4

Individual, Household, and
Environmental Factors Affecting
Food Choices and Access

Chapter 3 presented the evidence on relationships between participation in the Supplemental Nutrition Assistance Program (SNAP) and the potential for participants to achieve the program goals of improving food security and access to a healthy diet. This chapter presents evidence on individual, household, and environmental factors that affect food purchasing and consumption decisions and their impact on food choices and access and ultimately on the adequacy of SNAP allotments for achieving those goals. First, however, the chapter describes household food production theory as a framework for the discussion of these factors. After a brief review of the data and analytical challenges to research designed to broaden understanding of the issues facing SNAP participants, the final section presents a summary of findings and conclusions.

It should be noted that, in evaluating the available evidence, the committee determined it would be most useful to examine research questions with a focus on observational studies. This is because randomized controlled trials are infrequent among the types of studies considered. Much of the observational evidence available was cross-sectional, and the findings from these studies were considered in the context of the total available evidence, including that from both observational and experimental studies. All studies reviewed were evaluated by content area, study design, and publication source. Although they were not given equal weight with peer-reviewed publications, some publications from nongovernmental organizations and stakeholder groups also were considered because of the additional insight they provided into the behavioral aspects of participation in nutrition assistance



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4 Individual, Household, and Environmental Factors Affecting Food Choices and Access Chapter 3 presented the evidence on relationships between participa- tion in the Supplemental Nutrition Assistance Program (SNAP) and the potential for participants to achieve the program goals of improving food security and access to a healthy diet. This chapter presents evidence on indi­ vidual, household, and environmental factors that affect food purchasing and consumption decisions and their impact on food choices and access and ultimately on the adequacy of SNAP allotments for achieving those goals. First, however, the chapter describes household food production theory as a framework for the discussion of these factors. After a brief review of the data and analytical challenges to research designed to broaden under- standing of the issues facing SNAP participants, the final section presents a summary of findings and conclusions. It should be noted that, in evaluating the available evidence, the com- mittee determined it would be most useful to examine research questions with a focus on observational studies. This is because randomized con- trolled trials are infrequent among the types of studies considered. Much of the observational evidence available was cross-sectional, and the findings from these studies were considered in the context of the total available evi- dence, including that from both observational and experimental studies. All studies reviewed were evaluated by content area, study design, and publica- tion source. Although they were not given equal weight with peer-reviewed publications, some publications from nongovernmental organizations and stakeholder groups also were considered because of the additional insight they provided into the behavioral aspects of participation in nutrition as- 97

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98 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM sistance programs. The committee’s literature search strategy is described in Appendix D. HOUSEHOLD PRODUCTION THEORY AS AN ORGANIZING FRAMEWORK Consumers choose foods for consumption within the context of their own and their household’s preferences and available resources. According to basic economic theory, households purchase foods and other market goods to maximize utility, or well-being, based on their preferences and subject to the constraint that the cost of those goods is less than or equal to the sum of all sources of income. However, households are subject not only to an income constraint but also a time constraint. Thus, according to household production theory, households combine time and market goods to produce commodities for consumption in the household (Becker, 1965). In the context of food choices, food consumption requires not only money expenditures for purchasing food but also time expenditures for purchasing, preparing, and consuming food and for cleaning up after preparation and consumption. Therefore, the full price of consumption is the sum of the direct and indirect prices for food, where the direct price is the purchase cost, and the indirect price is the value of the time require- ments (Becker, 1965). The Becker model and its extensions help identify the types of individual and household factors that may be relevant in defining the adequacy of SNAP allotments. Furthermore, in the context of SNAP, the allotment is another source of “income” to the household that can be used to purchase food and may free up resources for the purchase of other types of market goods. A complication of household production theory as it applies to the pro- duction of commodities that require both market goods and time is that a household’s “technology” determines behavior in addition to its preferences (Pollak, 2011). A household’s technology could relate to human capital (e.g., food preparation knowledge) or physical capital (e.g., kitchen equip- ment). Furthermore, it could relate to the form of the production function transforming ingredients into foods for consumption, such as whether there are economies of scale in food production. Economies of scale relate to the fact that as household size increases, the incremental money and time expenditures for each individual are reduced because meals are prepared jointly, so the resources for acquiring, preparing, and serving are spread over more individuals. These economies of scale factor into the allocation of SNAP benefits based on household size. Recent research has investigated the trade-off between money expen- diture and time expenditure in food production. These studies have found that low-income individuals and households, like those at higher income

