BACKGROUND:The Implementation Leadership Scale (ILS) is widely used to measure implementation leadership for health innovations. While used often in behavioral health and other clinical settings, it remains untested in community public health contexts such as food retail. Healthy food retail strategies, including nutrition incentive programs, could benefit from measuring and subsequently strengthening leadership support to facilitate effective implementation. The objective of this study was to test the suitability of an adapted ILS to measure leadership support for a nutrition incentive program implemented in a brick-and-mortar food retail setting. METHODS:As part of a larger evaluation, a multidisciplinary team of practitioners, evaluators, and food retail representatives created a modified version of the ILS suitable for the food retail context. Food retailer staff and management from one privately-owned grocery chain who participated in implementing a nutrition incentive program for Supplemental Nutrition Assistance Program (SNAP) shoppers in Southern California completed a survey that included the adapted ILS. Of the 522 survey respondents from the larger evaluation, 473 retailers including management and staff provided complete responses for the ILS. We assessed construct validity, internal consistency reliability, and measurement invariance using differential item functioning (DIF) analyses, Cronbach's alpha, confirmatory factor analysis (CFA), and multiple-group CFA for the adapted ILS. RESULTS:DIF analyses indicated minimal evidence of measurement bias. The CFA supported the original four-factor ILS structure, with excellent internal consistency for the knowledgeable, supportive, and perseverant subscales and fair consistency for the proactive subscale. Further, the demonstrated measurement invariance between management and staff highlights the robustness of the ILS and its potential for assessing alignment or discrepancies in perceptions of implementation leadership between management and staff within food retail organizations. CONCLUSIONS:Findings suggest that the adapted ILS is a valid and reliable tool for measuring implementation leadership support for nutrition incentive programs in a food retail setting in the US. Future research should examine the adapted ILS across diverse food retail environments and healthy food retail strategies to improve its generalizability and applicability.

BACKGROUND:Produce prescription programs (PRx) have the potential to improve participants' fruit and vegetable intake (FVI), and food security (FS), but further information is needed to understand which program characteristics contribute to these participant outcomes. PURPOSE:To explore the associations between PRx design characteristics, incentive redemption, and program-level participant outcomes including FVI, FS, and perceived health. METHODS:An ecological, exploratory study with a quasi-experimental design (one group pre-test post-test) following the exploration, preparation, implementation, sustainment (EPIS) framework was used among Gus Schumacher Nutrition Incentive Program (GusNIP)-funded PRxs in the United States. Data were sourced from a GusNIP program operator survey (84% response rate; n = 80), PRx redemption data (n = 77), and an outcomes sample including redemption and participant outcomes data (n = 39 programs). Redemption data included program-level incentive distribution and redemption rates, measured as the dollar amount of incentives redeemed per participant per month. Participant data included changes in FVI (dietary screener questionnaire), FS (USDA household FS survey module), and perceived health (healthy days). Nonparametric and parametric comparisons were examined between program characteristics with program level-redemption rates and changes in aggregated participant-level outcomes. RESULTS:Program-level characteristics, design, and implementation features were associated both positively and negatively with redemption data and changes in participant outcomes including FVI, FS, and perceived health. Programs that provide more funds but serve fewer participants, offer transportation assistance, and offer staff training were positively associated with improved aggregated participant outcomes. CONCLUSIONS:This exploratory research identified factors to be considered for promoting favorable program and participant outcomes in GusNIP PRx and similar initiatives.

