Introduction
In 2013, the Supplemental Nutrition Assistance Program Education (SNAP-Ed) chronic disease prevention goals were expanded to include obesity prevention in addition to nutrition education and promotion. Funding explicitly was allocated to improve access to healthy foods and beverages by integrating education with policy, systems, and environmental change interventions. In Federal Fiscal Year 2017, the United States Department of Agriculture (USDA) distributed US$414 million to states to implement SNAP-Ed programs.
Prior studies have provided insights about the challenges low-income families confront in maintaining an adequate and healthy diet. The most detailed study on this topic, the 2013 SNAP Food Security In-Depth Interview Study, found that most SNAP recipients lack adequate financial resources to meet their needs; that families utilize multiple strategies to make their food resources last, but often run out of food and/or limit their diets; and that most SNAP households budget as though their SNAP benefits will cover all monthly food costs, though they routinely do not (Edin et al., Reference Edin, Boyd, Mabli, Ohls, Worthington, Green, Redel and Sridharan2013). Other studies have found that SNAP households use both formal and informal networks to sustain food resources throughout the month (Schenck-Fontaine et al., Reference Schenck-Fontaine, Gassman-Pines and Hill2017); and that cost, time, healthy food availability and quality, transportation and social norms are barriers to low-income households consuming an adequate, healthy diet (Eikenberry and Smith, Reference Eikenberry and Smith2004; Rose, Reference Rose2011; Haynes-Maslow et al., Reference Haynes-Maslow, Parsons, Wheeler and Leone2013; Zenk et al., Reference Zenk, Odoms-Young, Dallas, Hardy, Watkins, Hoskins-Wroten and Holland2013; Evans et al., Reference Evans, Banks, Jennings, Nehme, Nemec, Sharma, Hussaini and Yaroch2015). A 2011 study among low-income parents in Los Angeles found that cost, children's preferences, and easy access to fast food were the greatest barriers to healthy eating and that parents expressed interest in attending nutrition classes (Slusser et al., Reference Slusser, Kinsler, Erausquin, Thai and Neumann2011). A 2012 study suggested a variety of changes that could improve food access and nutrition among SNAP beneficiaries, including lowering the cost of and increasing access to healthy foods, modifying SNAP benefit distribution protocols, and strengthening SNAP-Ed (Center for the Study of the Presidency and Congress, 2012).
More recently, a few studies have assessed low-income individuals' perceptions of ways in which programs, policies and services could better meet their needs. These studies have identified solutions, including increasing SNAP benefit levels, limiting fast food outlets near schools, increasing access to healthy foods in stores and schools, and providing more family educational interventions that are culturally and linguistically relevant (Goh et al., Reference Goh, Bogart, Sipple-Asher, Uyeda, Hawes-Dawson, Olarita-Dhungana, Ryan and Schuster2009; Libman et al., Reference Libman, Beatty, Fiedler, Abbott, Green and Weiss2016; Leung et al., Reference Leung, Musicus, Willett and Rimm2017). A recent study found that food insecurity in the USA is associated with excess healthcare expenditures of US$77.5 billion dollars annually (Berkowitz et al., Reference Berkowitz, Basu, Meigs and Seligman2018); thus, solutions to reduce food insecurity are critical for improving personal, social and economic health and wellbeing.
Determining the best ways to utilize SNAP-Ed funding requires an analysis of multiple sources of information. The USDA requires states to conduct needs assessments of the population to understand the barriers they face in accessing healthy foods. This study aimed to explore the barriers and supports SNAP-Ed eligible parents in California experience related to feeding their families. Additionally, we sought to capture participants' SNAP-Ed intervention priorities.
The objective of this study was to answer the following research questions:
(1) What current challenges do SNAP-Ed eligible participants report in their efforts to feed their families?
(2) What sources of support and what gaps do participants identify?
(3) What opportunities do participants see to make healthy eating easier?
(4) What types of services and supports do participants recommend SNAP-Ed consider in their communities?
Methods
We conducted a qualitative cross-sectional study designed to capture SNAP-Ed eligible parents' perspectives on issues related to feeding their families. We collected data in eight focus groups with low-income adults in five counties throughout California from May to August 2017. The Institutional Review Boards of the State of California Health and Human Services Agency and the University of California, Davis, approved the study.
