Assessing the experience of dental students with an asynchronous online course about racism, cultural competence.

PURPOSE: University of Pennsylvania School of Dental Medicine and the University of Pennsylvania School of Social Policy and Practice (SP2) designed an asynchronous online course about racism and cultural competence to address student concerns about harmful interactions with peers across race/ethnicity. The Penn Experience Course establishes common language and concepts to facilitate difficult conversations about racism in the classroom and clinical spaces. METHODS: The course included six modules addressing the history of racism in the Philadelphia area and at the University of Pennsylvania: implicit bias and microaggressions; racism and other forms of oppression; gender identity and sexuality; construction of whiteness and white supremacy ideology; cultural humility, disparities, and equity; and access in healthcare. Students completed pre- and post-course surveys about their likelihood of engaging with the neighborhood surrounding Penn, confidence discussing the topics covered, and general experience with the course. RESULTS: Four hundred forty-nine students completed post-course surveys, 220 of which could be linked to precourse survey responses. Overwhelmingly, students reported a positive experience with the course, an increase in their likelihood to engage with the Penn neighborhood, and increased confidence in discussing course topics with peers. Many students suggested incorporating synchronous discussion, while a smaller group expressed resentment about the focus on whiteness, white fragility, and anti-Black racism. Several students of color expressed concern that the course centered the learning needs of white students. CONCLUSION: Asynchronous online content offers an effective and efficient way of teaching dental students about the basics of cultural competence. Educators should anticipate resistance from some white students and the distinct learning needs of students of color.

"This Could Mean Death for My Child": Parent Perspectives on Laws Banning Gender-Affirming Care for Transgender Adolescents.

OBJECTIVES: Numerous U.S. state legislatures have proposed bills to ban gender-affirming medical interventions for minors. Parents and caregivers play a critical role in advocating for and supporting their transgender and gender-diverse youth (TGDY). We aimed to understand parent and caregiver perspectives about this potential legislation and perceived effects on their TGDY's mental health. METHODS: We developed and launched a social-media based, anonymous online survey in February 2020 to assess parent and caregiver perspectives on proposed laws to ban gender-affirming medical interventions for minors. Participants were asked to respond to two open-ended questions about these laws; responses were coded to identify key themes. RESULTS: We analyzed responses from 273 participants from 43 states. Most identified as white (86.4%) female (90.0%) mothers (93.8%), and 83.6% of their TGDY had received gender-affirming medical interventions before age 18 years. The most salient theme, which appeared in the majority of responses, described parent and caregiver fears that these laws would lead to worsening mental health and suicide for their TGDY. Additional themes included a fear that their TGDY would face increased discrimination, lose access to gender-affirming medical interventions, and lose autonomy over medical decision-making due to government overreach. CONCLUSIONS: In this convenience sample, parents and caregivers overwhelmingly expressed fear that the proposed legislation will lead to worsening mental health and increased suicidal ideation for their TGDY. They implored lawmakers to hear their stories and to leave critical decisions about gender-affirming medical interventions to families and their medical providers.

Parent Participation in a Support Group for Families with Transgender and Gender-Nonconforming Children: "Being in the Company of Others Who Do Not Question the Reality of Our Experience".

Purpose: Parent support is considered crucial for the health of transgender and gender-nonconforming (trans/GNC) children, yet little research has focused on how to support parents and caregivers. This study considered the experience of participation in a support group for parents of transgender children on families. Methods: Online surveys were conducted with parents whose children were receiving clinical care at a gender specialty clinic and who participated at least once in a monthly support group. Close-ended questions addressed the importance of participation and open-ended questions addressed the specific ways it was helpful, how it impacted them and their trans/GNC child, and if they faced barriers to participating. Results: The majority of the 48 participants (77.1%) identified as female. The mean age of their trans/GNC child was 13.9 years (standard deviation 5.1, range 5-22 years); just over half (n=25) of their trans/GNC children identified as male. Participants overwhelmingly reported positive experiences with the support group, with 72.9% reporting that the group was either important or critically important to them and 66.7% reporting that it was important or critically important to their trans/GNC child. Perceived benefits included the opportunity to learn about legal, medical, and school issues and receive emotional support. Conclusion: Support groups provide an important complement to specialized clinical care for families with trans/GNC children. Logistical challenges, lack of age peers, and lack of people of color all served as limitations of the group. Further research is needed to understand the experiences of fathers and to determine if the support group model would be effective with racially/ethnically and economically diverse populations.

