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ObjectiveFruit and vegetable (F&V) intake is influenced by behavioural and environmental factors, but these have rarely been assessed simultaneously. We aimed to quantify the relative influence of supermarket availability, perceptions of the food environment and shopping behaviour on F&V intake.DesignA cross-sectional study.SettingEight counties in South Carolina, USA, with verified locations of all supermarkets.SubjectsA telephone survey of 831 household food shoppers ascertained F&V intake with a seventeen-item screener, primary food store location, shopping frequency and perceptions of healthy food availability, and supermarket availability was calculated with a geographic information system. Path analysis was conducted. We report standardized beta coefficients on paths significant at the 0·05 level.ResultsFrequency of grocery shopping at primary food store (β = 0·11) was the only factor exerting an independent, statistically significant direct effect on F&V intake. Supermarket availability was significantly associated with distance to utilized food store (β = −0·24) and shopping frequency (β = 0·10). Increased supermarket availability was significantly and positively related to perceived healthy food availability in the neighbourhood (β = 0·18) and ease of shopping access (β = 0·09). Collectively considering all model paths linked to perceived availability of healthy foods, this measure was the only other factor to have a significant total effect on F&V intake.ConclusionsWhile the majority of the literature to date has suggested an independent and important role of supermarket availability for F&V intake, our study found only indirect effects of supermarket availability and suggests that food shopping frequency and perceptions of healthy food availability are two integral components of a network of influences on F&V intake. [ABSTRACT FROM AUTHOR]

Food Security Partners of Middle Tennessee has created a novel model of assessment, grassroots policy development, and targeted research for engaging community members in an analysis of the local food system. This dynamic model can reduce the substantial investment required for a more conventional community food assessment and assumes that targeted research and community assessment constitute an ongoing process that can be concurrent with strategic action and advocacy. This model includes six stages: (1) organizing, planning, and relationship building; (2) information exchange; (3) grassroots policy development; (4) dissemination; (5) advocacy and strategic action campaigns; (6) evaluation; and (7) celebration. [ABSTRACT FROM AUTHOR]

Coalitions are important strategies for addressing complex social and health issues such as food insecurity. Communal in nature, coalitions are influenced by historical and contextual factors and involve explicit processes for facilitating collaborative and mutually beneficial strategies for change. In this case study, we provide a rich description of the contextual landscape underpinning a community-engaged food security coalition, an overview of their participatory planning process, and evidence of collaboration among coalition actors. We use qualitative and social network analyses. Results reveal the importance of time, consciousness raising, people power, and financial and political support for coalition development. These results illuminate increases in collaboration among coalition actors over a two-year time frame. [ABSTRACT FROM AUTHOR]

Federally qualified health centers (FQHCs) improve access to care for important health services (e.g., preventive care), particularly among marginalized and underserved communities. However, whether spatial availability of FQHCs influences care-seeking behavior for medically underserved residents is unclear. The objective of this study was to examine the relationships of present-day zip-code level availability of FQHCs, historic redlining, and health services utilization (i.e., at FQHCs and any health clinic/facility) in six large states. We further examined these associations by states, FQHC availability (i.e., 1, 2–4 and ≥5 FQHC sites per zip code) and geographic areas (i.e., urbanized vs. rural, redlined vs. non-redlined sections of urban areas). Using Poisson and multivariate regression models, we found that in medically underserved areas, having at least one FQHC site was associated with greater likelihood of patients seeking health services at FQHCs [rate ratio (RR) = 3.27, 95%CI: 2.27–4.70] than areas with no FQHCs available, varying across states (RRs = 1.12 to 6.33). Relationships were stronger in zip codes with ≥5 FQHC sites, small towns, metropolitan areas, and redlined sections of urban areas (HOLC D-grade vs. C-grade: RR = 1.24, 95%CI: 1.21–1.27). However, these relationships did not remain true for routine care visits at any health clinic or facility (β = −0.122; p = 0.008) or with worsening HOLC grades (β = −0.082; p = 0.750), potentially due to the contextual factors associated with FQHC locations. Findings suggest that efforts to expand FQHCs may be most impactful for medically underserved residents living in small towns, metropolitan areas and redlined sections of urban areas. Because FQHCs can provide high quality, culturally competent, cost-effective access to important primary care, behavioral health, and enabling services that uniquely benefit low-income and marginalized patient populations, particularly those who have been historically denied access to health care, improving availability of FQHCs may be an important mechanism for improving health care access and reducing subsequent inequities for these underserved groups. • Zip codes with ≥1 federally qualified health center (FQHC) increased the likelihood of FQHC use. • We found decreases in routine care visits (at any health clinic) in FQHC-hosting zip codes. • Racial/ethnic and socioeconomic factors partly explained differences in FQHC use. • FQHCs were most impactful in small towns, metropolitan areas, and redlined areas. [ABSTRACT FROM AUTHOR]

"Phenotype F counties differentiated from those of Phenotype D by having a 33% higher percentage of people who were physically inactive." now reads: "Phenotype F counties differentiated from those of Phenotype D by having more people who were physically inactive." Correction to: I Scientific Reports i https://doi.org/10.1038/s41598-023-30188-9, published online 20 February 2023 The original version of this Article contained an error in the Results section. [Extracted from the article]