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INDIVIDUAL, HOUSEHOLD, AND ENVIRONMENTAL FACTORS 99 levels, are time-constrained for meal preparation. A household needs both sufficient money and sufficient time to prepare healthy meals (Davis and You, 2011). The amount of time individuals spend preparing food for consumption in the household is affected by household and individual factors such as earnings; labor force participation; the number of children in the household; and sociodemographic characteristics such as education, ethnicity, and gender (Mancino and Newman, 2007). Having multiple jobs, inflexible hours, and night work, for example, is associated with limited time for choosing and preparing healthy foods (Devine et al., 2003). In addi­ ion, environmental factors such as region of the country and whether t an individual lives in a metropolitan area affect food consumption decisions (Mancino and Newman, 2007). Using data from the 2003-2004 American Time Use Survey (ATUS), which is administered by the Bureau of Labor Sta- tistics, Mancino and Newman (2007) found that household time resources have a greater effect than an individual’s earnings or household income on how much time is allocated to preparing foods. As described further in the next section, households in which women work full-time or are the single head of household have fewer time resources. In summary, multiple factors affect a household’s ability to transform foods available for purchase into foods that can be consumed. With the exception of foods purchased in prepared form, for example, one or more individuals within the household must have the necessary knowledge and physical ability to prepare foods from ingredients and sufficient time available for all the activities involved in food preparation; moreover, the household must have the necessary equipment to refrigerate, prepare, and cook foods. In addition, food knowledge and choices are strongly influenced by social and cultural preferences of individuals and households. Furthermore, envi- ronmental factors affect the types of foods available for purchase, the cost of those foods, and the means of transportation (a personal vehicle, a social net- work, or public transportation) that can be used to acquire the foods. Thus, the broader context of the theory of household production must address the various factors that influence the theory’s application to actual food choices. INDIVIDUAL AND HOUSEHOLD FACTORS This section describes individual and household factors affecting the adequacy of SNAP allotments: food choices; the time available for food purchasing and preparation; knowledge, skills, and abilities related to food preparation; and the availability of personal, nonpublic transportation for individuals and households. Implicitly, SNAP allotments are based on assumptions about these factors, and departures from these assumptions for individual participants may affect their ability to purchase healthy foods with their SNAP benefits.

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100 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM Food Choices Definition of the adequacy of SNAP allotments for achieving the pro- gram goals is closely linked to food choices. As illustrated by the Food Choice Process Model (Sobal and Bisogni, 2009), food choices are strongly influenced by events and experiences beginning early in life and continuing throughout the life course. The following discussion focuses on components of this model that are potentially related to the ability of SNAP participants to achieve the program goals: taste preferences, personal and social factors, employment status, acculturation, and access to personal transportation (which is also considered later in this section as a potential constraint on the access of SNAP participants to healthy foods). Taste Preferences Taste preferences often are cited as a primary motivator of indi­ viduals’ food choices (Drewnowski, 1997; Drewnowski and Levine, 2003; Drewnowski et al., 1999). While preferences for sweet and salty flavor appears to be innate, other preferences are clearly influenced by early ex- posure. Evidence reviewed by the committee included both social and envi- ronmental factors that can influence taste preferences. A review of research on taste preferences includes evidence that foods eaten by a woman during pregnancy and lactation can influence the infant’s early flavor experience (Birch, 1999). It is not clear, however, that such exposure has a lasting im- pact on the infant’s subsequent taste preferences, given the number of social and environmental factors that can influence the development of those pref- erences during infancy and childhood (Birch, 1999; Devine et al., 1999). Personal and Social Factors Food deprivation and irregular availability of food during childhood have been found to contribute to the development of poor eating behaviors (e.g., overeating and binging and having an emotional attachment to food), as well as to less healthful food choices in general. Olson and colleagues (2007) propose early food deprivation in childhood and associated attitudes and behaviors toward food as a possible mechanism for the association between childhood poverty and adult obesity. Food choices also are influenced by personal and cultural ideals, con- strained by resources and present contexts. Family structure, including single head of household versus married/partnered heads of household, the presence of children, the health of family members, and the roles of each family member in food choices all influence the household’s ability to be food secure and have access to a healthy diet (Devine et al., 1999; Evans

