Supplemental Nutrition Assistance Program Education Research Articles

Schools as Hubs of Health: A Comprehensive Supplemental Nutrition Assistance Program—Education Model for Promoting Wellness in Low-Income Communities

Research indicates that health interventions are most effective when they address multiple social determinants of health to support positive behavior. Schools as Hubs of Health, a comprehensive model of nutrition and physical activity education, was developed to support wellness within school communities defined as low-income by the national Supplemental Nutrition Assistance Program Education (SNAP-Ed). Components of the model include the following: classroom education; garden education; youth engagement; staff training; parent and community engagement; and policies, systems, and environments. Findings over the last decade indicate positive outcomes in nutrition and physical activity behaviors, youth leadership and engagement, and systems and environmental changes that support health and wellness.

The Shaping Healthy Choices Program: Improving the impact through community partnerships

The high prevalence of childhood overweight and obesity demonstrates the need for effective intervention strategies. The Shaping Healthy Choices Program (SHCP) is a school-based intervention that promotes nutrition and physical education, develops family and community partnerships, and incorporates foods available on the school campus, with the goal of achieving sustainable student health outcomes. Partnerships developed through implementation of the SHCP were analyzed using the RE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to assess the potential for adoption, scaling and sustainability of the program. The RE-AIM framework is a comprehensive approach to evaluating public health interventions through reach, effectiveness, adoption, implementation and maintenance. Partners of the SHCP include site staff (teachers, administration and health professionals), parents, peer teachers, and state and federal agencies, such as the Supplemental Nutrition Assistance Program Education (SNAP-Ed), which funds CalFresh Healthy Living, University of California (CFHL, UC), and UC Cooperative Extension. This analysis highlights how partnerships developed and sustained with the SHCP may serve as a model for other programs to expand, while also enabling programs to remain responsive to the diverse challenges and needs of local community partners.

Physical Activity Policy, Systems, and Environment Change Through Extension SNAP-Ed: A Multistate Perspective.

The Supplemental Nutrition Assistance Program-Education (SNAP-Ed) provides nutrition education and support for healthy living in SNAP-qualifying communities. SNAP-Ed supports policy, systems, and environmental (PSE) efforts to make the healthy choice an easier choice. SNAP-Ed implementers have widely adopted healthy eating PSE supports. However, physical activity (PA) PSE strategies are less common, with limited awareness between states of how other SNAP-Ed implementers approach PA-focused PSE work. Physical Activity Policy, Research, and Evaluation Network (PAPREN) Rural Active Living Workgroup project members sought to explore how Extension-based SNAP-Ed implements PA-focused PSE approaches. A sample of Extension-based SNAP-Ed program (n = 8) leaders were purposefully recruited from eligible universities in six of the seven SNAP-Ed regions. An interview guide to systematically collect information about current Extension SNAP-Ed implementation focused on PA PSE strategies was developed iteratively by the PAPREN Rural Active Living Workgroup Extension PA PSE project team. PA PSE Extension SNAP-Ed implementation efforts occurred at the state, county, and community levels and/or within local organizations. PA PSEs included school PA policy change, shared-use agreements, active transportation promotion, park development, walking challenges, and PA-promoting signage. All interviews highlighted the importance of partnerships at local, county, and state levels for PSE efforts. Extension-based SNAP-Ed shows potential to bring community partners together to plan and implement PA-focused PSE approaches. With a focus on SNAP-eligible people and substantial geographic reach, Extension SNAP-Ed is uniquely situated as a public health partner to broadly implement PA PSE changes.

Measuring Policy, Systems, and Environmental Changes at Elementary Schools Involved in SNAP-Ed New Mexico Programming, 2018-2022.

In 2018, the New Mexico Supplemental Nutrition Assistance Program-Education (SNAP-Ed NM) incorporated policy, systems, and environmental (PSE) strategies into the state plan to increase healthy eating and physical activity. Studies of multiple PSE strategies in elementary schools are lacking. We conducted assessments of physical activity and nutrition environments at 11 elementary schools in New Mexico before and after schools were given school-specific PSE recommendations and technical assistance. Baseline data were collected in 2018 by using the School Physical Activity and Nutrition Environment Tool (SPAN-ET), which measures policy, situational, and physical environments in elementary schools. PSE scores were calculated as the proportion of criteria met within and across 27 areas of interest. Implementation of evidence-based PSE interventions began in 2019. COVID-19 school closures delayed follow-up assessments until 2022. We analyzed descriptive data to examine changes in PSE scores over time. Overall mean PSE scores increased significantly from baseline (53.6%) to follow-up (62.7%). Nutrition PSE scores significantly increased by 17.6 percentage points; the policy environment showed the largest improvement (+26.0 percentage points), followed by the situational environment (+13.8 percentage points), and physical environment (+9.1 percentage points). We found a nonsignificant increase in the overall average physical activity score (+2.7 percentage points). Use of a standardized instrument for assessing implementation of PSE strategies across multiple schools showed significant overall improvement in nutrition scores and nonsignificant increases in physical activity scores. Providing school-specific recommendations combined with technical assistance may be an effective approach to implementing evidence-based nutrition and physical activity PSE strategies.

Advancing Inclusive Communication: Implementing an Audit to Center Equity in SNAP-Ed Programming.

Public health interventions rely on information exchange to influence health outcomes. Increasingly, practitioners are working to be intentional with public health messaging. The language used to communicate program objectives and health recommendations should reflect the community's lived experience and avoid perpetuating health and social inequities. Words and tone matter, and both should be inclusive and non-stigmatizing. Prioritizing a health equity lens for communication may require a critical review and revision of existing materials. This Practice Note highlights the development and implementation of an audit tool designed to systematically review a cookbook created to support healthy eating for families and individuals experiencing low income and participating in a Supplemental Nutrition Assistance Program-Education (SNAP-Ed) intervention in Maine. The purpose of the audit tool and the collaborative review process was to revise the cookbook content to ensure a weight-neutral, empowering approach to supporting the community's nutritional needs. The audit process resulted in a comprehensive methodology to examine intervention resources for inclusive communication approaches that avoid deficit framing, use person-first language, and do not overemphasize limited resources or appropriate cultures. The instrument and methodology are conceptually replicable and adaptable. In sharing the process and audit results, the authors seek to provide an example for practitioners to draw from for similar critical reviews of public health intervention resources and promotional materials.

