Clients' experiences and satisfaction with produce prescription programs in California: a qualitative evaluation to inform person-centered and respectful program models.

Background: Produce prescription programs have strong potential to improve food security, fruit and vegetable consumption, and health across the life course. Understanding clients' experiences and satisfaction with produce prescription programs is critical for evaluating the person-centeredness and quality of these programs. The objectives of this study were to (1) describe client experiences and satisfaction with produce prescription programs, with an emphasis on the extent to which they felt they were treated with respect and dignity, and (2) identify recommendations for improving client experiences. Methods: We conducted four focus group discussions with clients of produce prescription programs in two Federally Qualified Health Centers in California. We used a modified framework analysis approach and organized participants' experiences with programs into themes. Results: Three themes captured participants' program experiences. First, respectful produce prescription programming encompassed interactions with individuals delivering the programs that felt respectful (e.g., program staff showing they cared about participants' health and offering timely assistance with financial incentives) and disrespectful (e.g., not receiving prompt responses to questions about incentives), as well as aspects of program design perceived to be respectful (e.g., provision of gift cards as financial incentives, which offered privacy when purchasing produce). Second, having autonomy to use gift cards to choose their preferred fresh fruits and vegetables was viewed as a positive experience, though participants desired greater autonomy to shop at stores other than the program designated stores. Third, participants frequently discussed program usability, with some reporting that joining the programs and using the cards was easy, and others describing difficulties activating cards and using them at stores due to cashiers' lack of awareness of the programs. Overall, participants were highly satisfied with the programs. To improve client experiences, they recommended increasing privacy (e.g., by educating cashiers on the programs so that clients do not need to explain in public what the card is for) and autonomy (e.g., allowing cards to be used at other chain or local stores). Discussion: Our findings inform efforts to make produce prescription programs more person-centered and respectful, which in turn may increase program demand, engagement, and impact.

A Qualitative Investigation of Parent and Child Perceptions of School Food Allergy Policies in the United States.

BACKGROUND: Many schools implement well-intentioned food allergy policies; however, may not ease parents'/children's worry and concern. The purpose of this study was to (1) explore children's and parents' perceptions their school's food allergy policy and (2) compare these perceptions to the documented school policy. METHODS: Children ages 8 to 18 with a food allergy and their parents (N = 18 pairs) across the US completed one-on-one semi-structured, audio-recorded phone interviews. School food allergy policies were collected from school websites. Content analysis was applied to the transcriptions by two investigators to identify themes among parents and children. RESULTS: Parents and children described policies may impact the child's social and/or emotional well-being. Many opportunities for improvement were provided by parents and children. There is a wide variation in food allergy policies across the schools in this study, and overall, parents and children thought that policy enforcement needs to be improved. CONCLUSIONS: With so much variation in food allergy policies in schools coupled with inconsistent enforcement, parents and children may feel unsafe or unsupported by the school. Schools should adopt a team- or whole-school approach to develop and enforce policies that help protect children with food allergies.

Examining Factors Related to the Food Insecurity-Obesity Paradox in Low-Income Mothers and Fathers.

BACKGROUND: Prior research has indicated a varying relationship of food security and obesity risk between men and women yet factors affecting this relationship are unclear. OBJECTIVE: The objective of this study was to examine factors related to the gender disparity in the food insecurity-obesity paradox within a sample of low-income parents. METHODS: Low-income cohabiting mother and father pairs (n = 25) living with their child were interviewed individually using the United States Department of Agriculture Household Food Security Module, Center for Epidemiological Studies Depression Scale, and Coping Strategies Index to examine gendered factors related to the food insecurity-obesity paradox. RESULTS: There was a significant (P = .003) difference in report of adults in the household sacrificing consumption to feed young children between mothers (2.91 ± 0.92) and fathers (3.59 ± 0.73), with mothers reporting greater sacrifice and compromised diet quality to feed their children, but no significant correlation among body mass index, depression, and food insecurity was detected. CONCLUSIONS: Food insecure mothers may be more likely to compromise their diet quality to feed their children than fathers. This could help explain why the food insecurity-obesity paradox is significant only in women, and this work gives insights into gender-based differential consequences of food insecurity.

Diet Quality, Nutritional Adequacy, and Sociodemographic Characteristics of Mobile Food Pantry Users in Northeastern Connecticut.

