Government strategies to ensure the human right to adequate and healthy food facing the Covid-19 pandemic in Brazil. / Estratégias governamentais para a garantia do direito humano à alimentação adequada e saudável no enfrentamento à pandemia de Covid-19 no Brasil.

The Covid-19 pandemic revealed a concrete and immediate threat to food and nutrition security (FNS), especially for vulnerable groups. This study aimed to identify government strategies implemented in Brazil to provide the Human Right to Adequate and Healthy Food in high social vulnerability contexts during the Covid-19 pandemic. A cross-sectional study was carried out, with analysis of official documents published between March 20 and July 30, 2020, by the Federal Government, Federal District, Brazilian states, and capitals, focusing on measures to ensure availability and physical or financial access to food. Strategies implemented mainly involve food distribution and minimum income assurance. The following were implemented: Basic Emergency Income (Federal Government); Food Acquisition Program (PAA), and emergency financial aid (states); emergency food donation programs (states and municipalities). Existing measures were adapted to the pandemic, such as the National School Food Program (PNAE), the National Food Acquisition Program (PAA), and the distribution of food and staple food baskets. While essential, these strategies have limited scope and are insufficient to ensure FNS.

A pandemia de Covid-19 revelou a existência de ameaça concreta e imediata à segurança alimentar e nutricional (SAN), em especial de grupos vulnerabilizados. O estudo buscou identificar as estratégias governamentais implementadas no Brasil para prover o Direito Humano à Alimentação Adequada e Saudável em contextos de elevada vulnerabilidade social frente à Covid-19. Foi realizado um estudo transversal, com análise de documentos oficiais publicados entre 20 de março e 30 de julho de 2020 pela União, Distrito Federal, estados e capitais brasileiras, com foco em medidas que assegurem disponibilidade e acesso físico ou financeiro a alimentos. As estratégias implementadas envolvem fundamentalmente distribuição de alimentos e garantia de renda mínima. Foram instituídas: Renda Básica Emergencial (União); Programa de Aquisição de Alimentos (PAA) e auxílio financeiro emergencial (estados); programas de doação emergencial de alimentos (estados e municípios). Medidas existentes foram adaptadas frente à pandemia, como o Programa Nacional de Alimentação Escolar (PNAE), o Programa de Aquisição de Alimentos (PAA) nacional, a distribuição de alimentos e de cestas básicas. Embora importantes, essas estratégias têm alcance limitado e são insuficientes para assegurar a SAN.

Estratégias governamentais para a garantia do direito humano à alimentação adequada e saudável no enfrentamento à pandemia de Covid-19 no Brasil / Government strategies to ensure the human right to adequate and healthy food facing the Covid-19 pandemic in Brazil

Resumo A pandemia de Covid-19 revelou a existência de ameaça concreta e imediata à segurança alimentar e nutricional (SAN), em especial de grupos vulnerabilizados. O estudo buscou identificar as estratégias governamentais implementadas no Brasil para prover o Direito Humano à Alimentação Adequada e Saudável em contextos de elevada vulnerabilidade social frente à Covid-19. Foi realizado um estudo transversal, com análise de documentos oficiais publicados entre 20 de março e 30 de julho de 2020 pela União, Distrito Federal, estados e capitais brasileiras, com foco em medidas que assegurem disponibilidade e acesso físico ou financeiro a alimentos. As estratégias implementadas envolvem fundamentalmente distribuição de alimentos e garantia de renda mínima. Foram instituídas: Renda Básica Emergencial (União); Programa de Aquisição de Alimentos (PAA) e auxílio financeiro emergencial (estados); programas de doação emergencial de alimentos (estados e municípios). Medidas existentes foram adaptadas frente à pandemia, como o Programa Nacional de Alimentação Escolar (PNAE), o Programa de Aquisição de Alimentos (PAA) nacional, a distribuição de alimentos e de cestas básicas. Embora importantes, essas estratégias têm alcance limitado e são insuficientes para assegurar a SAN.