Racial/Ethnic Differences in Physical Activity in a Low-Income Sample in Texas.

National data reveal that the age-adjusted prevalence of leisure-time physical inactivity is higher among Blacks and Hispanics compared with Whites. However, these estimates do not consider nonleisure physical activity (PA). Also, race/ethnicity in these findings may by confounded by socioeconomic status disparities in PA. Here, we examine racial/ethnic differences in multiple measures of PA within a lower socioeconomic status sample. Participants in the current cross-sectional study (n = 1526 adults, aged ≥ 18y) were recruited from Supplemental Nutrition Assistance Program-Education classes (nutrition education classes that target low-income people) in Texas. Self-report data were obtained using survey questionnaires in spring and fall 2018. PA outcomes of 4 different intensities were assessed: mean daily time spent walking, engaging in moderate and vigorous PA, and sitting. Additional PA-related measures included use and awareness of community PA resources. Linear regression models examined racial/ethnic differences in the 4 PA outcomes after adjusting for participant gender, age, household composition measures, and various socioeconomic status measures. In this low-income sample, Hispanic and Black participants spent 6 to 9 more minutes per day walking and engaging in moderate and vigorous PA compared with White/other participants (P < .05 for each measure). Conversely, White/other participants reported spending 82 more minutes sitting per day than Black and Hispanic participants (P < .01). Overall, Black participants were most likely to utilize community PA resources and report ease of engaging in exercise. Together, these results reveal greater engagement in PA by racial/ethnic minorities in low-income communities compared with Whites. Our results have implications for tailoring PA programming to these communities.

SNAP-Ed Programming for College Students Experiencing Food Insecurity: A Qualitative Process-Focused Evaluation

BackgroundGrowing recognition of food insecurity experienced by college students has led to efforts on college campuses to provide students with food assistance benefits and related nutrition education. A Supplemental Nutrition Assistance Program—Education (SNAP-Ed) program was developed for college students as one of these efforts. ObjectiveTo explore program content, recruitment, and implementation through experiences of program implementers in a novel SNAP-Ed intervention among college students. DesignThis qualitative study used focus groups and a case study approach to elicit program implementers’ experiences delivering SNAP-Ed to college students. Participants/settingStudents, staff, and faculty (n = 26) implementing SNAP-Ed with college students experiencing food insecurity across eight campuses in the California State University system participated in 8 focus groups in 2021–2022. Main outcome measuresA process evaluation framework was used to evaluate content fit and orientation; recruitment, retention, and reach; and structure and capacity for implementation. Analyses performedFocus groups were recorded, transcribed, and coded via thematic analysis using NVivo (QSR International, Burlington, MA). ResultsFive themes were identified: (1) need for this work to extend college-based basic needs services; (2) importance of aligning programming with college student context/needs; (3) common factors important for attracting/engaging the audience; (4) program barriers; and (5) training/team sharing for extending ideas. ConclusionsStudy findings suggest tailoring SNAP-Ed programming to the needs of college students experiencing food insecurity, such as integrating student-relevant cooking skills, recipes, and topics of interest. Additional intervention and research efforts may lead to a new model for serving college students with SNAP-Ed.

Evaluating Physical Activity Resources to Support Health Equity in Arizona

We evaluated physical activity (PA) resources in lower-income Arizona communities to support the Supplemental Nutrition Assistance Program – Education (SNAP-Ed) in pursuing equitable policy, systems, and environment (PSE) interventions. In 2017, 71 PA resources across 10 counties (65% parks) were rated using the Physical Activity Resource Assessment (PARA) tool. Accessibility was high, but condition scores and attractiveness varied across resources, with no rural/urban differences. Results suggest that Extension SNAP-Ed staff can be agents of change by assessing resource condition where physical activity health inequities may exist and then convening partners to begin to address needed changes.

Contextual Factors Influencing the Adoption of Physical Activity Direct Education and Policy, Systems, and Environmental Change Initiatives by Virginia EFNEP and SNAP-Ed Staff

ObjectiveTo explore factors influencing the adoption of direct education programs and policy, systems, and environmental (PSE) change initiatives focused on physical activity for Supplemental Nutrition Assistance Program-eligible audiences by Virginia Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program-Education (SNAP-Ed) staff. MethodsOnline survey with Expanded Food and Nutrition Education Program and SNAP-Ed peer (paraprofessional) educators (n = 28) and SNAP-Ed agents (master of science level) (n = 9) in Virginia. Descriptive statistics were computed for sociodemographic characteristics and responses to questions on the basis of Likert-type scales. Exploratory factor analyses were run to identify the underlying structures of the different variables. ResultsThe main factors for peer educators were related to substituting nutrition programs or content for physical activity programs. Other factors included staff qualifications and expectations about leading vs teaching physical activities. For PSEs, the top factors were the capacity to reach many community members, attract new partners and stakeholders, and personal interest in the PSE. Conclusions and ImplicationsThe results provide insight into potential barriers and motivators for adopting physical activity education and PSEs within community-based initiatives and can be used to inform program planning and staff training. Additional research is warranted to examine other factors influencing the adoption and implementation of physical activity programs and PSEs.

Sensory-Informed Evaluation Method for Use With Peer Educators of Nutrition Education Programs

ObjectiveDetermine acceptance of unfamiliar recipes and investigate the practicality of a hybrid (remote and in-office) method of evaluating recipes. MethodsPeer educators from the University of Georgia's Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program-Education programs used a hybrid home-use test method to evaluate 8 recipes before and after preparation and tasting. We collected perceived and actual measures of recipe acceptance. The main outcomes included overall liking and preparation behaviors, analyzed using nonparametric approaches. ResultsNo significant differences (P > 0.05) were found between prepreparation and postpreparation overall liking or preparation behaviors for each recipe, supporting the practicality of the method. Liking of recipe preparation exceeded 7 out of 9 for all recipes, but ratings for recipe preparation willingness and perceived program participant ratings decreased after tasting. Conclusions and ImplicationsAlthough tasting new recipes is necessary to determine specific modifications, a hybrid recipe evaluation format is practical for introducing new recipes to peer educators when resources are limited.

