A Qualitative Study of Diverse Experts’ Views About Barriers and Strategies to Improve the Diets and Health of Supplemental Nutrition Assistance Program (SNAP) Beneficiaries

Abstract

The Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program, currently serves 44.7 million Americans with a budget of $75 billion in 2011. This study engaged leading experts for in-depth, semi-structured interviews to explore their opinions concerning the existing challenges and barriers to eating nutritiously in SNAP. Experts also proposed strategies for improving nutritional status among SNAP recipients. Twenty-seven individuals were interviewed from advocacy, government, industry, and research organizations. Interviews were recorded, transcribed, coded and analyzed for thematic content. The high cost of nutrient-rich foods, inadequate SNAP benefits, limited access to purchasing healthy foods, and environmental factors associated with poverty were identified as barriers that influence nutrition among low-income households in the United States. Six themes emerged among respondents from diverse sectors about how to address these challenges including: 1) providing SNAP participants with incentives to purchase nutrient-rich food consistent with the 2010 Dietary Guidelines for Americans; 2) restricting the purchase of nutrient-poor foods and beverages with program benefits; 3) modifying the frequency of SNAP benefit distribution; 4) enhancing nutrition education; 5) improving the SNAP retailer environment and 6) increasing state and federal level coordination and consistency of program implementation. Given the recent dramatic increase in SNAP enrollment, policymakers must address existing barriers as well as consider new strategies to improve nutrition policies in SNAP so that the program can continue to address food insecurity needs as well as provide a healthful diet for SNAP beneficiaries.

BACKGROUND

In 2010, 14.5 percent of US households were food-insecure, lacking consistent access to enough food for all family members to live an active and healthy life.¹ Food insecurity is associated with poor nutritional health and with negative health consequences across the lifespan.^2,3 Several studies have examined the associations between food insecurity and obesity. Among adult women, food insecurity may be positively associated with obesity, though results for children and adult men are mixed.^4–6

The Supplemental Nutrition Assistance Program (SNAP) is the largest of the U.S. Department of Agriculture’s nutrition assistance programs, and aims to alleviate food insecurity and improve the nutritional status of low-income individuals. In 2011, total program costs were $75 billion, with 44.7 million participants.⁷ Households are eligible if their income is ≤130% of the federal poverty level. As a result of economic factors and changes in SNAP policies, SNAP participation rates have increased by 158% in the past 10 years.^7,8 Despite the increase in participation, only 72% of all eligible persons participated in SNAP in 2009; barriers to participation still exist.⁹

The poor nutritional health among many low-income Americans underscores the importance of exploring ways to strategically use SNAP to encourage a healthier diet among participants.¹⁰ At the federal level, the legislation that authorizes and provides funding for SNAP and shapes the nation’s food supply is The Food, Conservation, and Energy Act of 2008, commonly known as the Farm Bill, which will be reauthorized in 2012.¹¹

Despite the recent name change to SNAP, the program has not been restructured to provide incentives for beneficiaries to purchase healthy foods; to restrict the purchase of nutrient-poor foods with SNAP benefits; or to strengthen the nutrition education component of the program.¹² SNAP-Ed, formerly the Food Stamp Nutrition Education Program¹³, currently funds activities to encourage SNAP participants to engage in healthy eating behaviors in accordance with the Dietary Guidelines for Americans¹⁴, yet effective approaches are not being employed in all states. In previous years, ideas have been proposed to improve the diets and health of SNAP beneficiaries, such as the USDA-funded Healthy Incentives Pilot¹⁵ and privately-funded initiatives that allow farmers markets to accept SNAP benefits and offer incentives to SNAP recipients to purchase fruits and vegetables at reduced prices¹⁶. However, requests by states to restrict the purchase of specific nutrient-poor foods (e.g. sugar-sweetened beverages) have been denied by the USDA, making it difficult to develop an evidence base for the impact of such restrictions.¹⁷ Research-based recommendations and policy changes have previously been made for other programs such as the National School Lunch Program¹⁸ and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)¹⁹; yet, little quantitative or qualitative research exist that examine the effectiveness of strategies to improve nutritional policies in SNAP.