This study examines the link between implementation of Strategies to Enhance Practice (STEPs) and outcomes. Twenty after-school programs (ASPs) participated in an intervention to increase children’s accumulation of 30 minutes/day of moderate to vigorous physical activity (MVPA) and quality of snacks served during program time. Outcomes were measured via accelerometer (MVPA) and direct observation (snacks). STEPs implementation data were collected via document review and direct observation. Based on implementation data, ASPs were divided into high/low implementers. Differences between high/low implementers’ change in percentage of boys accumulating 30 minutes/day of MVPA were observed. There was no difference between high/low implementers for girls. Days fruits and/or vegetables and water were served increased in the high/low implementation groups, while desserts and sugar-sweetened beverages decreased. Effect sizes (ES) for the difference in changes between the high and low group ranged from low (ES = 0.16) to high (ES = 0.97). Higher levels of implementation led to increased MVPA for boys, whereas girls MVPA benefited from the intervention regardless of high/low implementation. ESs of the difference between high/low implementers indicate that increased implementation of STEPs increases days healthier snacks are served. Programs in the high-implementation group implemented a variety of STEPs strategies, suggesting local adoption/adaptation is key to implementation. [ABSTRACT FROM AUTHOR]

Introduction: Afterschool programs (ASPs) across the US are working towards achieving the standard of all children accumulating 30min of moderate-to-vigorous physical activity (MVPA) during program time. This study describes the two-year impact of an intervention designed to assist ASPs meeting the 30min/day MVPA standard.Methods: Using a two-year delayed treatment, group randomized controlled trial, 20 ASPs serving ~1700 children/year (6-12yrs) were randomized to either an immediate (n=10, baseline-2013 and 2yrs intervention fall-2013-to-spring-2015) or delayed group (n=10, baseline 2013-2014 and 1yr intervention fall-2014-to-spring-2015). The intervention, Strategies-To-Enhance-Practice (STEPs), focused on programming MVPA in the daily schedule, training of staff and leaders, and ongoing technical support/assistance. Accelerometry-derived proportion of children meeting the 30min/day MVPA standard was measured in the spring of each year. Mixed model logistic regressions were used to examine the change in the odds of achieving the MVPA standard. Analyses were conducted in 2015. Data were collected in one southeastern US state.Results: Immediate boys (n=677) and delayed girls (n=658) increased the percent achieving 30min MVPA/day from 35.9% to 47.0% (odds ratio [OR]=1.88, 95% CI 1.18-3.00) and 13.1% to 19.1% (OR=1.42, 95% CI 1.03-1.96). Immediate girls (n=613) and delayed boys (n=687) exhibited a nonsignificant increase from 19.1% to 21.6% (OR=1.20, 95% CI 0.84-1.72) and 29.0% to 31.3% (OR=1.13, 95%CI 0.80-1.58).Conclusions: STEPs can have an impact on children's MVPA and time spent sedentary, yet was unable to fully achieve the goal of all children accumulating 30minMVPA/day. Additional efforts are need to identify strategies ASPs can use to meet this important public health standard. [ABSTRACT FROM AUTHOR]

Afterschool programs (ASPs) have potential to provide children moderate to vigorous physical activity (MVPA). The availability and types (e.g., free play or organized activities) of physical activity opportunities, their structure (e.g., presence of lines, elimination games), and staff behaviors (e.g., encouragement, engaged) can influence children’s MVPA. This study explored these factors in 20 ASPs serving over 1,700 elementary-age children. The occurrence, types, and structure of physical activity opportunities, and staff behaviors were collected via the SOSPAN (System for Observing Staff Promotion of Physical Activity and Nutrition). A total of 4,660 SOSPAN scans were completed across 63 complete program days (1,733 during physical activity opportunities). Physical activity opportunities were observed on 60 program days across all 20 sites, with 73% of those opportunities classified as free play. ASPs scheduled an average of 66.3 minutes (range 15-150 minutes) of physical activity opportunities daily. Games played included basketball, tag, soccer, and football. Staff rarely engaged in physical activity promotion behaviors, and the structure of organized games discouraged MVPA. For example, staff verbally promoted physical activity in just 6.1% of scans, while organized games were more likely to involve lines and elimination. Professional development training may enhance staffs’ physical activity promotion and the structure of activity opportunities. [ABSTRACT FROM AUTHOR]

Redlining was a racialized zoning practice in the U.S. that blocked fair access to home loans during the 1930s, and recent research is illuminating health problems in the current residents of these historically redlined areas. However, this work has not yet been holistically summarized. Here, we present the first systematic review and meta-analysis comparing health outcomes in redlined versus non-redlined neighborhoods in U.S. cities. We extracted relevant articles in PubMed, Web of Science, Cochrane and Science Direct databases published from January 2010 to September 2021. The search revealed 12 studies on preterm births (n = 3), gunshot-related injuries (n = 2), cancer (n = 1), asthma (n = 1), self-rated health (n = 1), multiple health outcomes (n = 2), heat-related outcomes (n = 1) and COVID-19 incidence and mortality (n = 1). A meta-analysis of three studies found the odds of having preterm birth was significantly higher (OR = 1.41, 95% CI: 1.05, 1.88; p = 0.02) among women living in redlined areas compared to those in non-redlined areas. Review of other outcomes revealed that gunshot-related injuries, asthma, heat-related outcomes, and multiple chronic conditions were worse in redlined areas, while associations with cancer varied by cancer type. In terms of cause-specific mortality, one study revealed no link between residential redlining and infant mortality rate, while one study on COVID-19 outcomes was inconclusive. Overall, this review presents evidence that living in historically redlined areas is associated with increased risk of multiple serious adverse health outcomes. Further research on mechanisms, remediation, and neighborhood-level interventions is needed to strengthen the understanding of the impacts of redlining on health. • First systematic review to examine the relationships between redlining and modern-day health inequities. • Residential redlining is associated with elevated risk for multiple chronic diseases. • Future research focusing on community-level interventions and policies may be informative and impactful. • Standardization of design and measurement of redlining is needed. [ABSTRACT FROM AUTHOR]