Development of an Innovative High School Nutrition Education Intervention for Pennsylvania Supplemental Nutrition Assistance Program-education

Development of an Innovative High School Nutrition Education Intervention for Pennsylvania Supplemental Nutrition Assistance Program-education

Latent class analysis identifies a promising combination of Supplemental Nutrition Assistance Program-Education interventions for improving student cardiorespiratory fitness

ObjectiveTo inform Supplemental Nutrition Assistance Program Education (SNAP-Ed) and other school-based interventions aiming to improve youth cardiorespiratory fitness, this study aimed to identify which SNAP-Ed school-based physical activity intervention combinations were associated with better student cardiorespiratory fitness. MethodsThis study, utilizing cross-sectional secondary data, included 5th and 7th grade students who attended SNAP-Ed-eligible public schools in California (n = 442,743 students; 4271 schools) and had complete 2016–17 state-mandated fitness test results. Latent class analysis was used to identify underlying school-based intervention combinations. Propensity score methods were used to ensure comparability of intervention and comparison schools, by calculating inverse probability weights. Multilevel models, using those inverse probability weights, assessed the associations between the identified intervention combinations and student cardiorespiratory fitness, as measured by VO2max. The models were adjusted for school-level variables (urbanicity, percent of students eligible for free- or reduced-price meals, total enrollment, and school type), child-level variables (age, gender, and race/ethnicity), and for clustering of students within schools. ResultsWe found that students attending schools with interventions focusing on comprehensive policy changes along with improving opportunities for physical activity had, on average, 1.17 mL/kg/min (95% CI: 0.72, 1.62) greater VO2max than students attending schools without any intervention. They also had statistically significantly greater VO2max compared to students attending schools with any other type of intervention combination. ConclusionOur results suggest that comprehensive school-based physical activity interventions that include policy changes along with improving physical activity opportunities may be the most effective approach for improving fitness and may warrant prioritization in SNAP-Ed efforts.

Supplemental Nutrition Assistance Program Education reductions during COVID-19 may have exacerbated health inequities

ObjectiveDescribe, and assess disparities in, the changes in Supplemental Nutrition Assistance Program Education (SNAP-Ed) that occurred the year before vs. the year when COVID-19 restrictions were implemented. DesignObservational study comparing reach, intensity, and dose of California Local Health Department (LHD) SNAP-Ed interventions in Federal Fiscal years 2019 and 2020 (FFY19, FFY20). AnalysisStudent t-tests determined significance of differences in the number of Direct Education (DE) programs, Policy, Systems and Environmental change (PSE) sites, people reached, and intervention intensity and dose between FFY19 and FFY20 using data reported online by LHDs. Linear regression assessed associations between census tract-level characteristics (urbanicity; percentages of population with income <185% of federal poverty level, under 18 years of age, and belonging to various racial/ethnic groups; and California Healthy Places Index) and changes in number of DE programs, PSE sites, people reached, and intervention dose between FFY19 and FFY20. ResultsFrom FFY19 to FFY20, the number of DE programs, PSE sites, people reached, and census tract-level intervention intensity and dose decreased. Higher census tract poverty, higher proportions of Black and Latino residents, and less healthy neighborhood conditions were associated with greater decreases in some intervention characteristics including PSE sites, PSE reach, DE programs, and DE dose. Conclusions and implicationsThese reductions in LHD SNAP-Ed interventions indicate reduced access to education and environments that support healthy eating and obesity prevention during a time when this support was especially needed to reduce risk of COVID-19 infection and complications. Disproportionately reduced access, may have worsened health disparities in already-disadvantaged communities. Assuring maintenance of SNAP-Ed interventions, especially in disadvantaged communities, should be a priority during public health emergencies.

California's Supplemental Nutrition Assistance Program-Education (SNAP-Ed) Be Better social marketing campaign: mothers' fruit and vegetable consumption and facilitation of children's healthy behaviours.

Evaluation of California Department of Public Health's three-year social marketing campaign (Be Better) to encourage healthy eating and water consumption among Supplemental Nutrition Assistance Program-Education (SNAP-Ed) California mothers. Andreasen's social marketing framework was used to outline the development and evaluation of the campaign. Quantitative, pre-post cross-sectional study with three cohorts nested within survey years. Generalised estimating equation modeling was used to obtain population estimates of campaign reach and changes in mothers' fruit and vegetable (FV) consumption and facilitative actions towards their children's health behaviours. CalFresh Healthy Living (California's SNAP-Ed). Three separate cohorts of SNAP mothers were surveyed (pre, post) between 2016 and 2018 inclusive. A total of 2229 mothers (ages 18-59) self-identified as White, Latina, African American or Asian/Pacific Islander participated. Approximately 82 percent of surveyed mothers were aware of the campaign as assessed by measures of recall and recognition. Ad awareness was positively associated with mothers' FV consumption (R2 = 0·45), with the proportion of FV on plates and with behaviours that facilitate children's FV consumption and limit unhealthy snacks and sugary drinks (βs ranged from 0·1 to 0·7). The campaign successfully reached 82 percent of surveyed mothers. Positive associations between California's Be Better campaign and targeted health behaviours were observed, although the associations varied by year and media channel (i.e. television, radio, billboards and digital). Most associations between ad awareness and outcomes were noted in years two and three of the campaign, suggesting that more than 1 year of campaign exposure was necessary for associations to emerge.

Federal Food Program Participation and Beverage Intake Among Families With Low Household Income

ObjectiveExamine beverage intake among families with low income by household participation in federal food assistance programs. DesignCross-sectional study conducted in fall/winter 2020 via an online survey. ParticipantsMothers of young children insured by Medicaid at the time of the child's birth (N = 493). Variables MeasuredMothers reported household federal food assistance program participation, later categorized as Supplementation Nutrition Program for Women, Infants, and Children (WIC) only, Supplemental Nutrition Assistance Program-Education (SNAP) only, both WIC and SNAP, and neither. Mothers reported beverage intake for themselves and their children aged 1–4 years. AnalysisNegative binomial and ordinal logistic regression. ResultsAfter accounting for sociodemographic differences between groups, mothers from households participating in WIC and SNAP consumed sugar-sweetened beverages (incidence rate ratio, 1.63; 95% confidence interval [CI], 1.14–2.30; P = 0.007) and bottled water (odds ratio, 1.76; 95% CI, 1.05–2.96; P = 0.03) more frequently than mothers from households in neither program. Children from households participating in WIC and SNAP also consumed soda (incidence rate ratio, 6.07; 95% CI, 1.80–20.45; P = 0.004) more frequently than children in either program. Few differences in intake were observed for mothers or children participating in only WIC or SNAP vs both programs or neither program. Conclusion and ImplicationsHouseholds participating in both WIC and SNAP may benefit from additional policy and programmatic interventions to limit sugar-sweetened beverage intake and reduce spending on bottled water.