Recruitment
In partnership with the California Department of Public Health, the research team invited 58 local health departments to host focus groups via a statewide SNAP-Ed newsletter and follow-up recruitment emails. Thirteen county health departments expressed interest. The first six to respond met study criteria, representing California's diversity in urbanicity (rural, midsize, urban) and geographic location (north, central, southern) and were invited to participate. Two counties declined after considering study details, so unselected interested counties were again invited to participate. One agreed, leading to a total of five participating counties. Though each county was invited to host two focus groups, two counties hosted only one group. We conducted a total of eight focus groups (Table 1).
Description of focus groups conducted with SNAP-Ed eligible adults in California
We asked participating counties to recruit study participants based on the demographics of SNAP-Ed eligible adults raising children in their county. We selected parents because more than two-thirds of SNAP benefits go to families with children (Center on Budget and Policy Priorities, 2017). All focus group participants were at least 18 years old, and each received a US$25 gift card in appreciation for their contributions.
Focus groups
Three researchers, each with previous experience conducting focus groups and two who were bilingual (English/Spanish), conducted data collection. Each focus group included a lead and co-facilitator. Focus group participants completed a demographic survey, which included questions about gender, age, race/ethnicity, education, employment, income, marital status, food assistance program participation and food security. Our focus group guide asked about participants' priorities for feeding their families, the challenges they face in feeding their families the way they would like to feed them, the strategies they use, and the types of support they feel would benefit them (Table 2). We recorded each focus group, which lasted approximately an hour and a half.
Focus group questions asked of SNAP-Ed eligible adults in California
Data analysis
We utilized a commercial service to transcribe focus group recordings and imported transcripts into Dedoose online software. The study team developed a codebook a priori consisting of categorical codes based on the main topics in the focus group guide. Three researchers read the transcripts and modified the codebook to accommodate additional concepts. Throughout the early analysis, we added categorical codes and subcodes, which organized the data further underneath a specific categorical code (for example, the categorical code ‘challenges’ evolved to include subcodes such as ‘food access,’ and ‘income’). The in-depth analysis further produced substantive codes and overarching findings.
Two researchers applied codes to focus group transcripts, both coding the first two transcripts and independently coding the remainder. We used Dedoose's inter-rater reliability test to ensure consistency in code application, achieving a Cohen's kappa statistic of 0.71, indicating good agreement. A third researcher provided content expertise during weekly analysis meetings in which preliminary findings, coding issues, and analysis questions were discussed. Additionally, we wrote memos that summarized findings from each of the eight individual focus groups. These memos were used to support the overall analysis and to generate brief reports of findings for local partners, which were shared between October 2017 and January 2018.
Results
Most participants were female (89%) and most (89%) were between the ages of 18–50 years (Table 3). Individuals identifying as Latino/a represented the largest ethnic group (42%), followed by African American (24%) and White (16%). Forty percent of participants were employed at least part-time and 33% identified as full-time caregivers at home. In the past year, most reported household participation in SNAP (69%) and/or school meals (60%), and most (62%) reported sometimes or often worrying about running out of food.
Demographic characteristics of SNAP-Ed eligible adults participating in focus group study in California (n = 55)
a Many participants did not answer the food program participation questions (missing values ranged from 6 to 10). Percents are calculated based only on those responding for this item.
Ten key findings and four additional findings emerged (Table 4). Key findings were discussed across all or nearly all focus groups and repeatedly within groups. Notably, more focus group discussion focused on participants' challenges than strategies, supports and ideas for program and policy interventions. The most salient finding was the challenge of inadequate income, which was discussed in all groups. Financial constraints due to inadequate income, high costs of housing, transportation, utilities, food and other expenses dominated discussions of what makes it difficult for people to feed their families. The sentiment that came through in most groups was that life was extremely difficult for participants. Additional key findings are related to the unaffordability of healthy diets; poor neighborhood food environments; participants' efforts to stretch food resources and overcome children's unhealthy food preferences; the stress and guilt participants experience related to feeding their children; and feedback and recommendations for programs and services that can support participants' efforts to feed their families healthfully.
