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Introduction: The U.S. safety net, which provides critical aid to households with low income, is composed of a patchwork of separate programs, and many people with low income benefit from accessing

Abstract Objective: The COVID-19 pandemic increased food insufficiency: a severe form of food insecurity. Drawing on an ecological framework, we aimed to understand factors that contributed to changes in food insufficiency from April to December 2020, in a large urban population hard hit by the pandemic. Design: We conducted internet surveys every 2 weeks in April–December 2020, including a subset of items from the Food Insecurity Experience Scale. Longitudinal analysis identified predictors of food insufficiency, using fixed effects models. Setting: Los Angeles County, which has a diverse population of 10 million residents. Participants: A representative sample of 1535 adults in Los Angeles County who are participants in the Understanding Coronavirus in America tracking survey. Results: Rates of food insufficiency spiked in the first year of the pandemic, especially among participants living in poverty, in middle adulthood and with larger households. Government food assistance from the Supplemental Nutrition Assistance Program was significantly associated with reduced food insufficiency over time, while other forms of assistance such as help from family and friends or stimulus funds were not. Conclusions: The findings highlight that during a crisis, there is value in rapidly monitoring food insufficiency and investing in government food benefits.

Introduction: Low-income immigrants who are eligible to participate in the Supplemental Nutrition Assistance Program (SNAP) participate at lower rates compared to non-immigrants. Immigrant households may be more likely to participate in SNAP if they live in areas with policies that integrate them into society and protect them from deportation. Methods: Data on low-income immigrant households came from the 2019 American Community Survey (N = 87,678). The outcome was whether any household member received SNAP in the previous 12 months. Immigrant policy exposures came from two sources: the State Immigration Policy Resource, which includes 18 immigrant criminalizing and integrating policies, and a database that identified ‘sanctuary policies’ (SP), which we summarized at the county level. Multivariable logistic regression adjusted for person/household-level and area-level confounders. Results: Living in a jurisdiction with a SP was associated with 21% higher odds of enrolling in SNAP compared to living in a jurisdiction without a SP (adjusted odds ratio [aOR] 1.21, 95% CI=1.11,1.31). Relative to the least immigrant friendly states, living in the most immigrant-friendly states was associated with 16% higher odds of SNAP enrollment (aOR=1.16, 95%CI=1.06–1.28). When SP and state-level immigrant friendly policy environment were cross-classified, SNAP participation was 23% and 26% higher for those living in jurisdictions with one- and both- exposures, respectively, relative to those with neither (aOR 1.23; CI 1.12,1.36; aOR 1.26; CI 1.15,1.37). Conclusions: Many at high risk of food insecurity – including immigrants and citizens in households with immigrants – are eligible for SNAP but under-enroll. Policies that welcome and safeguard immigrants could reduce under enrollment.

Abstract Background The Affordable Care Act (ACA) provisions, especially Medicaid expansion, are believed to have “spillover effects,” such as boosting participation in the Supplemental Nutrition Assistance Program (SNAP) among eligible individuals in the United States (US). However, little empirical evidence exists about the impact of the ACA, with its focus on the dual eligible population, on SNAP participation. The current study investigates whether the ACA, under an explicit policy aim of enhancing the interface between Medicare and Medicaid, has improved participation in the SNAP among low-income older Medicare beneficiaries. Methods We extracted 2009 through 2018 data from the US Medical Expenditure Panel Survey (MEPS) for low-income (≤ %138 Federal Poverty Level [FPL]) older Medicare beneficiaries (n = 50,466; aged ≥ 65), and low-income (≤ %138 FPL) younger adults (aged 20 to %138 FPL incomes, younger Medicare and Medicaid beneficiaries, and older adults without Medicare were excluded from this study. Using a quasi-experimental comparative interrupted time-series design, we examined (1) whether ACA’s support for the Medicare-Medicaid dual-eligible program, through facilitating the online Medicaid application process, was associated with an increase in SNAP uptake among low-income older Medicare beneficiaries, and (2) in the instance of an association, to assess the magnitude of SNAP uptake that can be explicitly attributed to the policy’s implementation. The outcome, SNAP participation, was measured annually from 2009 through 2018. The year 2014 was set as the intervention point when the Medicare-Medicaid Coordination Office started facilitating Medicaid applications online for eligible Medicare beneficiaries. Results Overall, the change in the probability of SNAP enrollment from the pre- to post-intervention period was 17.4 percentage points higher among low-income older Medicare enrollees, compared to similarly low-income, SNAP-eligible, younger adults (β = 0.174, P