BackgroundWhile food insecurity (FI) assesses household access to sufficient food, increasing attention is being paid to nutrition security (NS), the ability to obtain health-promoting foods.AimThis cross-sectional analysis examined differences in sociodemographics, diet quality, and health status between food insecure families with low versus high NS and assessed if FI and NS severity was associated with food assistance program use.MethodsData were obtained from the 2023 Massachusetts Statewide Food Access Survey of >3000 adults. FI was assessed using the United States Department of Agriculture 18-item Household Food Security Module, NS via a validated four-item scale, and diet quality via the Prime Diet Quality Score (PDQS). FI and NS were analyzed as binary and continuous variables. Inferential statistics assessed group differences. Logistic regression assessed associations between the severity of FI and NS and food assistance program use.SummaryHouseholds with FI, ≥1 child (≤18 years), and annual income ≤$50,000 (n = 335) were included. Forty-three percent reported low NS. Low (vs. high) household NS was associated with a higher prevalence of child-level FI (79% vs. 43%, P < 0.001), SNAP use (83% vs. 70%, P = 0.009), food pantry use (69% vs. 44%, P < 0.001), adult overweight/obesity (39% vs. 17%, P < 0.001), and lower adult PDQS (43 ± 5.1 vs. 44 ± 4.3, P = 0.023), indicating lower diet quality. More severe household FI and lower NS were associated with higher odds of SNAP and food pantry use (P < 0.001). These findings support expanding food assistance programs to increase nutritious food access for families with children before food and nutrition insecurity become severe.

Objective: This meta-ethnography aimed to examine and thematically analyze relevant qualitative studies to create a nutrition security conceptual framework. Design: Following the 7-step process for a meta-ethnography, we screened 6,831 studies and included eligible papers relating to nutrition security. Setting: US-based studies. Participants: 2,709 participants in 58 qualitative papers reviewed. Phenomenon of Interest: Nutrition security. Intervention: Not applicable. Analysis: Two researchers independently read and extracted data from each paper. This information was then combined, and 2 investigators generated themes to determine critical constructs of nutrition security. Constructs were then combined into a conceptual model. Results: The final conceptual framework includes 2 primary constructs (environmental circumstances and psychosocial functioning), 16 secondary constructs, and 51 tertiary constructs of nutrition security. Conclusions and Implications: This is the first meta-ethnography to focus on concepts related to nutrition security rather than food security. There is an overlap between our findings and the existing framework for food security, including the 6 pillars of food security and the 5 domains of food access. An improved understanding of nutrition security and the proposed conceptual framework established will help guide the development of improved nutrition security measures and interventions to improve diet quality and overall health.

Background: Food and nutrition security are key social determinants of cardiometabolic health. While food security reflects access to sufficient food, nutrition security incorporates the quality, consistency, and usability of food that supports long-term health. However, few studies have examined how household-level barriers to food utilization shape these relationships. Objective: This study assessed whether tangible (e.g., equipment, storage) and intangible (e.g., time, knowledge) food utilization barriers modify the associations between food and nutrition security and cardiometabolic outcomes in low-income adults. Methods: A cross-sectional survey was conducted among 486 low-income adults across five U.S. states. Participants reported household food security (USDA 18-item module), nutrition security (four-item scale), and utilization barriers (eight-item scale, categorized into tangible and intangible subscales). Self-reported diagnoses of hypertension, hyperlipidemia, and diabetes were combined into a cardiometabolic outcome. Mixed-effects logistic regression models, adjusted for sociodemographic and program participation factors, were used to assess associations and effect modification. Results: Higher nutrition security was associated with lower odds of cardiometabolic conditions (AOR = 0.59; 95% CI: 0.41-0.83). Tangible barriers significantly modified the relationship between nutrition security and hypertension (p-interaction = 0.04), with stronger protective effects observed in households without such barriers. No significant moderation effects were found for intangible barriers or for food security. Conclusions: Tangible household barriers influence the protective association between nutrition security and cardiometabolic outcomes. Public health strategies should address not only food access but also the practical resources required to store, prepare, and consume healthy foods effectively.

This study explored household-level resilience to household-level financial shocks (e.g. unexpected loss of income or large expenses) - a food insecurity risk factor. We conducted 47 semi-structured interviews across five states in the United States. The inductive thematic analysis revealed themes related to capacities a household may have to absorb, adapt, or transform their livelihood situation in response to a financial shock. Thirteen themes emerged related to monetary resources, social connections, situational barriers, and environmental factors that can impact resilience to food insecurity. Moving our focus upstream to better understand these issues may be crucial for intervention.