Poor diet quality among low-income populations is a major contributing factor to their poor health and wellbeing, and thus is a focus of many government aid programs. Mobile food pantries are an increasingly popular method of emergency food assistance, targeting the communities most affected by food insecurity; however, little is known about the dietary characteristics of mobile food pantry users. This study aims to characterize the diet quality and nutrient adequacy level and examine its association with sociodemographic characteristics among mobile food pantry users in Windham County, Connecticut. Surveys to assess food insecurity, diet composition, and sociodemographic characteristics were administered to 83 adult food pantry users. Participants (n = 40) completed a three-day dietary record for analysis of diet quality, and were found to have inadequate intakes of fruits, vegetables, whole grains and dairy, as well as some related micronutrients. At least 30% of participants had intakes below the Estimated Average Requirement (EAR) for vitamins A, C, E, calcium, zinc, magnesium, and folate. Intakes of added sugar, sugar sweetened beverages, and saturated fat were also above recommendations according to the United States Dietary Guidelines. Certain sociodemographic factors affected diet quality among this sample. For example, being male was associated with increased sugar-sweetened beverage and added sugar intake. This characterization of mobile pantry users will serve as a reference for developing nutrition education and determining the effectiveness of future interventions.

A qualitative investigation of body weight and weight loss-related attitudes of mothers and fathers in the context of food insecurity.

PURPOSE: To examine attitudes about body weight and weight loss among low-income parents of young children experiencing household food insecurity. METHODS: One-on-one interviews were conducted with 25 dyads of cohabitating low-income mothers and fathers who lived with their child aged 2.5-10 years old. Basic inductive analysis was conducted using NVivo to identify emerging themes related to body weight. RESULTS: Three main themes emerged including (1) weight loss as a "Blessing in Disguise," (2) trouble with losing weight, and (3) the impact of compromised diet quality. Some differences existed in themes between mothers and fathers, but both placed value on weight loss resulting from food insecurity. CONCLUSION: This research underscores the importance of sufficient nutrition assistance for limited resource families. A lack of money for food was a barrier towards maintaining a healthy weight but the value our culture places on weight loss even in times of despair was undeniably present. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

A pilot examination of the inter-rater reliability of the 18-item Household Food Security Module between cohabiting mothers and fathers.

Food insecurity, defined as the inability to access sufficient food for an active, healthy life, affects 11.1% of the US population and is primarily assessed using the United States Department of Agriculture's (USDA) 18-item Household Food Security Survey Module (HFSSM). The HFSSM is a self-report measure presumed to represent all household members, but it is unknown if cohabiting parents report food security differently. This pilot study aimed to determine (i) the inter-rater reliability of the HFSSM; (ii) the direction of any difference between responses to the HFSSM; and (iii) the item-level response similarities and differences among mothers and fathers of young children. Twenty-five pairs of low-income, food-insecure cohabiting parents of 2.5- to 10-year-old children participated in cognitive interviews assessing their level of food security using the USDA's HFSSM and completed related questionnaires. Intraclass correlations were computed to compare the responses of each dyad on the HFSSM overall and by item. Results revealed that overall report of food security was significantly but weakly correlated (r = .40, p = .02) within dyads. The majority of fathers (60%) reported higher food security scores on the HFSSM than their respective female partners. Furthermore, item-level intraclass correlations revealed that some HFSSM questions had poor reliability between cohabiting parents. This research identifies that a potential shortcoming of the HFSSM is the under-reporting of food insecurity by fathers compared with mothers within the household. These findings have implications for the utility of this measure used in national monitoring of the nation's food security.

Discourse Analysis: A Novel Analytical Technique for Qualitative Nutrition Research.

The objective of this report was to demonstrate the use of discourse analysis as a qualitative nutrition research analysis tool based on a case study of food-insecure parents. The US Department of Agriculture 18-item Household Food Security Module served as a framework for cognitive interviews. Data were analyzed using a basic inductive technique and then reanalyzed using discourse analysis. Discourse analysis tools including position design and identity building, I and we statements, collocational patterns, and the figured world tool unveiled findings otherwise not detected using basic inductive techniques. Discourse analysis and corresponding tools can contribute to qualitative nutrition research, particularly in inductive thesis-generating work.

How Are Fathers' Demographic Characteristics Related to Preschool-Age Children's Weight and Obesity Risk Factors?

Fathers (n = 149) of preschool children were interviewed using the Child Feeding, Role of the Father (ROF), and ROF at Mealtimes (ROFM) questionnaires to determine whether fathers' demographic characteristics are associated with child overweight. Low-income was associated with higher pressure to eat (p = .006) and perceived their child as higher weight (p = .001). Higher education level was associated with lower ROF (p = .018) and ROFM (p = .002) and higher child diet quality (p = .002). Father's BMI was positively associated with ROFM (p = .008). Certain fathers may be important targets in childhood obesity prevention programs.

Evaluation of Nutrition and Physical Activity Policies and Practices in Child Care Centers within Rural Communities.