P28-037-23 Student and School Characteristics Modify the Impact of Supplemental Nutrition Assistance Program Education (SNAP-Ed) on Student Dietary Outcomes

P28-037-23 Student and School Characteristics Modify the Impact of Supplemental Nutrition Assistance Program Education (SNAP-Ed) on Student Dietary Outcomes

The LSU AgCenter Healthy Communities Initiative: Community-Participatory Policy, Systems, and Environmental Change

Policy, systems, and environmental (PSE) change interventions to improve local food and physical activity environments play an important role in addressing the ongoing obesity crisis, especially in conjunction with nutrition, physical activity, and food resource management education. These interventions are particularly important tools to address health equity because education alone is insufficient to reduce racial disparities in obesity rates,1Mackey ER Burton ET Cadieux A et al.Addressing structural racism is critical for ameliorating the childhood obesity epidemic in Black youth.Child Obes. 2022; 18: 75-83Crossref PubMed Scopus (11) Google Scholar,2Kumanyika SK. A framework for increasing equity impact in obesity prevention.Am J Public Health. 2019; 109: 1350-1357Crossref PubMed Scopus (98) Google Scholar and maybe insensitive in the face of structural barriers to healthful eating and physical activity.3Kolavalli C. Whiteness and food charity: experiences of food insecure African-American Kansas City residents navigating nutrition education programs.Hum Organ. 2019; 78: 99-109Crossref Scopus (8) Google Scholar Federally funded nutrition education programs, including Supplemental Nutrition Assistance Program-Education (SNAP-Ed) and the Expanded Food and Nutrition Education Program (EFNEP), are encouraged by their funders to make PSE changes,4Galdamez I. NIFA-19-018 EFNEP integration of policy, systems, and environmental change efforts. https://nifa.usda.gov/nifa-19-018-efnep-integration-policy-systems-environmental-change-efforts. Accessed November 15, 2022.Google Scholar,5Burke MP Gleason S Singh A Wilkin MK. Policy, systems, and environmental change strategies in the Supplemental Nutrition Assistance Program-Education (SNAP-Ed).J Nutr Educ Behav. 2022; 54 (Published online 2022): 320-326Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar but funders do not specify whether PSE interventions should be designed by implementers or by the community implementers serve. For example, SNAP-Ed guidance does not provide instruction regarding the decision-making process for selecting PSE change strategies.6US Department of Agriculture, Food and Nutrition Service. FY 2023 Supplemental Nutrition Assistance Program Education (SNAP-ED) Plan Guidance: Nutrition Education and Obesity Prevention Program. US Department of Agriculture, Supplemental Nutrition Assistance Program; 2023.https://snaped.fns.usda.gov/sites/default/files/documents/FY2023_SNAPEd_PlanGuidance_FV.pdf. Accessed June 20, 2022.Google Scholar In addition, training on PSE change strategies for SNAP-Ed implementers generally focuses on federal guidelines, defining PSE change strategies, and providing examples of successful implementation.7Pope HC Draper C Younginer N Whitt O Paget C. Use of decision cases for building SNAP-Ed implementers’ capacities to realize policy, systems, and environmental strategies.J Nutr Educ Behav. 2020; 52: 512-521Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Similarly, EFNEP guidance does not instruct implementers on how to decide on the PSE change strategies.8Galdamez I. Expanded food and nutrition Education Program (EFNEP) integrating policy, systems, and environmental change efforts. https://connect.extension.org/g/efnep/resource/efnep-pse-guidance. Accessed November 15, 2022.Google Scholar Furthermore, EFNEP PSE training states that PSEs should be implemented through coordination with community partners, although those partners should not decide on PSEs.9Bishop-Smith C, Feighner A, Galdamez I. EFNEP PSE guidance and planning in the 5-year plan. https://efneppse.org/wp-content/uploads/2020/06/March-Webinar-Part-1-EFNEP-PSE-Guidance-and-Planning-in-the-5-Year-Plan.pdf. Accessed November 15, 2022.Google Scholar Including participants in the design and delivery of health-focused interventions may improve the recruitment and retention of participants, the appropriateness of the intervention for the target audience, and intervention sustainability.10Harris J Cook T Gibbs L et al.Searching for the impact of participation in health and health research: challenges and methods.BioMed Res Int. 2018; 20189427452Crossref PubMed Scopus (25) Google Scholar, 11Rifkin SB. Examining the links between community participation and health outcomes: a review of the literature.Health Policy Plan. 2014; 29: ii98-ii106Crossref PubMed Scopus (195) Google Scholar, 12Cargo M Mercer SL. The value and challenges of participatory research: strengthening its practice.Annu Rev Public Health. 2008; 29: 325-350Crossref PubMed Scopus (680) Google Scholar Community involvement in PSE change interventions is particularly vital to address structural racism, a contributor to increased obesity, food insecurity, and physical inactivity rates in marginalized communities that have been of increasing interest to public health professionals.1Mackey ER Burton ET Cadieux A et al.Addressing structural racism is critical for ameliorating the childhood obesity epidemic in Black youth.Child Obes. 2022; 18: 75-83Crossref PubMed Scopus (11) Google Scholar,13Singleton CR Uy WF Landry MJ. Strengthening cross-sector collaborations in hunger-relief efforts to address structural racism.J Nutr Educ Behav. 2021; 53: 93-94Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar,14Odoms-Young A Bruce MA. Examining the impact of structural racism on food insecurity: implications for addressing racial/ethnic disparities.Fam Community Health. 2018; 41: S3-S6Crossref PubMed Scopus (170) Google Scholar Interventions that aim to improve health equity and address health disparities should combine PSE changes and education and be implemented with participation and feedback from intended beneficiaries. However, recent reviews of nutrition interventions designed to address structural racism among African Americans, and interventions that obtained input from African American participants, indicate a lack of participatory interventions to address structural barriers to healthful eating.15Greene M Houghtaling B Sadeghzadeh C et al.Nutrition interventions addressing structural racism: a scoping review.Nutr Res Rev. 2022; : 1-53Google Scholar,16Greene M Houghtaling B Sadeghzadeh C et al.African Americans’ perceptions of nutrition interventions: a scoping review.Nutr Res Rev. 2022; : 1-20Google Scholar To our knowledge, no similar reviews have been found to assess nutrition or physical activity interventions to address structural racism in Hispanic and Native American populations. Given the benefits of community-driven PSE change interventions and the need for those approaches to promote health equity, implementers of health-focused Cooperative Extension programs may consider obtaining community buy-in and feedback when designing and implementing PSE change interventions rather than using a predetermined menu of strategies. However, putting the choice of PSE change strategy in the hands of community residents requires time and resources to engage and build trust with community members. The Louisiana State University Agriculture Center (LSU AgCenter) Healthy Communities Initiative was designed as a standardized process to engage underserved and historically marginalized communities despite different community needs and characteristics. Program materials are outlined in Table 1 and are publicly available online at: https://forms.office.com/r/R0zDrH9Diw. Materials include a timeline and plan for a community needs assessment, forum, coalition building, forum script, communication materials, coalition member job descriptions, PSE action plans, training materials, and evaluation materials.Table 1Components of the LSU AgCenter Healthy Communities Initiative MaterialsaAvailable online at: https://forms.office.com/r/R0zDrH9DiwComponentPurposeLSU AgCenter Healthy Communities Initiative program manual and timelineProvides implementers with all materials needed to solicit community input support for the implementation of PSE change interventionsHealthy Communities forum guidebIncluded in the LSU AgCenter Healthy Communities Initiative program manual.A script for implementers to lead a community focus group to determine which PSE change interventions to implementHealthy Communities coalition overview and coalition member job description templatesbIncluded in the LSU AgCenter Healthy Communities Initiative program manual.Provides coalition members an example of their role and purpose when participating in Healthy Communities coalitionsHealthy Communities coalition action plan templatebIncluded in the LSU AgCenter Healthy Communities Initiative program manual.Provides a method of keeping coalition members accountable to planned work when implementing PSE changesThe follow-up community forum and ripple effect mapping scriptA script for a second-time community forum to discuss work that has been completed, gather community input on future work and produce a ripple effect map to evaluate work that has been completedPSE change quick reference guideA short tool that shows implementers of nutrition education programs how to link their work to PSE change interventionsHealthy Communities talking pointsDescribes the LSU AgCenter Healthy Communities Initiative to potential partner organizations and PSE change sites to encourage participationFood system PSE change and collaborative decision-making toolHelps Healthy Communities Initiative implementers identify opportunities for PSE changes in their local food systemsLSU AgCenter indicates Louisiana State University Agriculture Center; PSE, policy, systems, and environmental.a Available online at: https://forms.office.com/r/R0zDrH9Diwb Included in the LSU AgCenter Healthy Communities Initiative program manual. Open table in a new tab LSU AgCenter indicates Louisiana State University Agriculture Center; PSE, policy, systems, and environmental. Cooperative Extension's 2014 National Framework for Health and Wellness outlined the need for PSE change interventions and education to address factors influencing behavior change according to the social ecological model.17Braun B, Bruns K, Cronk L, et al. Cooperative Extension's National Framework for Health and Wellness. www.aplu.org/wp-content/uploads/national-framework-for-health-and-wellness.pdf. Accessed November 15, 2022.Google Scholar This model describes influences on behavior beyond individual knowledge, such as interpersonal influences, societal and social norms, and environmental factors.18Langille JLD Rodgers WM. Exploring the influence of a social ecological model on school-based physical activity.Health Educ Behav. 