Objectives: To examine the relationships between food security, nutrition security, Supplemental Nutrition Assistance Program (SNAP) participation, and cardiometabolic outcomes, including hypertension, hyperlipidemia, or diabetes, among low-income U.S. individuals. Methods: A cross-sectional survey of 486 participants (April–June 2021) assessed food and nutrition security and cardiometabolic outcomes. Mixed-effects logistic regression models adjusted for covariates and included a random effect for state of residence. Moderation analyses evaluated SNAP participation’s impact. Results: Very low food security was associated with higher odds of having at least one cardiometabolic condition, such as hypertension, hyperlipidemia, or diabetes (AOR = 1.96; 95% CI: 1.04–3.69; p = 0.04). SNAP moderated this relationship (p-interaction = 0.007), with non-participants experiencing significantly higher risk. Non-SNAP participants with very low food security had 3.17 (95% CI = 1.17–8.61) times higher odds of having a cardiometabolic condition. Among SNAP participants, very low food security was not significantly associated with having a cardiometabolic condition (OR = 1.62; 95% CI = 0.64–4.13). Higher nutrition security was associated with lower odds of having at least one cardiometabolic condition (AOR = 0.59; 95% CI: 0.41–0.83; p = 0.002). Conclusions: Nutrition security and SNAP participation mitigate cardiometabolic risks, underscoring their importance in public health interventions.

BACKGROUND:One of the first survey measures for assessing nutrition security in the United States is referred to as the Household Nutrition Security Scale (HNSS). Although the analyses conducted in the original HNSS development study supported the validity and reliability of the scale, some survey development steps were beyond the scope of the original study, such as confirmatory factor analysis (CFA) and differential item functioning (DIF). OBJECTIVES:This study aims to conduct CFA and DIF analyses on the HNSS within a new statewide sample in Massachusetts. METHODS:From November 2022 to January 2023, the Greater Boston Food Bank and Mass General Brigham conducted a cross-sectional, statewide, representative survey of Massachusetts adults. In addition to other topics, respondents answered questions about sociodemographics and completed the HNSS. To assess CFA model fit, the Satorra-Bentler scaled chi-squared test, root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), and the Bentler Comparative Fit Index (CFI) were calculated. Cronbach's alpha was calculated to assess internal consistency. The Cochran-Mantel-Haenszel procedure was used to investigate DIF across demographic groups. RESULTS:Participants in the analytic sample (n = 2903) were mostly at or under age 54 (60.7%), women (58.0%), non-Hispanic White (71.3%), and with household incomes <$75,000 (71.1%). CFA model fit metrics were well within thresholds for adequate model fit [chi-square 5.213 (Degrees of freedom (DF) = 2, P = 0.074), RMSEA = 0.024 (95% confidence interval: 0.000, 0.049), SRMR = 0.006, and CFI = 0.999]. Cronbach's alpha was 0.923. There was no indication of DIF for any of the 4 items across groups for age, race/ethnicity, gender, educational attainment, income, having children in the household, or household size. CONCLUSIONS:These findings further support construct validity and reliability of HNSS, and the further use of the scale for research and program evaluation purposes within sociodemographically diverse samples of households.

Background: Produce prescription programs are a type of Food is Medicine (FIM) strategy to address food and nutrition insecurity and promote health among patients. Although produce prescription programs can be effective at improving health (e.g., reduce hemoglobin A1c), program designs tend to be highly heterogeneous, and the degree to which participants engage with the programs and redeem prescriptions varies widely. Objectives: The purpose of this qualitative study was to explore produce prescription programs design and implementation practices for promoting fruit and vegetable prescription redemption and participant engagement using an implementation science framework. Methods: Interview guide development followed the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework. We conducted 60-min semistructured interviews with Gus Schumacher Nutrition Incentive Program produce prescription program leads (n = 15) from across the United States to understand factors they felt impacted participant redemption and engagement. We used an inductive thematic analysis using a rapid qualitative approach and mapped emergent themes to EPIS constructs to identify themes. Results: We identified 16 relevant themes. These themes centered around ensuring programmatic fit to the participants and the setting, especially addressing access barriers, partnerships and staffing, added services provided, and systems for program monitoring and for participant navigation and communication. Conclusions: This study helps elucidate further about produce prescription program characteristics that may influence prescription redemption and engagement. These qualitative findings can help provide evidence to current program implementers and future researchers of the best practices for produce prescription programs and FIM interventions overall.

