Something to eat: experiences of food insecurity on the farm.

The health of farm owners and farmworkers has significant impacts on farm businesses, farming families, and local rural communities where agriculture is an important driver of social and economic activity. Rural residents and farmworkers have higher rates of food insecurity, but little is known about food insecurity among farm owners and the collective experiences of farm owners and farmworkers. Researchers and public health practitioners have stressed the need for policies that target the health and well-being of farm owners and farmworkers while remaining sensitive to the nature of life on the farm, yet farm owner and farmworker lived experiences have been understudied, especially in relation to one another. In-depth qualitative interviews were conducted with 13 farm owners and 18 farmworkers in Oregon. Modified grounded theory was used to analyze interview data. Data were coded using a three-stage process to identify salient core characteristics of food insecurity. Farm owner and farmworker meanings and interpretations of their food insecurity were often contradicted by evaluated food security scores using validated quantitative measures. According to such measures, 17 experienced high food security, 3 had marginal food security, and 11 had low food security, but narrative experiences suggested higher rates. Narrative experiences were categorized by core characteristics of food insecurity, including seasonal food shortages, resource stretching, working extended hours most days of the week, limited use of food assistance, and the tendency to downplay hardship. These unique factors have important implications for developing responsive policies and programs to support the health and well-being of farm livelihoods whose work enables health and well-being among consumers. Future studies to test the relationships between the core characteristics of food insecurity identified in this study and farm owner and farmworker meanings and interpretations of food insecurity, hunger, and nourishment are warranted.

Social Service Providers' Perceptions of Older Adults' Food Access During COVID-19.

The COVID-19 pandemic exacerbated risk factors for food insecurity among older adults, while also altering how government agencies and social service organizations could serve this population given their disproportionate vulnerability to the virus. The current study sought to understand social service providers' perspectives about how low-income community-dwelling older adults' access to food and related resources changed during the COVID pandemic. Data were collected via in-depth interviews with 22 social service providers from Oregon-based public and private social service agencies. Responses indicated that changes to older adults' food access during the pandemic stemmed from increases in public benefit amounts and social distancing guidelines. Participants indicated that temporary increases in SNAP allotments supported older adults' food security. Additionally, social distancing guidelines disrupted usual ways of procuring food, such as going to grocery stores, obtaining food with the assistance of family or neighbors, receiving deliveries from social programs, and visiting congregate meal sites. Food assistance programs changed their operations to reduce in-person interaction and increase the use of technology. When investigating older adults' food access, future research should consider adults' experiences of and barriers to SNAP receipt, social support from social networks and safety net programs, and technology access and knowledge.

Social service providers offer a unique perspective on older adults' food access.Interviews with providers documented older adult food access during COVID.Expanded federal assistance and social distancing shaped seniors' food access.Food access may vary by program eligibility, social support, and technology access.

The role of SNAP and WIC participation and racialized legal status in U.S. farmworker health.

BACKGROUND: Policies that restrict access to and use of the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) by legal status may disproportionately disadvantage particular racial and ethnic groups. While immigrant legal status, race, and ethnicity are recognized as independent social determinants of health, studies examining the extent to which legal status structures racial and ethnic health disparities are limited. Research is needed to identify factors that mitigate disparate health outcomes, such as SNAP and WIC. METHODS: Cross-sectional data from the 2009/2010 National Agricultural Workers Survey (N = 3,961) were analyzed. Chi-square tests and logistic regressions examined associations among self-reported health, race, ethnicity, legal status, and SNAP/WIC participation. RESULTS: Farmworkers reporting excellent or good health were more likely to be non-Hispanic White, U.S. citizen, aged 18-25, single, male, educated beyond primary school, living above the poverty level, without chronic health conditions, and located in the Midwest. Hispanic farmworkers had lower odds of reporting excellent or good health (OR 0.27, 95% CI 0.12-0.62). Among SNAP/WIC participants, Hispanic farmworkers had higher odds of reporting excellent or good health (OR 6.74, 95% CI 1.54-29.57) compared to non-Hispanic White farmworkers. There was no significant association between self-reported health and legal status. DISCUSSION: This study complements the extant literature showing racial and ethnic health disparities among the U.S. farmworker population. Results provide valuable insight on the health-protective potential of programs like SNAP and WIC, particularly among Hispanic farmworkers, who may be both less likely to be eligible and more hesitant to participate. These findings underscore the need to expand U.S. farmworkers' eligibility and participation in SNAP and WIC.

Self-Perceived Health and Chronic Conditions Among Users of Supplements With and Without Botanical Ingredients: Findings from the 2009-2014 National Health and Nutrition Examination Survey.