Promote practitioners' confidence to use and disseminate the PSE Readiness Assessment and Decision Instrument (PSE READI) to tailor PSE strategies to local contexts. There is increasing attention within the Supplemental Nutrition Assistance Program-Education (SNAP-Ed) toward implementation of PSE strategies to improve dietary outcomes among low-income populations. Tools to adapt PSEs to local levels of readiness and capacity are needed. SNAP-Ed and public health practitioners in Ohio. The PSE READI was designed to adapt implementation of four community nutrition PSEs: farmers' markets, farm-to-school, healthy eating in childcare, healthy food retail. After completing the assessment, a tailored report is provided with three recommendations to guide local PSE implementation, which are linked to a resource library with > 1,000 tools/guides. The tool was tested for usability and first disseminated via a day-long interactive training focused on supporting others use of the tool to assess, plan, and act to optimize PSE implementation in targeted areas. Pre- and post-survey design without randomization was used to test confidence in practitioners' ability to support and train others to use the PSE READI. Practitioners (N = 23) doing work in 60 Ohio counties participated in the PSE READI training. One-third reported PSE implementation is related to their current work plan; 41% supported others conducting PSEs. Confidence to support colleagues' implementation of PSEs (extremely/very confident: pre-35%, post-70%) and train colleagues to use the PSE READI tool (pre-10%, Post-70%) increased substantially after the training. The majority (87%) planned to use the PSE READI tool in the next three months. Post-training, practitioners reported they were "better equipped," "more informed," and "inspired." The PSE READI tool provides a feasible and efficient method to tailor PSE implementation to the realities of diverse communities. The tool and training were well-received by SNAP-Ed and public health practitioners resulting in an increase in practitioner confidence to support implementation of community nutrition PSEs. [ABSTRACT FROM AUTHOR]

Objective: Identify themes essential to implementing policy, system, and environmental (PSE) interventions within kindergarten to 12th-grade (K-12) settings and provide associated indicators of readiness and capacity to support healthy eating PSE work among Supplemental Nutrition Assistance Program-Education (SNAP-Ed) practitioners in Ohio., Design: Interview data were collected in Ohio from December, 2020 to May, 2021., Participants: Ohio SNAP-Ed practitioners (n = 12), community residents with low income (n = 26), and K-12 experts statewide (n = 10) and nationally (n = 3)., Phenomenon of Interest: Healthy eating PSE implementation., Analysis: We conducted a qualitative analysis to identify themes and indicators related to implementing healthy eating PSEs in schools. During virtual consensus conferences (December, 2021-April, 2022), themes and indicators were sorted and ranked by perceived importance to PSE implementation., Results: Four themes and 14 indicators were identified. Expert-derived weights quantified the themes' importance to PSE implementation efforts in K-12. Themes included: (1) school system support and capacity (weight 0.372), (2) school food environment (0.278), (3) SNAP-Ed practitioner capacity and resources (0.192), and (4) familial influence and awareness (0.158)., Conclusions and Implications: Findings provide guidance for tailoring healthy eating PSEs in K-12 schools using local levels of readiness and capacity. Results highlight targeted areas of focus to support the implementation of healthy eating PSE interventions in K-12 schools through SNAP-Ed programming in diverse contexts. Future research is needed on the applicability of these findings based on feedback from school district staff and community members with children in different school settings., (Copyright © 2024 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Opioid overdose deaths are dramatically increasing in the United States and disproportionately affecting minority communities, with the increasing presence of fentanyl exacerbating this crisis. Developing community coalitions is a long-standing strategy used to address public health issues. However, there is a limited understanding of how coalitions operate amid a serious public health crisis. To address this gap, we leveraged data from the HEALing Communities Study (HCS)-a multisite implementation study aiming to reduce opioid overdose deaths in 67 communities. Researchers analyzed transcripts of 321 qualitative interviews conducted with members of 56 coalitions in the four states participating in the HCS. There were no a priori interests in themes, and emergent themes were identified through inductive thematic analysis and then mapped to the constructs of the Community Coalition Action Theory (CCAT). Themes emerged related to coalition development and highlighted the role of health equity in the inner workings of coalitions addressing the opioid epidemic. Coalition members reported seeing the lack of racial and ethnic diversity within their coalitions as a barrier to their work. However, when coalitions focused on health equity, they noted that their effectiveness and ability to tailor their initiatives to their communities' needs were strengthened. Based on our findings, we suggest two additions to enhance the CCAT: (a) incorporating health equity as an overarching construct that affects all stages of development, and (b) ensuring that data about individuals served are included within the pooled resource construct to enable monitoring of health equity., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Gardening has been found to increase vegetable intake and reduce BMI; this suggests that it may improve diets by lowering inflammatory content. The goal of this study goal was to evaluate the effect of gardening on Dietary Inflammatory Index scores., Methods: Longitudinal data were collected annually between 2015 and 2018 from adults in low-income, urban neighborhoods of Cleveland and Columbus, Ohio. The authors measured the association between gardening and Dietary Inflammatory Index in the full data set using multivariable mixed-effect models with a random intercept for participant (Model 1; n =409). To further explore potential causation, the author used propensity score analyses in a subset of the data by building a 1-to-1 matched model (Model 2; n =339)., Results: Of 409 adults, 30.3% were gardeners with Dietary Inflammatory Index scores ranging from -6.228 to +6.225. Participating in gardening was associated with lower Dietary Inflammatory Index scores in the mixed-effects model (-0.45; 95% CI= -0.85, -0.04; Model 1) and the 1-to-1 matched model (-0.77; 95% CI= -1.40, -0.14; Model 2)., Conclusions: The analyses indicate that gardeners had lower Dietary Inflammatory Index scores than nongardeners, implying lower diet-driven inflammation. These findings highlight the potential for a causal relationship between gardening and Dietary Inflammatory Index, which should be confirmed in future studies. If this relationship is validated, strategies to increase gardening may be worth testing as primary prevention tools for diet-driven chronic disease., (© 2024 The Authors.)