Chronic disease self-management within the monthly benefit cycle of the Supplemental Nutrition Assistance Program.

OBJECTIVE: The present study explored chronic disease management over the monthly benefit cycle among primary food shoppers from households receiving Supplemental Nutrition Assistance Program (SNAP) benefits in Philadelphia, PA, USA. DESIGN: In-depth interviews, participant observation and surveys were conducted with the primary food shopper of SNAP households. SETTING: Interviews and surveys were conducted in a clinical setting at Children's Hospital of Philadelphia, at participants' homes, and in food procurement settings including grocery stores, food pantries and soup kitchens. PARTICIPANTS: Eighteen adults who received SNAP; five with a diet-related chronic condition, five managing the chronic condition of a family member and thirteen with overweight or obesity. RESULTS: All households had at least one member with a chronic disease or condition. Households reported that the dietary demands of managing chronic illnesses were expensive and mentally taxing. Food and financial shortfalls at the end of the benefit cycle, as well as reliance on charitable food assistance programmes, often had negative impacts on chronic disease self-management. CONCLUSIONS: Drawing from nearly 50 h of in-depth qualitative interviews with SNAP participants, the study highlights the dual cognitive burden of poverty and chronic disease and elucidates the particular challenges of food procurement and maintenance of diet quality throughout the benefit month faced by SNAP households with diet-related chronic diseases. Interventions targeted at reducing the cost of medically appropriate, healthy foods may help to improve chronic disease self-management within SNAP populations.

Food and financial coping strategies during the monthly Supplemental Nutrition Assistance Program cycle.

One in seven Americans participates in the Supplemental Nutrition Assistance Program (SNAP), making it the largest federally funded food assistance program. SNAP benefits are distributed once per month and both food spending and calorie consumption tend to decrease as time from benefit distribution increases. The monthly SNAP benefit cycle has serious implications for the health and financial stability of low-income families, a growing number of whom rely on SNAP as their sole source of income. Relatively little is known about the specific coping strategies households use to manage the SNAP cycle. The purpose of this study is to provide a critical exploration of the nature and timing of coping strategies for managing the SNAP cycle, including implications these coping mechanisms have for health and financial stability. This paper presents data from a prospective cohort study of mothers (n = 12) receiving SNAP benefits in Philadelphia between 2016 and 17. Both in-depth qualitative and survey methods were used. Participants reported on a variety of coping strategies they used to manage the SNAP cycle, including adjustments to shopping and eating patterns, mental accounting, emotional resilience, and social support. Instrumental social support was particularly vital in the final days of the benefit cycle, as were skipping meals and purchasing less expensive, energy-dense foods. Constant vigilance was required throughout the month to manage financial instability. The coping strategies for managing the SNAP cycle have short-term benefits, such as buffering against hunger and financial instability, however these survival strategies may have negative long-term repercussions for physical and financial health.

The Impact of a Non-profit Market on Food Store Choice and Shopping Experience: A Community Case Study.

Research evaluating the impact of new food stores in "food deserts" have reported limited impact on eating and health outcomes of residents who live nearby. Few studies have reported on shoppers' food store choices and experiences in these new stores. This study focused on residents' experience with a new non-profit food market in Chester, PA and analyzes spatial patterns regarding who did and did not choose to shop at the new store. Phone surveys (n = 135) and in-person interviews (n = 13) were conducted with the primary food shopper for households living in Chester 1-2 years, respectively, after the opening of a store. Participants who shopped at the new market reported positive experiences in regard to convenience, customer service, food quality, and prices and believed that the new market had a positive impact on the community. But most participants had not shopped at the new market, citing many of the same factors in their decision to shop at supermarkets outside the city. Our findings underscore the need to combine new food retail strategies with community engagement and other interventions, such as in-store promotions and health education programs, to maximize the number of people who shop at new food outlets designed to improve access to healthful foods.