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INDIVIDUAL, HOUSEHOLD, AND ENVIRONMENTAL FACTORS 101 et al., 2011; Wiig and Smith, 2009; Wiig Dammann and Smith, 2009). For example, children and other family members may influence the food deci- sions of the individual(s) procuring and preparing food to the detriment of the bottom-line cost, as well as the nutritional quality of what is purchased. As financial resources and consequent food security decline, low-income populations increasingly focus on price and quantity instead of prefer- ence and quality (Dachner et al., 2010; Wiig Dammann and Smith, 2009). They make use of a variety of family and community resources (Mammen et al., 2009), even resorting to strategies such as attending events where food is offered (e.g., church events), selling or pawning items, and eating discarded and out-of-date foods (Kempson et al., 2003). Specific strategies that impact nutritional quality include giving priority to meat above other foods; limiting fruits and vegetables because of cost and the short shelf life of fresh produce, combined with poorer flavor acceptance of canned varieties; limiting milk because of cost; and consuming more filling starches (Wiig and Smith, 2009). On the other hand, several qualitative studies of low-income women have found that having children has a positive influence on the mothers’ consumption of a nutritious diet, such as consuming more fruits and vegetables (Dubowitz et al., 2007), and on their motivation to improve the nutritional quality of their families’ diets even though they are constrained by cost and family members’ preferences (Evans et al., 2011). Recently, however, Laroche and colleagues (2012) analyzed data from the Coronary Artery Risk Development in Young Adults study to examine whether the percentages of saturated fat and energy intake and the daily intake levels for fruits and vegetables changed when children were present in the home. This longitudinal study of more than 2,500 adults found no relationship between becoming a parent and changes in the household’s eating habits, regardless of employment status. Employment Status Work life can influence food choices in several different ways. Quali- tative and quantitative research by Devine and colleagues (2003, 2009) examining the “spillover” of work into food choices among low- and moderate-wage workers revealed that long hours, inflexible schedules, shift work, and multiple jobs have an impact on the time and energy available for food procurement and preparation. Strategies used by workers for acquiring food under these conditions involved compromises viewed as unsatisfactory for maintaining a healthy diet, such as skipping meals, eating take-out meals, eating away from home, and limiting time to meet family needs and skipping family meals. Those who reported managing well had flexible work schedules, support from others for family responsibilities, and personal resources that included planning and cooking skills. The results