Abstract Objective: Food pantries and the Supplemental Nutrition Assistance Program (SNAP) are widely available resources for individuals facing food insecurity, yet the dietary quality of individuals using both programmes is not well characterised. We describe the dietary intake of individuals in North Texas who use both food pantries and SNAP to identify nutritional gaps and opportunities to improve food assistance programmes. Design: We analysed baseline data from a randomised controlled trial examining food security and dietary intake. At baseline, we administered the validated, 26-item Dietary Screener Questionnaire (DSQ). We calculated descriptive statistics for dietary intake variables and compared with the 2020–2025 Dietary Guidelines for Americans recommended intake values. Setting: Two large food pantries in Dallas County, TX. Participants: Eligible participants were English or Spanish speaking adults receiving SNAP benefits who had used the food pantry within the last 4 months. Results: We analysed baseline DSQ data from 320 participants (mean age 47 years; 90% female; 45% Black or African American; 37% Hispanic or Latino). Despite receiving SNAP benefits and food pantry assistance, most participants did not meet the minimum recommended intake values for fruits (88.4%), vegetables (97.4%), fibre (90·7%), whole grains (99·7%), dairy products (98·4%) and Ca (83·4%). Furthermore, 73·2% of participants exceeded the maximum recommended intake for added sugar. Still, the gap between median daily intake and recommended daily intake could be partially bridged with food obtained through current food assistance programmes. Conclusions: Multilevel, coordinated approaches within both SNAP and food pantry networks are needed to improve diet quality in individuals receiving food assistance.

IntroductionThe Supplemental Nutrition Assistance Program (SNAP) is the largest federal nutrition assistance program in the United States, and played a critical role in mitigating food insecurity during the COVID-19 pandemic. In 2021, the updated Thrifty Food Plan (TFP), which provides the basis of SNAP benefit allotments, led to a 21% monthly benefit increase for SNAP participants. The objective of this study was to examine the effects of the TFP re-evaluation on food insecurity, diet quality, and mental health using a natural experiment design.MethodsA longitudinal, web-based study was conducted among 1,004 United States adults with incomes at or below $65,000 in September 2021 (prior to the policy change) and February 2022 (after the policy change). Outcomes of interest included household food security, diet quality, perceived stress, and anxiety/depression, assessed using validated instruments. We used difference-in-differences regression modeling to assess the effects of the policy change on participants’ outcomes, adjusting for sociodemographic covariates. Qualitative responses to open-ended questions about the policy change were analyzed using thematic analysis.ResultsPrior to the policy change, SNAP participants had significantly worse food insecurity, lower diet quality scores, and higher perceived stress and anxiety/depression when compared to non-participants (all Ps 0.05). Qualitative responses suggested that rising food prices and growing inflation potentially negated the benefits of the policy change; however, most SNAP participants described the added benefits as helpful in purchasing additional food supplies and offsetting other household costs during this period.DiscussionThe TFP benefit increase may have helped to prevent inflation-related disparities in food insecurity and health outcomes from widening among SNAP participants and non-participants. Further research is needed to determine the long-term impacts of this policy change.

Food retailers are key stakeholders in the development, implementation, and effectiveness of Supplemental Nutrition Assistance Program (SNAP) nutrition pilot programs. Qualitative interviews were conducted to gather insight from food retailers regarding the feasibility of proposed strategies to improve food choices among SNAP participants. Two corporate and six local-level food retailer managers were identified for interviews based on SNAP participation, rural- urban code, and type of food retail settings in the selected counties. Qualitative thematic analysis was performed by four research team members, and themes were identified via consensus. Marketing, incentive, and disincentive program models were well-received, while restriction and stocking standards models were less well-received. Food retailers viewed simple programs with easy implementation and educational components positively. Driving sales and programs that align with corporate and social responsibility goals were important factors related to willingness to participate in pilot programs. Insights from this present study can inform future pilot programs and promote food retailer buy-in.