Abstract The Covid-19 pandemic revealed a concrete and immediate threat to food and nutrition security (FNS), especially for vulnerable groups. This study aimed to identify government strategies implemented in Brazil to provide the Human Right to Adequate and Healthy Food in high social vulnerability contexts during the Covid-19 pandemic. A cross-sectional study was carried out, with analysis of official documents published between March 20 and July 30, 2020, by the Federal Government, Federal District, Brazilian states, and capitals, focusing on measures to ensure availability and physical or financial access to food. Strategies implemented mainly involve food distribution and minimum income assurance. The following were implemented: Basic Emergency Income (Federal Government); Food Acquisition Program (PAA), and emergency financial aid (states); emergency food donation programs (states and municipalities). Existing measures were adapted to the pandemic, such as the National School Food Program (PNAE), the National Food Acquisition Program (PAA), and the distribution of food and staple food baskets. While essential, these strategies have limited scope and are insufficient to ensure FNS.

Benefits of Oral Health Education at Women, Infant, and Children (WIC) Clinic Visits: Assessments of Parent's Oral Health Beliefs, Behaviors and Dental Access in O'ahu, Hawai'i.

Improving oral health outcomes in Hawai'i for children and families remains a high priority. Children in the state are leading the nation with the highest caries rates, while women before, during, and after pregnancy are failing to receive regular and necessary dental care resulting in poor health outcomes. To answer for this need, an educational intervention was conducted among families enrolled in the Kapi'olani Medical Center for Women and Children's Women, Infant, and Children program (WIC) in O'ahu. The project included the following activities: (1) identification the oral health beliefs and behaviors of families, (2) providing oral health education to families, and (3) reassessing beliefs and behaviors in 3-6 months to document the impact of theeducation session. Participants consisted of 81 families resulting in the data on 176 children and 4 pregnant women. Of the 81 families, 40 representing84 children completed the follow-up oral health questionnaire. Results of the assessment and education demonstrated a positive impact on the family's oral health behaviors. Parents were 6.61 times as likely to report using fluoride toothpaste in the follow-up visit compared to their initial visit (95% confidence interval [CI] = 3.12-14.00). Additionally, statistically significant changes were noted in the frequency of children's daily tooth brushing (odds ratio [OR] = 2.15, 95% CI = 1.33-3.46), as well as in the incidence of children receiving fluoride varnish application over time (OR = 2.66, 95% CI = 1.50-4.73). These results provide further evidence that initiating a simple educational intervention can have a positive impact on oral health behaviors in groups that are at highest risk for developing dental disease in Hawai'i.

Food Bank-Based Diabetes Prevention Intervention to Address Food Security, Dietary Intake, and Physical Activity in a Food-Insecure Cohort at High Risk for Diabetes.

PURPOSE AND OBJECTIVES: Although food insecurity is associated with poor dietary intake and risk of chronic disease, few studies have demonstrated the effectiveness of diabetes prevention interventions delivered through food banks. Food banks serve vulnerable communities. The purpose of this pilot project was to assess the effectiveness of a food bank-delivered intervention aimed at improving food security and reducing risk factors for type 2 diabetes among at-risk clients. INTERVENTION APPROACH: We screened adult English- and Spanish-speaking food bank clients for type 2 diabetes risk at 12 community food distribution sites in Alameda County, California. Screening and enrollment for a pilot intervention took place from November 2017 to March 2018. Intervention components were delivered from November 2017 through March 2019. The intervention included monthly diabetes-appropriate food packages, text-based health education, and referrals to health care. EVALUATION METHODS: Food bank staff members administered surveys to participants at baseline, 6 months (midpoint), and 12 months (postintervention); participants self-reported all responses. Primary outcomes assessed were food security status, dietary intake, health-related behaviors, and body mass index (BMI). Information on demographic characteristics, food pantry access, health care use, and symptoms of depression was also collected. RESULTS: We screened 462 food bank clients for eligibility. Of the 299 who were eligible, 244 enrolled; 90.6% were female, 80.1% were Hispanic, and 49.1% had an annual household income less than $20,000. At baseline, 68.8% of participants had low or very low food security. At midpoint, participants had significant improvements in food security status, dietary intake, physical activity, health status, and depression scores. Mean BMI did not change. IMPLICATIONS FOR PUBLIC HEALTH: This intervention demonstrated that food banks can effectively screen clients at high risk for diabetes and improve household food security and other risk factors for diabetes. Food banks may be an important and strategic partner for health care systems or community-based organizations working to prevent diabetes in food-insecure populations.

