The Benefits and Challenges of Providing School Meals during the First Year of California's Universal School Meal Policy as Reported by School Foodservice Professionals.

States in the U.S. are newly implementing universal school meal (USM) policies, yet little is known about the facilitators of their success and the challenges they confront. This study evaluated the challenges and facilitators faced by school food authorities (SFAs) implementing California's universal school meal (USM) policy during its inaugural year (2022-2023) using an online survey. In March 2023, 430 SFAs reported many benefits, including increased meal participation (64.2% of SFAs) and revenues (65.7%), reduced meal debt (41.8%) and stigma (30.9%), and improved meal quality (44.3%) and staff salaries (36.9%). Reported challenges include product/ingredient availability (80.9%), staffing shortages (77.0%), vendor/distributor logistics issues (75.9%), and administrative burden (74.9%). Top facilitators included state funding (78.2%) and increased federal reimbursement (77.2%). SFAs with fewer students eligible for free or reduced-price meals (as opposed to SFAs with more) reported greater increases in meal participation and reductions in stigma but also more administrative burdens. Larger SFAs reported greater increases in revenues, staff salaries, and improvements in meal quality than smaller SFAs but also more challenges. Overall, California's USM policy has enhanced student access to healthy meals while mitigating social and financial barriers. Understanding California's experience can inform other jurisdictions considering or implementing similar policies.

Potential mechanisms linking poverty alleviation and health: an analysis of benefit spending among recipients of the U.S. earned income tax credit.

BACKGROUND: The earned income tax credit (EITC) is the largest U.S. poverty alleviation program for low-income families, disbursed annually as a lump-sum tax refund. Despite its well-documented health impacts, the mechanisms through which the EITC affects health are not well understood. The objective of this analysis was to examine self-reported spending patterns of tax refunds among EITC recipients to clarify potential pathways through which income may affect health. METHODS: We first examined spending patterns among 2020-2021 Assessing California Communities' Experiences with Safety Net Supports (ACCESS) study participants (N = 241) and then stratified the analysis by key demographic subgroups. RESULTS: More than half of EITC recipients reported spending their tax refunds on bills and debt (52.3%), followed by 49.4% on housing, and 37.8% on vehicles. Only 3.3% reported spending on healthcare. (Note: respondents could list more than one possible spending category.) Participants ages 30 + were more likely to spend on bills and debt relative to those ages 18-29 (57.6% versus 39.4%, respectively). Other subgroup analyses did not yield significant findings. CONCLUSIONS: Our findings suggest that EITC recipients primarily use their refunds on bills and debt, as well as on household and vehicle expenses. This supports the idea of the EITC as a safety net policy which addresses key social determinants of health.

Perceptions and Experiences of Supplemental Nutrition Assistance Program (SNAP) Participants Related to Receiving Food and Nutrition-Related Text Messages Sent Agency-Wide: Findings from Focus Groups in San Diego County, California.

We developed and sent a series of five monthly text messages promoting fruit and vegetable consumption to approximately 170,000 SNAP participants in San Diego County, California. The text messages, which were sent in English and Spanish, included links to a dedicated bilingual website offering additional information, including how to select, store, and prepare seasonal fruits and vegetables, health benefits of different fruits and vegetables, recipes, and tips to reduce food waste. To our knowledge, this represents the first instance of a SNAP agency providing nutrition information directly to SNAP participants. We conducted seven focus groups (four in English and three in Spanish) with a convenience sample of twenty-six text message recipients, to elicit their perceptions of this intervention, self-reported behavior changes, and recommendations for moving forward. Respondents reported overwhelmingly positive perceptions of this effort, including increased intake of fruits and vegetables, and trying new fruits and vegetables. Participants also reported improved perceptions of SNAP. Virtually all would like this effort to continue, and many would like to receive the messages more frequently than once a month. This effort represents a relatively low-cost approach that SNAP agencies can implement to provide SNAP participants with food and nutrition information that can help them to improve their diets, optimize their food dollars, and enhance their feelings of well-being related to participating in the program.