Abstract Background The Supplemental Nutrition Assistance Program (SNAP) is the largest anti-hunger program in the United States. Two proposed interventions to encourage healthier food expenditures among SNAP participants have generated significant debate: financial incentives for fruits and vegetables, and restrictions on foods high in added sugar. To date, however, no study has assessed the impact of these interventions on the benefit cycle, a pattern of rapid depletion of SNAP benefits that has been linked to worsening nutrition and health outcomes over the benefit month. Methods Low-income households not currently enrolled in SNAP (n = 249) received benefits every 4 weeks for 12 weeks on a study-specific benefit card. Households were randomized to one of four study arms: 1) incentive (30% incentive for fruits and vegetables purchased with study benefits), 2) restriction (not allowed to buy sugar-sweetened beverages, sweet baked goods, or candy using study benefits), 3) incentive plus restriction, or 4) control (no incentive or restriction). Weekly household food expenditures were evaluated using generalized estimating equations. Results Compared to the control group, financial incentives increased fruit and vegetable purchases, but only in the first 2 weeks after benefit disbursement. Restrictions decreased expenditures on foods high in added sugar throughout the benefit month, but the magnitude of the impact decreased as the month progressed. Notably, restrictions mitigated cyclical expenditures. Conclusions Policies to improve nutrition outcomes among SNAP participants should consider including targeted interventions in the second half of the month to address the benefit cycle and attendant nutrition outcomes. Trial registration ClinicalTrial.gov, NCT02643576 . Retrospectively registered December 22, 2014.

Surveillance data indicate that food security rates increased among Supplemental Nutrition Assistance Program (SNAP) participants during the COVID-19 pandemic (2020 and 2021) compared with pre-pandemic (2019), but this could have been due to increased participation from better resourced households. Our objective was to examine if demographic differences between SNAP-participating households in each year were responsible for the increased prevalence of food secure households. We calculated the observed 30-d food security prevalence among SNAP-participating households for each year. We used indirect standardisation to produce expected 2020 and 2021 prevalences with 2019 as the standard population using household size, income, age, sex, race, Hispanic ethnicity, presence of children, single parent household, metropolitan status and census region. We calculated standardised prevalence ratios (SPRs) to understand if the observed prevalence was higher than expected given any changes in the demographic profile compared to 2019. The Current Population Survey data were collected by the United States Census Bureau and Department of Agriculture. Our sample included 5,245 SNAP-participating households. The observed prevalence of food secure households increased by 3⋅6 percentage points comparing 2019 to 2020 (SPR = 1⋅06, 95 % confidence interval = 1⋅00, 1⋅11) and by 8⋅6 percentage comparing 2019 to 2021 (SPR = 1⋅13, 95 % confidence interval = 1⋅07, 1⋅18). The greater prevalence of food secure SNAP households during the pandemic did not appear to be attributable to socio-demographic differences compared to pre-pandemic. Despite hesitance among policymakers to expand or enhance social safety net programmes, permanently incorporating COVID-19-related policy interventions could lessen food insecurity in years to come.

Structural racism has contributed to increased poverty, food insecurity, and obesity rates among African Americans relative to Whites. Nutrition education programs should therefore consider how well they serve this population. The objective of this investigation was to assess whether African American and White Supplemental Nutrition Assistance Program Education (SNAP-Ed) participants in Louisiana had comparable dietary behavior outcomes by conducting secondary data analysis of previous program evaluations from 2017-2018 and 2018-2019 among African American and White SNAP-Ed participants (n = 434). Variables measured included pre- to post-intervention changes in dietary behaviors (e.g., self-reported consumption frequency of fruit, vegetables, whole grains, low-fat dairy, sugar-sweetened beverages, and juice). Statistical analyses included t-tests stratified by race and Pearson’s chi-square test for categories of change in dietary behaviors. In categorical analyses, Whites had increased consumption, and African Americans had decreased consumption of whole grain pasta following SNAP-Ed participation. Among those who did not change consumption patterns following SNAP-Ed participation, African Americans were more likely to consume fruit juice and juice-flavored sugary drinks at a rate above median consumption compared to White participants. Future research should identify how program participation is followed by different dietary behavior outcomes in different races and explore how SNAP-Ed could specifically address barriers to equity.

This study estimates the economy-wide impacts of two components of U.S. federal spendingÑnutrition programs and farm support programsÑusing an applied general equilibrium model. Both programs slightly reduce overall economic output and have important distributional effects. Farm programs reduce expenditures on a wide array of goods and services throughout the economy, including agricultural products, primarily since the programs reduce the spending power of taxpayers in general. Nutrition programs also reduce expenditures for some goods and services but raise the demand for agricultural products as well certain sectors for which the marginal propensity to consume is high among low-income households.