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102 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM of these studies were confirmed in a much larger cross-sectional study of a population of more than 3,700 diverse parents of adolescents participating in Project F-Eat (Bauer et al., 2012). Full-time working mothers reported spending less time in meal preparation, preparing fewer family meals, and consuming fewer fruits and vegetables. When work-life stress was higher, the outcome was a less healthful food environment overall, exemplified by even fewer family meals and more frequent consumption of fast foods and sugar-sweetened beverages. These effects did not differ between mothers and fathers. Acculturation Acculturation among immigrant populations has been shown to be asso­ iated with changes in both diet quality and food security (Mazur et al., c 2003). Most of this research has been in Latino populations, which have disproportionately high levels of food insecurity (Coleman-Jensen et al., 2012) and in which acculturation among youth appears in part to increase the negative effects of poverty on childrens’ diet quality (Mazur et al., 2003). In a recent study of the impact of acculturation on food security, D ­ hokarh and colleagues (2011) retrospectively analyzed respondents to the 1998-1999 Acculturation and Nutrition Needs Assessment survey of low- income Puerto Rican households to examine the impact of acculturation and social capital indicators on nutrition and health outcomes. The analysis focused on a convenience sample of women (N = 200) with young children in the Hartford, Connecticut, area who were either SNAP participants or SNAP-eligible. Among study participants surveyed, 76 percent were found to be food insecure. A bivariate analysis found positive associations between food insecurity and being unemployed, not owning a car, having older children, speaking Spanish only, planning to return to Puerto Rico, not attending Latino church or cultural events, receiving SNAP benefits that did not last the entire month, and accessing emergency food assistance. Likewise, a multivariate analysis showed positive associations between be- ing unemployed, single, born in the United States, speaking Spanish only, planning to return to Puerto Rico, not attending Latino church or cultural events, and having SNAP benefits that did not last the entire month. These results illustrate the complexity of the relationship between acculturation and food insecurity in this Latino population. Another cross-sectional study, also in Hartford, examined the differences between low-income pregnant women who were Puerto Rican (N = 243) or non–Puerto Rican Latinas. The Puerto Rican women were more acculturated than the other Latinas and had diets that were higher in fat and sugar and lower in veg- etables (Hromi-Fiedler et al., 2012). The presence of acculturation covaried with ethnicity so could not be assessed separately.

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INDIVIDUAL, HOUSEHOLD, AND ENVIRONMENTAL FACTORS 103 A qualitative focus-group study of Special Supplemental Nurition Pro- gram for Women, Infants, and Children (WIC)–eligible women who were mothers of infants and were either first-generation immigrants or U.S.-born found differences in attitudes related to food procurement and preparation (Dubowitz et al., 2007). Although there were similarities between the two groups, including time and money constraints on food choices, those born in the United States were more likely to buy prepared foods, including fast foods, and were less likely to travel to shop for foods they wanted. No difference was found in levels of food security, with both groups being marginally food insecure. As with Latina populations, lack of acculturation was found to be re- lated to food insecurity among mothers with young children who were refu- gees from Liberia in West Africa (Hadley et al., 2007). In a mixed methods ­ study (15 qualitative interviews followed by a survey of 101 women), food insecurity was higher, at 73 percent, among those who had been in the United States only 1 year than among those who had resided in the United States for 3 years, at 33 percent. Food insecurity generally was negatively associated with measures of acculturation, including perceived difficulty in understanding the language and time in the United States (p < 0.05). Access to Personal Transportation One additional factor influencing food choice is the availability of per- sonal, nonpublic transportation. Households without a personal vehicle or access to public transportation must rely on alternative means—­ alking w or biking to a store close at hand or social networks (family, friends, neigh- bors) that provide reliable transport. People with disabilities are particularly at risk, often completely dependent on social networks for access to food. For example, an in-depth qualitative study of food access among 28 low- income rural, village, and inner-city families with disabled primary grocery shoppers found that they relied on social networks for assistance with food shopping (Webber et al., 2007). An unexpected finding in this study was that nearly half of the participants had a variety of health conditions and disabili- ties that limited their access to food, in particular, healthy, affordable food. Time Purchasing and preparing a healthy diet can be a time-intensive pro- cess for households that do not use commercially prepared foods. Produc- ing healthy meals requires a number of activities, skills, and resources that include planning, transportation to and from a grocery store or other food outlet, shopping, preparation, and cleanup. Thus, time involv- ing food prepara­ion is particularly relevant to defining the adequacy of t

