Participant voices: examining issue, program and policy priorities of SNAP-Ed eligible adults in California

Abstract The Supplemental Nutrition Assistance Program Education (SNAP-Ed) aims to prevent obesity and chronic disease among SNAP-eligible families by facilitating healthy eating and active living. This study aimed to capture the voices of California SNAP-Ed eligible parents to inform program planners of their challenges in feeding their families, their available supports and priorities for intervention. We conducted eight focus groups with 55 participants across five counties in California from May through August 2017. Trained researchers used Dedoose to code and analyze data for substantive themes and overarching findings.Ten key findings and 4 additional findings were identified. Participants experience multiple challenges, primarily inadequate income and limited access to high quality, affordable healthy food contrasted with easy access to affordable unhealthy food. Despite efforts to manage food resources, most struggle to afford adequate diets. Employed parents confront a particularly challenging dual poverty of money and time. Many parents report feeling guilt related to feeding their children. Participants appreciate available programs and services and suggest increasing community input; providing sustainable programs; lowering the cost of and improving access to healthy food; reducing access to unhealthy food; modifying food assistance efforts; and improving nutrition education and promotion. Overall, low-income parents in California struggle to feed their families the way they would like. Participants generally understand what to feed their children, but struggle with how to do it, perceiving their circumstances and environments as inhospitable to healthy eating. Participants' suggestions can help SNAP-Ed programs and other efforts better support families' needs.


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., 2013). Other studies have found that SNAP households use both formal and informal networks to sustain food resources throughout the month (Schenck-Fontaine et al., 2017); 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, 2004;Rose, 2011;Haynes-Maslow et al., 2013;Zenk et al., 2013;Evans et al., 2015). 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., 2011). 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., 2009;Libman et al., 2016;Leung et al., 2017). 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., 2018); 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). 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.

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.
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 408 Wendi Gosliner and Heena Shah 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.
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., 2013). 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, 2011). 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 (1) Think about a typical day. How does your family prepare/serve/eat meals? (2) In a perfect world, where you could have things exactly the way you want, how would you and your family eat? (3) Think about the days when your family eats in a way you feel good about. What helps that to happen? (4) Think about the days when your family eats in a way you don't feel good about. What happens on those days? (5) People often come up with creative strategies to help their family eat the way they would like. Can you share any strategies you or families you know use? (6) What do you think are the biggest challenges related to food and eating that people in your community are struggling with? (7) How is your community able to respond to the challenges we just discussed? (8) Which, if any community organizations, have been helpful to you or others you know in being able to eat the way they would like? (9) What ideas do you have about what could be done to help your family or families you know to eat the way you/they would like to? (10) What do you think is most helpful about the work being done in your community now? (11) What would you most like to see SNAP-Ed do in your community in the future? (12) If you were interested in eating according to the USDA MyPlate recommendations, what would your family or others in your community need, to eat the way this plate recommends?
studies similarly have found this desire to eat healthfully (Zachary et al., 2013). 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., 2018). 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., 2004;Moore and Diez Roux, 2006;Zenk et al., 2013). 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, 2010;Andreyeva et al., 2011). 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., 2013).
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., 2014;Jabs and Devine, 2006;Venn and Strazdins, 2017) 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  (44) Associate's degree 4 (7) Bachelor's degree 4 (7) Master's or Doctoral degree 1 (2)   Key Finding 3: The local food environment is not supportive of healthy eating, with participants confronting both limited and poor quality grocery stores and cheap, convenient, highly promoted unhealthy options.
3.1 But it is hard, I can say, for a lot of us to get the nutritious food we want, because one they keep closing down all of our grocery stores.
3.2…it might just be the stores that I go to. The fruits and vegetables, they're bad. Gnats and stuff all over… 3.3 There's actually three grocery stores in thatwithin those shopping centers-but the quality of the produce is just bad, really bad. [Another participant responds] Right. Also, there's like, with all of the fast food that's around it, that overshadows the grocery store.
3.4 Hamburgers and everything is like US$1, but salads are like US$5. They make it hard for people to want to eat healthy when it costs so much. The one that's healthy should be cheaper than a hamburger.
3.5 …because when you go to the grocery store, the first thing you see are the chips, cookies, and sodas on sale.
Additional Finding 1: Participants perceive their traditional cultural foods as being unhealthy.
1.1 Let's look at breakfast, for example… as Latinos, we are used to eating beans, eggs… cheese and cream, chilaquiles…tortillas. So, how do we have balanced breakfasts?
1.2 … before I used rice in every meal, every day. And now weeks will go by and I won't cook rice. I mean, we're trying to avoid using it as much. But yeah, whole wheat, no-they saw that it was brown and said 'what? Why did you change colors all of a sudden?' I said, 'We're trying to eat healthier.' 1.3 In my house, when my grandma wanted to show that she loves you, she'll make you a good meal with a whole bunch of unhealthy foods, from corn bread with a whole bunch of sugar, mac and cheese, Kool Aid and two cups of sugar. So just learning to think of food as fuel and information as opposed to the way we used food in our community for such a long time… Additional Finding 2: Concerns about food waste limit purchases of and experimentation with fresh, perishable foods.
2.1 You can't buy fresh because… it's going to spoil.