Prageet K Sachdev, Mahsa Babaei, Jeanne H Freeland-GravesDepartment of Nutritional Sciences, College of Natural Sciences, The University of Texas at Austin, Austin, TX 78712, USAAbstract: The Supplemental Nutrition Assistance Program (SNAP) is the largest federal program that provides assistance for the purchase of foods to low-income households in the United States. SNAP plays a valuable role in alleviating hunger and food insecurity in poor households; however, one consideration that remains relatively unexplored is the influence of this program on food choices. Food choices are guided by several factors in low-income individuals, including the cost of food, household size, nutrition knowledge, availability of fresh foods in the neighborhood, transportation, and cultural factors. Also, the complex relationship between SNAP participation and food choices is further confounded by the factors of demographics, food insecurity, poverty, and self-selection. There is a lack of quantitative investigations that directly evaluate food choices in SNAP recipients. As a result, this review will focus on summarizing finding from studies that assessed food purchasing patterns, diet quality, and weight gain in SNAP participants. These outcomes may serve as proxy measures to evaluate the food choices made by SNAP participants. In addition, this review discusses many behavioral economic strategies such as reducing the cost of healthy foods, providing monetary benefits for purchase of healthy foods, increasing the SNAP benefits, incentivizing small food retailers to offer more food choices in low-income neighborhoods, increasing grocery stores and supermarkets in poor neighborhood, and strengthening the SNAP-Ed program; some of which have been previously adopted to promote the selection of healthy foods in SNAP participants. SNAP has the potential to impact food choices in the society, as such longitudinal studies are needed to evaluate the effectiveness of any reforms in SNAP benefits or restrictions, which may seem logical but not impact food choices in reality.Keywords: Supplemental Nutrition Assistance Program, food choices, grocery purchase, diet, diet quality, obesity

Cost-offset community supported agriculture (CO-CSA) appears to be a promising way to increase low-income households’ access and intake of fresh produce, while also helping CSA farms expand their farm business. Yet single farms operating CO-CSAs may struggle to balance the demands of farming with CO-CSA program administration, funding, and recruitment. To address these chal­lenges, CO-CSA programs operated by nonprofits have emerged, equipped with dedicated infrastruc­ture, resources, and staffing. This study aims to describe organizational models and best practices of nonprofit CO-CSA programs, using a qualitative approach. We conducted interviews with five well-established nonprofit CO-CSA programs in the U.S. Administration of these five nonprofit CO-CSAs took several forms: (1) providing direct sub­sidies to individual CO-CSA member farms; (2) functioning themselves as an aggregator, packer, and distributor of regional produce; and (3) sourcing from an in-house farm incubator or food hub, then packing and coordinating delivery to pick-up sites. Nonprofit CO-CSA funding strategies included grants from federal and local government sources, private donations, fundrais­ing, and grants. Marketing efforts occurred via social media, community events, and word of mouth. Both fundraising and recruitment were greatly facilitated by relationships with community partners. Having dedicated staff, as well as a com­munity that values local agriculture and social jus­tice, were identified as success factors. This descriptive, qualitative study systematically com­pares the attributes of five nonprofit CO-CSA programs. Future research should focus on identifying the cost-effectiveness of nonprofit CO-CSAs, compare the relative merits of single-farm and nonprofit CO-CSAs, and quantify the eco­nomic benefit of CO-CSA programs for farmers and local communities.

To improve low-income families’ access to fresh local produce, some farmers offer subsidized or “cost-offset” community supported agriculture (CO-CSA) shares. We evaluated a structured planning and implementation process conducted during the final intervention year of the Farm Fresh Foods for Healthy Kids (F3HK) study, which aimed to help participating farmers (N=12) to sustain a CO-CSA program after study funding ended. The process included training webinars, planning tools to develop CO-CSA continuation funding and recruitment strategies, regional coach­ing teams to provide technical assistance, and peri­odic group conference calls to facilitate shared learning among F3HK farmers. Our evaluation explored the content of farmers’ CO-CSA contin­u­ation plans, their experiences during implementa­tion, their opinions about the planning process, and their future plans regarding their CO-CSA. We found that F3HK farmers used diverse methods to plan, recruit, and raise funds, with each farm adapt­ing strategies to fit their local conditions and farm business. Many farmers found success with word-of-mouth advertising and CSA member donations. Yet lack of farm resources—time, money, and ex­pertise—was a continual barrier to moving for­ward. As with full price CSAs, reciprocity was a key factor: farmers needed to consider the needs and preferences of low-income consumers, and CO-CSA members needed to understand their financial responsibility to the farmer. In general, F3HK farmers appreciated the continuation planning pro­cess, but expressed a desire for more technical assistance with grant writing. Farmers were com­mitted to the success of the CO-CSA continuation planning process, and most intended to continue the CO-CSA the following year.

