used to evaluate inter-rater reliability. Overall, the instrument had mostly high inter-rater reliability with more than 75% of items with kappa scores between 0.80 and 1.00, indicating almost perfect reliability. More than half of the physical store features and 47% of the social store features had almost perfect reliability and about 37% and 47%, respectively, had substantial reliability. Measuring factors associated with the physical and social environment of food stores with mostly high reliability is feasible. Systematic documentation of the physical and social features of food stores using objective measures may promote a more comprehensive understanding of how neighborhood food environments influence health.

Associations between neighborhood availability and individual consumption of dark-green and orange vegetables among ethnically diverse adults in Detroit.

Diets rich in dark-green and orange vegetables have been associated with a reduction in chronic diseases. However, most Americans do not consume the number of daily servings recommended by the 2005 Dietary Guidelines for Americans. An increasing number of studies suggest that changes to the neighborhood food environment may be critical to achieving population-wide improvements in eating. The objective of this study was to examine the relationship between observed neighborhood availability and individual consumption of dark-green and orange vegetables among low- to moderate-income and ethnically diverse adults in Detroit. This study used a cross-sectional design that drew upon a 2002-2003 community survey and 2002 in-person audit of food stores. A total of 919 adults (mean age 46.3 years, 52.2% female) including African Americans (56.7 %), Latinos (22.2%), and whites (18.7%) residing in three Detroit communities participated in the survey. Two-level weighted, hierarchical linear regression was used to analyze the data. On average, survey respondents ate 0.61 daily servings of dark-green and orange vegetables. Residents of neighborhoods with no stores carrying five or more varieties of dark-green and orange vegetables were associated with an average of 0.17 fewer daily servings of these foods compared with residents of neighborhoods with two stores carrying five or more varieties of dark-green and orange vegetables (P=0.047). These findings suggest that living in a neighborhood with multiple opportunities to purchase dark-green and orange vegetables may make an important contribution toward meeting recommended intakes.

The one-pager: a practical policy advocacy tool for translating community-based participatory research into action.

The multiple and diverse perspectives, skills, and experiences inherent in community-academic partnerships make them uniquely positioned to educate policy makers and advocate for health equity. Effective communication tools are critical to successfully engage in the policy-making process. Yet few resources emphasize the development and use of practical tools for translating community-based participatory research (CBPR) findings into action. The purpose of this article is to describe a CBPR process for developing and using a one-page summary, or "one-pager," of research findings and their policy implications. This article draws on the experience of the Healthy Environments Partnership (HEP), a community-academic partnership in Detroit, Michigan. In addition to describing these processes, this article includes a template for a one-pager and an example of a one-pager that was written for and presented to federal policy makers.

Farm-to-school programs: perspectives of school food service professionals.

OBJECTIVE: This qualitative study used a case study approach to explore the potential of farm-to-school programs to simultaneously improve children's diets and provide farmers with viable market opportunities. DESIGN: Semistructured interviews were the primary data collection strategy. SETTING: Seven farm-to-school programs in the Upper Midwest and Northeast regions of the United States. PARTICIPANTS: Seven school food service professionals, 7 farmers, and 4 food distributors recruited from 7 farm-to-school programs. PHENOMENON OF INTEREST: Interviews probed why farmers, school food service professionals, and food distributors participate in farm-to-school programs and how they characterize the opportunities and challenges to local school food procurement. ANALYSIS: Data were analyzed using thematic coding and data displays. RESULTS: School food service professionals described 3 motivators for buying locally grown food for their cafeterias: (1) "The students like it," (2) "The price is right," and (3) "We're helping our local farmer." Students' preference for locally grown food was related to food quality, influence of school staff, and relationships with farmers. Buying food directly from farmers and wholesalers was associated with lower prices and flexible specifications, and the "local feel." CONCLUSIONS AND IMPLICATIONS: Understanding school food service professionals' motivations for buying locally grown food is critical to the sustainability of farm-to-school programs.

Results from the 2004 Michigan Farm-to-School Survey.

The purpose of this study was to investigate Michigan school food service directors' interest in, and opportunities and barriers to, implementing a farm-to-school program. Farm-to-school may be a timely and innovative approach to improving the school food environment and helping food service directors meet their nutrition goals for school meals. Health and agriculture advocates have recognized the importance of farm-to-school in addressing health issues and creating opportunities for farmers and rural communities. Research subjects were 664 food service directors representing school districts across Michigan. Respondents (n = 383) reported a high degree of interest in sourcing food from local producers (73% reported being very interested or interested). Interest was significantly augmented (83%) when respondents were asked to assume that these foods were available through current vendors. Interest was independent of free/reduced lunch participation rate or school district location (rural, suburban, urban location). Food service directors expressed diverse motivations for their interest in farm-to-school, including supporting the local economy and community; accessing fresher, higher-quality food; and potentially increasing students' fruit and vegetable consumption. The most frequently reported barriers and concerns included cost, federal and state procurement regulations, reliable supply, seasonality of fruits and vegetables, and food safety. Michigan school food service directors appear ready to make linkages with local agriculture. However, there is need to address the concerns and barriers through education; inclusion of community partners, such as current vendors; funding; and state and federal policies that support local purchasing.