2.2
We're afraid to experiment. It's wasting the food on the one hand, but on the other hand, you're changing your taste buds.

You can buy a box of Rice-A-Roni and it
can be on the shelf for a while. That broccoli -especially because my fridge is terrible--it's only going to last me literally like four or five days. It's not going to stretch as much, you know … Additional Finding 3: Participants perceive school foods negatively.
3.1 At school they just give them food that has been heated up and they get used to that food, so that's when they stop eating a lot of vegetables. They no longer want to eat fruit because at school, they get pizza, they get hamburgers.
3.2 If they go in at school and they eating all this cheap junk food, who wants to come home and eat some vegetables?
3.3 My kids, they don't want to go there [to eat the school meals]. They say, 'I'm not going over there, Mommy.'

STRATEGIES
Finding 4: Participants utilize various food acquisition strategies, such as buying staple and shelf-stable foods, shopping at multiple stores to get the best deals, buying foods on sale, and seeking food donations to stretch their dollars and food assistance benefits.
4.1 Because when I get my food stamps, I try to stock up. Stock up every meat, canned goods… vegetables I know go bad within a couple of days, so I try to buy just for that week and save, but even at the end of the month, I'm out. It's just not enough.
(Continued ) 4.2 You got to go to all these different stores, because you're trying to get the best deals and try toyou're maneuvering around all the stores.
4.3 And I do make the dollar stretch by always buying in bulk, and buying things on sale, and cut coupons like my hands just have no feeling in them anymore from all the cutting that I do.
4.4 I go to the food banks and I pick up-first is, of course, all the veggies, because you can make a good meal with veggies… 4.5 I get WIC, so I wait until the end of the month to use that because that comes in handy for me. We get our peanut butter, our bread, our eggs and cheese and tortillas. So we can live off of that for two weeks… Finding 5: Participants report children's taste preferences to be challenging, but many implement strategies to encourage themselves and their children to eat healthfully. 5.3 What I do is afternoon, I will peel some cucumbers for her. I'll put some cucumbers, pears, or apples on the table… I try not to have cookies or Cheetos or things like that in the house.
5.4 I encourage the girls to cook with me.
5.5 Well, I changed about almost two years ago, because I was diagnosed with diabetes. So, I had to radically change my food, and at home, I don't buy any soda.

IMPACT
Finding 6: Participants experience a great deal of stress and guilt related to being unable to provide their children with the quality and quantity of food they feel they should.
6.1 Like when you expect your kids to eat good, and they end up not eating good. You feel so bad that theyespecially maybe you supposed to provide for them like three square meal a day, and you providing like two square meal a day. Maybe because… you couldn't afford to buy the food. I mean, you don't feel good about that. It makes you feel so uncomfortable.
6.2 … if I'm, like, busy throughout the day, or like rushing to do whatever, or can't get home early enough to make dinner, then of course then that's when the fast food comes in. I be like this money I'm spending on this fast food, it could have been like a meal for a couple days. You know what I'm saying? So I feel guilty about spending the money for one meal when it could have been a meal for like at least a day or two, or more.
6.3 I feel guilty [after taking kids out for fast food], but then the next day, I'll try to make a good meal, like vegetables, to not feel that way-so guilty.
6.4 But, when you say, 'Okay, have them eat pizza,' then at night, I feel bad and I think, 'They're not eating right… it's not right to have them eat pizza and hamburgers'…. It's not fair that because of work, I have to leave and later on it's going to affect their health because of the food. Yes, it's hard.