Feasibility and Response to the San Diego County, California, Supplemental Nutrition Assistance Program (SNAP) Agency Sending Food and Nutrition Text Messages to All Participants: Quasi-Experimental Web-Based Survey Pilot Study.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) provides over 40 million Americans with money for food without typically providing participants with food or nutrition information. Educational SMS text messages can reach large numbers of people, and studies suggest SNAP participants appreciate nutrition education and have access to mobile phones. OBJECTIVE: Using a pre-post intervention design, we assessed the feasibility of, and program satisfaction and outcomes resulting from, the San Diego County, California SNAP agency sending monthly food and nutrition education SMS text messages to all SNAP participants to increase fruit and vegetable purchasing and consumption. METHODS: We developed and sent 5 behavioral science-informed SMS text messages with links to a project website in English and Spanish with information about selecting, storing, and preparing seasonal fruits and vegetables. The San Diego County SNAP agency sent monthly texts to ~170,000 SNAP households from October 2020 to February 2021. SNAP participants completed web-based surveys in response to a text invitation from the SNAP agency in September 2020 (baseline, n=12,036) and April 2021 (follow-up, n=4927). Descriptive frequencies were generated, and adjusted multiple linear mixed models were run on a matched data set of participants that completed both baseline and follow-up surveys (n=875) assessing pre- or postattitudes, behaviors, knowledge, and self-efficacy. We used adjusted logistic regression models to assess differences between the matched (n=875) and nonmatched (n=4052) participants related to experiences with the intervention (questions asked only at follow-up). RESULTS: After the intervention, matched participants reported significant increase in knowing where to get information about selecting, storing, and preparing fruits and vegetables (3.76 vs 4.02 on a 5-point Likert scale with 5=strongly agree, P<.001); feeling good about participating in SNAP (4.35 vs 4.43, P=.03); and thinking the CalFresh program helps them eat healthy (4.38 vs 4.48, P=.006). No significant pre- or postdifferences were found in fruit or vegetable consumption, though most participants at follow-up (n=1556, 64%) reported their consumption had increased. Among the sample that completed the follow-up survey only (n=4052, not including 875 participants who completed follow-up and baseline), 1583 (65%) and 1556 (64%) reported purchasing and eating more California-grown fruits and vegetables, respectively. Nearly all respondents appreciated the intervention (n=2203, 90%) and wanted it to continue (n=2037, 83%). CONCLUSIONS: SNAP can feasibly provide food and nutrition messages via text to participants. A monthly text campaign was well received by responding participants and improved some measures of their self-reported knowledge, self-efficacy, produce consumption, and perceptions of SNAP participation. Participants expressed interest in continuing to receive texts. While educational messages will not solve the complex food and nutrition challenges confronting SNAP participants, further work should employ rigorous methods to expand and test this intervention in other SNAP programs before considering to implement it at scale.

Understanding Take-Up Of The Earned Income Tax Credit Among Californians With Low Income.

The Earned Income Tax Credit (EITC) is the largest poverty alleviation program for families with children in the US, and it has well-documented health effects. However, not all eligible families receive benefits. The Assessing California Communities' Experiences with Safety Net Supports (ACCESS) Study interviewed 411 EITC-eligible Californians with young children to understand low take-up of the federal EITC and California's supplemental CalEITC. Interviews were conducted in English and Spanish in 2020 and 2021 to gather information on sociodemographic characteristics, tax filing, and EITC receipt (verified via tax forms). Among those eligible for the EITC or CalEITC, 9 percent of participants did not file taxes; among those who did file taxes, about 84 percent received the EITC, and 83 percent received the CalEITC. Lower likelihood of federal EITC receipt among those eligible and filing taxes was associated with being younger, not speaking English, and not having prior knowledge of the EITC. Lower likelihood of CalEITC receipt among those eligible and filing taxes was associated with not speaking English. These findings can inform policies and community interventions to increase EITC take-up and thereby help address health equity.

Social and Economic Factors Related to Healthcare Delay Among Low-Income Families During COVID-19: Results from the ACCESS Observational Study.