Food security is a commonly screened for health-related social need at hospitals and community settings, and until recently, there were no tools to additionally screen for nutrition security. The purpose of this study was to assess the potential advantage of including a one-item brief nutrition security screener (BNSS) alongside the commonly used two-item Hunger Vital Sign (HVS) food security screener for identifying individuals with diet-related health risks. Cross-sectional survey data were collected from April to June 2021. Generalized linear mixed models were used to assess associations between screening status and dietary and health variables. Recruitment was done across five states (California, Florida, Maryland, North Carolina, and Washington) from community-based organizations. Participants (n = 435) were, on average, 44.7 years old (SD = 14.5), predominantly women (77%), and racially/ethnically diverse. In adjusted analyses, being in the food insecure and nutrition insecure group (but not the food insecure and nutrition secure or food secure and nutrition insecure groups) was associated with significantly increased odds for self-reported "fair" or "poor" general health [OR = 2.914 (95% CI = 1.521-5.581)], reporting at least one chronic condition [2.028 (1.024-4.018)], and "low" fruit and vegetable intake [2.421 (1.258-4.660)], compared with the food secure and nutrition secure group. These findings support using both the HVS and BNSS simultaneously in health-related social needs screening to identify participants at the highest risk for poor dietary and health outcomes and warrant further investigation into applying these screeners to clinical and community settings.

The purpose of this study was to identify policy, technological, and programmatic changes necessary for adoption and implementation of WIC online ordering with online transactions. A Delphi technique was used to identify and prioritize challenges from WIC decision-makers and stakeholders. WIC participants were identified as primary users of online ordering systems with retail store staff as important secondary users. Thematic analysis identified challenges in: 1) Rules/Regulations; 2) Shopping Experience; 3) Security, Confidentiality, Fraud, and State Agency Processes; 4) Training and Education; and 5) Equitable Access/Buy-in. The study identified initial processes that impact adoption, implementation, and maintenance of WIC online ordering.

BackgroundInadequate nutrition and poor diet quality are associated with heightened risk for diabetes. The connection between food insecurity measures and diabetes has been established, with evidence indicating that SNAP participation contributes to reductions in food insecurity. Recently developed nutrition security measures, defined as the ability to acquire healthful foods to prevent diseases, and its association with diabetes and SNAP participation is not yet understood.ObjectiveThe purpose of this study is to assess the relationship between nutrition security and food security in relation to diabetes overall, and by SNAP participation and nutrition security as potential modifiers.MethodsSecondary data analysis of cross-sectional pilot study data collected from adults in five US states [N= 517]. Logistic regression mixed models included moderation analysis and clustering effects by state to address site level confounding.ResultsHigher nutrition security scores among adults, after adjusting for confounders, were significantly associated with lower odds of diabetes risk (AOR= 0.59; 95% CI: 0.40, 0.87; P value=0.008). Statistically significant interaction effect of differences according to SNAP participation was observed for nutrition security (Phomogeneity/interaction =0.021), adjusting for age, gender, race/ethnicity, education, employment, NSLP, WIC, food pantry use, household with children, survey mode, and food security. The association between food security and diabetes was not statistically significant overall. However, statistically significant interaction effect of differences according to SNAP participation was observed for food security (Phomogeneity/interaction=0.047). Further, no interaction effect of differences by nutrition security was found between food security and self-reported diabetes/pre-diabetes (Phomogeneity/interaction=0.250).ConclusionsThis study sheds light on the early exploration of the intricate relationship between nutrition security and diabetes. The findings suggest that a higher nutrition security score, after adjusting for confounders, is significantly associated with lower odds of diabetes risk. Notably, there is statistically significant interaction effects in these associations based on SNAP participation.