Background: The Supplementary Nutrition Assistance Program (SNAP) is a critical lifeline for millions of low-income US families, but some studies suggests that it may inadvertently increase obesity risk. Building on research contesting the SNAP-obesity link, we examine the effect of SNAP participation on BMI among multiyear participants at varying levels of SNAP benefit levels to provide some of the first evidence on the relationship between SNAP participation, state-level SNAP resources, and body weight. We focus on children given the strong links between early-life obesity and later-life health. Methods: Linking state-level data on SNAP benefit levels with three waves of longitudinal individual-level data from the Child Development Supplement of the Panel Study of Income Dynamics, we use child- and state-level fixed effects to examine whether exogenous differences in SNAP benefit allotments influence the relationship between SNAP participation and weight gain. Results: Lower SNAP benefit levels were associated with only modest increases in BMI among children; higher benefit levels showed no association with BMI. Conclusions: Although concerns that more food assistance promotes obesity have spurred calls for cuts in the SNAP program, we find the opposite — that SNAP participation is associated with an increase in childhood BMI only when benefit levels are low. This study adds to the mounting evidence suggesting that SNAP does not cause obesity. It also contributes to the literature on the political economy of health, especially that pertaining to social policy variation across US states.

Sales taxes on either grocery food or restaurant food exist in almost every U.S. county. By combining county-level sales tax data with the USDA's recent national household food acquisition and purchase survey, we examine how a food sales tax affects consumers' expenditures on grocery and restaurant food. We find that a grocery tax reduces consumers' grocery food expenditures and increases restaurant food expenditure and a restaurant food sales tax increases consumers' grocery food expenditures. We also find no differential impacts from food sales taxes based on consumers' income or participation status in the Supplemental Nutrition Assistance Program.

Abstract Background To encourage the consumption of more fresh fruits and vegetables, the 2014 United Sates Farm Bill allocated funds to the Double Up Food Bucks Program. This program provided Supplemental Nutrition Assistance Program beneficiaries who spent $10 on fresh fruits and vegetables, in one transaction, with a $10 gift card exclusively for Michigan grown fresh fruits and vegetables. This study analyzes how fruit and vegetable expenditures, expenditure shares, variety and purchase decisions were affected by the initiation and conclusion, as well as any persistent effects of the program. Methods Changes in fruit and vegetable purchase behaviors due to Double Up Food Bucks in a supermarket serving a low-income, predominantly Hispanic community in Detroit, Michigan were evaluated using a difference in difference fixed effects estimation strategy. Results We find that the Double Up Food Bucks program increased vegetable expenditures, fruit and vegetable expenditure shares, and variety of fruits and vegetables purchased but the effects were modest and not sustainable without the financial incentive. Fruit expenditures and the fruit and vegetable purchase decision were unaffected by the program. Conclusions This study provides valuable insight on how a nutrition program influences a low-income, urban, Hispanic community’s fruit and vegetable purchase behavior. Policy recommendations include either removing or lowering the purchase hurdle for incentive eligibility and dropping the Michigan grown requirement to better align with the customers’ preferences for fresh fruits and vegetables.

Farmers’ markets have been implemented to improve access to nutritious foods, yet use is low among people receiving Supplemental Nutrition Assistance Program (SNAP) benefits. This study’s objectives were to assess the feasibility of implementing the FreshLink Ambassador intervention to promote use of farmers’ markets located in high SNAP neighborhoods, describe information dissemination by Ambassadors, and evaluate intervention impact on SNAP use. The theory-based and data-driven intervention trained nine community residents as FreshLink Ambassadors in 2017; eight completed the study. Ambassadors conducted weekly outreach disseminating coupons to promote use of three intervention markets. Four comparison markets were selected to evaluate impact on SNAP use. SNAP sales from 2016 to 2017, standardized per vendor per market day open, were compared using paired and cluster-adjusted t-tests, p < .05. FreshLink Ambassadors conducted 155 outreach events reaching 1,138 people through coupon dissemination. The coupon redemption rate was 13.9%; redemption was significantly higher for people 50+ years of age, without children in the household, not currently receiving SNAP benefits, and living in the zip code with an intervention market. Intervention versus comparison markets had greater improvements in standardized SNAP sales ($0.73 vs. $0.44). These changes were not statistically significant but may be practically significant for farmers’ market operations. Findings provide evidence that implementation of the peer-to-peer outreach approach was feasible and coupon redemption rates exceeded industry standards indicating the “product” promoted by FreshLink Ambassadors was considered advantageous. Future research is warranted to evaluate different strategies intended to promote social access to farmers’ markets within a broader agenda to advance health equity.