Diet Quality Over the Monthly Supplemental Nutrition Assistance Program Cycle.

INTRODUCTION: Supplemental Nutrition Assistance Program (SNAP) benefits, which are distributed monthly, help low-income families put food on their tables. Both food spending and caloric intake among recipients decrease over the month following benefit receipt. This pattern, termed the "SNAP-cycle," has serious implications for health and food security of low-income households. To understand better the SNAP-cycle, this study explored (1) differences in diet quality between SNAP and non-SNAP households and (2) the association between the SNAP-cycle and diet quality. METHODS: Multivariate linear regression with SNAP households in the U.S. Department of Agriculture's Food Acquisition and Purchase Survey to evaluate changes in diet quality as time from SNAP distribution increased. Diet quality of food purchases was measured by Healthy Eating Index-2010 total and component scores. Data were collected 2012-2013 and analyzed 2016-2017. RESULTS: Overall dietary quality was low throughout the SNAP-cycle (n=1,377, mean Healthy Eating Index 46.14 of 100). SNAP households had significantly lower Healthy Eating Index scores compared with eligible and ineligible nonparticipants (p<0.05). After controlling for covariates, households in the final 10 days of the benefit cycle had Healthy Eating Index-2010 total scores 2.95 points lower than all other SNAP households (p=0.02). Significant declines in Healthy Eating Index fruit and vegetable scores contributed to worsening diet quality over the SNAP-cycle. CONCLUSIONS: This study provides evidence of low dietary quality throughout the SNAP-cycle with significantly lower Healthy Eating Index scores in the final 10 days of the benefit month. This suggests less healthy purchasing occurs when resources are diminished, but overall that current SNAP levels are insufficient to consistently purchase foods according to dietary guidelines.

Family food purchases of high- and low-calorie foods in full-service supermarkets and other food retailers by Black women in an urban US setting.

Public health interventions to increase supermarket access assume that shopping in supermarkets is associated with healthier food purchases compared to other store types. To test this assumption, we compared purchasing patterns by store-type for certain higher-calorie, less healthy foods (HCF) and lower-calorie, healthier foods (LCF) in a sample of 35 black women household shoppers in Philadelphia, PA. Data analyzed were from 450 food shopping receipts collected by these shoppers over four-week periods in 2012. We compared the likelihood of purchasing the HCF (sugar-sweetened beverages, sweet/salty snacks, and grain-based snacks) and LCF (low-fat dairy, fruits, and vegetables) at full-service supermarkets and six other types of food retailers, using generalized estimating equations. Thirty-seven percent of participants had household incomes at or below the poverty line, and 54% had a BMI >30. Participants shopped primarily at full-service supermarkets (55%) or discount/limited assortment supermarkets (22%), making an average of 11 shopping trips over a 4-week period and spending mean (SD) of $350 ($222). Of full-service supermarket receipts, 64% included at least one HCF item and 58% at least one LCF. Most trips including HCF (58%) and LCF (60%) expenditures were to full-service or discount/limited assortment supermarkets rather than smaller stores. Spending a greater percent of total dollars in full-service supermarkets was associated with spending more on HCF (p = 0.03) but not LCF items (p = 0.26). These findings in black women suggest a need for more attention to supermarket interventions that change retailing practices and/or consumer shopping behaviors related to foods in the HCF categories examined.

Where do U.S. households purchase healthy foods? An analysis of food-at-home purchases across different types of retailers in a nationally representative dataset.