The Supplemental Nutrition Assistance Program-Education identified food pantries as a targeted setting for policy, system, and environmental (PSE) interventions to promote healthy eating among households who rely on pantries to supplement their food needs. The present study sought to identify factors influencing capacity and readiness to implement healthy eating PSE interventions in food pantries. Qualitative interviews were conducted via zoom with twenty-six community residents with experience receiving SNAP benefits and twelve SNAP-Ed staff in rural and urban counties in Ohio to identify themes and indicators related to community/organisational capacity and readiness to implement healthy eating PSE interventions in food pantries. Themes and related indicators generated based on inductive and deductive coding of interview transcripts were prioritised and weighted by eleven community nutrition experts during a virtual consensus conference. Five themes emerged; expert-derived weights (scaled low, 0 to high, 1) reflect the perceived importance of each to implementation of healthy eating PSE interventions in food pantries: food pantry capacity and logistics [0⋅252], networks and relationships [0⋅228], community nutrition practitioner capacity [0⋅212], food pantry user characteristics [0⋅156], and stigma and stereotypes [0⋅1⋅52]. Overall, seventeen indicators were identified reflecting these themes. Successful and sustained PSE interventions at food pantries will require a tailored approach that considers food pantries' capacity, needs and opportunities within the community, and capacity of community nutrition practitioners. The themes and indicators identified provide guidance for responsive PSE approaches in food pantries that meet communities where they are., (© The Author(s) 2023.)

Child care centers in the United States allow many parents and caregivers to work in and outside of the home and support the growth and development of children. Child care closures and COVID-19 mitigation measures at the onset of the pandemic heightened the need for and awareness of the role of child care as core infrastructure. The purpose of our study was to examine the perceived role and benefits of child care based on the lived experiences of parents/caregivers and staff navigating child care during the pandemic. We conducted in-depth qualitative interviews with parents/caregivers ( n  = 20) of children who attended child care and staff ( n  = 12) who were working at child care programs in Ohio from September to November 2020. Qualitative data were coded and analyzed through the lens of four frameworks (i.e., capabilities, developmental, economics, and mutualism) related to child well-being. Our results highlight the perceived value of child care (a) for fostering capabilities and developmental growth in children; (b) for providing economic benefits for children, parents, and staff of child care programs; and (c) as an essential infrastructure that mutually benefits children, parents, families, staff, and the community. Findings support existing evidence regarding the broader impacts of child care and further investigation into the role of child care. We highlight the potential need for further investments in policies, resources, and supports for child care that reflects its essentialness and generative role., Competing Interests: No potential conflict of interest was reported by the authors., (© 2022 Elsevier Inc. All rights reserved.)

At the start of the Coronavirus Disease of 2019 (COVID-19) pandemic, the risk of cases in childcare programs was unknown. Thus, a rapid-response research approach was launched in Ohio childcare settings. Passive surveillance data from a state-operated incident reporting system were evaluated to estimate the number of COVID-19 cases from 15 August 2020 to 1 January 2021. Additionally, active surveillance with self-administered reverse transcriptase-polymerase chain reaction (RT-PCR) tests were conducted among staff at 46 childcare programs. Finally, six zoom-based focus groups with program administrators were used to gain feedback. Staff and children in childcare settings contributed 0.38% and 0.15% of the COVID-19 cases in Ohio during this timeframe, respectively. RT-PCR testing identified 3 unrecognized cases (0.88% of tests), and all occurred when the statewide positivity rate was >5%. Focus groups revealed that access to affordable cleaning supplies, masks, and reliable staffing were critical. Perhaps most importantly, we conclude that expanding the incident reporting system to include a childcare census would allow for the tracking of future health problems with highly valuable incidence rate estimations.