Postpartum Depression Screening and Referrals in Special Supplemental Nutrition Program for Women, Infants, and Children Clinics.

OBJECTIVES: To examine the relationships among participants' demographic, social, and health characteristics and positive screening scores for symptoms of postpartum depression (PPD); to examine the feasibility of referring to a case management program women with symptoms of PPD who are accessing Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services; and to identify barriers to screening and treatment programs for women with symptoms of PPD. DESIGN: Descriptive, cross-sectional study followed by a process evaluation. SETTING: Two WIC clinics in a large southeastern U.S. city. PARTICIPANTS: One group (n = 302) included women with infants younger than 12 months who were screened for symptoms of PPD. The second group (n = 31) included case managers (n = 7), nutritionists (n = 12), advisory board members (n = 7), and student volunteers (n = 5) who participated in focus groups. METHODS: We conducted an initial screening of women for symptoms of PPD using the two-item Patient Health Questionnaire (PHQ-2). Participants with scores of 2 or greater (n = 73) were asked to complete the nine-item PHQ (PHQ-9) and the Edinburgh Postnatal Depression Scale. Participants were referred for case management services if they scored 10 or greater on the PHQ-9 or Edinburgh Postnatal Depression Scale (n = 29) and agreed to the referral (n = 19). We transcribed and analyzed the qualitative data recorded during focus groups. RESULTS: Participants with no health insurance and limited support in caring for their infants were more likely to report symptoms of PPD. Overall, 302 women were screened for PPD, indicating the feasibility of PPD screening in WIC clinics. Of the 19 participants referred to case management, 47% (n = 9) accessed care. The results of focus groups illuminated barriers to screening and treatment programs for women at the individual, local, and macrosystem levels. CONCLUSION: Our findings show the feasibility of PPD screening in WIC clinics. However, some participants did not receive mental health services after referral because of various barriers, which highlights the need to integrate mental health providers into WIC clinics.

Perception of the operating agents about the Brazilian National School Feeding Program.

OBJECTIVE: Identify the perception operating agents have on the Brazilian National School Feeding Program. METHODS: This is an observational, cross-sectional and quali-quantitative study developed in non-probability and convenience sampling selected in an event promoted by the National Fund for Educational Development in 2015 in Rio de Janeiro. Data were collected through questions related to pre-defined categories concerning the National School Feeding Program. The questionnaire was answered by 43 nutritionists, 41 members of the School Feeding Board, and 16 school feeding administrators from 38 cities of Rio de Janeiro. The narrative analysis was based on benchmarks of cognitive analysis of public policies. The association among variables was investigated with chi-square test, being calculated the power for association testing. RESULTS: The perception of the implementation of the National School Feeding Program has been characterized by some challenges: 1) low number of nutritionists to meet the demand from schools; 2) low adhesion to the public call for the purchase of family farming products due to bureaucratic difficulties and insufficient local food production; 3) reduced coverage of food and nutritional measures due to the restriction of human, material and financial resources; and 4) limitation of the participation of the School Feeding Board due to insufficient training and transport for regular visits. The adequacy of the number of nutritionists showed statistically significant association with the purchase of family farming products (p = 0.002; power = 99%) and with the food and nutritional education activities (p = 0.021; power = 79%). CONCLUSIONS: The results indicate the need for employment of nutritionist in sufficient numbers to meet the demands of the National School Feeding Program, investment in educational activities of healthy eating in schools, training of the School Feeding Board, greater availability of vehicles for school visits and assistance to family farmers in order to facilitate their participation in programs of institutional purchases and encourage the diversification of production.