The objective of this research was to investigate associations among self-reported health status, chronic conditions, and use of dietary supplements containing botanicals and describe reasons for use among U.S. adult supplement users. This was a cross-sectional analysis using data from the 2009-2014 National Health and Nutrition Examination Survey (NHANES). Supplement information was collected with a 30-day recall interview. Self-reported general health status and doctor-informed diagnoses of chronic conditions were assessed using a health status questionnaire. We used weighted multivariate logistic regressions to assess associations between supplement use and perceived health and number of chronic conditions. Participants were 16,958 non-institutionalized U.S. adults aged 20 years and older. Adults with excellent or very good self-perceived health were more likely to use botanical supplements than adults with good perceived health (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.28-1.74). Adults with three or more chronic conditions were more likely to report using botanical supplements than adults with no chronic conditions (aOR, 1.49; 95% CI, 1.13-1.69). The most frequently reported reasons for both non-botanical and botanical supplements use were "personal choice or influenced by advertisements or word of mouth," "improve health," and "specific health conditions" (93.3%, 84.2%, and 64.7%, respectively). While perceptions of health are more positive among adults using botanical supplements, chronic conditions and reasons for botanical supplements use related to personal choice, improving health, or addressing specific conditions were more likely. Differentiating botanical supplements from other complementary and integrative therapies may be useful for facilitating a deeper understanding of the reasons.

Food security and alternative food acquisition among US low-income households: results from the National Food Acquisition and Purchasing Survey (FoodAPS).

OBJECTIVE: To determine the characteristics of US low-income households that use alternative food acquisition strategies and to examine the association between food security and alternative food acquisition. DESIGN: Cross-sectional analysis. The ten-item Adult Food Security Survey Module was used to determine food security status. Self-reported data were used to determine food acquisition from community food sources, social networks and household food production. SETTING: The National Food Acquisition and Purchasing Survey (FoodAPS), 2012. PARTICIPANTS: The sample consisted of 2534 low-income households (≤185 % of the federal poverty line) in the USA. RESULTS: Households using alternative food acquisition strategies were more likely to have a primary respondent who was non-Hispanic White, born in the USA, and female, and more likely to live in a rural area, have higher income and own a home than households not using alternative acquisition strategies. Very low food security was positively associated with the use of community food sources (aOR = 2·26 (95 % CI 1·15, 4·46)). There was no association between food security and food acquisition from social networks or household food production. CONCLUSIONS: Use of alternative food acquisition strategies varied by specific demographic characteristics among low-income households, suggesting opportunities for outreach and promotion of alternative acquisition strategies in specific subpopulations in the USA. Future research should examine whether quantity and quality of food received from these sources are associated with food security.

The Association Between Food-Away-From-Home Frequency and a Higher BMI Varies by Food Security Status in US Adults.

BACKGROUND: For decades, Americans have increasingly relied on food away from home (FAFH) despite its association with negative health outcomes. Little is known about FAFH frequency and expenditures of adults with lower food security (FS) and their association with health outcomes, such as BMI. OBJECTIVES: We evaluated patterns of adults' FAFH purchases by FS status and other demographic characteristics, and examined the association between FAFH frequency and BMI in adults of varying levels of FS. METHODS: This cross-sectional study used data from the Consumer Behavior Survey, Food Security Survey, and anthropometric measurements to assess FAFH frequency and expenditures, FS, and calculated BMI of adults (≥18 y) who participated in the NHANES 2007-2014 (n = 20,733). We used multinomial logistic regression to examine the association between FAFH frequency quartiles (quartile 1: 0 n/wk; quartile 2: 1-2 n/wk; quartile 3: 3-4 n/wk; quartile 4: ≥5 n/wk) and BMI by FS category. RESULTS: Although FAFH frequency was similar across FS levels, adults with high FS spent more dollars (${\$}$213.60) and a greater proportion (29.4%) of their food budget on FAFH compared with adults with marginal, low, and very low FS (${\$}$133.00, ${\$}$116.20, ${\$}$103.30 and 21.4%, 19.7%, 20.0%, respectively). Obesity prevalence was highest in adults with low FS (42.9%) and very low FS (41.5%), and lowest in adults with high FS (33.7%). FAFH frequency and BMI were positively associated in adults with high (P < 0.001), marginal (P = 0.025), and low (P = 0.024) FS, but not in adults with very low FS (P = 0.589). CONCLUSIONS: FAFH is frequent in adults regardless of FS status. The positive association between FAFH and BMI is the strongest in adults with high FS, the group with the lowest prevalence of obesity. Conversely, BMI was not associated with FAFH in adults with very low FS, despite their higher prevalence of obesity.