2010; 37: 879-894Crossref PubMed Scopus (101) Google Scholar The leadership of nutrition and health education programs implemented through Cooperative Extension recommended that implementers use PSE change approaches to address food insecurity and obesity.4Galdamez I. NIFA-19-018 EFNEP integration of policy, systems, and environmental change efforts. https://nifa.usda.gov/nifa-19-018-efnep-integration-policy-systems-environmental-change-efforts. Accessed November 15, 2022.Google Scholar,19US Department of Agriculture Food & Nutrition Service. Supplemental Nutrition Assistance Program Education Guidance: Nutrition Education and Obesity Prevention Grant Program. US Department of Agriculture; 2015. https://snaped.fns.usda.gov/library/materials/fy-2016-snap-education-plan-guidance. Accessed August 12, 2022.Google Scholar In response, the LSU AgCenter's Family and Consumer Sciences (FCS) Program launched the LSU AgCenter Healthy Communities Initiative.20Holston D Stroope J Cater M Kendall M Broyles S. Implementing policy, systems, and environmental change through community coalitions and extension partnerships to address obesity in rural Louisiana.Prev Chronic Dis. 2020; 17: E18Crossref PubMed Scopus (15) Google Scholar In this initiative, LSU AgCenter FCS agents were encouraged to form coalitions to secure community input, foster partnerships, and guide the implementation of PSE change efforts. These staff previously worked to provide research-based nutrition education to the public and did not engage in formal community development or PSE change work. From 2014 to 2020, program policies and tools were developed and refined to arrive at the current version of the Healthy Communities Initiative materials, which guide implementers through the process of holding a community forum, determining which PSE change strategies to implement, recruiting coalition members, holding coalition meetings, and building action plans to address PSE change strategies. Beginning in 2018, all FCS agents hired by the LSU AgCenter were required to implement the Healthy Communities Initiative within their first year of employment, beginning with an informal needs assessment. In this assessment, FCS agents collect information on resources and needs of their communities and locate any underserved and historically marginalized areas according to census-tract level poverty data and information from local key informants such as mayors, city council members, community and religious leaders, neighborhood associations, health workers, and others. After identifying communities on the basis of these assessments, FCS staff hold community forums in which residents identify and prioritize strategies for PSE changes according to a standard set of questions provided in the LSU AgCenter Healthy Communities Initiative materials. Although there are no minimum or maximum attendance restrictions, if there are > 12 attendees, the group is split into 2 smaller groups to discuss community needs and develop separate PSE change strategies before reassembling as a larger group to vote on and prioritize the suggested PSE strategies. Forums typically occur in-person, but adaptations to a virtual format were necessary during the coronavirus disease 2019 pandemic.21Greene MD Stroope J Holston D. Adapting ripple effect mapping to a virtual survey format.J Ext. 2022; 60 (Article 9)Google Scholar Forums guide community members toward generating a list of priority health concerns that may or may not include nutrition and physical activity. If the community does not address nutrition and physical activity, follow-up questions will specifically ask about those areas. If only nutrition or physical activity concerns are mentioned, the forum facilitator encourages attendees to think outside those topics and consider other aspects influencing the community's health. Forum attendees then create a list of possible strategies to improve the health of their community. The concept of PSE change is not discussed, but community members are encouraged to think of strategies that will result in a long-term change to their community, and the facilitator may guide suggested strategies toward PSE interventions. Residents then vote on which strategies would be most important to implement and which strategies would be easiest to implement. Strategies typically include some nutrition and physical activity-focused strategies, but not all strategies need to be directly related to those aspects of health. Community forums also serve as a way to recruit residents to participate in community coalitions. Following the initial forum and recruitment for the community coalition, the coalition members pool local resources and/or recruit outside organizations to address identified needs. These resources typically include volunteer support, donations from local businesses, and in-kind support such as land for parks or gardens or space to implement environmental changes. Recruiting outside funding and resources is important for organizations with limited funds or restrictions on using those funds. Strategies to make PSE changes are different for each community. Examples include healthy retail programs, produce distribution programs, school and community gardens, and the stenciling of vacant lots and playgrounds at community centers and schools with images promoting activity (eg, hopscotch and instructions for bodyweight exercises). The implementation of these strategies differs in each community, and assistance from state FCS leadership is provided to individual FCS staff to guide implementation. Therefore, program materials focus heavily on the community forum, coalition building, and evaluating progress toward PSE change and the outcomes of PSE change interventions. A mixed-methods evaluation led by the program evaluator was used to assess the LSU AgCenter's progress toward PSE changes and the impact of those changes. Mixed-methods evaluation designs are essential tools to uplift participants’ voices and advance equity through evaluation.22Mertens DM. Transformative paradigm: mixed methods and social justice.Journal of Mixed Methods Research. 2007; 1: 212-225Crossref Scopus (347) Google Scholar Although FCS staff from all funding sources use the same evaluation, the evaluation was conducted according to the SNAP-Ed evaluation framework.23Naja-Riese A Keller KJM Bruno P et al.The SNAP-Ed Evaluation Framework: demonstrating the impact of a national framework for obesity prevention in low-income populations.Transl Behav Med. 2019; 9: 970-979Crossref PubMed Scopus (19) Google Scholar The framework suggests staff collect and report the number, type, and strength of partnerships, coalitions, PSE changes made to improve nutrition and physical activity environments, PSE changes accompanied by education or training, and outside resources supporting those PSE changes. These indicators are described in greater detail in Table 2. The evaluation was deemed exempt from review by the LSU AgCenter Institutional Review Board under blanket approval for program evaluation.Table 2Quantitative Outcomes of the LSU AgCenter Healthy Communities InitiativeSelected SNAP-Ed Evaluation Framework IndicatoraMore information on the SNAP-Ed evaluation framework indicators is available at (https://snapedtoolkit.org/framework/index/). The letters indicate the duration of the expected change (ST, MT, LT), and each category has several indicators, represented by the numbers following the letters. The table presents relevant indicators selected to evaluate the LSU AgCenter Healthy Communities Initiative, but other indicators are listed on the SNAP-Ed websiteFY2020FY2021FY2022TotalST7a. Partnerships establishedbPartner organizations that regularly meet, exchange information, and identify and implement mutually reinforcing activities that will contribute to the adoption of ≥ 1 PSE change intervention5026988312,031ST7b. Partnership strength NetworkcDefined as sending and receiving information related to the LSU AgCenter Healthy Communities Initiative547488216 CooperatordDefined as working with LSU AgCenter to deliver nutrition or physical activity education programs142195245582 CoordinationeDefined as working with LSU AgCenter to implement PSE changes at 1 location78177128383 CoalitionfDefined as membership in an LSU AgCenter Healthy Communities coalition working to implement PSE changes at multiple locations112133158403 CollaborationgDefined as working with LSU AgCenter to jointly lead planning and implementation of educational or PSE change activities.116177212505ST8. Coalitions established4652146244MT5a Nutrition-focused PSE changes532880161 MT5b. Policy changes70916 MT5c. Systems changes33161968 MT5d. Environmental changes331852103MT6a. Physical activity-focused PSE changes324069141 MT6b. Policy changes70310 MT6c. Systems changes1015732 MT6d. Environmental changes283859125LT5a. PSE changes that included education or staff training103922LT9. Leveraged resources LT9b. Funding (total dollars spent)$4,379,863$111,700$4,827$4,496,390 LT9c. In-kind support (volunteer hours)2,6091,8381,2065,653 LT9c. In-kind support (value of volunteer hours at $25.43/h)$66,347$46,740$30,667$143,754FY indicates fiscal year; LSU AgCenter, Louisiana State University Agriculture Center; LT, long term; MT, medium term; PSE, policy, systems, or environmental; SNAP-Ed, Supplemental Nutrition Assistance Program-Education; ST, Short term.a More information on the SNAP-Ed evaluation framework indicators is available at (https://snapedtoolkit.org/framework/index/). The letters indicate the duration of the expected change (ST, MT, LT), and each category has several indicators, represented by the numbers following the letters. The table presents relevant indicators selected to evaluate the LSU AgCenter Healthy Communities Initiative, but other indicators are listed on the SNAP-Ed websiteb Partner organizations that regularly meet, exchange information, and identify and implement mutually reinforcing activities that will contribute to the adoption of ≥ 1 PSE change interventionc