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104 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM SNAP allotments. The committee identified several studies that found a disconnect between the assumptions of the Thrifty Food Plan (TFP), which is used as the basis for the SNAP maximum benefit, and in turn for SNAP allotments, and resource constraints among low-income households. The TFP market baskets take into account the types and quantities of nutritious foods that can be purchased with the maximum SNAP benefit, but they do not consider time required for food preparation. Davis and You (2010, 2011) analyzed the money and time requirements associated with the TFP. They matched ATUS data with the Food Security Supplement to create a dataset providing total weekly food expenditures and daily time alloca- tions, along with household composition information, for approximately 6,300 single-headed households. They found mean expenditures for food of $107.37 per week and a total amount of time involved in food production of about 4.41 hours per week. Applying a mean price of time of $10.48 per hour, the total mean money-time requirements can be estimated at an average of $178 per week. Thus while actual monetary expenditures are 35 percent greater than required to meet the TFP target, actual expenditures accounting for the cost of time are 40 percent less than the TFP target. Across households in the dataset, 62 percent spent enough to meet the TFP target when only money costs were considered, but just 13 percent did so when time costs were included in the cost calculation. The TFP provides the potential for an adequate diet and makes a ­llowance for including some commercially prepared foods (Carlson et al., 2007). However, using the Center for Nutrition Policy and Promotion (CNPP) publication Recipes and Tips for Healthy, Thrifty Meals (CNPP, 2000), which provides 2 weeks’ worth of meals with recipes and prepara- tion times, the average estimated time requirement is 16.1 hours per week or 2.3 hours per day (Davis and You, 2010; Rose, 2007). In their study, Davis and You (2010) included a sensitivity analysis of 8 hours per week to account for different food choices and recipe combinations, consistent with the Economic Research Service (ERS) publication Who Has Time to Cook?, which reports that 13-16 hours per week is required for food preparation (Mancino and Newman, 2007). Household factors also impact the time available for food preparation. Low-income households with either two adults or a single-parent head of household working less than 35 hours per week reported allocating enough time for food preparation to meet the TFP target. However, low-income women working full-time spent too little time in food preparation to meet the TFP’s implied requirement of at least 80 minutes per day (Mancino and Newman, 2007). The time required for each step in the procurement and preparation of food is also affected by household factors and resources, such as the avail- ability of public transportation or ownership of a vehicle; access to food

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INDIVIDUAL, HOUSEHOLD, AND ENVIRONMENTAL FACTORS 105 outlets carrying a variety of healthful foods; the availability of household equipment with which to store (e.g., refrigerator or freezer) and prepare (e.g., range and oven) food; and the knowledge and skills to plan, choose, and prepare foods that meet dietary needs within budgetary limits. While limited data exist on the time costs of this entire process, it is clear that a money-time trade-off is entailed in the preparation step, with convenience foods that are wholly or partially preprepared having a higher monetary cost than foods prepared largely from basic unprocessed ingredients— i.e., from “scratch,”—that require more preparation time (Mancino and N ­ ewman, 2007). Available time resources thus affect the choices between commercially prepared and home-prepared foods and potentially the nutri­ tional quality of the diet as well (Beshara et al., 2010; Devine et al., 2003, 2009; Jabs and Devine, 2006). In addition to the general shift to more women in the workforce, Rose (2007) points to several government policies that have specifically promoted employment among low-income women over the last two decades, such as increases in the earned income tax credit. This trend, as well as the increasing number of single-parent households among SNAP participants, has altered the allocation of time resources, decreasing the amount available to spend on food preparation (Mancino and Newman, 2007). Time use surveys conducted between 1965 and 2000 show a decrease in time spent in food preparation, with less time for working than nonworking women: 4.5 versus 7.9 hours per week, respectively. Nonworking women in food secure households responding to the 1996-1997 National Food Stamp Program Survey reported significantly greater time expenditures relative to this latter figure, an average of 13.9 hours per week (Rose, 2007). In the 2003-2004 ATUS, women working full-time in households at 130 percent or less of the federal poverty level reported 5.41 hours per week spent in food preparation and cleanup, compared with 8.2 hours per week for those not working (Mancino and Newman, 2007). Regression models pointed to certain individual and household characteristics that partially explained women’s time reported for food preparation and cleanup: having a partner, the number of children in the household, and age were positively associ- ated, whereas having unhealthy adults in the household was negatively associated. Low-income men reported spending less time than women, and low-income men who were not working reported spending twice as much time as men working full-time—3.0 versus 1.5 hours per week, respectively. Having a household partner or a young child was positively associated with time men dedicated to food preparation. Estimating direct food costs and monetizing time costs using the USDA Food Security Supplement and the 1  To compare across studies, Mancino and Newman (2007) used data in minutes per day that were then converted to hours per week (m/d × 7 d/60 m).