Participant Perceptions of the Double Up Food Bucks Program at Oregon Farmers' Markets.

OBJECTIVE: To explore perceptions of program impact among Double Up Food Bucks participants in Oregon. METHODS: Data were collected from 1,223 Double Up Food Bucks participants at 42 Oregon farmers' markets. Chi-square tests of independence and logistic regressions were used to examine associations among key variables. RESULTS: Most participants reported buying more fruits and vegetables (FVs) (91.0%), trying new FV types (82.2%), eating less processed food (69.8%), having more food available at home (81.1%), and perceiving improvements in health (87.9%). Perceptions of affordability were higher among younger adults (P < 0.001) and households with 3-5 people (P = 0.02), with children (P < 0.001), and without chronic disease (P = 0.003). Perceptions of increased FV purchases were higher in households with children (P = 0.009) and reported overall health improvements were higher among non-White participants (P = 0.04). Perceptions of increased FV purchases and affordability were associated with other positive program outcomes. CONCLUSIONS AND IMPLICATIONS: Participants may perceive barriers to purchasing FVs from farmers' markets, which are not fully addressed by the increased purchasing power from a FV incentive. Targeted redesign, outreach, and education may improve program experiences among groups with less positive perceptions. Further research to identify explanations for variation in program experience is needed.

Predicting Attrition in a Text-Based Nutrition Education Program: Survival Analysis of Text2BHealthy.

BACKGROUND: Text-based programs have been shown to effectively address a wide variety of health issues. Although little research examines short message service (SMS) text messaging program characteristics that predict participant retention and attrition, features of SMS text message programs, such as program duration and intensity, message content, and the participants' context, may have an impact. The impact of stop messages-messages with instructions for how to drop out of an SMS text message program-may be particularly important to investigate. OBJECTIVE: The aim of this study was to describe attrition from Text2BHealthy, a text-based nutrition and physical activity promotion program for parents of low-income elementary school children, and to determine the impact of message content and number of stop messages received on attrition. METHODS: Using data from 972 parents enrolled in Text2BHealthy, we created Kaplan-Meier curves to estimate differences in program duration for different SMS text message types, including nutrition, physical activity, stop, and other messages. Covariates, including rurality and number of stop messages received, were included. RESULTS: Retention rates by school ranged from 74% (60/81) to 95.0% (132/139), with an average retention rate of 85.7% (833/972) across all schools. Program duration ranged from 7 to 282 days, with a median program duration of 233 days and an average program duration of 211.7 days. Among those who dropped out, program duration ranged from 7 to 247 days, with a median program duration of 102.5 days. Receiving a stop message increased the probability of attrition compared with receiving messages about nutrition, physical activity, or other topics (hazard ratio=51.5, 95% CI 32.46-81.7; P<.001). Furthermore, each additional stop message received increased the probability of attrition (hazard ratio=10.36, 95% CI 6.14-17.46; P<.001). The degree of rurality also had a significant effect on the probability of attrition, with metropolitan county participants more likely to drop out of the program than rural county participants. The interaction between SMS text message type and total number of stop messages received had a significant effect on attrition, with the effect of the number of stop messages received dependent on the SMS text message type. CONCLUSIONS: This study demonstrates the potential of SMS text message programs to retain participants over time. Furthermore, this study suggests that the probability of attrition increases substantially when participants receive messages with instructions for dropping out of the program. Program planners should carefully consider the impact of stop messages and other program content and characteristics on program retention. Additional research is needed to identify participant, programmatic, and contextual predictors of program duration and to explicate the relationship between program duration and program efficacy.

Adherence to prenatal iron-folic acid supplementation in low- and middle-income countries (LMIC): a protocol for systematic review and meta-analysis.