Food shopping decisions are pathways between food environment, diet and health outcomes, including chronic diseases such as diabetes and obesity. The choices of where to shop and what to buy are interrelated, though a better understanding of this dynamic is needed. The U.S. Department of Agriculture's nationally representative Food Acquisitions and Purchase Survey food-at-home dataset was joined with other databases of retailer characteristics and Healthy Eating Index-2010 (HEI) of purchases. We used linear regression models with general estimating equations to assess relationships between trip, store, and shopper characteristics with trip HEI scores. We examined HEI component scores for conventional supermarkets and discount/limited assortment retailers with descriptive statistics. Overall, 4962 shoppers made 11,472 shopping trips over one-week periods, 2012-2013. Trips to conventional supermarkets were the most common (53.6%), followed by supercenters (18.6%). Compared to conventional supermarkets, purchases at natural/gourmet stores had significantly higher HEI scores (ß = 6.48, 95% CI = [4.45, 8.51], while those from "other" retailers (including corner and convenience stores) were significantly lower (-3.89, [-5.87, -1.92]). Older participants (versus younger) and women (versus men) made significantly healthier purchases (1.19, [0.29, 2.10]). Shoppers with less than some college education made significantly less-healthy purchases, versus shoppers with more education, as did households participating in SNAP, versus those with incomes above 185% of the Federal Poverty Level. Individual, trip, and store characteristics influenced the healthfulness of foods purchased. Interventions to encourage healthy purchasing should reflect these dynamics in terms of how, where, and for whom they are implemented.

Using Geographic Information Systems to Visualize Relationships Between Perinatal Outcomes and Neighborhood Characteristics When Planning Community Interventions.

OBJECTIVE: To describe maternal morbidity, birth outcomes, and neighborhood characteristics of urban women from a racially segregated city with the use of a geographic information system (GIS). DESIGN: Exploratory neighborhood-level study. Existing birth certificate data were linked and aggregated to neighborhood-level data for spatial analyses. SETTING: Southern city in New Jersey. SAMPLE: Women and their 7,858 live births that occurred between 2009 and 2013. METHODS: Secondary analyses of extant sources were conducted. Maternal health and newborn birth outcomes were geocoded and then aggregated to the neighborhood level for further exploratory spatial analyses through our GIS database. An iterative process was used to generate meaningful visual representations of the data through maps of maternal and infant health in 19 neighborhoods. RESULTS: The racial and ethnic residential segregation and neighborhood patterns of associations of adverse birth outcomes with poverty and crime were illustrated in GIS maps. In 43% of the births, women had a documented medical risk. Significantly more preterm births occurred for Black women (p < .01) and women older than 35 years of age (p = .01). The rate of diabetes was greater in Hispanic women, and the rate of pregnancy-related hypertensive disorders was greater in Black women. CONCLUSION: Data-driven maps can provide clear evidence of maternal and infant health and health needs based on the neighborhoods where mothers live. This research is important so that maternity care providers can understand contextual factors that affect mothers in their communities and guide the design of interventions.

Discrete Choice Model of Food Store Trips Using National Household Food Acquisition and Purchase Survey (FoodAPS).

Where households across income levels shop for food is of central concern within a growing body of research focused on where people live relative to where they shop, what they purchase and eat, and how those choices influence the risk of obesity and chronic disease. We analyzed data from the National Household Food Acquisition and Purchase Survey (FoodAPS) using a conditional logit model to determine where participants shop for food to be prepared and eaten at home and how individual and household characteristics of food shoppers interact with store characteristics and distance from home in determining store choice. Store size, whether or not it was a full-service supermarket, and the driving distance from home to the store constituted the three significant main effects on store choice. Overall, participants were more likely to choose larger stores, conventional supermarkets rather than super-centers and other types of stores, and stores closer to home. Interaction effects show that participants receiving Supplemental Nutrition Assistance Program (SNAP) were even more likely to choose larger stores. Hispanic participants were more likely than non-Hispanics to choose full-service supermarkets while White participants were more likely to travel further than non-Whites. This study demonstrates the value of explicitly spatial discrete choice models and provides evidence of national trends consistent with previous smaller, local studies.

Why do you shop there? A mixed methods study mapping household food shopping patterns onto weekly routines of black women.