Background: Food insecurity and other social determinants of health are increasingly being measured at routine health care visits. Understanding the needs and behaviors of individuals or families who screen positive for food insecurity may inform the types of resources they need. The goal of this research was to identify modifiable characteristics related to endorsement of two food insecurity screener questions to better understand the resources necessary to improve outcomes., Methods: Analysis was conducted focusing on cross-sectional survey data collected in 2015-2016 from participants (N = 442) living in urban neighborhoods in Ohio with limited access to grocery stores. Food insecurity was assessed by the endorsement of at least one of two items. These were used to categorize participants into two groups: food insecure(N = 252) or food secure (N = 190). Using logistic regression, we estimated the association between several variables and the food insecure classification., Results: Those that used their own car when shopping for food had lower odds of reporting food insecurity, as did those with affirmative attitudes related to the convenience of shopping for and ease of eating healthy foods. As shopping frequency increased, the odds of food insecurity increased. Food insecurity also increased with experience of a significant life event within the past 12 months. There was an 81% increase in the odds of reporting food insecurity among participants who received Supplemental Nutrition Assistance Program benefits compared to those not receiving Supplemental Nutrition Assistance Program benefits., Conclusions: Along with referrals to SNAP, clinicians can further address screening-identified food insecurity through provision of transportation supports and linkages to other social services while collaborating on community initiatives to promote convenient and easy access to healthy foods. The needs and behaviors associated with screens indicating food insecurity also have implications for impacting other SDH, and thus, health outcomes., (© 2021. The Author(s).)

Using a relational approach, this study investigates whether shopping close to home moderates the relationship between the proximate food environment and diet. To address this question, we develop the proximate food retail quality (PFRQ) score, an inverse-distance weighted measure of all food retailers within a resident's neighborhood that incorporates audit data of each food retailer. This study relies on data collected through 24-h dietary recalls and psychosocial surveys administered to 449 adults in two socioeconomically matched neighborhoods. Food retailer audits collected data on the availability, price, and quality of healthful foods. Seventy-one percent of study participants report conducting at least 50% of their food shopping within approximately one mile of their home. Household income and education are associated with likelihood to shop close to home, while access to a personal vehicle is not. Finally, results suggest that, for residents who shop primarily close to home, a one unit increase in proximate food retail environment score is associated with a 17.2-point increase in HEI-2010 score, a measure of overall diet quality that ranges from zero to 100. This study suggests that the food environment matters for those who use it and that a low-quality proximate food environment can amplify individual disadvantage., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Living in a low-income neighborhood with low access to healthy food retailers is associated with increased risk for chronic disease. The U.S. Healthy Food Financing Initiative (HFFI) provides resources to support the development of infrastructure to improve neighborhood food environments. This natural experiment examined a HFFI funded food hub that was designed to be implemented by a community development corporation in an urban neighborhood in Cleveland, Ohio. It was intended to increase access to affordable, local, and healthy foods; establish programs to increase social connections and support for healthy eating; and create job opportunities for residents. We used a quasi-experimental, longitudinal design to externally evaluate food hub implementation and its impact on changes to the built and social environment and dietary patterns among residents living in the intervention neighborhood (n = 179) versus those in a comparison (n = 150) neighborhood. Overall, many of the food hub components were not implemented fully, and dose and reach of the executed food hub components was low. There were statistically significant improvements in observed availability of healthy foods in the intervention neighborhood versus the comparison neighborhood. There were no changes over time in diet quality scores, total caloric intake, or fruit and vegetable intake in the intervention neighborhood. In conclusion, low dose implementation of a food hub led to small improvements in availability of healthy foods but not in dietary patterns. Findings highlight challenges to implementing a food hub in neighborhoods with low access to healthy food retailers.