This study engaged experts from diverse sectors to identify the barriers to eating nutritiously on a limited income and reports multi-level strategies for improving the diets and health of SNAP participants.

METHODS

Setting

This study is part of a multi-component initiative conducted by the Center for the Study of the Presidency and Congress that aims to identify and recommend policy strategies to improve the nutritional status of SNAP participants, particularly children and families.

Study population and data collection

In-depth, semi-structured interviews were used to explore the opinions of 27 experts about the factors that influence the eating patterns and dietary behaviors of SNAP recipients and elicited strategies to improve nutrition in SNAP. A 10-question interview guide was developed to examine respondents’ perceptions of existing barriers as well as innovative strategies to improve the nutritional status of SNAP beneficiaries using recent scientific studies about SNAP participation (Table 1).^20–27 These questions targeted multiple levels of SNAP policies that might influence health (e.g. individual, retailer, government).

Table 1.

Discussion questions for key informant interviews.

In your opinion, what are the most significant challenges or barriers to improving nutrition for SNAP beneficiaries? What are the most promising or innovative strategies that could improve nutrition in the program? What ideas do you know of or might suggest that have not yet been tested? Could strong incentives and nutrition education efforts be targeted towards particular subpopulations within the SNAP program? What is your opinion about the use of restrictions on foods purchased in SNAP, given New York City’s recent initiative to extend SNAP restrictions on prepared foods and alcohol to sodas? What scientific evidence is needed to support any proposed changes to SNAP provisions? How can SNAP leverage its relationship with retailers (both large and small) to improve the food environment for consumers? Are there any promising methods of using existing technological innovations, such as the SNAP electronic benefit card or food bar codes, or other technologies, such as mobile phones, to improve participant’s nutrition and nutrition education? How could SNAP partner with other assistance programs, initiatives, and communities? (Examples include Temporary Assistance for Needy Families (TANF), the Healthy Corner Stores Network initiative, and faith-based community programs, among others.) Given the program’s increasing enrollment in the midst of a difficult budgetary environment, how can SNAP deliver additional incentives, nutrition education, or other program improvements in a cost-effective manner? How might recent public and policy attention to childhood obesity, including the passage of the Healthy, Hunger-free Kids Act, the activities of the First Lady’s Let’s Move! campaign, and other industry and government initiatives affect or be leveraged to affect potential changes to the SNAP program?

SNAP, Supplemental Nutrition Assistance Program

Key informants were selected through purposive sampling.²⁸ Snowball techniques were also utilized, whereby key informants referred qualified colleagues for the interview.²⁹ All study participants had at least 5 years of experience working with SNAP in the sectors of academia/research (n=7), government (n=7), anti-hunger or health advocacy (n=10), or industry (n=3). Individuals from different sectors were selected to provide a range of expertise in research-based knowledge of factors influencing food policy, administrative challenges of policy change, and insight into supply-side barriers and solutions.

Each respondent completed a 45–60 minute telephone interview. The same questions were used across all interviews; however, a flexible conversation format allowed interviewers to delve deeply into certain topics and respond to new issues introduced by respondents. Respondents were also encouraged to discuss additional topics related to SNAP. Interviews were conducted between April and June of 2011. The study protocol was considered exempt by the Harvard School of Public Health Institutional Review Board for the collection of de-identified, non-confidential research information.