Examining Barriers and Facilitators to Delivering SNAP-Ed Direct Nutrition Education in Rural Communities.

PURPOSE: To better understand the barriers to implementing Supplemental Nutrition Assistance Program Education (SNAP-Ed) direct education programming in rural communities, as well as strategies to overcome these barriers. This includes (1) barriers to implementing direct education in rural communities, and (2) facilitators to overcoming direct-education barriers in rural communities. DESIGN: This was a qualitative study that included in-depth interviews. SETTING: Fifteen states across all 7 SNAP-Ed regions. PARTICIPANTS: Participants were eligible if they (1) were SNAP-Ed staff who were involved with implementing programs; (2) implemented at least 50% of their programming in rural communities, and (3) worked in their role for at least 12 months. Twenty-seven (n = 27) staff participated in interviews. MEASURES: Online surveys ascertained if participants were interested in participating in a 60-minute interview about implementing SNAP-Ed in rural communities. Interviews were semistructured and focused on the barriers and facilitators to implementing SNAP-Ed direct-education nutrition programming in rural areas. ANALYSIS: Qualitative interviews were analyzed using content analysis in Atlas.ti. RESULTS: Barriers to implementing direct education in rural communities included lack of healthy food and physical activity infrastructure to reinforce messages taught in class, funding restrictions, transportation for SNAP-Ed staff and the perception that this was also a problem for participants, and SNAP-Ed staff being seen as "outsiders" (not from the community). Facilitators included partnering with other organizations to increase recruitment and retention of SNAP-Ed participants, buy-in from local leaders, and SNAP-Ed staff being from the community. CONCLUSION: Partnerships between SNAP-Ed programs and non-SNAP-Ed organizations were essential in helping to recruit and retain participants. The SNAP-Ed staff should get buy-in from local leaders before starting direct-education programming. The SNAP-Ed programs should explore innovative delivery modalities including online and text messaging due to transportation issues in widespread rural geographies. Lastly, more work should be done to complement SNAP-Ed direct education with policy, systems, and environmental change initiatives.

Perception of the operating agents about the Brazilian National School Feeding Program / Percepção de agentes operadores do Programa Nacional de Alimentação Escolar

ABSTRACT OBJECTIVE Identify the perception operating agents have on the Brazilian National School Feeding Program. METHODS This is an observational, cross-sectional and quali-quantitative study developed in non-probability and convenience sampling selected in an event promoted by the National Fund for Educational Development in 2015 in Rio de Janeiro. Data were collected through questions related to pre-defined categories concerning the National School Feeding Program. The questionnaire was answered by 43 nutritionists, 41 members of the School Feeding Board, and 16 school feeding administrators from 38 cities of Rio de Janeiro. The narrative analysis was based on benchmarks of cognitive analysis of public policies. The association among variables was investigated with chi-square test, being calculated the power for association testing. RESULTS The perception of the implementation of the National School Feeding Program has been characterized by some challenges: 1) low number of nutritionists to meet the demand from schools; 2) low adhesion to the public call for the purchase of family farming products due to bureaucratic difficulties and insufficient local food production; 3) reduced coverage of food and nutritional measures due to the restriction of human, material and financial resources; and 4) limitation of the participation of the School Feeding Board due to insufficient training and transport for regular visits. The adequacy of the number of nutritionists showed statistically significant association with the purchase of family farming products (p = 0.002; power = 99%) and with the food and nutritional education activities (p = 0.021; power = 79%). CONCLUSIONS The results indicate the need for employment of nutritionist in sufficient numbers to meet the demands of the National School Feeding Program, investment in educational activities of healthy eating in schools, training of the School Feeding Board, greater availability of vehicles for school visits and assistance to family farmers in order to facilitate their participation in programs of institutional purchases and encourage the diversification of production.