Defined as sending and receiving information related to the LSU AgCenter Healthy Communities Initiatived Defined as working with LSU AgCenter to deliver nutrition or physical activity education programse Defined as working with LSU AgCenter to implement PSE changes at 1 locationf Defined as membership in an LSU AgCenter Healthy Communities coalition working to implement PSE changes at multiple locationsg Defined as working with LSU AgCenter to jointly lead planning and implementation of educational or PSE change activities. Open table in a new tab FY indicates fiscal year; LSU AgCenter, Louisiana State University Agriculture Center; LT, long term; MT, medium term; PSE, policy, systems, or environmental; SNAP-Ed, Supplemental Nutrition Assistance Program-Education; ST, Short term. Quantitative data collection occurred through FCS staff recording progress toward these indicators, such as the number and attendance of coalition meetings, partnerships, and PSE changes. The FCS staff reported these data using an application called Dynamics, developed by the LSU AgCenter information technology staff according to specifications provided by the LSU AgCenter SNAP-Ed Principal Investigator, program manager, and evaluator. The application served as a database for this information and was linked to a data visualization platform called Power BI. This allowed the evaluator to track PSE changes, coalitions, and partnerships and determine which changes most commonly occurred, what resources supported them, and where they occurred. A qualitative, participatory evaluation was then conducted to obtain an indepth understanding of the impact of these projects. This evaluation occurred through ripple effect mapping (REM), a collaborative session during which residents and partner organizations share program successes grouped into categories according to the community capitals framework (CCF) and displayed on a graphic visualization or map of all reported impacts from the coalition's work. The CCF describes different aspects of a community that may be affected by an intervention, such as human capital (knowledge and skills of residents) and built capital (physical changes to a community).24Chazdon S Emery M Hansen D Higgins L Sero R A Field Guide to Ripple Effects Mapping. University of Minnesota Libraries Publishing, 2017Google Scholar,25Emery M Flora C. Spiraling-up: mapping community transformation with community capitals framework.Community Dev. 2006; 37: 19-35Crossref Google Scholar This participatory evaluation method empowers residents and partner organizations to engage in decisions about the evaluation process, ensuring that it serves the needs of residents and partner organizations.26Minkler M Wallerstein N. Community-Based Participatory Research for Health: From Process to Outcomes. John Wiley & Sons, 2011Google Scholar These methods are an essential component of any program evaluation that aims to promote social justice,27Mertens DM. Transformative Research and Evaluation. Guilford Press, 2008Google Scholar and critical for community-based programs that seek to make lasting change and address community needs. Once Healthy Communities coalitions made ≥ 1 PSE change addressing the original needs identified at the community forum, the program evaluator held a REM session according to a fixed set of questions publicly available with program materials. Discussion responses were coded by the evaluator in a deductive process according to the CCF.25Emery M Flora C. Spiraling-up: mapping community transformation with community capitals framework.Community Dev. 2006; 37: 19-35Crossref Google Scholar,28Saldaña J. The Coding Manual for Qualitative Researchers. Sage, 2015Google Scholar In some cases, REM sessions occurred virtually or through surveys followed by a focus group discussion, methods that have been described elsewhere.29Greene MD Stroope J Holston D. Adapting ripple effect mapping to a virtual survey format.J Ext. 2022; 60: 9Google Scholar Since 2020, LSU AgCenter FCS agents have reported building 2,031 partnerships, 244 Healthy Communities coalitions, and implementing 302 PSE (Table 2). Most nutrition-focused PSE changes were environmental changes (eg, promoting healthy retail options or systems, including encouraging farmer's markets to accept SNAP benefits). Most PSE changes focused on physical activity were environmental, such as adding walking trails. Qualitative results from REM sessions held in 5 communities demonstrated that participants in all sessions identified program impacts in each of the constructs of the CCF. The most frequently cited impacts across all 5 sessions were impacts on human capital, such as increased knowledge of accessible gardening techniques after the establishment of an accessible teaching garden. The least frequently cited capital was natural capital, such as reducing erosion and collecting rainwater after a coalition received a grant for rain barrels. Additional examples of outcomes identified through REM are available online alongside program materials. Common outcomes across all coalitions included improving access to and attractiveness of areas for physical activity, raising awareness of the needs of marginalized communities, and enhancing the ability to advocate for communities. Through REM, community members and PSE implementation partners also noted benefits such as bringing together politically divided communities for a common cause, improving awareness of the needs of underserved communities, and reducing politicians’ negative perceptions of a majority African American area of a community. The initiative and program materials have been adapted for use by Cooperative Extension Service staff in 2 states. As of July 2022, the LSU AgCenter Healthy Communities Initiative materials have been downloaded 26 times since it was made publicly available in March 2022. The LSU AgCenter Healthy Communities Initiative is a community-participatory model that aims to foster physical activity- and nutrition-focused PSE changes that serve the needs of historically marginalized populations. Qualitative results indicated that most impacts were seen in human capital, which was expected, given that the intervention is implemented by FCS agents who focus on providing nutrition and physical activity education. However, obesity prevention programs that go beyond nutrition- and physical activity-focused PSE and educational interventions may be better suited to addressing health equity.15Greene M Houghtaling B Sadeghzadeh C et al.Nutrition interventions addressing structural racism: a scoping review.Nutr Res Rev. 2022; : 1-53Google Scholar,30Hummer R Hamilton E. Population Health in America. University of California Press, 2019Google Scholar,31Link BG Phelan J. Social conditions as fundamental causes of disease.J Health Soc Behav. 1995; Spec: 80-94Crossref Scopus (3771) Google Scholar For example, Kumanyika's Getting to Equity framework for obesity prevention outlines the need to improve the social and economic resources of marginalized communities.2Kumanyika SK. A framework for increasing equity impact in obesity prevention.Am J Public Health. 2019; 109: 1350-1357Crossref PubMed Scopus (98) Google Scholar Differences in financial resources have been proposed to be a fundamental cause of health disparities,31Link BG Phelan J. Social conditions as fundamental causes of disease.J Health Soc Behav. 1995; Spec: 80-94Crossref Scopus (3771) Google Scholar and a method through which structural racism results in racial disparities in obesity and food insecurity.32Aaron DG Stanford FC. Is obesity a manifestation of systemic racism? A ten-point strategy for study and intervention.J Intern Med. 2021; 290: 416-420Crossref PubMed Scopus (26) Google Scholar,33Harrell CJP Burford TI Cage BN et al.Multiple pathways linking racism to health outcomes.Du Bois Rev. 2011; 8: 143-157Crossref PubMed Scopus (158) Google Scholar Participants in REM sessions identified benefits to areas not typically serviced by FCS agents, such as providing computers to low-income students and establishing an addiction rehabilitation center. These impacts may play a role in targeting fundamental causes of obesity by improving economic prospects and social cohesion of communities, and the LSU AgCenter Healthy Communities Initiative may provide an opportunity for nutrition educators to undertake such an approach while encouraging physical activity and nutrition PSE changes. Furthermore, innovations that build social capital in ways described at REM sessions (coming together across political and racial divides) have greater potential to improve health equity than interventions that do not bring together people from different political and racial groups.34Mason C Barraket J Friel S O'Rourke K Stenta CP Social innovation for the promotion of health equity.Health Promot Int. 2015; 30: ii116-ii125Crossref PubMed Scopus (51) Google Scholar Future work will need to assess program impacts when implemented in diverse settings and/or with members of historically marginalized communities, such as African Americans and Native Americans. It is important to provide specific interventions addressing the needs of those communities to alleviate disparities in obesity rates and food insecurity because race-neutral approaches tend to perpetuate existing inequalities.1Mackey ER Burton ET Cadieux A et al.Addressing structural racism is critical for ameliorating the childhood obesity epidemic in Black youth.Child Obes. 2022; 18: 75-83Crossref PubMed Scopus (11) Google Scholar,35Bonilla-Silva E Racism Without Racists: Color-Blind Racism and the Persistence of Racial Inequality in the United States. Rowman & Littlefield Publishers, 2006Google Scholar,36Delaney SW Essien UR Navathe A. Disparate impact: how colorblind policies exacerbate Black–White health inequities.Ann Intern Med. 2021; 174: 1450-1451Crossref PubMed Scopus (7) Google Scholar Finally, future work is needed to assess the sustainability and long-term impact of PSE changes implemented through the LSU AgCenter Healthy Communities Initiative. This investigation was deemed exempt from review by the Louisiana State University Agriculture Center Institutional Review Board under blanket approval for program evaluation. Program materials related to this intervention are available at: https://forms.office.com/r/9VUxvGNuF8. This study was funded by the US Department of Agriculture Supplemental Nutrition Assistance Program-Education and Louisiana State University Extension.