Farmers play a critical role in increasing access to and affordability of fruits and vegetables in low-income communities by accepting Supplemental Nutrition Assistance Program (SNAP) benefits at farmers markets. However, only 40% of farmers markets nationally accept SNAP benefits. This study evaluates barriers farmers perceive in accepting SNAP in farmers markets. We recruited 134 farmers using convenience sampling from six pre-season regional growers meetings hosted in Alabama; 92 farmers met inclusion criteria and completed the anonymous, 51-question survey. The survey measured demographics, perceived barriers and promotional opportunities within constructs of the Social Ecological Model (SEM). We used descriptive statistics to summarize char­acteristics, and chi-square, Mann-Whitney U and t-tests to analyze differences in characteristics between those farmers who accept SNAP and those who do not. The most frequently cited barriers to SNAP acceptance included lack of internet access, increased burden for processing payments, increased need for bookkeeping, limited availability of information about the application process and payment system, limited support from the market for completing the application, a small customer base and limited number of SNAP clien­tele. Comparative analyses revealed statistically sig­nificant differences in demographics and perceived barriers between those who accept SNAP and those who do not. Findings from this study pro­vide a more in-depth understanding of challenges farmers face in accepting SNAP. These can be addressed through education, policy, systems and environmental solutions at various levels of the SEM to overcome barriers to SNAP acceptance, ultimately increasing access to and affordability of fruits and vegetables for low-income communities.

Immigrant families are known to be at higher risk of food insecurity compared to non-immigrant families. Documented immigrants in the U.S.

Farmers markets are promoted to improve access to healthy food for low-income consumers by providing affordable produce via Supplemental Nutrition Assistance Program Electronic Benefit Transfer (SNAP/EBT). Having SNAP/EBT at markets also expands revenue opportunities for participating farmers. Market managers play a key role in implementing SNAP/EBT and promoting business opportunities for farmers, yet they are not motivated equally by public health and business goals. There are few studies examining market managers' influence on food access for low-income households and business opportunities for farmers. We examined associations between managers' motivations and (1) food access for low-income households, measured by SNAP/EBT availability, and (2) business vitality, measured by vendor participation. A survey assessing manager motivation, SNAP/EBT availability, and vendor participation was sent to all market managers (N=271) in North Carolina. Seventy (26%) managers completed the survey. Multiple regression models were used to examine the association between managers' motivations to (1) improve access to healthful food and SNAP/EBT availability, and to (2) support business opportunities and total vendor count, weekly vendor count, and the number of vendors who sell only what they produce ("producer-only"). There was no significant association between food access motivation and SNAP/EBT availability, or business motivation and total and weekly vendor count. A high business motivation score was positively associated with having 13 more producer-only vendors at the market. Manager pay was positively correlated with vendor participation, including total vendor, weekly, and producer-only vendor counts. Our results suggest that public health interventions should emphasize the business opportunities offered by SNAP/EBT at farmers' markets, ultimately leveraging market managers' business goals to encourage SNAP/EBT implementation.

Farmers markets are generally considered one of the healthiest places to purchase food. However, less than 1% of food assistance dollars are redeemed at farmers markets. Because farmers markets have operated historically as cash operations, they are still experimenting and struggling to find ways to redeem electronic food share benefits. Much work on electronic benefit transfer (EBT) has focused on barriers from users' perspectives. Farmers markets have often been overlooked during the transition from food stamps to EBT. This paper takes an in-depth look at barriers and facilitators to successful implementation of EBT at farmers markets from the market manager's perspective. The researchers interviewed a semi¬random geographic sample of farmers market managers across Wisconsin (N=13) to determine if and how the electronic Supplemental Nutrition Assistance Program benefits are redeemed at their market and identify factors that impede or aid EBT redemption. Data were analyzed using grounded theory analysis. Several positive and negative themes emerged from the interviews as factors associated with successful EBT programs, including community support, perceived match of EBT with market mission, stable financing, perceived benefit to vendors, and vendor acceptance of EBT. Farmers markets have the potential to reduce food insecurity through EBT redemption. Understanding the main barriers as well as effective strategies for successful implementation of EBT in farmers markets is imperative to realize the full potential of this program. Understanding difficulties from market managers' perspectives is important to inform future policy initiatives to streamline reimbursement at farmers markets.