BACKGROUND: Daily iron-folic acid supplementation reduces anemia and various adverse obstetric outcomes such as preterm delivery, low birthweight, hemorrhage, and perinatal and maternal morbidity and mortality. However, its supplementation has not been successful that attributed to several determinants including poor adherence. Therefore, we aimed to conduct a systematic review and meta-analysis on the prevalence and determinants of adherence to prenatal iron-folic acid supplementation in low- and middle-income countries. In addition, we will develop a conceptual framework in the context of low- and middle-income countries (LMIC). METHODS/DESIGN: We will search PubMed, MEDLINE, EMBASE, EBSCO, Web of Science, SCOPUS, WHO Global Index Medicus, and African Journals Online (AJOL) databases to retrieve relevant literatures. Observational (i.e., case-control, cohort, cross-sectional, survey, and surveillance reports) and quasi-randomized and randomized controlled trial studies conducted in LMIC will be included. The Newcastle-Ottawa Scale (NOS) and Joanna Briggs Institute (JBI) critical appraisal checklist will be used to assess the quality of observational and randomized controlled trial studies respectively. The pooled prevalence and odds ratio of determinants of adherence will be generated using a weighted inverse-variance meta-analysis model. Statistical heterogeneity among studies will be assessed by Cochran's Q χ2 statistics and Higgins (I2 statistics) method. The result will be presented using forest plots and Harvest plots when necessary. Furthermore, we will perform Jackknife sensitivity and subgroup analysis. Data will be analyzed using comprehensive meta-analysis software (version 2). DISCUSSION: Contemporary evidence about the prevalence and determinants of adherence in LMIC will be synthesized to generate up-to-date knowledge. To our knowledge, this is the first systematic review. It would have substantial implications for researchers, clinicians, and policymakers for optimizing maternal and child health outcomes in LMIC. SYSTEMATIC REVIEW REGISTRATION: The protocol has been registered on International Prospective Register of Systematic Review (PROSPERO), University of York Center for Reviews and Dissemination ( https://www.crd.york.ac.uk/ ), registration number CRD42017080245 .

Feasibility of bidirectional text messages in evaluating a text-based nutrition education program for low-income parents: Results from the Text2BHealthy program.

Text messages are increasingly used in the delivery of health education programs. One appealing aspect of this approach is the possibility of remotely collecting participant data to use in program tailoring or evaluation. The purpose of the present study is to test the feasibility of using text messages to collect participant data. Using data from 33 texted evaluation questions sent through the Text2BHealthy nutrition education program for low-income parents (n=108-1521) response rates under different incentive and prompting strategies were examined. Response rates are generally low across a pilot year and three program years, ranging from 10-55%. While incentives seemed to be ineffective at improving response rates, results indicate that prompting participants to respond may increase response rates. Individuals who respond to an initial question are highly likely to respond to a follow-up question (88-99%) and to report positive behaviors (68-100%). Responses received through text may be unrepresentative and positively biased. Text messages may be a supplemental data collection strategy in nutrition education programs, but low response rates and response bias undermine data quality.

The Role of the Supplemental Nutrition Assistance Program in the Relationship between Food Insecurity and Probability of Maternal Depression.

Food insecurity is a substantial stressor for many households. Though an association between food insecurity and depression has been well established, most studies have been cross-sectional. Although many receive benefits from the Supplemental Nutrition Assistance Program (SNAP), its role in reducing distress associated with food insecurity is unclear. Using data from 1,225 women who participated in the Fragile Families and Child Wellbeing Study, this study investigated 1) whether change in food security status predicts change in depression severity over a two-year period, 2) whether participating in SNAP predicts depression, and 3) whether the relationship between food insecurity and depression varies based on receipt of SNAP. Food insecurity was linked to probability of depression over time. Additionally, for those who became food insecure over the two-year period, losing SNAP benefits was associated with increased probability of depression, while gaining benefits was associated with reduced probability of depression. This suggests that the SNAP program offsets emotional hardship for those who have recently become food insecure. Further research is needed to evaluate the most efficient and efficacious means to reduce food insecurity and improve emotional wellbeing among vulnerable families.

Project ReFresh: Testing the Efficacy of a School-Based Classroom and Cafeteria Intervention in Elementary School Children.

BACKGROUND: The purpose of this study was to assess the effect of a school-based nutrition program using a cafeteria environment intervention and classroom nutrition education on self-reported fruit and vegetable (FV) consumption, self-efficacy to select FV, and preference for healthy foods. METHODS: Using quasi-experimental pre-post design with 3 study conditions, a total of 665 fourth- and fifth-grade students participated in the study. The comprehensive intervention included a behavioral economics cafeteria intervention and weekly classroom nutrition education for 1 academic year. The intervention was designed and delivered by the extension system. RESULTS: The comprehensive group showed significant improvement in some indicators including eating vegetables for lunch (p = .007), number of days eating vegetables (p < .001) and fruits (p < .001) in the last week, and self-efficacy in preparing FV at home (p = .034) compared to the control and cafeteria groups. Food preference of some food items, including oatmeal (p = .036 for cafeteria group, p < .001 for comprehensive group), whole grain noodles (p = .011 for comprehensive group), and vegetables (p = .003 for comprehensive group), significantly improved in the cafeteria and/or comprehensive group. CONCLUSIONS: Classroom nutrition education combined with cafeteria improvement has the potential to improve diet-related behavior of elementary school children. Also, collaborative partnership between schools and extension can enhance program sustainability.