Data analysis

All respondents provided verbal consent to participate. With the exception of one person, all respondents provided consent to be recorded. For this respondent, the interviewer had the assistance of a note taker who collected detailed information from the responses. Other interviews were transcribed verbatim from audio recordings and checked for errors by the research team immediately following each interview. All transcripts were initially reviewed by a project team researcher (Leung) responsible for the coordination of data analysis. The transcripts were coded based on broad categories of themes in the study aims, the major topics and the interview guide. Emerging sub-themes within those categories were identified from the interviews and each one was assigned a specific code. Three project team researchers (Leung, Hoffnagle, Pendyala) independently coded and reviewed each transcript to resolve discrepancies and achieve consensus. Specific statements from the interviews that met the criteria of multiple codes were assigned all matching codes. The entire coding team met regularly to modify the coding scheme and incorporate new ideas from emerging data until data saturation was reached. A final review of emergent themes was conducted by the three project team researchers who agreed upon the final list of themes. Illustrative quotes were selected to highlight central themes. The final transcripts were entered into NVivo (QSR International Pty Ltd, Version 9, 2010, Doncaster, Victoria, Australia), to help sort and organize the themes, and examine whether any patterns emerged by respondents’ sectors.

RESULTS AND DISCUSSION

Key informants identified existing challenges or barriers as well as innovative strategies to improve the nutritional status of SNAP beneficiaries (Table 2). There was significant overlap in the responses from individuals across all sectors. The results are reported combining their responses, unless patterns emerged that were specific to one sector.

Table 2.

Emerging themes and sub-themes from key informant interviews.

Existing challenges/barriers to improving nutrition for SNAP

Theme: High cost of nutrient-rich foods

Theme: Inadequate SNAP benefit amounts

Theme: Limited access to purchasing healthy foods

Theme: Environmental factors associated with poverty

Proposed strategies to improve nutrition in SNAP

Theme: Incentives to purchase nutrient-rich food

Theme: Restrict the purchase of energy-dense foods of minimal cost and nutritional value with SNAP benefits

Theme: Modify how SNAP benefits are distributed

Theme: Enhance nutrition education

Theme: Improve the SNAP retailer environment

Theme: Increase state and federal level coordination and consistency of program implementation

SNAP, Supplemental Nutrition Assistance Program

Existing challenges/barriers to improving the diets and health of SNAP recipients

Respondents identified economic, political and environmental challenges and barriers to improving the nutritional status of SNAP participants. These included the high cost of nutrient-rich foods, inadequate monthly SNAP benefit amounts, and environmental factors associated with poverty.

Cost of nutrient-rich foods

Most respondents described the primary barrier to obtaining nutrient-rich foods among SNAP recipients as the high cost of fruits and vegetables. Respondents explained that SNAP participants may purchase nutrient-poor foods and beverages, instead of purchasing fruits and vegetables in order to stretch their budget:

“When you consider the cost of food and what’s actually available, we can preach to people all we want to about the elements of good nutrition, but if they can’t go out and actually realize that because they can’t afford it because the cost of food overall is so high, I think that is the main barrier right there.” (Government sector)

Inadequate SNAP benefit amounts

Respondents discussed the current benefit levels as inadequate for participants to purchase nutrient-rich foods, particularly for participants at the higher end of the SNAP income distribution:

“People who have food stamps often don’t have enough [benefits]…Unhealthy food is often cheaper so people are forced to spend their money on less healthy food simply because they’re not getting enough benefits each month.” (Advocacy sector)

Several respondents suggested that inadequate benefit levels may contribute to cyclical eating patterns, where participants increase food consumption when benefits are received and reduce food consumption when benefits are depleted.

Environmental factors associated with poverty

Respondents described aspects of the physical environment including a shortage of supermarkets in low-income neighborhoods, lack of nutritious foods in convenience stores, and the inability to use SNAP benefits at farmers’ markets as factors that influence food purchasing behaviors among SNAP recipients:

“One of the most significant barriers is the food environment that is the retail environment within the store and also the kind of stores that are available [in the community]. We understand the food environment being quite a challenge to access healthy food for SNAP participants.” (Government sector)

“There’s not always a grocery store in close proximity to some of our recipients, especially in rural communities. I’ve heard it termed food deserts. Small convenience stores tend to stock only foods that sell very quickly and they don’t always stock fruits and vegetables.” (Government sector)

Several respondents described broader environmental factors such as neighborhood violence and lack of transportation as other barriers to healthy food access. Given these factors, respondents explained the importance of acknowledging that SNAP participants may consider nutrition as secondary to more urgent pressures, such as time constraints or transportation issues, and that researchers should be mindful of these challenges when designing nutrition policies:

“There are other things that go along with being low-income— they may have a sporadic and stressful job situation; they may have complications related to where people live; there may be other things going on that may make it hard to get good nutrition.” (Academic/research sector)

Proposed strategies to improve nutrition in SNAP

In response to the existing challenges and barriers discussed, participants proposed innovative strategies targeting three levels, the individual, the retailer, and state and federal policy, to improve the nutritional status of SNAP recipients.

