A focus group study among insufficiently physically active African American adults regarding technology-delivered team-based gamification for physical activity promotion.

Background: Gamification represents a promising approach for facilitating positive social interactions among groups of individuals and is increasingly being leveraged in physical activity (PA) interventions to promote enhanced intervention engagement and PA outcomes. Although African American (AA) adults experience disparities associated with health conditions that can be ameliorated with increased PA, little is known about how best to culturally target PA gamification strategies for this population. The purpose of this study was to gather perspectives from AA adults residing in the Southeast United States and subsequently identify themes to help inform the cultural adaptation of an existing electronic and mobile health (e/mHealth) gamification- and theory-based PA intervention for teams of insufficiently active AA adults. Methods: An AA moderator facilitated six online focus groups among AA adults (n=42; 93% female; 45.09±9.77 years; 34.40±57.38 minutes/week of reported moderate-intensity equivalent PA), using a semi-structured focus group guide. Drawing from a content analysis approach, transcripts were coded and salient themes were identified. Results: The focus groups revealed the following seven themes: (I) motivation (team-based gamification motivating); (II) accountability (team-based gamification promotes accountability); (III) competition (competitive elements attractive); (IV) weekly challenges (prefer to choose weekly PA challenges); (V) leaderboard feedback (preference for viewing steps and active minutes via a leaderboard); (VI) cultural relevancy (prefer elements reflective of their race and culture that promote team unity); (VII) teammate characteristics (mixed preferences regarding ideal sociodemographic characteristics and starting PA level of teammates). Conclusions: Integrating team-based gamification in an e/mHealth-based PA intervention may be acceptable among AA adults. The identification of specific design preferences and perceptions of the value of the social environment points to the need to consider surface-level and deep structure cultural targeting when developing and further exploring best practices regarding gamified PA interventions for insufficiently active AAs.

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.

Examining demographic characteristics and food access indicators from the location of vegan soul food restaurants in the south.

Objective: There have been a number of soul food restaurants serving exclusively vegan meals opening up across the country to appeal to African Americans and others interested in eating healthier soul foods. This study determined the number of restaurants serving vegan soul foods in the South and identified the locations of these restaurants in order to understand the characteristics of the surrounding communities that they serve.Design: Two reviewers identified restaurants using standardized search criteria for menu items in the 16 states (and the District of Columbia) that are categorized as being in the South from the Census Bureau. Mean percentage of African Americans, poverty rates, and obesity rates by county where restaurants were located were collected via census data. Restaurants were classified as being in or out of a food desert zone using the United States Department of Agriculture's (USDA) food atlas map (0.5- and 1.0-mile radius). T-tests were conducted to test for differences in the census data between the restaurants that were considered to be in and out of a food desert zone.Results: Overall, 45 restaurants met the inclusion criteria. Counties where restaurants were located had a mean African American population of 36.5 ± 18.5%, mean poverty rate of 15.5 ± 3.85% and mean obesity rate of 26.8 ± 4.8%. More than one third (n = 18, 40.0%) of the restaurants were considered to be in a food desert zone. There were no significant differences in the mean population, obesity, and poverty rates between restaurants classified in a food desert zone and restaurants not located in a food desert zone.Conclusion: A significant number of restaurants were classified in food desert zones, implying their potential to provide healthier meals by serving vegan soul foods to residents in the surrounding neighborhoods. Future work should assess how these restaurants might influence healthier eating habits in their communities.

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.

Conditioned to eat while watching television? Low-income caregivers' perspectives on the role of snacking and television viewing among pre-schoolers.

OBJECTIVE: Although television (TV) viewing is frequently paired with snacking among young children, little is known about the environment in which caregivers promote this behaviour. We describe low-income pre-schoolers' snacking and TV viewing habits as reported by their primary caregivers, including social/physical snacking contexts, types of snacks and caregiver rationales for offering snacks. These findings may support the development of effective messages to promote healthy child snacking. DESIGN: Semi-structured interviews assessed caregiver conceptualizations of pre-schoolers' snacks, purpose of snacks, snack context and snack frequency. SETTING: Interviews occurred in Boston, Massachusetts and Philadelphia, Pennsylvania, USA. SUBJECTS: Forty-seven low-income multi-ethnic primary caregivers of children aged 3-5 years (92 % female, 32 % Hispanic/Latino, 34 % African American) described their child's snacking in the context of TV viewing. RESULTS: TV viewing and child snacking themes were described consistently across racial/ethnic groups. Caregivers described snacks offered during TV viewing as largely unhealthy. Labels for TV snacks indicated non-nutritive purposes, such as 'time out', 'enjoyment' or 'quiet.' Caregivers' primary reasons for providing snacks included child's expectations, behaviour management (e.g. to occupy child) and social time (e.g. family bonding). Some caregivers used TV to distract picky children to eat more food. Child snacking and TV viewing were contextually paired by providing child-sized furniture ('TV table') specifically for snacking. CONCLUSIONS: Low-income caregivers facilitate pre-schoolers' snacking and TV viewing, which are described as routine, positive and useful for non-nutritive purposes. Messages to caregivers should encourage 'snack-free' TV viewing, healthy snack options and guidance for managing children's behaviour without snacks or TV.