Background: Diet is critical to chronic disease prevention, yet there are persistent disparities in diet quality among Americans. The socioecological model suggests multiple factors, operating at multiple levels, influence diet quality., Objective: The goal was to model direct and indirect relationships among healthy eating identity, perceived control of healthy eating, social support for healthy eating, food retail choice block scores, perceptions of healthy food availability, and food shopping behaviors and diet quality measured using Healthy Eating Index-2010 scores (HEI-2010) for residents living in two urban communities defined as food deserts., Design: A cross-sectional design was used including data collected via self-reported surveys, 24-dietary recalls, and through objective observations of food retail environments., Participants/setting: Data collection occurred in 2015-2016 in two low-income communities in Cleveland (n=243) and Columbus (n=244), OH., Main Outcome Measure: HEI-2010 scores were calculated based on the average of three 24-hour dietary recalls using the Nutrition Data System for Research., Analysis: Separate path models, controlled for income, were run for each community. Analysis was guided by a conceptual model with 15 hypothesized direct and indirect effects on HEI-2010 scores. Associations were considered statistically significant at P<0.05 and P<0.10 because of modest sample sizes in each community., Results: Across both models, significant direct effects on HEI-2010 scores included healthy eating identity (β=.295, Cleveland; β=.297, Columbus, P<0.05) and distance traveled to primary food store (β=.111, Cleveland, P<0.10; β=.175, Columbus, P<0.05). Perceptions of healthy food availability had a significant, inverse effect in the Columbus model (β=-.125, P<0.05). The models explained greater variance in HEI-2010 scores for the Columbus community compared with Cleveland (R 2 =.282 and R 2 =.152, respectively)., Conclusions: Findings highlight the need for tailored dietary intervention approaches even within demographically comparable communities. Interventions aimed at improving diet quality among residents living in food deserts may need to focus on enhancing healthy eating identity using culturally relevant approaches while at the same time addressing the need for transportation supports to access healthy food retailers located farther away., (Copyright © 2019 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Farm-to-school interventions are recommended strategies to improve dietary behaviors among school-aged children. Tools are needed to assess community readiness and capacity to optimize farm-to-school implementation. The objective of this study was to identify and prioritize factors to inform tailored farm-to-school implementation by practitioners working in diverse contexts., Methods: Practitioners and community residents (N = 194) participated in semistructured interviews (N = 18) and focus groups (N = 23). Thematic analysis was conducted to identify themes and subthemes influencing farm-to-school implementation. The subthemes were operationalized into measureable indicators. The themes and their associated indicators were prioritized through a consensus conference with an expert panel (N = 18)., Results: The qualitative data analysis and consensus conference yielded 4 themes and 17 indicators associated with community readiness and capacity to implement farm-to-school. The themes represent school capacity, networks and relationships, organizational and practitioner capacity, and community resources and motivations., Conclusions: Findings highlight a range of indicators of community readiness and capacity needed to support farm-to-school implementation. Results offer guidance for tailoring intervention delivery based on levels of community, school, practitioner, and organizational readiness and capacity., (© 2019 The Authors. Journal of School Health published by Wiley Periodicals, Inc. on behalf of American School Health Association.)

A key gap in existing food environment research is a more complex understanding of the interplay between physical and social contexts, including the influence of social networks on food habits. This mixed methods research examined the nature of social connections at food procurement places among a sample of 30 people receiving Supplemental Nutrition Assistance Program (SNAP) benefits in an urban setting. Results highlight the significance of social connections as motivators to use food places, the value of access to information and other resources at food places, and the role of weak ties with actors within food places to facilitate utilization and interaction. Social connections at the varied places individuals procure food may be leveraged to disseminate information and resources to further healthy food access., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Nutrition-related policy, system, and environmental (PSE) interventions such as farmers' markets have been recommended as effective strategies for promoting healthy diet for chronic disease prevention. Tools are needed to assess community readiness and capacity factors influencing successful farmers' market implementation among diverse practitioners in different community contexts. We describe a multiphase consensus modeling approach used to develop a diagnostic tool for assessing readiness and capacity to implement farmers' market interventions among public health and community nutrition practitioners working with low-income populations in diverse contexts. Modeling methods included the following: phase 1, qualitative study with community stakeholders to explore facilitators and barriers influencing successful implementation of farmers' market interventions in low-income communities; phase 2, development of indicators based on operationalization of qualitative findings; phase 3, assessment of relevance and importance of indicators and themes through consensus conference with expert panel; phase 4, refinement of indicators based on consensus conference; and phase 5, pilot test of the assessment tool. Findings illuminate a range of implementation factors influencing farmers' market PSE interventions and offer guidance for tailoring intervention delivery based on levels of community, practitioner, and organizational readiness and capacity.