At the individual level, proposed strategies would provide financial incentives to purchase nutrient-rich foods such as fruits and vegetables; restrict the purchase of nutrient-poor foods and beverages with SNAP benefits; modify how frequently SNAP benefits are distributed; and enhance nutrition education.

Incentives

To overcome cost barriers, several respondents, including all three industry respondents, suggested providing financial incentives for purchasing healthy food. The USDA-funded Massachusetts’ Healthy Incentives Pilot Program, which provides incentives for purchasing fruits and vegetables, was referenced as a promising model to encourage the purchase of nutrient-rich foods. In other states, there are some privately-funded incentives programs in farmers’ markets targeting SNAP participants.³⁰ One respondent explained:

“What we found is that in the [farmers’] markets where they had the doubling incentive dollars (if they spent at least 5 dollars, they would get an additional 5 dollars). The traffic increased and it has not plateaued. It has continued to increase. … I think the incentive brought people there and even without the incentive, they kept coming back.” (Academia/research sector)

Restrictions

Another proposed strategy is to restrict SNAP participants’ ability to purchase nutrient-poor foods and beverages with SNAP benefits. One industry respondent explained:

“This is supplemental nutrition…[SNAP] is using tax dollars so the government has a right to make restrictions. I see no reason why the Dietary Guidelines shouldn’t come into play here. And if [participants] have discretionary income beyond that to spend on sodas and chips, that’s fine.” (Industry sector)

Respondents were asked specifically about a recently denied waiver that would have restricted soda purchases with SNAP benefits in New York City.¹⁷ The majority of respondents who spoke in support of the proposal were from the academia/research sector:

“I wouldn’t go so far as to say we should limit candies, cookies, and things like that. However, the science is proven on sugary drinks that [it] contributes to weight gain. SNAP money shouldn’t be going toward subsidizing these beverages.” (Academia/Research sector)

Representatives from anti-hunger groups opposed the proposal and expressed concern that such restrictions may be patronizing:

“Just because you are low-income, it doesn’t mean that you should be told what to buy. We are more in favor of increasing the cost of unhealthy foods and decreasing the price of healthy foods.” (Advocacy sector)

Respondents across all sectors agreed that incorporating a planned evaluation into the New York City proposal would have been useful in assessing the feasibility of a food-specific restriction, and its subsequent impact on participants’ dietary behaviors.

Modify the frequency of SNAP benefit distribution

Respondents from academia/research and government expressed concern about the monthly distribution of SNAP benefits. Several respondents suggested that the current monthly distribution of benefits be replaced with a biweekly distribution to address cyclical eating patterns and provide SNAP recipients with greater flexibility:

“It would be better for SNAP beneficiaries to access their benefits twice a month. Now, a lot of families get their benefits at the beginning [of the month]…and they go to the supermarket and buy a lot of food. They’re not buying fruits and vegetables; they’re buying processed foods that will last a month. That’s not very healthy.” (Academia/Research sector)

Another proposed strategy included distributing different benefit packages to children and adults, where the children’s package would include only certain nutritious foods and the adult’s package would have fewer restrictions. An additional suggestion was to refocus SNAP as a cash-out system by replacing a portion or all of SNAP benefits with equivalent cash income.