Recruitment and retention in an SMS-based health education program: Lessons learned from Text2BHealthy.

While text messages or short messaging service programs are increasingly utilized for delivering health education, few studies have explored the unique challenges of recruiting and retaining participants in such programs. This study utilizes survey and focus group data from Text2BHealthy, a short messaging service-based nutrition and physical activity promotion program, to examine barriers to enrollment and facilitators of retention among parents of elementary school students. Results show that participants were hard to reach with recruitment materials, had difficulty with self-enrollment, and were apprehensive about program costs. However, 89-90 percent of participants were retained. Results suggest that providing manual enrollment options, alternative program delivery methods (e.g. email messages), and opportunities to reenroll may facilitate participation in short messaging service-based health education and promotion programs.

More than Just Not Enough: Experiences of Food Insecurity for Latino Immigrants.

Undocumented Latino immigrants often struggle to provide food for their families. In an attempt to inform efforts to create effective programs and policies promoting food security, this study explored the experience of food insecurity for low-income, undocumented Latino immigrants. In-depth qualitative interviews were conducted with 24 undocumented Latino immigrants. Modified grounded theory was used to analyze the interview data. The experience of food insecurity was similar to other groups' experiences, as it entailed inadequate amount and quality of food. However, immigration and documentation status presented unique vulnerabilities for food insecurity related to unfamiliar food environments, remittances and separation, employment, and community and government resources. Cultural and structural factors that may shape the experience of and response to food insecurity are discussed along with implications for policy and programming.

Personal weight status classification and health literacy among Supplemental Nutrition Assistance Program (SNAP) participants.

The purpose of this study was to examine the conceptual gap between self-perceived weight and body mass index (BMI), and to assess the knowledge gap between perceived importance of following dietary guidelines and health literacy levels. Adults (n = 131) eligible for the Supplemental Nutrition Assistance Program (SNAP) were interviewed at eleven SNAP regional offices in Maryland. Based on BMI calculated from self-reported height and weight, 65.6% of participants were overweight or obese while 40.5% perceived that they were overweight or obese. In sub-group analysis categorized by BMI, only 20.0% in the overweight and 20.0% in the obese group correctly perceived themselves as being overweight or obese. Following dietary guidelines was perceived as important by a majority of participants, but only 43.5% had adequate health literacy. Conceptual and knowledge gaps between self-perception and objective health status existed in the low-income SNAP-eligible sample. Future studies need to address these gaps because misperceived weight status and insufficient health literacy are critical barriers to inducing behavioral change.

Health literacy and nutrition behaviors among low-income adults.

The purpose of this study was to explore the relationship between health literacy and nutrition behaviors using a low-income sample. Face-to-face surveys at 11 social services offices generated a convenience sample of 154 Supplemental Nutrition Assistance Program (SNAP)-eligible adults. We assessed health literacy, fruit and vegetable intake, food label use, consumption of healthy foods, and demographic characteristics. Thirty seven percent of the sample had adequate health literacy as measured by the Newest Vital Sign (NVS). Race and parenthood were significantly related to health literacy scores. Adequate health literacy, as measured by the NVS, was associated with frying chicken less often and eating the peels of fresh fruit more often. The findings suggest that health practitioners should ensure nutrition-related messages are accessible to all of their clients, especially those with the lowest health literacy levels.

Household food security and fruit and vegetable intake among low-income fourth-graders.

OBJECTIVE: To examine the relationship between household food security and children's and parents' fruit, vegetable, and breakfast consumption and fruit and vegetable availability. DESIGN: Cross-sectional study using matched parent-child surveys. SETTING: Title I elementary schools in Maryland. PARTICIPANTS: Ninety-two low-income parent-child dyads recruited from fourth-grade nutrition education programs completing a baseline evaluation. MAIN OUTCOME MEASURES: Fruit and vegetable intake, breakfast consumption, and fruit and vegetable availability in home and school. ANALYSIS: Chi-square tests, 1-way ANOVA. RESULTS: Thirty-six percent of parents reported low/very low household food security, and both parents and students reported low fruit and vegetable intake. Students from households with low food security who were not participating in school nutrition programs had the lowest vegetable consumption and the fewest number of days consuming breakfast, indicating a relatively greater need for enrollment than their peers. CONCLUSIONS AND IMPLICATIONS: Few differences between children in food-secure and food-insecure households were observed, which underscores the need for research on food insecurity and children's eating behaviors. Examination of other factors influencing fruit and vegetable intake and improvements in food environments and programs are needed. Efforts to increase enrollment among eligible students in school nutrition programs may reduce negative consequences of household food insecurity.