Delayed medical care is a negative consequence of the COVID-19 pandemic for families with young children. Our study used data from the Accessing California Communities' Experiences with Safety net Supports (ACCESS) survey, a cross-sectional study that assessed experiences with safety-net programs among working families with low incomes (n=491). From August 2020 to May 2021, we conducted interviewer-administered surveys of low-income families with young children (ages zero to eight) in California and asked questions about whether participants had delayed medical care for their children or themselves. We found that delaying care for children was associated with lack of childcare and with the child having pre-existing conditions. Delaying parental medical care was associated with lack of childcare, experiences of racism, government mistrust, and perceptions of welfare stigma. These results suggest that health care access may be improved through a focus on supporting childcare systems and addressing structural racism.

The California Nutrition Incentive Program: Participants' Perceptions and Associations with Produce Purchases, Consumption, and Food Security.

We examined the associations of a Supplemental Nutrition Assistance Program (SNAP) point-of-purchase financial incentive program at farmers' markets with produce purchase, consumption, and food security outcomes. We conducted cross-sectional, interviewer-administered intercept surveys with 325 adult SNAP participants at six incentive programs, five comparison farmers' markets, and nine comparison supermarkets in California in the summer of 2018. The program provided dollar-for-dollar point-of-purchase incentives with $10 or $20 maximum at participating farmers' markets. We measured produce consumption by an NCI screener; food security by the USDA 6-item screener; and program satisfaction with open-ended questions asked of a subsample. The quantitative analysis involved multilevel linear and logistic regression, adjusted for covariates. Qualitative data were coded and analyzed thematically. Shoppers at farmers' markets offering $20 incentives had significantly higher odds of purchasing most of their produce at farmers' markets than shoppers at $10 incentive (3.1, CI: 1.1, 8.7) or comparison markets (8.1, CI 2.2, 29.7). Incentives were not associated with quantitatively measured produce consumption. Each additional incentive dollar was associated with reduced odds of food insecurity (0.987, CI 0.976, 0.999). Participants appreciated the program; supermarket shoppers lacked awareness. Point-of-purchase incentives are appreciated and underutilized. Further understanding of optimal program design for produce consumption and food security impact is needed.

Comparison of Fruit and Vegetable Prices between Farmers' Markets and Supermarkets: Implications for Fruit and Vegetable Incentive Programs for Food Assistance Program Participants.

This cross-sectional study was part of a larger evaluation of a fruit and vegetable (FV) incentive program for Supplemental Nutrition Assistance Program (SNAP) participants in California. We examined the price differences in FV to explore whether these could help explain a previously observed lack of effect of the incentive program on FV consumption. Differences by type (organic/no-spray or conventional), among a convenience sample of farmers' markets (n = 11) and nearby supermarkets (n = 7), were assessed using Wilcoxon rank-sum tests adjusting for clustering by market. We calculated the cost of market baskets comprising recommended FV servings for a household using median prices to consider the implications of FV price differences for SNAP shoppers who use financial incentives for FV. We found that farmers' markets primarily offered organic FV while supermarkets primarily offered conventionally grown FV. Farmers' market prices tended to be lower than supermarkets for organic FV but higher for conventional FV. Compared to supermarkets, the market basket composed only of organic FV cost USD 16.34 less at farmers' markets, whereas a basket comprised of a mix of conventionally and organically grown FV cost USD 3.68 more. These differences warrant further exploration; FV price and type should be considered in studies aimed at understanding the impact of SNAP financial incentive programs.

Participants' Experiences of the 2018-2019 Government Shutdown and Subsequent Supplemental Nutrition Assistance Program (SNAP) Benefit Disruption Can Inform Future Policy.