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106 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM ATUS for 2004 and 2005, time was found to be more constraining than money, with time costs adding about 35 percent to total food costs (Davis and You, 2011). Thus, if labor costs are not included, the real cost of food for low-income households is severely underestimated. Knowledge, Skills, and Abilities According to the 2010 Dietary Guidelines for Americans (DGA), very few Americans consume diets that meet the DGA recommendations (USDA and HHS, 2010). The complexity of the food and information environ- ments makes it difficult for all consumers to improve their dietary patterns. Contento (2007) makes the case that this complexity calls for nutrition education to give individuals the knowledge and skills necessary to navigate these environments in a way that results in healthful food choices. SNAP participants need to be especially skillful in making choices within the con- straints of available resources so they can maximize the purchasing power of their SNAP benefits. The committee found limited research directly documenting a lack of nutrition and resource management knowledge and skills among low- income populations generally, or among SNAP participants specifically. One cross-sectional study, by Gleason and colleagues (2000), investigated knowledge and attitudes, but not skills. This study, using data from the 1994-1996 Continuing Survey of Food Intakes by Individuals and the Diet and Health Knowledge Survey, found that among adults, factual knowl- edge about the health consequences of specific dietary practices and which practices are most healthful was lower among low-income (<130 percent of the poverty level) (N = 1,464) than higher-income (N = 4,194) respon- dents. In addition, no significant differences in knowledge were found between SNAP participants (N = 435) and nonparticipants (N = 1,029). Low-income participants believed that eating a healthy diet (rich in fruits and vegetables, limited in fat and cholesterol) was important, but this belief did not translate into confidence that they were making healthful choices, suggesting a possible lack of the skills needed to translate nutri- tion knowledge into practice. SNAP participants reported even lower confidence than low-income nonparticipants in the healthfulness of their choices. In regression analyses, knowledge and attitudes did not mediate the relationship between SNAP participation and dietary intake. The food resource management skills of planning, shopping, and preparation are recognized as necessary to translate knowledge into practice (­ ontento, C 2007). However, the study by Gleason and colleagues (2000) did not in- vestigate resource management knowledge and skills and how they would impact dietary intake and food security in the context of resource con- straints. The authors do conclude that their study provides “circumstantial

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INDIVIDUAL, HOUSEHOLD, AND ENVIRONMENTAL FACTORS 107 evidence that there is a role for increasing nutrition education and promo- tion among participants” (p. 155). In addition to knowledge, several studies point to the effect of percep- tions of time pressure or self-efficacy as related to meal preparation, factors that are at least somewhat modifiable by nutrition education. For example, a random digit dial survey (N = 458) of meal preparers found a negative effect on diet quality of respondents’ perceptions of time pressure as related to meal preparation that was moderated by self-reported knowledge of nutrition, along with years of formal education and perceptions of health risk (Mothersbaugh et al., 1993). More recently, Beshara and colleagues (2010) investigated the effects of perceived time pressure and other related variables on the healthiness of meals served over a 7-day period to school- aged children in Australia. Among the 120 mothers surveyed, no significant relationship was found between perceived time pressure and healthiness of meals. The study did find, however, that mothers’ self-confidence in their ability to prepare healthy meals was predictive of dietary quality. The authors point to social cognitive theory (Contento, 2007), which provides a theoretical basis for much of the community-based nutrition education provided to low-income audiences. Federally Funded Nutrition Education USDA provides funding for several programs focused on improving nu- trition knowledge and skills either as the sole purpose (e.g., the Expanded Food and Nutrition Education Program [EFNEP]) or in conjunction with nutrition assistance programs (e.g., SNAP-Education [SNAP-Ed]). Both of these educational initiatives (described in Box 4-1) aim to enhance partici- pants’ ability to meet the recommendations of the DGA. Both use theory- guided interventions that take into account participants’ existing strengths and emphasize building skills for resource management through planning meals and shopping wisely so as to use both nutrition assistance program benefits and cash to make healthy food choices (FNS, 2012; NIFA, 2009a). Food preparation skills are included to teach participants how to provide food with less reliance on more expensive convenience and fast foods. More evaluation studies have been done of EFNEP than of SNAP-Ed, partly because EFNEP is an older program, beginning nationally in 1969, 20 years before the establishment of SNAP-Ed. Studies evaluating the ef- fectiveness of EFNEP can be applied to assessments of SNAP-Ed for several reasons: The target populations are similar; the objectives are similar; and EFNEP is delivered solely through the Land Grant University Cooperative Extension System, the same system that delivers the largest number of SNAP-Ed programs across the country, generally using the same curricula and approaches (NIFA, 2009b).