Findings (in bold type) and supporting quotations (in italics) from focus groups with SNAP-Ed eligible adults in California.
In addition to key findings, four additional findings emerged. These were discussed across fewer groups and/or were not as frequently mentioned within focus groups relative to key findings. The additional findings are related to perceptions of traditional cultural foods; the ways in which fear of waste impacts food acquisition and preparation decisions; concerns about the quality of school foods; and ways in which food assistance supports are perceived as inadequate to support employed parents. Key findings and additional findings are presented in Table 4, utilizing participants' voices to articulate the points.
Discussion
Improving dietary outcomes for SNAP families is crucial for reducing chronic disease risk, improving quality of life, and reducing healthcare costs. This study highlights SNAP-Ed eligible parents' perspectives about the challenges they face in feeding their families and their suggestions for support. Previous studies have reported many similar findings, yet our study highlights persistent needs, raising both new and ongoing issues and concerns in the current context and climate.
Context
Most study participants reported being unable to acquire sufficient healthy food for their families. Not unexpectedly, financial constraints were the primary challenge impacting participants' ability to feed their families the way they would like. The 2013 SNAP Food Security In-Depth Interview Study similarly found that inadequate financial resources prevented families from meeting their basic needs (Edin et al., Reference Edin, Boyd, Mabli, Ohls, Worthington, Green, Redel and Sridharan2013). We found that even those employed, utilizing SNAP, and/or taking advantage of charitable food assistance programs struggle to secure a consistent, healthy diet. The high cost of housing, utilities and transportation in the context of low wage work and poor economic opportunity often present insurmountable challenges. Many participants characterized their lives as a struggle to survive. Some participants reported having family or other supports that mitigated the struggle. As Rose reported, we found that in addition to the numerous structural barriers to healthy eating that emerged, human agency also played a role in supporting healthful food acquisition (Rose, Reference Rose2011). Participants reported utilizing various coping strategies to navigate their challenging circumstances; yet, despite the agency exercised, most participants reported not being able to feed their families the way they would like. Simplistic understandings of the challenges people face or the solutions that might benefit them are not likely to solve complex challenges such as poverty and food insecurity. Addressing structural barriers with attention to cultivating a deeper understanding of the interplay between structural constraints, social support and agency is needed to develop optimal solutions.
Barriers
Our study found that participants want to eat healthfully; however, most reported that healthy eating is too expensive. Other studies similarly have found this desire to eat healthfully (Zachary et al., Reference Zachary, Palmer, Beckham and Surkan2013). Interestingly, participants often equated fruits and vegetables with healthy eating, yet described fruits and vegetables as unaffordable. Consistent with participants' reports, a recent observational study in California found that fruits and vegetables in low-income SNAP-Ed eligible neighborhoods were more expensive than county average prices (Gosliner et al., Reference Gosliner, Brown, Sun and Woodward-Lopez2018). Furthermore, that study found produce in convenience stores in these neighborhoods, when available, to be of poor quality and high cost.
In contrast to the difficulty participants described in accessing healthy foods, unhealthy foods were characterized as too easy to access. While participants discussed a range of unhealthy products available—junk foods at schools and corner stores, processed ready-to-heat microwaveable foods, etc.—fast food restaurants were a focus. Fast food restaurants were prevalent in participants' neighborhoods and their pricing strategies were seen to encourage unhealthy choices. Similarly, grocery store placement of cheap unhealthy foods, particularly those on sale, also was described as a barrier to healthy eating. Multiple studies support participants' reports of their poor local food environments (Block et al., Reference Block, Scribner and Desalvo2004; Moore and Diez Roux, Reference Moore and Diez Roux2006; Zenk et al., Reference Zenk, Odoms-Young, Dallas, Hardy, Watkins, Hoskins-Wroten and Holland2013). Additionally, research suggests that corporate investments in targeted marketing—including advertising on television and social media, as well as the location of food outlets and the placement and price of products—are effective in influencing behaviors (Grier and Kumanyika, Reference Grier and Kumanyika2010; Andreyeva et al., Reference Andreyeva, Kelly and Harris2011). Participants in this study reported struggling with environments shaped by this targeted marketing in ways that deepen, rather than alleviate, their food-related challenges. Consistent with Zachary et al., we saw that in a retail food environment with limited access to affordable healthy food and easy access to relatively affordable unhealthy food, participants describe making purchases not based upon adult preferences, but as tradeoffs between their food environments and food budgets (Zachary et al., Reference Zachary, Palmer, Beckham and Surkan2013).