Enhance nutrition education

Many respondents discussed ideas regarding the role that nutrition education could play in improving eating practices among SNAP recipients. Proposed ideas ranged from allowing more flexible formats and topic coverage in SNAP-Education programs, to increased program evaluation to promote effective approaches. Presently, SNAP nutrition education materials cannot discourage specific foods or beverages.³¹ Other respondents suggested creating community-based opportunities for SNAP recipients to engage in healthy living activities, such as partnerships between restaurants, schools, and food banks to provide classes and workshops to engage children. Additionally, respondents recommended utilizing social marketing approaches to reach SNAP participants in grocery stores. Using point-of-purchase marketing has been effective in increasing stocking and sales of nutrient-rich foods, especially when paired with increasing display space or moving produce to high-traffic areas of grocery stores.^32,33

“We have a point of purchase social marketing campaign in stores. Corner stores like the materials especially because we’re asking them to include healthy products. …. Store owners are enthusiastic about the materials and offer suggestions to put all their whole grain items together in one section to show that they are promoting these items.” (Advocacy sector)

Respondents also underscored the importance of evaluating the effectiveness of ongoing SNAP nutrition education programs:

“What we’ve been talking about here is not spending more money on education. Or if you’re going to, prove that it’s working. Do some more evaluations of those programs. And if more money ends up going into SNAP education, if it’s really changing the dietary behaviors of SNAP participants, it’d be good to know that.” (Academia/Research sector)

Many respondents recognized that education alone is not enough to counteract the multiple economic, political and environmental factors that influence food purchasing in low-income contexts:

“We can’t use education as the only intervention to try to encourage healthier diets. There needs to be a connection between education and the opportunity to implement that new information in people’s life.” (Advocacy sector)

Improving the SNAP retailer environment

At the food retailer level, one strategy was to require stricter criteria to become an approved SNAP vendor, similar to stores participating in WIC. Respondents suggested this would encourage vendors to stock healthier foods such as whole grain breads, fruits and vegetables:

“Some stores that hardly have anything decent to eat in them are approved SNAP vendors. So [the USDA] could tighten up the criteria for what you need to have to be an approved SNAP vendor.” (Industry sector)

Respondents also recommended providing incentives for small SNAP vendors to sell healthy foods. Incentives could be provided for stores to move unhealthy foods to the back of the store; provide refrigeration units to sell fruits and vegetables; and encouraging collaborations between stores for buying fruits and vegetables at lower wholesale prices and reselling at an affordable price.

Increasing state and federal-level coordination and consistency

At the state and federal government levels, respondents from academia/research, advocacy and government proposed the development of consistent nutrition messages that align with the 2010 Dietary Guidelines for Americans (14), and increased administrative coordination among all federal nutrition assistance programs. Strengthening program coordination would not only make the program more cost-effective and efficient, but could have a beneficial impact on participants’ nutrition. Some respondents specifically suggested merging the administration of both SNAP and the WIC program. This could also yield other benefits by simplifying the application process, providing consistent nutrition messages, and improving the quality of foods available in small grocery stores that accept both SNAP and WIC benefits. As one respondent suggested:

“If we’re trying to do three things—income supplementation, an investment in health, and hunger prevention/food security— with SNAP, WIC, and School Lunch, they’re not mutually exclusive. There’s no reason they can’t be all brought together to have a better result.” (Government sector)

Limitations

One limitation is that the interview questions were not established under a conceptual or theoretical framework; rather questions were developed to address the various levels where existing SNAP policies might influence health (e.g. individual, retailer, government), and to examine the feasibility of current policy proposals to improve nutrition in SNAP.

CONCLUSION

This study identified existing barriers and proposed innovative strategies to improve the nutritional status of SNAP participants, drawing from the opinions of leading experts in health, policy and the food industry. Given the record-high enrollment, SNAP has the potential to influence the dietary behaviors of one out of seven Americans.⁸ With the concurrent problems of food insecurity and obesity among low-income US populations, policymakers must consider these strategies to strengthen SNAP so this critical program can continue to provide access to food, but also, importantly, to promote good nutrition for its participants. The upcoming Farm Bill reauthorization, which will provide funding and establish SNAP policies for at least the next five years, offers a significant opportunity to align farm and food policy with national public health priorities in the fight against poor nutrition and obesity among low-income populations.