Background:Inadequate nutrition and poor diet quality are associated with a heightened risk of diabetes. The connection between food insecurity measures and diabetes has been established, with evidence indicating that Supplemental Nutrition Assistance Program (SNAP) participation contributes to reductions in food insecurity. Recently developed nutrition security measures, defined as the ability to acquire healthful foods to prevent diseases, and their association with diabetes and SNAP participation are not yet understood.Objectives:This study aimed to assess the relationship between food security and nutrition security in relation to diabetes overall and by SNAP participation and nutrition security as potential modifiers.Methods:Secondary data analysis of cross-sectional pilot study data collected from adults in 5 US states (N = 517). Logistic regression mixed models included moderation analysis and clustering effects by state to address site-level confounding.Results:Higher nutrition security scores among adults, after adjusting for confounders, were significantly associated with lower odds of diabetes risk (adjusted odds ratio = 0.59; 95% confidence interval: 0.40, 0.87; P value = 0.008). Statistically significant interaction effect of differences according to SNAP participation was observed for nutrition security (Phomogeneity/interaction = 0.021), adjusting for age, gender, race/ethnicity, education, employment, National School Lunch Program, Special Supplemental Nutrition Program for Women, Infants, and Children, food pantry use, household with children, survey mode, and food security. The association between food security and diabetes was not statistically significant overall. However, statistically significant interaction effect of differences according to SNAP participation was observed for food security (Phomogeneity/interaction = 0.047). Further, no interaction effect of differences in nutrition security was found between food security and self-reported diabetes/prediabetes (Phomogeneity/interaction = 0.250).Conclusions:This study sheds light on the early exploration of the intricate relationship between nutrition security and diabetes. The findings suggest that a higher nutrition security score, after adjusting for confounders, was significantly associated with lower odds of diabetes risk. Notably, there were statistically significant interaction effects in these associations based on SNAP participation.

Background Federal food assistance programs are working towards online grocery shopping. Online ordering in Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is emerging following successful implementation in Supplemental Nutrition Assistance Program (SNAP).Objective To identify anticipated challenges, potential solutions, and expected costs of WIC online ordering.Design Cross-sectional, mixed-methods, web-based, survey research.Subjects and setting Data were collected from December 2020 to January 2021. Purposeful and snowball sampling included WIC stakeholders involved in developing processes and systems required for WIC online ordering. Respondents represented diverse geographic areas, levels of intraorganizational authority, and WIC benefit card types.Statistical analyses performed The research team used a rapid analysis and lean coding approach to identify emergent themes from open-ended survey responses. Descriptive statistics were used to describe the distribution of responses across themes and stakeholder types.Results Respondents (n 1/4 145) described 812 anticipated challenges within 20 themes grouped into five topic areas: rules and regulations; shopping experience; security, confidentiality, fraud, and WIC State agency processes; training, assistance, and education; and equitable access and buy-in. Addressing anticipated regulatory issues were among the few concrete potential solutions described. The two most frequent costs reported were increased staff time and start-up and ongoing technology costs.Conclusions This study identified several, critical anticipated challenges and considerations that will help prepare WIC state agencies for opportunities to expand online ordering to WIC participants.J Acad Nutr Diet. 2023;123(10):1449-1460.

This study examined consumption of fruits and vegetables, foods with added sugar and sugar-sweetened beverages (SSBs) based on the frequency of food pantry use. A repeated cross-sectional study was conducted among food pantry clients (n = 563) in Omaha, Nebraska. Daily intake of individual dietary items was combined into each final dietary outcome measure and dichotomized: <1 time per day or >= times per day. Descriptive statistics were produced, and a logistic regression model was fit. More frequent pantry use was associated with 2.1 times greater odds of consuming foods with added sugar one or more times per day compared to non-pantry users.