Many participants reported struggling with a lack of time in addition to a lack of money. The combined struggle of inadequate time and income often was associated with low-wage employment. A few studies have explored the relationship between time and diet (Monsivais et al., Reference Monsivais, Aggarwal and Drewnowski2014; Jabs and Devine, Reference Jabs and Devine2006; Venn and Strazdins, Reference Venn and Strazdins2017) but more work is needed to identify effective solutions that produce healthy dietary outcomes at an affordable cost with limited stress for working families. Participants in our study reported that lack of time led them to both eat and feed their families junk food, fast food and highly processed prepared foods, such as microwaveable snacks. While a few time-constrained parents talked about using slow cookers to prepare healthy foods, the predominant experience of participants was that fast food was the only option for family meals when time was tight. A study in the UK found that time constraints negatively influence the diets of people with low wages (Shaw, Reference Shaw2012). Further, studies have shown that when time and labor are included in calculating the cost of the Thrifty Food Plan (which provides the basis of SNAP benefit calculations), the plan is not affordable even for low-income households with adequate monetary resources (Davis and You, Reference Davis and You2010, Reference Davis and You2011). We found that participants struggled to balance the demands of food preparation with low wage work. Their experiences highlight the challenges created by a food assistance benefit system that fails to consider the time and work demands of meal preparation, particularly in the context of household employment. While federal policymakers debate additional work requirements for safety net programs such as SNAP and Medicaid (Aron-dine et al., Reference Aron-dine, Chaudhry and Broaddus2018; Brasher, Reference Brasher2018), the experiences of focus group participants suggest that these services currently are not designed effectively to support working families. Further adding to participants' challenges, the SNAP benefit formula assumes that families spend 30% of income on food; however, USDA reports that by 2007, Americans as a whole spent <10% of income on food—in 2014, that broke into 5.5% on food at home and 4.3% on food away from home (USDA 2016).(United States Department of Agriculture (USDA) Economic Research Service, 2016) While dollars spent on dining out in the USA have spiked, SNAP benefits still require home food preparation. Generally in the USA, as incomes rise, families rely more on full-service dining establishments and less on fast food options (Kim and Leigh, Reference Kim and Leigh2011). Although research on the effects of full-service restaurant meals on diet quality and health are not well established, some evidence suggests that on average they are moderately healthier than fast food meals (An, Reference An2016). At the least, higher income families are presented with a variety of prepared meal options when time is tight; however, low-income working families feel restricted to cheap, unhealthful fast food meals. Working participants in the present study expressed that SNAP benefits were inadequate when incomes rose. Given that when earned income increases, SNAP benefits are reduced by subtracting 30% of net income from the SNAP allotment, people who gain income understandably feel their reduced benefit is inadequate. Reconsidering SNAP benefit formulas generally—and specifically related to earned income, particularly in light of the critical tradeoff between money and time demands—could help to modernize the SNAP program. More research is needed to determine how food benefits best support low-income families, given the realities of modern life. Studies could assess how benefit increases and/or allowance for the purchase of healthy prepared foods affect health and wellbeing.
We were surprised to hear participants consistently characterize many traditional ethnic foods, such as tortillas and rice, as unhealthy. Many felt that only fruits, vegetables and unfamiliar foods—such as quinoa and brown rice or whole wheat pasta—were healthy. This suggests that more work is needed to ensure that nutrition messaging supports healthy, traditional diets and incorporates participants' cultural backgrounds and that messages are not over-simplified detrimentally.