Integrating Human-Centered Design Methods Into a Health Promotion Project: Supplemental Nutrition Assistance Program Education Case Study for Intervention Design.

Human-centered design, or design thinking, offers an extensive toolkit of methods and strategies for user-centered engagement that lends itself well to intervention development and implementation. These methods can be applied to the fields of public health and medicine to design interventions that may be more feasible and viable in real-world contexts than those developed with different methods. The design team aimed to develop approaches to building food skills among caregivers of children aged 0-5 years who are eligible for a federal food assistance program while they were in the grocery store. They applied 3 specific human-centered design methods-Extremes and Mainstreams, Journey Mapping, and Co-Creation Sessions-to collaboratively develop intervention approaches to enhance Supplemental Nutrition Assistance Program Education (SNAP-Ed) reach and impact across food retail settings. Extremes and Mainstreams is a specific kind of purposive sampling that selects individuals based on characteristics beyond demographics. Journey Mapping is a visual tool that asks individuals to identify key moments and decision points during an experience. Co-Creation Sessions are choreographed opportunities for individuals to explicitly contribute to the design of a solution alongside research or design team members. Ten caregivers with diverse lived experiences were selected to participate in remote design thinking workshops and create individual journey maps to depict their grocery store experiences. Common happy points and pain points were identified. Nine stakeholders, including caregivers, SNAP-Ed staff, and grocery store dieticians, cocreated 2 potential intervention approaches informed by caregivers' experiences and needs: a rewards program and a meal box option. These 3 human-centered design methods led to a meaningful co-design process where proposed interventions aligned with caregivers' wants and needs. This case study provides other public health practitioners with specific examples of how to use these methods in program development and stakeholder engagement as well as lessons learned when adapting these methods to remote settings.