In recent reviews of available measures, no existing measures assessed all four pillars of food security and most only assessed one or two pillars–predominantly the access pillar. The purpose of this study was to preliminarily develop novel measures of availability, utilization, and stability that are complementary to the USDA’s household food security survey measure (HFSSM). A formative phase included an expert advisory group, literature scans, and interviews with individuals experiencing food insecurity. From April-June 2021, the new measures were piloted in five states (California, Florida, Maryland, North Carolina, and Washington). The cross-sectional pilot survey included the new measures (perceived limited availability, utilization barriers, and food insecurity stability), scales and items for validation (e.g., food security, and self-reported dietary and health outcomes), and demographic questions. Exploratory factor analysis was used to assess dimensionality, internal consistency was assessed using Kuder-Richardson formula 21 (KR21), and convergent and discriminant validity were assessed using Spearman’s correlation coefficients. Also, a brief screener version was created for the utilization barriers measure that may be necessary for certain applications (e.g., clinical intake screening to inform referrals to assistance programs). The analytic samples (perceived limited availability (n = 334); utilization barriers (n = 428); food insecurity stability (n = 445)) were around 45 years old on average, most households had children, over two-thirds were food insecure, over three-fourths were women, and the samples were racially/ethnically diverse. All items loaded highly and unambiguously to a factor (factor loadings range 0.525–0.903). Food insecurity stability showed a four-factor structure, utilization barriers showed a two-factor structure, and perceived limited availability showed a two-factor structure. KR21 metrics ranged from 0.72 to 0.84. Higher scores for the new measures were generally associated with increased food insecurity (rhos = 0.248–0.497), except for one of the food insecurity stability scores. Also, several of the measures were associated with statistically significantly worse health and dietary outcomes. The findings support the reliability and construct validity of these new measures within a largely low-income and food insecure sample of households in the United States. Following further testing, such as Confirmatory Factor Analysis in future samples, these measures may be used in various applications to promote a more comprehensive understanding of the food insecurity experience. Such work can help inform novel intervention approaches to address food insecurity more fully.

This qualitative study aimed to understand the actions, challenges, and lessons learned for addressing the food and water needs of flood survivors, with a special focus on vulnerable populations and the implications for food security, to inform future disaster response efforts in the U.S. Semi-structured in-depth interviews were conducted from January to August 2020 with the local, state, and national stakeholders (n = 27) involved in the disaster response to the 2019 Nebraska floods, particularly those involved in providing mass care, such as food, water, and shelter, for the flood survivors. The challenge themes were related to limited risk awareness and apathy, the large scope of the impact, the difficulty with coordination and communication, the challenges in risk communication, the limited local-level capacity, and the perceived stigma and fear limiting the utilization of governmental assistance. The mitigation recommendations included the need to consider zoning and infrastructure updates, the implementation of efficient systems that leverage technology for coordination and communication, and guidance on how to address certain human factors. This study reinforces previous findings related to flood disasters and adds to our understanding of disaster response and food insecurity. The practical takeaways from this study can inform future flood-related disaster mitigation approaches in Nebraska and other rural areas.

The purpose of this study was to preliminarily develop novel self-administered measures to assess nutrition security and choice in dietary characteristics. Measures were piloted in a convenience sample of households at risk for food insecurity in the United States. The survey included the new measures, construct validation variables (household food security, self-reported general health, and dietary variables), and demographic questions. Exploratory factor analysis was used to assess dimensionality, internal (Cronbach's alpha (CA)), and construct validity were assessed (Spearman's correlation). Multivariate logistic regression models were used to assess added utility of the new measures beyond food security measurement. Finally, brief screener versions of the full measures were created. Participants in the analytic sample (n = 380) averaged 45 years old, 71% experiencing food insecurity, 42% with high school diploma or less, 78% were women, and racially/ethnically diverse. Scores for the Household Nutrition Security (CA = 0.85; Mean = 2.58 (SD = 0.87)), Household Healthfulness Choice (CA = 0.79; Mean = 2.47 (SD = 0.96)), and Household Dietary Choice (CA = 0.80; Mean = 2.57 (SD = 0.90)) were positively associated with food security (0.401-0.657), general health (0.194-0.290), fruit and vegetable intake frequency (0.240-0.280), and "scratch-cooked" meal intake (0.328-0.350), and negatively associated with "processed" meal intake (-0.162 to -0.234) and an external locus of nutrition control (-0.343 to -0.366). Further, findings show that the new measures are useful for assessing risk for poor dietary and health outcomes even after controlling for household food security status and sample characteristics. These findings are encouraging and support reliability, construct validity, and utility of these new measures. Following further testing, such as Confirmatory Factor Analysis in future samples, these measures may be used in various applications to contribute to a better understanding of households' limitations for accessing healthful foods and foods that meet their preferences.