Objective: Hemodialysis patients' ability to access food that is both compatible with a renal diet and affordable is affected by the local food environment. Comparisons of the availability and cost of food items suitable for the renal diet versus a typical unrestricted diet were completed using the standard Nutrition Environment Measures Survey and a renal diet-modified Nutrition Environment Measures Survey., Design: Cross-sectional study., Setting: Twelve grocery stores in Northeast Ohio., Main Outcome Measure: Availability and cost of food items in 12 categories., Results: The mean total number of food items available differed significantly (P ≤ .001) between the unrestricted diet (38.9 ± 4.5) and renal diet (32.2 ± 4.7). The mean total cost per serving did not differ significantly (P = 0.48) between the unrestricted diet ($5.67 ± 2.50) and renal diet ($5.76 ± 2.74)., Conclusion: The availability of renal diet food items is significantly less than that of unrestricted diet food items, but there is no difference in the cost of items that are available in grocery stores. Further work is needed to determine how to improve the food environment for patients with chronic diseases., (Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Evaluate farmers' market (FM) use patterns among Supplemental Nutrition Assistance Program (SNAP) recipients., Design: Cross-sectional survey administered June to August, 2015., Setting: Cleveland and East Cleveland, OH., Participants: A total of 304 SNAP recipients with children. Participants lived within 1 mile of 1 of 17 FMs. Most were African American (82.6%) and female (88.1%), and had received SNAP for ≥5 years (65.8%)., Main Outcome Measures: Patterns of FM shopping, awareness of FM near home and of healthy food incentive program, use of SNAP to buy fruits and vegetables and to buy other foods at FMs, receipt of healthy food incentive program., Analysis: Two-stage cluster analysis to identify segments with similar FM use patterns. Bivariate statistics including chi-square and ANOVA to evaluate main outcomes, with significance at P ≤ .05., Results: A total of 42% reported FM use in the past year. Current FM shoppers (n = 129) were segmented into 4 clusters: single market, public market, multiple market, and high frequency. Clusters differed significantly in awareness of FM near home and the incentive program, use of SNAP to buy fruit and vegetables at FMs, and receipt of incentive., Conclusions and Implications: Findings highlight distinct types of FM use and had implications for tailoring outreach to maximize first time and repeat use of FMs among SNAP recipients., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Geographic information systems (GISs) have been used to define fast food availability, with higher availability perhaps promoting poorer quality diets. Alternative measures involve perceptions; however, few studies have examined associations between GIS-derived and perceived measures of the food environment., Methods: Telephone surveys of 705 participants within an eight-county region in South Carolina were analyzed using logistic regression to examine relationships between geographic presence of and distance to various types of food retailers and perceived fast food availability., Results: The mean distance to the nearest fast food restaurant was 6.1 miles, with 16% of participants having a fast food restaurant within 1 mile of home. The geographic presence of and distance to all food retailer types were significantly associated with perceived availability of fast food in unadjusted models. After adjustment, only the presence of a fast food restaurant or pharmacy was significantly associated with greater odds of higher perceived availability of fast food. Greater odds of lower perceived availability of fast food were observed with the presence of a dollar store and increasing distance to the nearest supermarket or pharmacy., Conclusions: Measures of fast food availability, whether objective or perceived, may not be interchangeable. Researchers should carefully decide on the appropriate measurement tool-GIS-derived or perceived-in food environment studies., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Documentary filmmaking approaches incorporating community engagement and awareness raising strategies may be a promising approach to evaluate community-based participatory research. The study purpose was 2-fold: (1) to evaluate a documentary film featuring the formation and implementation of a farmers' market and (2) to assess whether the film affected awareness regarding food access issues in a food-desert community with high rates of obesity. The coalition model of filmmaking, a model consistent with a community-based participatory research (CBPR) approach, and personal stories, community profiles, and expert interviews were used to develop a documentary film (Planting Healthy Roots). The evaluation demonstrated high levels of approval and satisfaction with the film and CBPR essence of the film. The documentary film aligned with a CBPR approach to document, evaluate, and disseminate research processes and outcomes.

Widely adopted nutrition policies for afterschool programs (ASPs) focus on serving a fruit/vegetable daily and eliminating sugar-sweetened foods/beverages. The impact of these policies on the nutrient profile of snacks served is unclear. Evaluate changes in macro/micronutrient content of snacks served in ASPs. A 1-year group randomized controlled trial was conducted in 20 ASPs serving over 1700 elementary-age children. Intervention ASPs received a multistep adaptive framework intervention. Direct observation of snack served was collected and nutrient information determined using the USDA Nutrient Database, standardized to nutrients/100 kcal. By post-assessment, intervention ASPs reduced total kcal/snack served by 66 kcal (95CI -114 to -19 kcal) compared to control ASPs. Total fiber (+1.7 g/100 kcal), protein (+1.4 g/100 kcal), polyunsaturated fat (+1.2 g/100 kcal), phosphorous (+49.0 mg/100 kcal), potassium (+201.8 mg/100 kcal), and vitamin K (+21.5 μg/100 kcal) increased in intervention ASPs, while added sugars decreased (-5.0 g/100 kcal). Nutrition policies can lead to modest daily caloric reductions and improve select macro/micronutrients in snacks served. Long-term, these nutritional changes may contribute to healthy dietary habits.

Background: Recent evidence indicates a widening gap in fruit and vegetable (F/V) consumption between high- and low-income Americans. This gap is related, in part, to decreased access to food retailers that sell fresh F/V in low-income communities. Farmers' markets are identified as a strategy for improving F/V consumption by increasing access to these foods., Objectives: The aim of this systematic review was to examine literature published from 1994 to 2014 to identify facilitators and barriers of farmers' markets use, particularly among low-income consumers., Design: Peer-reviewed literature was identified in Ebsco Host (Academic Search Complete). Inclusion criteria for abstract review was primary research focused on farmers' market use identifying 87 studies for full-text review. Full-text review identified articles focused on facilitators and/or barriers of farmers' market use resulting in 49 articles. At least two reviewers completed review of all articles., Results: Of the 49 articles, 39% specified inclusion of low-income consumers and fewer than 15% focused on racial and ethnic minorities. Few studies were guided by theory and/or used standardized metrics. Results indicate farmers' market use is influenced by multiple economic, service delivery, spatial-temporal, social, and personal factors. Among studies that included low-income populations (n=19), key barriers to farmers' market use were perceptions that food assistance benefits were not accepted, belief that food variety at farmers' markets was limited, lack of access to transportation, lack of racial/ethnic diversity in the market space, and mismatch between markets and personal lifestyles. There is wide variation in study design and reporting standards and infrequent use of standardized measures limiting comparisons across studies., Conclusions: There is a need to establish valid and reliable metrics and reporting standards for evaluating farmers' markets. Findings may inform interventions, programs, and policies to promote farmers' market use., (Copyright © 2016 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

The Community Empowerment Center used a community-engaged approach to build capacity among residents to develop and implement interventions focused on creating a healthier environment. The Center partnered with residents living in a public housing community and adjacent low-income neighborhood and provided support through a mini-grant program. A six-session training program guided community members in mini grant development; 25 individuals attended at least one session. Six grant proposals were submitted; three were awarded $12,000 each for intervention implementation. Findings offer a model for engaging residents from low-resource settings in intervention development, implementation, and sustainability for community health promotion.