BACKGROUND: The effectiveness of initiatives to increase healthy food access may be affected by where people decide to shop. People with poor neighborhood access to large grocery stores develop shopping patterns that require traveling to other areas, and some people who do have neighborhood access also travel elsewhere for food shopping. We sought to gain an understanding of household food shopping patterns in a sample of Black women in terms of where they shopped and why. METHODS: All food shopping trips of 35 low- or middle/high-income black mothers or caregivers living with at least one child were identified from grocery shopping receipts collected over four consecutive weeks. Food shopping locations were mapped along with locations of participants' homes and other places they visited during weekly routine travels (e.g. work, child's school). Semi-structured individual interviews elicited narrative information about whether and how grocery shopping trips were linked to routine travels. Inductive content analysis was utilized to identify emergent themes from interviews. Themes were considered in relation to geospatial distances and travel patterns identified through mapping of participants' shopping. RESULTS: Participants shopped at an average of six different stores, traveling on average a total of 35 miles (sd = 41) (Euclidian distance) over the four weeks. The most frequented store was within a mile of home (57%) or home or another place visited in the weekly routine for about 77% of participants. Interview results emphasized the concept of convenience which referred to geographical proximity to the home or routine destinations and also to potential to save time because several stores were co-located or because the store layout was easy to navigate and familiar. Store selection also related to mode of transportation, pricing, and family preference for certain foods. CONCLUSION: People have specific reasons for consistently shopping in areas outside of their neighborhood of residence. Incorporating considerations other than proximity (e.g. time saving while shopping, promoting less familiar foods, pricing) into food environment interventions may facilitate use of new stores by neighborhood residents and thereby increase the viability of these stores as health-promoting food environment interventions.

How important is perception of safety to park use? A four-city survey.

PURPOSE: To determine individual- and park-related characteristics associated with adults visiting their closest neighborhood park and involvement in sports, walking, and sedentary activities. DESIGN: Cross-sectional study. SETTING: Neighborhoods surrounding 24 parks in four United States metropolitan areas. SUBJECTS: Adults (N = 3,815) (25% African American, 12% Hispanic, and 56% Non-Hispanic White) living within .5 mile of one of 24 public parks. MEASURES: Anonymous surveys and park observations. ANALYSIS: Chi-square statistics and logistic regression including individual and park characteristics. RESULTS: Thirty-seven percent reported never having visited their park; 16% reported using it for regular exercise. Respondents who perceived the parks as safe or very safe had 4.6 times the odds of visiting the parks. Active sports participation was associated with being male, ages 18 to 24, and of African American heritage. Walking was associated with being female, age 47+, and reporting fair or poor health. Females, Hispanics, and those reporting fair/poor health were more likely to report sedentary activities. Park characteristics associated with park use included fewer physical incivilities, closer proximity to homes, more facilities, and organized activities. CONCLUSIONS: Perceptions of park safety were strongly associated with ever having visited a respective park, while park characteristics appeared to influence the types of activities performed. Increasing the number of organized activities and offering a variety of different facilities may encourage park use.

Using systematic observations to understand conditions that promote inter-racial experiences in neighbourhood parks.

We analysed observations from 31 neighbourhood parks, with each park mapped into smaller target areas for study, across five US cities generated using the System for Observing Play and Recreation in the Community (SOPARC). In areas where at least two people were observed, less than one-third (31.6%) were populated with at least one white and one non-white person. Park areas that were supervised, had one or more people engaged in vigorous activity, had at least one male and one female present, and had one or more teens present were significantly more likely to involve interracial groups (p<0.01 for each association). Observations in parks located in interracial neighbourhoods were also more likely to involve interracial groups (p<0.05). Neighbourhood poverty rate had a significant and negative relationship with the presence of interracial groups, particularly in neighbourhoods that are predominantly non-white. Additional research is needed to confirm the impact of these interactions. Urban planning and public health practitioners should consider the health benefits of interracial contact in the design and programming of neighbourhood parks.