RESUMO OBJETIVO Identificar a percepção de agentes operadores sobre o Programa Nacional de Alimentação Escolar. MÉTODOS Trata-se de um estudo observacional, transversal e quali-quantitativo desenvolvido em amostra não probabilística e selecionada por conveniência em um evento promovido pelo Fundo Nacional de Desenvolvimento da Educação em 2015 no Rio de Janeiro. Os dados foram coletados com o auxílio de um questionário cujas questões se relacionavam a categorias pré-definidas relacionadas ao Programa Nacional de Alimentação Escolar. O questionário foi respondido por 43 nutricionistas, 41 membros do Conselho de Alimentação Escolar e 16 gestores da alimentação escolar de 38 municípios do Rio de Janeiro. A análise das narrativas foi baseada em referenciais de análise cognitiva de políticas públicas. A associação entre as variáveis foi investigada com o teste qui-quadrado , sendo calculado o poder do teste das associações. RESULTADOS A percepção da execução do Programa Nacional de Alimentação Escolar foi caracterizada por alguns desafios: 1) baixo quantitativo de nutricionistas para atender à demanda das escolas; 2) baixa adesão à chamada pública para compra de produtos da agricultura familiar por dificuldades burocráticas e insuficiência de produção local de alimentos; 3) reduzida abrangência das ações de educação alimentar e nutricional pela restrição dos recursos humanos, materiais e financeiros; e 4) limitação na atuação do Conselho de Alimentação Escolar por oferta insuficiente de capacitação e de transporte para as visitas regulares. A adequação do quantitativo de nutricionistas mostrou associação estatisticamente significante com a compra de produtos da agricultura familiar (p = 0,002; poder = 99%) e com as atividades de educação alimentar e nutricional (p = 0,021; poder = 79%). CONCLUSÕES Os resultados indicam a necessidade de contratação de nutricionistas em número suficiente para atender às demandas do Programa Nacional de Alimentação Escolar, investimento em atividades educativas de alimentação saudável nas escolas, capacitação do Conselho de Alimentação Escolar, maior disponibilidade de veículos para visitas escolares e assistência aos agricultores familiares para facilitar a participação em programas de compras institucionais e oportunizar a diversificação de produção.

Early Childhood Education Centers' Reported Readiness to Implement the Updated Child and Adult Care Food Program Meal Pattern Standards in the United States, 2017.

BACKGROUND: The Child and Adult Care Food Program (CACFP) serves nutritious meals/snacks to >3.6 million children in early childhood education (ECE) centers. This study provides a nationwide assessment of nonhome-based CACFP-participating ECE centers' awareness of and reported readiness for implementing updated CACFP standards/best practices that took effect October 1, 2017. METHODS: A national frame of 38,760 centers serving children ages 0-5 was developed. A web-based survey of 5483 sampled centers, stratified by census division, was conducted between August 22 and September 30, 2017. One thousand three hundred forty-three centers (25%) located in 47 states and the District of Columbia responded. Surveys were primarily completed by center directors/assistant directors (71%). Nonresponse adjusted multivariate regressions were conducted, controlling for center/zip code-level characteristics. RESULTS: The majority of centers reported being "very" familiar with the updated standards and met specific standards/best practices. Centers that reported being "somewhat" (vs. "very") familiar with the standards were less prepared and likely to have begun implementation and more likely to need additional time, money, and staff. Centers that reported being "not"/"somewhat" familiar (vs. "very") with the updated standards were also less likely to meet specific standards/best practices. Center preparedness and standards/best practices varied by weekly rates/fees charged. Centers in the West (vs. South) were more likely to report meeting sugary cereal standards and fruits and vegetables as a snack component best practice. CONCLUSIONS: While most centers reported familiarity with and were prepared to implement the updated CACFP standards, readiness is not universal. Technical assistance and training should ensure that all centers are trained on the updated standards.

