Capacity, Communication, and Coordination Are Key to Successful Implementation of Policy, Systems, and Environmental Strategies at SNAP-Ed Partner Sites in One Southeastern US State: A Qualitative Approach.

BACKGROUND: The United States Department of Agriculture expanded the Supplemental Nutrition Assistance Program (SNAP)-Ed program to all 50 states in 2004. In 2010, the Healthy, Hunger-Free Kids Act required that agencies implementing SNAP-Ed support policy, systems, and environmental (PSE) strategies, in addition to providing direct education (DE). Research has evaluated the impact of PSEs on health, but few studies have investigated the process of PSE implementation. OBJECTIVE: The objective of this study was to identify facilitators and barriers to PSE implementation at SNAP-Ed partner sites from the perspectives of site contacts and SNAP-Ed implementers. DESIGN: This study employed a qualitative longitudinal design. The PSE planning and implementation process was observed over 1 year at SNAP-Ed partner sites. Semistructured interviews were conducted with site contacts and SNAP-Ed implementers throughout the year. PARTICIPANTS/SETTING: Participants were SNAP-Ed implementers (n = 8) and site contacts (n = 18) from 18 partner sites where both PSE and direct education were occurring. SNAP-Ed implementers were debriefed once, and site contacts were interviewed three times over the course of the study. This study was conducted in a Southern US state with SNAP-Ed partner sites that intended to implement PSEs. The duration of data collection was October 2017 through September 2018. ANALYSIS: A thematic analysis of barriers and facilitators to PSE implementation across sites was conducted. RESULTS: The PSE implementation barriers were lack of site or implementer readiness or capacity; breakdowns in communication; and DE prioritized over PSE. Facilitators were effective communication; site capacity or readiness; and alignment between site and SNAP-Ed goals. CONCLUSIONS: Communication, capacity, and coordination between SNAP-Ed and partner sites were key components over the timeline of PSE planning and potential implementation.

First Analysis of Nationwide Trends in the Use of the SNAP-Ed Evaluation Framework.

OBJECTIVE: To understand Supplemental Nutrition Assistance Program-Education (SNAP-Ed) Implementing Agencies'(SIAs) use of the SNAP-Ed Evaluation Framework (Framework), which is a tool that includes 51 indicators that SNAP-Ed programs can use to measure the success of their programs in the first 5 years after its release. METHODS: A repeated cross-sectional study design was utilized to administer electronic surveys to between 124 and 154 SIAs who received SNAP-Ed funding in fiscal years 2017, 2019, and 2021. Analyses included descriptive statistics and tests of proportions. RESULTS: Most SIAs indicated that they used the Framework to inform both data collection instruments and program planning decisions and the rates remained relatively constant over the 3 time points (> 80%). The most common specific use of the Framework across all 3 time points was to define, count, or measure the work accomplished, but this statistically decreased from 2017 (76%) to 2021 (57%) (z-score = 3.31; P < 0.001). CONCLUSIONS AND IMPLICATIONS: The results of this analysis confirmed that 5 years after its introduction, uptake and use of the Framework was high and that, as a whole, SIAs focused on priority indicators set by the US Department of Agriculture, with no notable increases in addressing and measuring longer-term, multisector, and population-wide outcomes. The systematic study of the Framework's usability over time has a broader application to other national health promotion initiatives with shared frameworks.

Readiness of SNAP-Ed Implementers to Incorporate Policy, Systems, and Environmental Approaches into Programming.

OBJECTIVE: To identify the readiness of Supplemental Nutrition Assistance Program Education (SNAP-Ed) implementers to facilitate policy, systems, and environmental (PSE) changes in conjunction with delivering direct nutrition education. DESIGN: Qualitative study using semistructured interviews. SETTING: A southeastern state. PARTICIPANTS: Purposive sample of SNAP-Ed staff (n = 19) from state implementing agencies (n = 3) in 1 state. PHENOMENON OF INTEREST: Readiness using the validated framework: readiness equals motivation coupled with general-capacities and innovation-specific capacities (R = MC2). ANALYSIS: Interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed using an iterative approach to the analysis via emergent coding and constant comparison. RESULTS: Although a general sense of motivation is present among implementers to meet the new federal guidelines, nutrition education is still prioritized. General capacity for SNAP-Ed implementers, comprised communication, training, and funding and staffing, was limited. Innovation-specific capacities around the implementation of PSEs revealed limited knowledge, experience, and resources among most implementers. CONCLUSIONS AND IMPLICATIONS: Identifying the nuanced and interrelated aspects of motivation and capacity of SNAP-Ed implementers to incorporate PSEs into their direct education interventions could inform tailored strategies for increasing readiness, such as through training, reallocation of resources, or program restructuring.