The federal government shutdown from 22 December 2018 to 25 January 2019 created an unprecedented disruption in Supplemental Nutrition Assistance Program (SNAP) benefits. We conducted a cross-sectional qualitative study to begin to capture how the disruption affected food security and wellbeing among a small sample of California SNAP participants. We collected data from 26 low-income adults in four focus groups in four diverse California counties. We found that participants routinely struggle to secure an adequate and healthy diet in the context of high costs of living, the shutdown and benefit disruption added to participants' stress and uncertainty and exacerbated food insecurity, and it diminished some participants' faith in government. Participants reported that, while having additional benefits in January felt like a relief from typical end-of-month deprivation, the subsequent extended gap between benefit distributions and a lack of clarity about future benefits caused cascading effects as participants later had to divert money from other expenses to buy food and faced added uncertainty about future economic stability. Additionally, the shutdown highlighted challenges related to the availability, timing, and tone of communications between participants and SNAP agencies. Participants recommended that SNAP adjust benefit and eligibility levels to better address costs of living, improve customer service, and avoid future disruptions.

The Impact of a Multipronged Intervention to Increase School Lunch Participation among Secondary School Students in an Urban Public School District.

Introduction: Schools meals offer a critical opportunity for improving youths' diets, particularly for economically disadvantaged students. We examine the impact of a multipronged intervention to increase middle and high school students' lunch participation in an urban school district. Methods: In school years 2015-2016 through 2017-2018, a quasi-experimental study was conducted in 24 secondary schools, half (n = 12) of which received the following intervention: cafeteria redesign, additional school lunch points-of-sale (mobile carts and vending machines), and teacher education. Results: From baseline to follow-up, lunch participation dropped 4.1% in intervention and 5.1% in comparison schools (difference-in-difference 1.0%, 95% CI 0.5-1.4). The overall decline in lunch participation occurred simultaneously with a drop-in free or reduced-price meal eligibility (from 72% to 58%) across all schools, which is likely related to changing local economic conditions, including a county-wide minimum wage increase that began in summer 2015. Among students eligible for free or reduced-price meals, participation decreased 1.8% in intervention and 4.9% in comparison schools (difference-in-difference 3.1%, 95% CI: 2.5-3.7), with a larger difference-in-difference seen in high schools (5.0%, 95% CI: 4.2-5.9) than middle schools (1.8%, 95% CI: 0.8-2.6). Conclusions: While this intervention demonstrated a modest, but significant relative increase in school lunch participation, the effect was not sufficient to halt large district-wide declines in participation during this study period. Given the significant time, money, and political capital required to implement the intervention, districts should carefully consider similar investments. Broader public policies or other changes to economic conditions that affect eligibility for means-tested benefits-in this case, a strengthening local economy coupled with an increased local minimum wage-may influence school lunch participation more than school-level interventions.

Alternatives to SNAP: Global Approaches to Addressing Childhood Poverty and Food Insecurity.

The Supplemental Nutrition Assistance Program (SNAP) in the United States is a key element of the nation's safety net. Yet, 12.5 million US children live in households that experience food insecurity, despite national spending of $65 billion on SNAP alone.In analyses integrating data from the 36 Organisation for Economic Co-operation and Development (OECD) countries, we found that child poverty and food insecurity are much higher in the United States than in most of the other OECD countries. The United States has higher total social spending than other OECD countries, but a lower rate of spending on children and families. This international comparison suggests that potentially effective solutions implemented in other countries might help further alleviate US childhood poverty and food insecurity.Broadly, we recommend increasing investments in families with children, particularly low-income families. Our specific recommendations include increasing SNAP benefits, establishing additional benefits to support low-income families with young children, and implementing a universal child allowance. Achieving substantial reductions in child poverty and food insecurity will require overcoming many challenges, including the current US political climate, a national history of underinvestment in social programs, a lack of political will, and a culture of structural racism.

Leaders' Experiences in Planning, Implementing, and Evaluating Complex Public Health Nutrition Interventions.