Avaliação do Programa Nacional de Alimentação Escolar: revisão da literatura / Evaluation of the National School Food Program: review of the literature

Resumo O Programa Nacional de Alimentação Escolar (PNAE) representa uma estratégia importante de promoção da alimentação saudável. Objetivou-se realizar uma análise sumária das pesquisas avaliativas sobre o PNAE. Pesquisa bibliografica do período de 2010 a 2015 nas bases de dados Bireme e SciELO. Foram selecionados 12 artigos vinculados à área, dos quais oito analisaram a inserção do nutricionista no PNAE; sete, a aquisição de alimentos da agricultura familiar; cinco, a implantação dos Conselhos de Alimentação Escolar; cinco, a execução dos cardápios; e quatro, os recursos financeiros destinados ao PNAE. Apontam-se problemas na atuação do nutricionista e dos Conselhos de Alimentação Escolar, na aquisição de alimentos da agricultura familiar e na composição dos cardápios (baixo conteúdo de frutas e hortaliças). Destaca-se a necessidade de maior atenção relacionada à execução do PNAE, de maneira a garantir uma alimentação escolar dentro de princípios que promovam a segurança alimentar e nutricional. Novos estudos avaliativos sobre o Programa são fundamentais para o fornecimento de subsídios aos gestores públicos com fins de aprimorar a sua execução.

Abstract The National School Food Program (PNAE) constitutes an important strategy for the promotion of healthy eating. The objective was to perform a brief analysis of evaluative research on the PNAE. It involved a search of the literature from 2010 to 2015 in the Bireme and Scielo databases. Twelve articles were selected linked to the area, eight of which analyzed the insertion of the nutritionist in the PNAE; seven, to buy food from family farms; five, the implementation of School Food Councils; five, the compilation of menus; and four, funding destined for the PNAE. Problems in the performance of the nutritionist and the School Food Councils, on buying food from family farms and in the compilation of the menus (low fruit and vegetable content) were detected. The need for greater attention to execution of the PNAE was highlighted in order to ensure school food within guidelines that promote food and nutrition security. Further evaluation studies about the program are fundamental for the provision of subsidies to public managers for purposes of enhancing its implementation.

Status report - FoodReach Toronto: lowering food costs for social agencies and community groups. / Rapport d'étape - FoodReach Toronto : réduire le coût des aliments pour les organismes sociaux et les groupes communautaires.

Toronto has the largest absolute number of food insecure households for any metropolitan census area in Canada: of its 2.1 million households, roughly 252 000 households (or 12%) experience some level of food insecurity. Community organizations (including social agencies, school programs, and child care centres) serve millions of meals per year to the city's most vulnerable citizens, but often face challenges accessing fresh produce at affordable prices. Therefore in 2015, Toronto Public Health, in collaboration with public- and private-sector partners, launched the FoodReach program to improve the efficiency of food procurement among community organizations by consolidating their purchasing power. Since being launched, FoodReach has been used by more than 50 community organizations to provide many of Toronto's most marginalised groups with regular access to healthy produce.

RÉSUMÉ: Toronto compte plus de ménages en situation d'insécurité alimentaire que les autres régions métropolitaines de recensement au Canada : sur 2,1 millions de ménages, environ 252 000 (soit 12 %) vivent dans une certaine forme d'insécurité alimentaire. Les organismes communautaires (organismes sociaux, programmes scolaires, garderies) servent des millions de repas par année aux citoyens les plus vulnérables de la ville, mais rencontrent souvent des difficultés à obtenir des produits frais à prix abordable. C'est dans ce contexte, afin d'améliorer l'efficience de l'approvisionnement alimentaire des organismes communautaires en consolidant leur pouvoir d'achat, que le Bureau de santé publique de Toronto, en collaboration avec des partenaires des secteurs public et privé, a créé en 2015 le programme FoodReach. Depuis sa création, FoodReach a permis à plus d'une cinquantaine d'organismes communautaires d'obtenir un accès régulier à des produits sains pour de nombreux groupes parmi les plus marginalisés de Toronto.

Education for WIC Peer Counselors About Breastfeeding the Late Preterm Infant.