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136 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM tifying stores can be difficult as information from some sources (e.g., proprietary databases of stores by category, size, and other attributes) may not always be up-to-date and thus may be incon- sistent with information from federal sources such as USDA-FNS. Moreover, efforts to improve food access often are designed to solve local problems, which may vary considerably, leading to i ­ssues of generalizability. • For purposes of assessing the adequacy of SNAP allotments, it is necessary to understand — ow prices paid by SNAP recipients vary relative to those paid h by other populations; — hat types of foods are purchased by SNAP recipients using their w benefits; and — ow benefits received from other federal nutrition assistance h programs are used by individual SNAP participants. Data gaps exist for prices, quantities, and types of foods purchased by SNAP participants using SNAP benefits or other resources by type of food outlet. If these data could be linked to information on basic household fac- tors such as ages of SNAP recipients, numbers of children, region of the country, and rural or urban setting, analyses could be carried out to assess which individual, household, and environmental factors are most important in defining the adequacy of SNAP allotments. SUMMARY OF FINDINGS AND CONCLUSIONS The evidence reviewed in this chapter reveals a number of individual, household, and environmental factors that can influence the adequacy of SNAP allotments. The committee’s findings based on this evidence take into account the robustness of the evidence and the likely impact of a given factor on the feasibility of an evidence-based definition of allotment adequacy. Although the committee acknowledges that most of the obser- vational studies evaluated are cross-sectional, the findings considered col- lectively and in the context of the totality of the available evidence suggest that the factors with the greatest influence on the adequacy of SNAP allot- ments are availability of time to purchase and prepare meals, geographic variation in prices, and access to food outlets (at the environmental level). Consideration of these factors can inform the development of a definition of the adequacy of SNAP allotments and transform implicit assumptions underlying the determination of SNAP benefits into explicit statements that can be evaluated for SNAP participants. Factors for which the evidence is not strong enough to warrant their consideration in analyses to support an evidence-based assessment of the adequacy of SNAP allotments include nu-

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INDIVIDUAL, HOUSEHOLD, AND ENVIRONMENTAL FACTORS 137 trition knowledge, skills, and abilities, and transportation (at the individual/ household level). The committee notes, however, that some factors, such as access to personal transportation, may be beyond the scope of USDA-FNS to use in an assessment of allotment adequacy. Availability of Time to Purchase and Prepare Meals The committee’s review of evidence on the amount of time needed by most households, in particular those with a working head of household, to purchase and prepare food for healthy meals is inconsistent with the assumptions of the TFP. In addition, the resource constraints experienced by many low-income households, such as reduced transportation access to food outlets, widen the disconnect between the time needed to prepare meals consistent with the TFP and the reality of the amount of time avail- able to these households. Further, evidence from analyses of household food expenditures suggests that the result of failing to account for labor costs is severe underestimation of the real cost of food for low-income households. Geographic Variation in Prices The evidence reviewed by the committee shows that food prices vary substantially across geographic regions of the country and between rural and urban areas. Yet the cost of the TFP, which serves as the basis for deter- mining the maximum SNAP benefit, is not adjusted by geographic region, with the exception of Alaska and Hawaii. SNAP participants in locales with higher food prices would likely have greater difficulty than those in areas with lower food prices in purchasing the types and amounts of foods de- termined in the TFP as adequate to meet their needs for a healthy diet. The evidence points further to a lack of data on the magnitude of the impact of differences in food prices across locales on the ability of SNAP participants to purchase sufficient quantities of healthy foods based on household com- position assumptions (Gundersen et al., 2011). Access to Food Outlets Overall, the evidence reviewed by the committee suggests that ac- cess to supermarkets is lower among low-income and minority popula- tions than other population groups and that individuals without access to super­ arkets experience greater disparity in availability of healthier m foods, such as fresh fruits and vegetables, in their neighborhood food outlets. In addition, a lack of transportation infrastructure was found to be the most defining characteristic of limited food access for small-town and rural areas.