"What do you think of when I say the word 'snack'?" Towards a cohesive definition among low-income caregivers of preschool-age children.

Despite agreement that snacks contribute significant energy to children's diets, evidence of the effects of snacks on health, especially in children, is weak. Some of the lack of consistent evidence may be due to a non-standardized definition of snacks. Understanding how caregivers of preschool-aged children conceptualize and define child snacks could provide valuable insights on epidemiological findings, targets for anticipatory guidance, and prevention efforts. Participants were 59 ethnically-diverse (White, Hispanic, and African American), low-income urban caregivers of children age 3-5 years. Each caregiver completed a 60-90 min semi-structured in-depth interview to elicit their definitions of child snacks. Data were coded by two trained coders using theoretically-guided emergent coding techniques to derive key dimensions of caregivers' child snack definitions. Five interrelated dimensions of a child snack definition were identified: (1) types of food, (2) portion size, (3) time, (4) location, and (5) purpose. Based on these dimensions, an empirically-derived definition of caregivers' perceptions of child snacks is offered: A small portion of food that is given in-between meals, frequently with an intention of reducing or preventing hunger until the next mealtime. These findings suggest interrelated dimensions that capture the types of foods and eating episodes that are defined as snacks. Child nutrition studies and interventions that include a focus on child snacks should consider using an a priori multi-dimensional definition of child snacks.

Parenting around child snacking: development of a theoretically-guided, empirically informed conceptual model.

BACKGROUND: Snacking contributes to excessive energy intakes in children. Yet factors shaping child snacking are virtually unstudied. This study examines food parenting practices specific to child snacking among low-income caregivers. METHODS: Semi-structured interviews were conducted in English or Spanish with 60 low-income caregivers of preschool-aged children (18 non-Hispanic white, 22 African American/Black, 20 Hispanic; 92% mothers). A structured interview guide was used to solicit caregivers' definitions of snacking and strategies they use to decide what, when and how much snack their child eats. Interviews were audio-recorded, transcribed verbatim and analyzed using an iterative theory-based and grounded approach. A conceptual model of food parenting specific to child snacking was developed to summarize the findings and inform future research. RESULTS: Caregivers' descriptions of food parenting practices specific to child snacking were consistent with previous models of food parenting developed based on expert opinion [1, 2]. A few noteworthy differences however emerged. More than half of participants mentioned permissive feeding approaches (e.g., my child is the boss when it comes to snacks). As a result, permissive feeding was included as a higher order feeding dimension in the resulting model. In addition, a number of novel feeding approaches specific to child snacking emerged including child-centered provision of snacks (i.e., responding to a child's hunger cues when making decisions about snacks), parent unilateral decision making (i.e., making decisions about a child's snacks without any input from the child), and excessive monitoring of snacks (i.e., monitoring all snacks provided to and consumed by the child). The resulting conceptual model includes four higher order feeding dimensions including autonomy support, coercive control, structure and permissiveness and 20 sub-dimensions. CONCLUSIONS: This study formulates a language around food parenting practices specific to child snacking, identifies dominant constructs, and proposes a conceptual framework to guide future research.

A qualitative study of parents' perceptions and use of portion size strategies for preschool children's snacks.

OBJECTIVE: Increases in childhood obesity correspond with shifts in children's snacking behaviors and food portion sizes. This study examined parents' conceptualizations of portion size and the strategies they use to portion snacks in the context of preschool-aged children's snacking. METHODS: Semi-structured qualitative interviews were conducted with non-Hispanic white (W), African American (AA), and Hispanic (H) low-income parents (n = 60) of preschool-aged children living in Philadelphia and Boston. The interview examined parents' child snacking definitions, purposes, contexts, and frequency. Verbatim transcripts were analyzed using a grounded theory approach. Coding matrices compared responses by race/ethnicity, parent education, and household food security status. RESULTS: Parents' commonly referenced portion sizes when describing children's snacks with phrases like "something small." Snack portion sizes were guided by considerations including healthfulness, location, hunger, and timing. Six strategies for portioning snacks were presented including use of small containers, subdividing large portions, buying prepackaged snacks, use of hand measurement, measuring cups, scales, and letting children determine portion size. Differences in considerations and strategies were seen between race/ethnic groups and by household food security status. CONCLUSIONS: Low-income parents of preschool-aged children described a diverse set of considerations and strategies related to portion sizes of snack foods offered to their children. Future studies should examine how these considerations and strategies influence child dietary quality.