Can you party your way to better health? A propensity score analysis of block parties and health.

While other indicators of social capital have been linked to health, the role of block parties on health in Black neighborhoods and on Black residents is understudied. Block parties exhibit several features of bonding social capital and are present in nearly 90% of Philadelphia's predominantly Black neighborhoods. This analysis investigated: (1) whether or not block parties are an indicator of bonding social capital in Black neighborhoods; (2) the degree to which block parties might be related to self-rated health in the ways that other bonding social indicators are related to health; and (3) whether or not block parties are associated with average self-rated health for Black residents particularly. Using census tract-level indicators of bonding social capital and records of block parties from 2003 to 2008 for 381 Philadelphia neighborhoods (defined by census tracts), an ecological-level propensity score was generated to assess the propensity for a block party, adjusting for population demographics, neighborhood characteristics, neighborhood resources and violent crime. Results indicate that in multivariable regression, block parties were associated with increased bonding social capital in Black neighborhoods; however, the calculation of the average effect of the treatment on the treated (ATT) within each propensity score strata showed no effect of block parties on average self-rated health for Black residents. Block parties may be an indicator of bonding social capital in Philadelphia's predominantly Black neighborhoods, but this analysis did not show a direct association between block parties and self-rated health for Black residents. Further research should consider what other health outcomes or behaviors block parties may be related to and how interventionists can leverage block parties for health promotion.

Individual and community factors associated with geographic clusters of poor HIV care retention and poor viral suppression.

BACKGROUND: Previous analyses identified specific geographic areas in Philadelphia (hotspots) associated with negative outcomes along the HIV care continuum. We examined individual and community factors associated with residing in these hotspots. METHODS: Retrospective cohort of 1404 persons newly diagnosed with HIV in 2008-2009 followed for 24 months after linkage to care. Multivariable regression examined associations between individual (age, sex, race/ethnicity, HIV transmission risk, and insurance status) and community (economic deprivation, distance to care, access to public transit, and access to pharmacy services) factors and the outcomes: residence in a hotspot associated with poor retention-in-care and residence in a hotspot associated with poor viral suppression. RESULTS: In total, 24.4% and 13.7% of persons resided in hotspots associated with poor retention and poor viral suppression, respectively. For persons residing in poor retention hotspots, 28.3% were retained in care compared with 40.4% of those residing outside hotspots (P < 0.05). Similarly, for persons residing in poor viral suppression hotspots, 51.4% achieved viral suppression compared with 75.3% of those outside hotspots (P < 0.0.05). Factors significantly associated with residence in poor retention hotspots included female sex, lower economic deprivation, greater access to public transit, shorter distance to medical care, and longer distance to pharmacies. Factors significantly associated with residence in poor viral suppression hotspots included female sex, higher economic deprivation, and shorter distance to pharmacies. CONCLUSIONS: Individual and community-level associations with geographic hotspots may inform both content and delivery strategies for interventions designed to improve retention-in-care and viral suppression.

Concentration of tobacco advertisements at SNAP and WIC stores, Philadelphia, Pennsylvania, 2012.

INTRODUCTION: Tobacco advertising is widespread in urban areas with racial/ethnic minority and low-income households that participate in nutrition assistance programs. Tobacco sales and advertising are linked to smoking behavior, which may complicate matters for low-income families struggling with disparate health risks relating to nutrition and chronic disease. We investigated the relationship between the amount and type of tobacco advertisements on tobacco outlets and the outlet type and location. METHODS: By using field visits and online images, we inspected all licensed tobacco retail outlets in Philadelphia (N = 4,639). Point pattern analyses were used to identify significant clustering of tobacco outlets and outlets with exterior tobacco advertisements. Logistic regression was used to analyze the relationship between the outlet's acceptance of Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the presence of tobacco advertisements. RESULTS: Tobacco outlets with exterior tobacco advertisements were significantly clustered in several high-poverty areas. Controlling for racial/ethnic and income composition and land use, SNAP and WIC vendors were significantly more likely to have exterior (SNAP odds ratio [OR], 2.11; WIC OR, 1.59) and interior (SNAP OR, 3.43; WIC OR, 1.69) tobacco advertisements than other types of tobacco outlets. CONCLUSION: Tobacco advertising is widespread at retail outlets, particularly in low-income and racial/ethnic minority neighborhoods. Policy makers may be able to mitigate the effects of this disparate exposure through tobacco retail licensing, local sign control rules, and SNAP and WIC authorization.