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138 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM Nutrition Knowledge, Skills, and Abilities The evidence reviewed by the committee suggests that evaluations of nutrition education programs for low-income participants that include skill-based education show change in behavioral outcomes. This finding lends credence to the theory that nutrition knowledge and skills are limited and that education is necessary to assist households in maximizing the purchasing power of their SNAP benefits. However, evidence on the influ- ence of nutrition knowledge and skills on the ability of SNAP participants to purchase and prepare healthy foods consistent with the assumptions of the TFP is insufficient to support a conclusion about the relevance of these factors to an evidence-based definition of the adequacy of SNAP allotments. Assessing the nutrition skills of the SNAP population directly (i.e., through direct observation) would be difficult at the population level. However, several variables likely to be associated with skill level could be assessed— for example, skills normally used (e.g., using grocery store lists, planning meals, using recipes with raw ingredients), perceived level of these skills, and self-efficacy to perform the skills. REFERENCES Andreyeva, T., D. M. Blumenthal, M. B. Schwartz, M. W. Long, and K. D. Brownell. 2008. MarketWatch: Availability and prices of foods across stores and neighborhoods: The case of New Haven, Connecticut. Health Affairs 27(5):1381-1388. Andreyeva, T., F. J. Chaloupka, and K. O. Brownell. 2011. Estimating the potential of taxes on sugar-sweetened beverages to reduce consumption and generate revenue. Preventive Medicine 52:413-416. Arnold, C. G., and J. Sobal. 2000. Food practices and nutrition knowledge after graduation from the Expanded Food and Nutrition Education Program (EFNEP). Journal of Nutri- tion Education and Behavior 32(3):130-138. Atkinson, N. L., A. S. Billing, S. M. Desmond, R. S. Gold, and A. Tournas-Hardt. 2007. Assessment of the nutrition and physical activity education needs of low-income, rural mothers: Can technology play a role? Journal of Community Health 32(4):245-267. Atkinson, N. L., S. M. Desmond, S. L. Saperstein, A. S. Billing, R. S. Gold, and A. Tournas- Hardt. 2010. Assets, challenges, and the potential of technology for nutrition education in rural communities. Journal of Nutrition Education and Behavior 42(6):410-416. Babey, S. H., A. L. Diamant, T. A. Hastert, S. Harvey, H. Goldstein, R. Flourney, R. Banthia, ­ V. Rubin, and S. Treuhaft. 2008. Designed for disease: The link between local food environments and obesity and diabetes. http://www.healthpolicy.ucla.edu/pubs/files/­ Designed_for_Disease_050108.pdf (accessed June 14, 2012). Backman, D., V. Scruggs, A. A. Atiedu, S. Bowie, L. Bye, A. Dennis, M. Hall, A. Ossa, S. Wertlieb, and S. B. Foerster. 2011. Using a toolbox of tailored educational lessons to improve fruit, vegetable, and physical activity behaviors among African American women in California. Journal of Nutrition Education and Behavior 43(4 Suppl. 2):S75-S85. Bauer, K. W., M. O. Hearst, K. Escoto, J. M. Berge, and D. Neumark-Sztainer. 2012. Parental employment and work-family stress: Associations with family food environments. Social Science and Medicine 75(3):496-504. Becker, G. S. 1965. A theory of the allocation of time. Economic Journal 75(299):493-517.

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