OBJECTIVE: To explore California local health department leaders' experiences planning, implementing, and evaluating nutrition promotion and obesity prevention programs for low-income families. DESIGN: Qualitative, cross-sectional study using semi-structured in-depth interviews and panel interviews conducted in 2015-2016. SETTING: California local health departments (LHDs) funded by the California Department of Public Health to implement Supplemental Nutrition Assistance Program-Education (SNAP-Ed). PARTICIPANTS: The authors recruited SNAP-Ed leaders from all 58 California LHDs implementing SNAP-Ed. Leaders from 49 LHDs participated: 36 in hour-long, in-depth interviews and 13 in 1 of 3 90-minute group panel interviews. PHENOMENON OF INTEREST: Processes, facilitators, and barriers connected to delivering SNAP-Ed reported by leaders in planning, implementing, and evaluating local programs. ANALYSIS: Interviews were transcribed, coded, and analyzed using Dedoose software. RESULTS: Leaders grappled with introducing, implementing, and integrating policy, systems, and environmental change interventions (PSEs). Information used to make planning decisions varied widely across LHDs. Partnership with nontraditional organizations was described as a resource- intensive, nonlinear process with recognized potential for benefit. Rural programs reported specific and different experiences compared with their urban counterparts. CONCLUSIONS AND IMPLICATIONS: Implementing new, complex interventions to improve diet and activity environments and behaviors is both exciting and challenging for local leaders. They expressed a desire for additional resources and capacity building to facilitate success, particularly related to policy, systems, and environmental change programs. Attention to the specific needs of rural counties is needed.

Availability, quality and price of produce in low-income neighbourhood food stores in California raise equity issues.

OBJECTIVE: To assess produce availability, quality and price in a large sample of food stores in low-income neighbourhoods in California. DESIGN: Cross-sectional statewide survey. SETTING: Between 2011 and 2015, local health departments assessed store type, WIC (Supplemental Nutrition Program for Women, Infants, and Children)/SNAP (Supplemental Nutrition Assistance Program) participation, produce availability, quality and price of selected items in stores in low-income neighbourhoods. Secondary data provided reference chain supermarket produce prices matched by county and month. t Tests and ANOVA examined differences by store type; regression models examined factors associated with price. SUBJECTS: Large grocery stores (n 231), small markets (n 621) and convenience stores (n 622) in 225 neighbourhoods. RESULTS: Produce in most large groceries was rated high quality (97 % of fruits, 98 % of vegetables), but not in convenience stores (25 % fruits, 14 % vegetables). Small markets and convenience stores participating in WIC and/or SNAP had better produce availability, variety and quality than non-participating stores. Produce prices across store types were, on average, higher than reference prices from matched chain supermarkets (27 % higher in large groceries, 37 % higher in small markets, 102 % higher in convenience stores). Price was significantly inversely associated with produce variety, adjusting for quality, store type, and SNAP and WIC participation. CONCLUSIONS: The study finds that fresh produce is more expensive in low-income neighbourhoods and that convenience stores offer more expensive, poorer-quality produce than other stores. Variety is associated with price and most limited in convenience stores, suggesting more work is needed to determine how convenience stores can provide low-income consumers with access to affordable, high-quality produce. WIC and SNAP can contribute to the solution.

The ethical basis for promoting nutritional health in public schools in the United States.

Schools may have an ethical obligation to act in response to the precipitous increase in the incidence of obesity among children. Using a bioethics framework, we present a rationale for school programs to improve the nutritional quality of students' diets. Because children are required to spend half their waking hours in school and because they consume a substantial portion of their daily food there, school is a logical focus for efforts to encourage healthy dietary behaviors to prevent obesity and its consequent individual and collective costs. We suggest that beyond strategic considerations, the concept of the common good justifies actions that may appear to conflict with freedom of choice of children, parents, and school staff, or with the interests of food and beverage companies.

Walking the talk: Fit WIC wellness programs improve self-efficacy in pediatric obesity prevention counseling.

Six sites of the California Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participated in a staff wellness pilot intervention designed to improve staff self-efficacy in counseling WIC clients about childhood overweight. A pre-post test design with intervention and control groups was used; outcome measures included staff perceptions of the intervention's effects on the workplace environment, their personal habits and health beliefs, and their counseling self-efficacy. Intervention site staff were more likely to report that the workplace environment supported their efforts to make healthy food choices (P <.001), be physically active (P <.01), make positive changes in counseling parents about their children's weight (P <.01), and feel more comfortable in encouraging WIC clients to do physical activities with their children (P <.05).