The social dynamics of healthy food shopping and store choice in an urban environment.

To respond to the high prevalence of obesity and its associated health consequences, recent food research and policy have focused on neighborhood food environments, especially the links between health and retail mix, proximity of food outlets, and types of foods available. In addition, the social environment exerts important influences on food-related behaviors, through mechanisms like role-modeling, social support, and social norms. This study examined the social dynamics of residents' health-related food-shopping behaviors in 2010-11 in urban Philadelphia, where we conducted 25 semi-structured resident interviews-the foundation for this paper-in addition to 514 structured interviews and a food environment audit. In interviews, participants demonstrated adaptability and resourcefulness in their food shopping; they chose to shop at stores that met a range of social needs. Those needs ranged from practical financial considerations, to fundamental issues of safety, to mundane concerns about convenience, and juggling multiple work and family responsibilities. The majority of participants were highly motivated to adapt their shopping patterns to accommodate personal financial constraints. In addition, they selectively shopped at stores frequented by people who shared their race/ethnicity, income and education, and they sought stores where they had positive interactions with personnel and proprietors. In deciding where to shop in this urban context, participants adapted their routines to avoid unsafe places and the threat of violence. Participants also discussed the importance of convenient stores that allowed for easy parking, accommodation of physical disabilities or special needs, and integration of food shopping into other daily activities like meeting children at school. Food research and policies should explicitly attend to the social dynamics that influence food-shopping behavior. In our social relationships, interactions, and responsibilities, there are countless opportunities to influence-and also to improve-health.

Food insecurity, neighborhood food access, and food assistance in Philadelphia.

An estimated 17.6 million American households were food insecure in 2012, meaning they were unable to obtain enough food for an active and healthy life. Programs to augment local access to healthy foods are increasingly widespread, with unclear effects on food security. At the same time, the US government has recently enacted major cuts to federal food assistance programs. In this study, we examined the association between food insecurity (skipping or reducing meal size because of budget), neighborhood food access (self-reported access to fruits and vegetables and quality of grocery stores), and receipt of food assistance using the 2008, 2010, and 2012 waves of the Southeastern Pennsylvania Household Health Survey. Of 11,599 respondents, 16.7% reported food insecurity; 79.4% of the food insecure found it easy or very easy to find fruits and vegetables, and 60.6% reported excellent or good quality neighborhood grocery stores. In our regression models adjusting for individual- and neighborhood-level covariates, compared to those who reported very difficult access to fruits and vegetables, those who reported difficult, easy or very easy access were less likely to report food insecurity (OR 0.62: 95% CI 0.43-0.90, 0.33: 95% CI 0.23-0.47, and 0.28: 95% CI 0.20-0.40). Compared to those who reported poor stores, those who reported fair, good, and excellent quality stores were also less likely to report food insecurity (OR 0.81: 95% CI 0.60-1.08, 0.58: 95% CI 0.43-0.78, and 0.43: 95% CI 0.31-0.59). Compared to individuals not receiving food assistance, those receiving Supplemental Nutrition Assistance Program (SNAP) benefits were significantly more likely to be food insecure (OR 1.36: 95% CI 1.11-1.67), while those receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (OR 1.17: 95% CI 0.77-1.78) and those receiving both SNAP and WIC (OR 0.84: 95% CI 0.61-1.17) did not have significantly different odds of food insecurity. In conclusion, better neighborhood food access is associated with lower risk of food insecurity. However, most food insecure individuals reported good access. Improving diet in communities with high rates of food insecurity likely requires not only improved access but also greater affordability.