Mothers of late preterm infants need ongoing support because they often find establishing breastfeeding (BF) to be complex and difficult. Special Supplemental Nutrition Program for Women, Infants and Children peer counselors provide BF information and emotional support to new mothers in many communities. However, their current training does not include education about BF for the late preterm infant. The purpose of this report is to present important information about BF and the late preterm infant that can enhance peer counselors' ability to offer appropriate support. The effect of this education on outcomes such as BF rates, maternal self-efficacy, infant hospital readmissions, and peer counselors' self-efficacy needs to be investigated.

Validation of a Collaboration Readiness Assessment Tool for Use by Supplemental Nutrition Assistance Program-Education (SNAP-Ed) Agencies and Partners.

OBJECTIVE: To evaluate content and face validity of a collaboration readiness assessment tool developed to facilitate collaborative efforts to implement policy, systems, and environment changes in Supplemental Nutrition Assistance Program-Education (SNAP-Ed). METHODS: Evaluation of the validity of the tool involved 2 steps. Step 1 was conducted with 4 subject matter experts to evaluate content validity. Step 2 used an iterative cognitive testing process with 4 rounds and 16 SNAP-Ed staff and community partners to evaluate face validity. RESULTS: Subject matter experts found that survey items appropriately matched the content area indicated and adequately covered collective efficacy, change efficacy, and readiness. Cognitive testing with SNAP-Ed staff and partners informed modifications and resulted in adequate face validity. CONCLUSIONS AND IMPLICATIONS: The ability to measure collaboration readiness will allow agencies and community partners that implement SNAP-Ed to target areas that facilitate collaboration efforts needed for policy, systems, and environment change and collective efficacy. Further cognitive testing of the tool with other populations is needed to ensure its applicability and usefulness. Evaluation of the reliability of the tool with a broad range of SNAP-Ed programs and community agencies is also recommended.

Restructuring a State Nutrition Education and Obesity Prevention Program: Implications of a Local Health Department Model for SNAP-Ed.

CONTEXT AND OBJECTIVE: The US Department of Agriculture Supplemental Nutrition Assistance Program-Education (SNAP-Ed) funds state programs to improve nutrition and physical activity in low-income populations through its Nutrition Education and Obesity Prevention grants. States vary in how they manage and structure these programs. California substantially restructured its program in 2012 to universally position local health departments (LHDs) as the programmatic lead in all jurisdictions. This study sought to determine whether California's reorganization aligned with desirable attributes of decentralized public management. DESIGN, SETTING, AND PARTICIPANTS: This study conducted 40 in person, semistructured interviews with 57 local, state, and federal SNAP-Ed stakeholders between October 2014 and March 2015. Local respondents represented 15 counties in all 7 of California's SNAP-Ed regions. We identified 3 common themes that outlined advantages or disadvantages of local public management, and we further defined subthemes within: (1) coordination and communication (within local jurisdictions, across regions, between local and state), (2) efficiency (administrative, fiscal, program), and (3) quality (innovation, skills). We conducted qualitative content analysis to evaluate how respondents characterized the California experience for each theme, identifying positive and negative experiences. RESULTS: California's LHD model offers some distinct advantages, but the model does not exhibit all the advantages of decentralized public management. Strategic planning, partnerships, subcontracting, and fiscal oversight are closer to communities than previously. However, administrative burden remains high and LHDs are limited in their ability to customize programs on the basis of community needs because of state and federal constraints. CONCLUSIONS: California's use of a universal LHD model for SNAP-Ed is novel. Recent federal SNAP-Ed changes present an opportunity for other states to consider this structure. Employing small-scale approaches initially (eg, pilot efforts) may facilitate effective transitions. For an LHD model to be effective, LHDs must be adept at managing administrative complexity and capable of succeeding within stringent federal/state requirements.

Multiple Comorbidities and Interest in Research Participation Among Clients of a Nonprofit Food Distribution Site.