“A Growing Relationship”: Cultivating Organizational Readiness to Influence Implementation of Policy, Systems, and Environmental (PSE) Change Programming in SNAP-Ed Funded School-Community Partnerships

ObjectiveProvide a nuanced understanding of how Supplemental Nutrition Assistance Program-Education (SNAP-Ed) implementers decide what programming a school is ready to implement and the organizational factors that facilitate the initial implementation of programming in schools. DesignCase studies conducted at schools during 2018–19. SettingNineteen School District of Philadelphia schools receiving nutrition programming funded by SNAP-Ed. ParticipantsInterviews were conducted with 119 school staff and SNAP-Ed implementers. A total of 138 hours of observations of SNAP-Ed programming were completed. Phenomenon of InterestHow do SNAP-Ed implementers decide what PSE programming a school is ready to implement? What organizational factors can be developed to facilitate the initial implementation of PSE programming in schools? AnalysisInterview transcripts and observation notes were coded deductively and inductively on the basis of theories of organizational readiness for programming implementation. ResultsSupplemental Nutrition Assistance Program-Education implementers focused on schools’ existing capacity when determining readiness for programming. Conclusions and ImplicationsFindings suggest that if SNAP-Ed implementers only focus on a school's existing capacity when assessing its readiness for programming, the school might not receive the programming it needs. Findings suggest SNAP-Ed implementers could develop a school's readiness for programming by concentrating efforts on cultivating relationships, program-specific capacity, and motivation at schools. Findings have equity implications for partnerships in underresourced schools that may have limited existing capacity and consequentially could be denied vital programming.

African American Perceptions of Service Provided by Supplemental Nutrition Assistance Program-Education: A Qualitative Exploration

ObjectiveTo assess African Americans’ satisfaction with Supplemental Nutrition Assistance Program-Education (SNAP-Ed) in Louisiana. MethodsAfrican American facilitators conducted 5 focus group discussions with 25 African American SNAP-Ed participants according to issues identified by African American SNAP-Ed implementers in Louisiana. Focus group discussion transcripts were coded independently using inductive and in vivo coding by 2 members of the research team. ResultsParticipants viewed lessons as race-neutral and thought they should include more information about African American history and culture. Participants also noted a lack of engagement with the African American community and stressed the need for the program to employ African American staff. However, participants thought the information was important for African Americans in the context of medical issues faced by their community. Conclusions and ImplicationsFindings indicate that SNAP-Ed in Louisiana be modified to address African American food history and culture, additional African American staff and better engagement with the African American community.