PROGRAM and POLICY FEEDBACK AND RECOMMENDATIONS
Finding 7: Participants appreciate the support they receive, in terms of nutrition education programs, food benefits, and charitable food programs. . I thought it was useful… they would say that it was for us to experiment and make changes and so it wouldn't affect our grocery budget so much.
7.3 I know it's a big issue, even for me, like you know you got to provide lunch now for the summer, and it's like another meal and it's like time, a lot in your hands when you get home… But I'm glad they have a free lunch.
7.4 … the church where I go… they have this program which they have free food for people, and it's, um, food from [a major grocery chain]. So I know that that's helpful for them. Sometimes I do take some eggs because it's like really good food, because you know their food is so expensive, so they do have some good food.
And that's one of the places I know that they're helping and it's good that they have that.
Additional Finding 4: Participants express that available programs and services don't provide adequate support for working families.
4.1 She works, right? So how is she going to go to the pantry and get… They do have those foods that they give to the people, but what about the working people?"

4.2
We're taking care of your kids. We're driving, doing your laundry, scrubbing your toilets. But you don't want to give us basic needs as medical care? Are you kidding me? [background-yeah.] Yeah, it's a serious joke out there. It's never going to get right until they start looking at everyone just as a person, and not by where they came from, or where they were born, or what tongue they speak.

And then just like my [SNAP] office
isn't open when I get off work, so then I'll find a way to get off early someday, like work extra hours Monday in order tobut not everyone can do that. Yes, I know. I went to all this last week and now I have to figure out a way to get off early another day so I can go and actually give them the paperwork. It just stopped for no reason.
4.4 And I just feel like SNAP is likeyou feel like you getting ahead, as soon as they find out any income that you make, then they pull a rug right from under your feetand I'm back to zero. And it's not enough. I don't think it is enough.
Finding 8: Participants would like programs to be better informed by and connected to expressed community needs and would like to be more involved in decision-making related to programs and services. 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, 2012). 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 You, 2010, 2011). 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., 2018;Brasher, 2018), 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, 2011). 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 . 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 8.3 [Speaking about specific SNAP-Ed interventions] The stuff that they do is once a year. Once a year, and barelyand rarely. Then they want you to take-[another participant interrupts, saying] Then they barely fund it.
Finding 9: Participants recommend multiple ways in which policies, systems, and community environments could change to help them better meet their goals for feeding their families, such as increased benefit levels, improved transportation, easier access to healthy food retailers, more affordable healthy foods, and other changes to food assistance benefits.
9.1 More money would be helpful, because it would afford us the opportunity to spend more on those perishable foods, which are fresh fruits and vegetables. 9.2 I was thinking better public transportation, because I think that was something that I thought that was echoed by a lot of people… I think that if there were more grocery stores and then add a few more bus lines to your timetable or something. Certainly that's where there's this like clear, apparent need for it. 9.3 Well, for them to lower the price of vegetables, because, for example, this last week-my daughter really likes strawberries, but strawberries are always very expensive, but this last week, at [a chain grocery store], they were 88 cents a pound, so I bought a lot of strawberries, but I know they're not going to last, so this week, my daughter didn't ask for Hot Cheetos, because I would give her a plate of strawberries or other fruit to feed her and ease her hunger while dinner isn't ready or like a snack. I think so, to lower the price of fruits and vegetables.
9.4 For there to be programs to help us out with coupons, so we could get things a little cheaper. I think it would be something good, because we wouldn't have the excuse that we can't buy it, but sometimes-and to be honest, sometimes we can't afford everything. We would like to be able to afford everything, but sometimes it's not possible and if there was a way that if you bought vegetables, they would be a little cheaper or something, something where they could help us out with that, I think it would be great. 9.5 They should have more restaurants that offer healthier choices that you can actually use your food stamp card… 9.6 I want Blue Apron to accept stamps.
Finding 10: Participants see many opportunities to improve nutrition education, promotion, and advocacy in their communities. 10.2 I think better advertising, more honest advertising about healthy foods, fresh fruits, and vegetables and I think the USDA working with the communities where a lot of SNAP eligible people are served, will it be a good idea? Advocate for us as we advocate for ourselves.
10.3 Advertise it more -more so I say like when it comes to healthy eating and the farmers' market, we see it more so on flyers and stuff… [another participant] If a person doesn't know that they existthis is all wonderful what you do, but if nobody like really knows about it, it's not been getting into the people that you're trying to help.
10.4 … if they want to help the community, they should continue helping and seeking sponsors, but don't let it end, continue, because as we mentioned, we go to some [nutrition programs] and then they disappear, and we don't know what happened.
10.5 So, like, our communities are not always aware about the healthier options that's available for them… [if we knew] we could then start to demand access to those from our city representatives.
unhealthy. Many felt that only fruits, vegetables and unfamiliar foods-such as quinoa and brown rice or whole wheat pastawere 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., 2013;Daniel, 2016). 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, 2006), 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., 2016). 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 policymakers, 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 crosssectional 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….'