Date of Award

2024

Degree Type

Dissertation

Degree Name

Doctor of Philosophy in Health Sciences

Department

Nutrition

First Advisor

Sarah Amin

Abstract

Background: Children and families experiencing low income in the United States are at a greater risk of food insecurity (FI) and suboptimal diet quality than the general population. Childhood FI, which is associated with numerous poor health and developmental outcomes, has become so pervasive that the American Academy of Pediatrics recommends universal FI screenings. Routine FI screening in clinical settings presents opportunities for clinic-community partnerships to connect families experiencing FI with food access and nutrition education (FANE) programs. A variety of FANE programs, including the Supplemental Nutrition Assistance Program - Education (SNAP-Ed), are administered at the federal level to promote healthy living. Following the shift of FANE programming and services to online platforms during the COVID-19 pandemic, the federal government began investing in the modernization of FANE programs, including SNAP-Ed. However, there remains a paucity of clinic-community FANE programs incorporating implementation science methods into their development and evaluation.

Objectives: To leverage implementation science methods in the development and evaluation of a SNAP-Ed clinic-community FANE program, and examine relevant implementation determinants and strategies used by SNAP-Ed implementing agencies in clinic-community programs, nationwide.

Methods: A robust formative evaluation was conducted incorporating data from a survey and interviews pediatricians, and interviews with FANE program staff and parents experiencing food insecurity. Pediatricians (n=14) and parents (n=7) were recruited from the same pediatric primary care clinic in Rhode Island (RI) to participate in semi-structured interviews examining experiences with FANE programs and addressing FI in the clinic setting. RI-based FANE program staff participated in semi-structured interviews examining perspectives around clinical-community partnerships. Leveraging the findings from the formative evaluation, we developed a SNAP-Ed clinic-community FANE m-health intervention for parents and caregivers of young children, and conducted an 8-week pilot feasibility study. Parents (n=27) were recruited from the same clinic to participate in the pilot study, and we evaluated the intervention’s feasibility, acceptability, and appropriateness using a combination of retention, nutrition behavior survey, and participant feedback data. A subsequent nationwide mixed-methods study was conducted to understand facilitators, barriers, and general experiences implementing SNAP-Ed FANE programming with healthcare and clinic partners. SNAP-Ed professionals from each of the seven USDA regions participated in a survey (n=51) and subsequent virtual interview (n=23). Interviews were guided by an implementation science framework and were used to understand implementation determinants (facilitators and barriers) and implementation strategies used by SNAP-Ed staff with clinic/healthcare partners. Interviews were thematically analyzed using a deductive/inductive hybrid approach.

Results: The formative evaluation revealed gaps in pediatrician knowledge of nutrition and food access resources and FANE programs. Pediatricians viewed FI screening as time-consuming, citing limited time for appointments in clinic, while parents valued clinicians addressing nutrition and FI during visits, underscoring a need for streamlined and feasible strategies for clinicians to screen and refer parents to FANE programming and resources during clinic visits. The pilot FANE m-health program demonstrated high feasibility, acceptability, and appropriateness among parents who screened positive for FI during clinic visits, with 93% (n=25) participants retained through the duration of the intervention. Pre/post tests using nutrition behavior surveys revealed a significant increase in frequency of family meals and repeat offerings to children (p<0.05). When examining implementation of SNAP-Ed FANE programming nationwide, we found that SNAP-Ed professionals most often partnered with outpatient clinics to deliver a combination of direct education and policy, systems, and environmental change strategies. SNAP-Ed professionals reported barriers to implementation including USDA-mandated SNAP-Ed policies around program delivery and incentives, high healthcare staff turnover, and a lack of healthcare partner familiarity with SNAP-Ed. SNAP-Ed professionals most commonly utilized implementation strategies including educational outreach visits, accessing external funding, and identifying healthcare team-based champions.

Conclusions: Overall, this body of work illustrates several opportunities to incorporate implementation science methods into the design, delivery, and evaluation of SNAP-Ed clinic-community FANE programming. Further innovations in how clinicians and other clinic-based staff address pediatric FI must be developed to streamline the process of connecting families with FI to resources. Additionally, SNAP-Ed professionals and implementing agencies would benefit from guidance, toolkits, and resources to help guide clinic-community partnerships and FANE program implementation.

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