Background: Well-designed evaluation is necessary to document the impact of farmers' markets (FMs) on health, economic, and community outcomes. However, the complex nature of FMs poses challenges for evaluation., Objective: Our goal is to describe a participatory, multilevel framework used to evaluate a FM implemented at a federally qualified health center (FQHC) in a rural community in the Southeastern United States., Methods: An iterative, collaborative process involving three feedback loops was used to engage community stakeholders in the development, implementation, and utilization of the multilevel evaluation plan., Lessons Learned: A participatory approach helped to navigate the complexities of evaluating FMs and promoted stakeholder engagement. The evaluation became a core element of the intervention that informed continuous quality improvement (CQI). The development of strong university- community partnerships facilitated the ongoing use of results., Conclusions: The evaluation framework presented may be used to promote community engagement and rigor for evaluation of future FMs.

Measures of neighborhood food environments have been linked to diet and obesity. However, the appropriate measurement methods and how people actually perceive their food environments are still unclear. In a cross-sectional study of 939 adults, the perceived presence of food outlets was compared to the geographic-based presence of outlets within a participant's neighborhood, utilizing percent agreement and Kappa statistics. Perceived presence was based on survey-administered questions, and geographic-based presence was characterized using 1-, 2-, 3- and 5-mile (1-mile=1.6km) Euclidean- and network-based buffers centered on each participant's residence. Analyses were also stratified by urban and non-urban designations. Overall, an individual's perceived neighborhood food environment was moderately correlated with the geographic-based presence of outlets. The performance of an individual's perception was most optimal using a 2- or 3-mile geographic-based neighborhood boundary and/or when the participant lived in a non-urban neighborhood. This study has implications for how researchers measure the food environment., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Farmers' markets have the potential to improve the health of underserved communities, shape people's perceptions, values, and behaviors about healthy eating, and serve as a social space for both community members and vendors. This study explored the influence of health care provider communication and role modeling for diabetic patients within the context of a farmers' market located at a federally qualified health center. Although provider communication about diet decreased over time, communication strategies included: providing patients with "prescriptions" and vouchers for market purchases; educating patients about diet; and modeling healthy purchases. Data from patient interviews and provider surveys revealed that patients enjoyed social aspects of the market including interactions with their health care provider, and providers distributed prescriptions and vouchers to patients, shopped at the market, and believed that the market had potential to improve the health of staff and patients of the federally qualified health center. Provider modeling of healthy behaviors may influence patients' food-related perceptions and dietary behaviors.

People with healthy eating identities report healthier diets and demonstrate greater receptivity to nutrition interventions, but other types of eating identity are likely important. We developed the Eating Identity Type Inventory (EITI) to assess affinity with four eating identity types; healthy, meat, picky, and emotional. This study assessed factorial validity, using confirmatory factor analysis (CFA) and established reliability and convergent validity of the EITI. In a telephone survey, 968 primary household food shoppers completed the EITI and a dietary questionnaire; 101 repeated the EITI approximately 1month later.CFA revealed that an 11-item model provided acceptable fit (χ(2)=206; df=38), CFI=.938, NNFI=.925, RMSEA=.070; SRMR=.059). The EITI demonstrated acceptable internal consistencies with Cronbach alpha's ranging from .61 to .82 and good test-retest reliability for healthy, emotional, and picky types (Pearson's correlations ranging from .78 to .84). Ordinary Least Squares (OLS) used to assess relationships between eating identity type and diet analyses demonstrated significant hypothesized relationships between healthy eating identity and healthier dietary intake and meat and picky eating identities and less healthy dietary intake. The EITI could facilitate behavioral and cognitive research to yield important insights for ways to more effectively design messages, interventions, and policies to promote healthy dietary behaviors., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: A 22-week federally qualified health center (FQHC)-based farmers' market (FM) and personal financial incentive intervention designed to improve access to and consumption of fruits and vegetables (FVs) among low-income diabetics in rural South Carolina was evaluated., Methods: A mixed methods, one-group, repeated-measures design was used. Data were collected in 2011 before (May/June), during (August), and after (November) the intervention with 41 diabetes patients from the FQHC. FV consumption was assessed using a validated National Cancer Institute FV screener modified to include FV sold at the FM. Sales receipts were recorded for all FM transactions. A mixed-model, repeated measures analysis of variance was used to assess intervention effects on FV consumption. Predictors of changes in FV consumption were examined using logistic regression., Results: A marginally significant (p=0.07) average increase of 1.6 servings of total FV consumption per day occurred. The odds of achieving significant improvements in FV consumption increased for diabetics using financial incentives for payment at the FM (OR: 38.8, 95% CI: 3.4-449.6) and for those frequenting the FM more often (OR: 2.1, 95% CI: 1.1-4.0)., Conclusions: Results reveal a dose-response relationship between the intervention and FV improvements and emphasize the importance of addressing economic barriers to food access., (Copyright © 2013 Elsevier Inc. All rights reserved.)