BACKGROUND: Although some researchers have examined nutrition and physical activity policies within urban child care centers, little is known about the potentially unique needs of rural communities. METHODS: Child care centers serving preschool children located within low-income rural communities (n = 29) from seven states (Indiana, Kansas, Michigan, North Dakota, Ohio, South Dakota, and Wisconsin) were assessed to determine current nutrition and physical activity (PA) practices and policies. As part of a large-scale childhood obesity prevention project, the Community Healthy Living Index's previously validated Early Childhood Program Assessment Tool was used to collect data. Descriptive statistical analysis was conducted to identify high-priority areas. Healthy People 2020 and the Academy of Nutrition and Dietetics' recommendations for nutrition and PA policies in child care centers were used as benchmarks. RESULTS: Reports of not fully implementing (<80% of the time) recommended nutrition-related policies or practices within rural early child care centers were identified. Centers not consistently serving a variety of fruits (48%), vegetables (45%), whole grains (41%), limiting saturated fat intake (31%), implementing healthy celebration guidelines (41%), involving children in mealtime (62%), and referring families to nutrition assistance programs (24%) were identified. More than one third of centers also had limited structured PA opportunities. Although eligible, only 48% of the centers participated in the Child and Adult Care Food Program. CONCLUSIONS: Overall, centers lacked parental outreach, staff training, and funding/resources to support nutrition and PA. These results provide insight into where child care centers within low-income, rural communities may need assistance to help prevent childhood obesity.

Association of fathers' feeding practices and feeding style on preschool age children's diet quality, eating behavior and body mass index.

The associations of parental feeding practices and feeding style with childhood obesity have gained more attention in the literature recently; however, fathers are rarely included within these studies. The aim of this research was to determine the relationship of paternal feeding practices on child diet quality, weight status, and eating behavior, and the moderating effect of paternal feeding style on these relationships in preschool age children. This study included a one-time, one-on-one interview with biological fathers of preschoolers (n = 150) to assess feeding practices (Child Feeding Questionnaire), feeding style (Caregiver Feeding Style Questionnaire), child eating behaviors (Child Eating Behavior Questionnaire), and diet quality (24 hour recall, Healthy Eating Index). Height and weight for each father and child were also measured and Body Mass Index (BMI) or BMI z-score calculated. Linear regression was used to test the relationship between paternal feeding practices, style and child diet quality and/or body weight. Overall, the findings revealed that a father's feeding practices and feeding style are not associated with children's diet quality or weight status. However, child eating behaviors are associated with child BMI z-score and these relationships are moderated by paternal feeding practices. For example, child satiety responsiveness is inversely (ß = -.421, p = 0.031) associated with child BMI z-score only if paternal restriction scores are high. This relationship is not significant when paternal restriction scores are low (ß = -.200, p = 0.448). These results suggest that some child appetitive traits may be related to child weight status when exposed to certain paternal feeding practices. Future studies should consider the inclusion of fathers as their feeding practices and feeding style may be related to a child's eating behavior.

Investigating the Relationship of Body Mass Index, Diet Quality, and Physical Activity Level between Fathers and Their Preschool-Aged Children.

BACKGROUND: Diet quality and physical activity are two important factors in determining a child's risk for obesity. In early childhood, parents may serve as role models for these behaviors. However, few studies have examined associations of a father's body mass index (BMI), dietary intake, and physical activity with his preschool-aged child. OBJECTIVE: The purpose of this study was to examine relationships between fathers' and children's body weight, diet quality, and physical activity. DESIGN: This cross-sectional study included one-on-one interviews with fathers (n=150) of preschool-aged children conducted by a trained interviewer (a registered dietitian nutritionist). PARTICIPANTS: To be eligible, biological fathers (n=150) of preschool-aged children (aged 3 to 5 years) were required to regularly eat at least one meal per week with their child and be able to read or speak English. They could be of any race, ethnicity, income, or education level. MAIN OUTCOME MEASURES: During the interview, diet quality was assessed using a single 24-hour recall and the Healthy Eating Index-2010. Physical activity was assessed using the Pre-Physical Activity Questionnaire. Height and weight for each father and child were also measured. BMI and BMI z scores were calculated for fathers and children, respectively. STATISTICAL ANALYSES PERFORMED: Linear regression was used to test relationships between fathers' and children's body weight, diet quality, and physical activity while controlling for income level, race, and ethnicity. RESULTS: Overall, the findings revealed that there were significant, positive relationships between father-child weight status (ß=.03; P=0.05), overall diet quality (ß=.39; P<0.0001), and weekday (ß=.27; P=0.002) and weekend (ß=.62; P=0.001) vigorous physical activity. CONCLUSIONS: These results suggest that there are relationships between fathers' and children's BMI z score, dietary intake, and physical activity level. Future research should consider the inclusion of fathers in obesity prevention programs for young children.