The concerns we heard about food waste impacting food acquisition and feeding choices of participants are important and are consistent with a limited number of studies (Zachary et al., Reference Zachary, Palmer, Beckham and Surkan2013; Daniel, Reference Daniel2016). While research suggests that higher income professionals buy the fresh fruits and vegetables they know they should eat even though they are often wasted (Shaw, Reference Shaw2006), our findings suggest that income-constrained parents refrain from purchasing these items due to a fear of food waste. Finally, participants' negative perceptions of school foods suggest that more work is needed to connect parents, children and school personnel to ensure that schools are providing healthy appealing foods supported by the community.
Impact
While many focus group participants knew what they should be feeding their families, most felt unable to afford the recommended diet. This disconnect between what parents think is right for their children and the reality of what they are able to provide led many parents to feel guilt and shame. A sociological study has suggested that the stress food preparation entails may not be worth the health benefit of home-cooked meals (Bowen et al., Reference Bowen, Elliott and Brenton2016). More work is needed to understand and address parental stress related to feeding families, particularly the experience of knowing the foods provided are not optimal for one's children but lacking the means to change it.
Program and policy feedback and recommendations
Although participants spoke about structural issues such as wages, access to employment, housing costs and educational opportunities when they discussed challenges in feeding their families, conversations about intervention priorities focused more on direct assistance to relieve immediate food insufficiency. Many people requested more charitable or government-sponsored food giveaways to assist them when food is scarce. They appreciated programs that provide free food, particularly high-quality foods and fresh produce and wanted more of those.
Although most participants were not familiar with SNAP-Ed by name, many described helpful nutrition education classes and generally appreciated SNAP-Ed interventions. Still, they recommended multiple ways in which SNAP-Ed could better support them, such as making healthy foods more accessible and affordable than unhealthy foods, providing more nutrition education programs, sustaining interventions and resources and better marketing services in communities. Participants expressed a desire to have more input in decision-making and for policy-makers, programs and services to better understand the issues facing their communities. Finally, participants articulated a need for SNAP benefit increases, and suggest that being able to purchase healthy ready-to-eat foods would support them to feed their families healthfully when time is limited. We learned that in soliciting participant input to guide SNAP-Ed program or policy decisions, attention to the method of eliciting information is critical. Language and structure of interviews can influence participants' likelihood of identifying structural or immediate supports.
Limitations
This study has a number of limitations. We conducted a cross-sectional qualitative study in five counties in a large state. While our findings are consistent with prior studies, we likely have not represented the voices of many low-income Californians. Many of the participants in our focus groups had attended nutrition education classes, and thus, were likely more knowledgeable about nutrition than the general population. A few participants did not meet study criteria of currently raising children. At one group, many of the participants were SNAP beneficiaries working at a local food justice organization, so had heightened awareness of the issues being discussed. Further, while we followed qualitative research protocols, the nature of this work includes researcher bias. Having a team of three people checking our data interpretations helped to minimize our individual biases, but the findings likely reflect aspects of our knowledge and experiences that are difficult to remove from our analytic lens.
Conclusion
This study finds that income is the primary challenge focus group participants confront. Limited income greatly constrains families' diets, and when combined with limited time, leaves people with few options but to feed their children inexpensive, highly processed foods and fewer healthy foods, increasing their chronic disease risk. Healthy diets are desired but unaffordable, and this conflict causes many parents a great deal of stress. SNAP-Ed programs are funded to improve food environments and support SNAP-eligible families' efforts to eat healthfully. Participants are grateful for the services provided and would benefit from SNAP-Ed and other leaders seeking input about ways to improve their diets. This study reminds us that the USA is a long way from meeting Article 25 of the Universal Declaration of Human Rights, which states, ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food….’
Author ORCIDs
Wendi Gosliner, 0000-0001-5092-9289
Acknowledgements
We thank Isabel Rangel for conducting focus groups and participating in coding and preliminary analysis. We also thank Pat Crawfod, Ken Hecht, and Caitlin Daniel for providing thoughtful feedback on a draft manuscript. We appreciate the SNAP-Ed program leaders and community organizations who recruited participants and hosted focus groups and the study participants who shared their time and life experiences. The California Department of Public Health Nutrition Education and Obesity Prevention Branch supported this effort. The project was funded by USDA's Supplemental Nutrition Assistance Program Education. This institution is an equal opportunity employer.
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