BACKGROUND: Persons accessing food from nonprofit distribution sites face numerous challenges and typically have significant unmet health needs. However, given limited and intermittent healthcare system engagement, this vulnerable population is underrepresented in clinical research. We sought to better understand the health needs of a nonclinical population to inform future research and interventions. METHODS: Focus groups were conducted in English (n = 4) and Spanish (n = 4) with clients of Crossroads Community Services (CCS), the largest distributor of North Texas Food Bank. Discussions probed participants' health status, healthcare utilization, understanding and utilization of mammography, and attitudes toward participation in research. RESULTS: Participants included 42 CCS clients, primarily Hispanic or African American women. Participants reported multiple comorbid conditions among household members, yet utilization of health services was often limited by cost. The majority expressed interest in participating in research to communicate their health concerns and obtain emotional support. CONCLUSION: CCS clients represent a high-need, under-reached population willing to engage in health-related research that affords them opportunity to connect with peers in group settings and obtain information to improve management of daily life challenges. The Community Assistance Research (CARe) Initiative, a community-academic collaboration, establishes a much-needed opportunity for ongoing clinical research and intervention among this underserved population.

Concentration of tobacco advertisements at SNAP and WIC stores, Philadelphia, Pennsylvania, 2012.

INTRODUCTION: Tobacco advertising is widespread in urban areas with racial/ethnic minority and low-income households that participate in nutrition assistance programs. Tobacco sales and advertising are linked to smoking behavior, which may complicate matters for low-income families struggling with disparate health risks relating to nutrition and chronic disease. We investigated the relationship between the amount and type of tobacco advertisements on tobacco outlets and the outlet type and location. METHODS: By using field visits and online images, we inspected all licensed tobacco retail outlets in Philadelphia (N = 4,639). Point pattern analyses were used to identify significant clustering of tobacco outlets and outlets with exterior tobacco advertisements. Logistic regression was used to analyze the relationship between the outlet's acceptance of Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the presence of tobacco advertisements. RESULTS: Tobacco outlets with exterior tobacco advertisements were significantly clustered in several high-poverty areas. Controlling for racial/ethnic and income composition and land use, SNAP and WIC vendors were significantly more likely to have exterior (SNAP odds ratio [OR], 2.11; WIC OR, 1.59) and interior (SNAP OR, 3.43; WIC OR, 1.69) tobacco advertisements than other types of tobacco outlets. CONCLUSION: Tobacco advertising is widespread at retail outlets, particularly in low-income and racial/ethnic minority neighborhoods. Policy makers may be able to mitigate the effects of this disparate exposure through tobacco retail licensing, local sign control rules, and SNAP and WIC authorization.

Development and implementation of client-centered nutrition education programs in a 4-stage framework.

The Texas Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) sought to engage the WIC staff and community in the implementation of relevant and effective client-centered nutrition education. The program was implemented in a 4-stage framework. The collaborative process of developing client-centered nutrition education allowed members to learn from one another, thus ensuring commitment to client-centered nutrition education from all levels of staff. The co-created materials and trainings developed during the implementation played a key role. Evaluation feedback started at the infancy of implementation and gave all community members a stake in developing client-centered nutrition education and an opportunity to be invested in its success, which led to increased execution at the local agency level over the implementation stages.

Providing nutrition education to recently resettled refugees: piloting a collaborative model and evaluation methods.

Resettled refugees experience high levels of food insecurity because of low English proficiency, limited job skills, and lack of understanding of the United States food system. This study evaluated integrating Supplemental Nutrition Assistance Program Education (SNAP-Ed) into English as Second Language (ESL) classes taught at a worksite- training program for recently resettled refugees and the feasibility of using food purchase receipts. A convenience sample of resettled refugees participated in SNAP-Ed one hour for 12 weeks during ESL classes. Food purchase receipts were collected for purchases one week prior to, first three weeks, last three weeks, and one week after classes. Participants were from 17 countries and 50% completed 12 lessons. Fifty-nine participants turned in receipts and 93% used SNAP funds. By integrating SNAP-Ed into ESL classes at a worksite-training center a hard-to-reach eligible population was reached. Further validation is needed to use food purchase receipts.