Aim: To describe the theoretical basis, and implementation of a randomized controlled trial to improve the diet and nutrition of low-income families in the United States. Background: Numerous community and state-wide programs exist in the United States to help improve the health and well-being of people with low incomes. One state-wide program, Small Steps to Health (Small Steps), focuses on improving diet and nutrition among SNAP (Supplemental Nutrition Assistance Program) recipients. Small Steps is a series of 10 1-hour educational classes that focus on a range of nutritional and diet topics, including: how to read food labels, how to prepare and cook home meals, as well as various ways to improve diet (e.g., reducing fat/sugar and increasing fruit/vegetable consumption). This program has been found to be effective in increasing vegetable consumption, meal planning, and physical activity. However, there has been no difference found in overall diet change nor in difficult diet behavior change, such as eliminating sugary drinks, reducing fast food intake, and replacing high-fat and sugar snacks with healthier options. Changing difficult behaviors requires more than education. For example, research shows that learning why sugary drinks are unhealthy is not enough to stop people from drinking these beverages. Beyond education, people benefit from counseling that focuses on increasing motivation and confidence, assistance with overcoming barriers, identifying social support, and creating specific action plans. Providing behavior change counseling to large numbers of people is challenging, however. Widespread use of short-message services (SMS) provides one potential tool for researchers to help individuals change difficult behaviors. For instance, SMS intervention is effective at helping smokers reduce or eliminate cigarettes, increase patients adherence to various medical regiments, and most importantly, aid in weight loss. Although promising, one of the limitations with current SMS interventions is that most have relied on providing reminder texts at the conclusion of an education/counseling session(s) − either reinforcing previous educational material or providing basic motivational messages. Very few have focused on incorporating effective counseling techniques to promote behavior change through interactions with participants during these educational sessions. The aim of our study is to explore what types of SMS behavior change techniques are most effective at helping individuals make challenging behavior change regarding diet and nutrition − Counseling vs. personalized Coaching vs. Reminding text messages. Method: To describe the design and rationale of an SMS randomized four-arm control trial that compares the dietary changes of an intervention using: 1) a standardized Counseling SMS group; 2) a personalized Coaching SMS group; 3) an educational information Reminding SMS group; each of which are compared to 4) the usual care control condition of a No SMS group. The Counseling and Coaching SMS groups were developed based on constructs of social cognitive theory (self-efficacy, motivation and outcome expectations) and the theory of planned behavior (barriers, social support, and action plans). Reminding SMS was the attention-control group and No SMS was the true control. A total of up to 300 SNAP recipients enrolled in the Small Steps to Health program in the state of Indiana will be randomized into one of four groups for three months to determine the efficacy of text-based behavioral interventions focusing on diet and nutrition. Every two weeks, participants will focus on a specific dietary behavior corresponding with the first four lessons taught in the Small Steps class. Behavior Change 1 (weeks 1 & 2): drink water instead of sugary beverages. Behavior Change 2 (weeks 3 & 4): eat breakfast every day. Behavior Change 3 (weeks 5 & 6): choose fruit as snacks and dessert instead of calorie-laden sweet and high-fat snack foods. Behavior Change 4 (weeks 7 & 8): switch to low-fat calcium sources. The main outcome measured is improvement in overall diet using a Self- 24-Hour Dietary Recall (ASA-24) and a Food Frequency Questionnaire (NHANES Food Questionnaire). Secondary outcomes are: specific behavior changes (as described above) as well as confidence, motivation and outcome expectation. Study completion is anticipated in May 2016. Conclusion: The results of this SMS intervention will inform the Small Steps program on the best way to incorporate technology into their program. In other words, does standardized counseling, personalized coaching or simple reminders work best for helping SNAP recipients improve their diets? If effective, the results will be implemented into the Small Steps To Health program.