Health Clinic Readiness to Implement Nutrition Supports in Partnership With SNAP-Ed.

OBJECTIVE: To assess the readiness of health clinics to implement nutrition support strategies in partnership with the Supplemental Nutrition Assistance Program Education (SNAP-Ed) program. DESIGN: Qualitative study using semistructured interviews. SETTING: South Carolina. PARTICIPANTS: A convenience sample of key informants (n = 26) from health clinics (n = 15) interested in partnering with the SNAP-Ed program. PHENOMENON OF INTEREST: Health clinic readiness to implement nutrition supports, including motivation, current capacities, and capacity-building needs. ANALYSIS: Interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed descriptively and thematically. RESULTS: Clinics were most interested in implementing food insecurity screenings and making referrals to resources for accessing nutritious foods and produce prescription programs. Motivation was largely driven by a commitment to prevent chronic disease and on the basis of past success implementing a healthy eating strategy. A wide range of current capacities and capacity-building needs to implement strategies of interest were identified. CONCLUSIONS AND IMPLICATIONS: Findings suggest the readiness of some clinics to partner with SNAP-Ed to implement nutrition support strategies and identifies early insights on areas practitioners might need to engage clinics in for capacity-building. Some implementers might need further training before having their own capacity to support clinics in the wide range of nutrition support strategies included, which could be explored in future studies.

Use of Decision Cases for Building SNAP-Ed Implementers' Capacities to Realize Policy, Systems, and Environmental Strategies.

OBJECTIVE: To develop and validate decision cases as a capacity-building training tool for implementing policy, systems, and environmental (PSE) change strategies. DESIGN: Study phases were: (1) in-depth interviews conducted repeatedly over a year with Supplemental Nutrition Assistance Program Education (SNAP-Ed) partner sites and once with SNAP-Ed implementers to identify dilemmas when implementing PSE change strategies; (2) decision cases developed to highlight dilemmas; and (3) focus groups with SNAP-Ed implementers to determine decision case utility as a capacity-building training tool. SETTING: A southeastern state. PARTICIPANTS: SNAP-Ed partner sites and implementers; Focus group participants. INTERVENTION: Decision cases. ANALYSIS: To establish content validity, a thematic analysis of interviews identified common dilemmas when implementing PSE change strategies. SNAP-Ed implementers' focus groups provided feedback to determine the utility and validity of decision cases developed from the analysis. RESULTS: Common dilemmas of implementation of PSE change strategies reported by SNAP-Ed partner sites (n = 20) and implementers (n = 8) were lack of site and educator readiness and capacity; communication breakdowns; and prioritization of nutrition education over PSE implementation. Focus group participants (n = 8) reviewed a case and discussion guide and recommended them as a capacity-building tool for training. CONCLUSIONS AND IMPLICATIONS: Using decision cases could help build SNAP-Ed implementers' capacities to implement nutrition PSE change strategies and strengthen partnerships.

Stretching Food and Being Creative: Caregiver Responses to Child Food Insecurity.

OBJECTIVE: To examine the strategies and behaviors caregivers use to manage the household food supply when their children experience food insecurity as measured by the US Department of Agriculture's Household Food Security Survey Module. DESIGN: Cross-sectional survey with open-ended questions collected in person. SETTING: Urban and nonurban areas, South Carolina, US. PARTICIPANTS: Caregivers who reported food insecurity among their children (n = 746). PHENOMENON OF INTEREST: Strategies and behaviors used to manage the household food supply. ANALYSIS: Emergent and thematic qualitative coding of open-ended responses. RESULTS: The top 3 strategies and behaviors to change meals were (1) changes in foods purchased or obtained for the household, (2) monetary and shopping strategies, and (3) adaptations in home preparation. The most frequently mentioned foods that were decreased were protein foods (eg, meat, eggs, beans), fruits, and vegetables. The most frequently mentioned foods that were increased were grains and starches (eg, noodles), protein foods (eg, beans, hot dogs), and mixed foods (eg, sandwiches). CONCLUSIONS AND IMPLICATIONS: Caregivers use a wide variety of strategies and behaviors to manage the household food supply when their children are food insecure. Future work should examine how these strategies might affect dietary quality and well-being of food-insecure children.