Availability,Participation,and Interest in Workplace Wellness Programs for Head Start Educators

Abstract

Background:

Head Start (HS) is the largest federally funded early childhood education program in the United States. It prepares children socially, emotionally, and academically and sets the foundation for school readiness and academic success. In 2024, the Head Start Program Performance Standards were updated to provide enhanced support and workforce stability, including improvements in health and wellness. This study assessed the availability, participation, satisfaction, and interest in Workplace Wellness Programs (WWPs) for HS educators.

Methods:

An electronic survey was sent to nearly 74,000 HS grantees and educators; 2,611 complete surveys were included in the analysis. Descriptive analyses examined the availability, participation, satisfaction, and interest in WWPs, and multivariate regression analyses identified factors associated with WWP participation.

Results:

Approximately 71% of HS educators reported access to at least one WWP. The most common programs available were health education and promotion (51%), stress management (25%), and healthy lunch and snack options (20%). Participation rates for available programs ranged from 6% to 93%, and interest in unavailable programs ranged from 40% to 93%. Job dissatisfaction was associated with lower odds of participating in any WWP or in health education and wellness programs. Receipt of community food assistance was associated with lower odds of participating in nutrition and stress management programs.

Conclusions:

There is considerable variability in availability, participation, and interest in WWPs among HS educators. Research is needed to understand if expression of interest would translate into take-up of WWPs, identify strategies to reduce barriers, and increase participation.

Study Importance Questions

What is Already Known about This Subject?

Early childhood education prepares children socially, emotionally, and academically and sets the foundation for school readiness and academic success. Head Start (HS) is the largest federally funded early childhood education program in the United States. Early childhood educators, including HS educators, frequently experience stress and burnout due to workplace demands and low pay. Limited funding and administrative support are common barriers to implementing Workplace Wellness Programs (WWP)s in early childhood settings. Additionally, when offered, workplace demands, timing, and program content are often cited as barriers to participation in these programs. When offered, programs focusing on mental health and physical wellness initiatives have been successful.

What Are the New Findings in Your Article?

Results of a survey of HS educators in all 50 states, the District of Columbia, and territories indicate that educators have access to varying WWPs; the most frequently available program is general health and wellness education, followed by healthy lunch and snack options. When available to HS educators, participation in and satisfaction with various WWPs is high. Educators who do not have access to specific programs reported that they are most interested in access to healthy lunch and snack options, onsite fitness centers or gym membership discounts, and health education and promotion programs.

How Might Your Results Change the Direction of Research or Practice?

Findings from this study show that although HS educators report limited access to individual WWPs, participation and interest in various WWPs are high. Results highlight the need to understand whether the educators’ expression of interest would translate into take-up if new WWPs were offered at HS centers, considering respondent characteristics as well as barriers and facilitators associated with participation in WWPs.

Introduction

Early childhood educators prepare young children socially, emotionally, and academically and set the foundation for school readiness and academic success. Head Start (HS) is the largest federally funded early childhood education program in the United States; in FY2023, 250,000 program staff and 542,000 adult volunteers served 778,420 children.¹

The physical and emotional demands of enriching the lives of children and families can negatively affect the overall health of educators.² Soon after COVID closure policies were relaxed, the National Head Start Association (NHSA) found that 20% of HS and Early HS classrooms were closed, primarily due to staffing issues, resulting in lower child enrollment rates than funded slots. Staff vacancies, stemming from low compensation and burnout due to working conditions, were identified as reasons for the reduced workforce.³ This workforce decline has received national attention. In 2024, new Federal requirements (“New Rule”) updated the Head Start Program Performance Standards (HSPPS) to support and stabilize the HS workforce, including requirements for wages and benefits, breaks for staff, and enhanced supports for staff health and wellness.⁴

One strategy to address staff health and wellness is through Workplace Wellness Programs (WWPs). In education settings, WWPs have been shown to increase educator morale, improve perceptions of handling stress, and improve overall wellbeing.⁸ Many employers consider such programs a worthwhile investment with economic benefits because the provision has been shown to reduce risk factors associated with obesity, diabetes, and heart disease, lessen health care costs for employers, improve job satisfaction and productivity, and prevent high turnover.^5,6 A 2019 study by researchers at the National Institute for Occupational Health and Safety found that 47% of workers had access to workplace health promotion programs, and among those with access, only 58% chose to participate.⁷

HS programs currently place an emphasis on comprehensive wellness strategies encompassing various dimensions of staff well-being, including physical, emotional, social, and occupational health. The Office of Head Start (OHS) provides an array of strategies for promoting staff wellness (45 CFR §75.431) and the NHSA toolkit provides resources to address several dimensions of staff wellness.⁹ However, data on the landscape of existing WWPs and participation rates in the context of HS programs with an emphasis on center-based educators is limited.^2,10 Findings from this study provide timely insights from educators about the availability of, participation in and interest in WWPs. HS Centers planning to implement the New Rule can use these findings to develop impactful WWPs for their staff.

Methods

Design and Participants

This study was a cross-sectional National Health and Wellness survey (NHWS) of HS, Early HS, American Indian and Alaska Native (AIAN), and Migrant center-based educators in all 50 States, the District of Columbia, and US territories. Notices in the NHSA member newsletter (2022 Fall and Winter editions) alerted HS educators on the membership list about the upcoming survey. An invitation email with a link to the survey was sent separately by the study team and the NHSA. The NHSA provided the study team with the 2021–2022 Office of Head Start (OHS) Program Information Report (PIR) of HS grantees. The PIR was randomized into two equally distributed lists (primary sample and reserve sample), and the study team sent an invitation email to 1002 HS grantees in the primary sample list, requesting them to forward the email to all educators (n = 53,161) at their centers. In addition, NHSA sent the invitation email with a link to the survey to all member educators (n = 20,347). Assuming that the survey link would be distributed to 46,000–50,000 educators, our target survey response count ranged from 2,300–2,500, representing a 5% response rate to obtain a nationally representative sample.

The survey was fielded in April 2023. Upon navigating to the survey link, participants were presented with an informed consent statement and required to click on the “I agree” acceptance checkbox to proceed to the survey. Survey respondents were asked their role (teacher, assistant teacher, other), and those with other roles were informed that they were not eligible for the survey. After completing the survey, respondents were asked if they would like to receive a $25 e-gift card. Those who replied “yes” were linked to a separate electronic survey which asked for their first name and an email address for the e-gift card (sent within a week of survey completion).

The anticipated data collection period was eight weeks with two planned reminder emails scheduled for weeks 3 and 5. The target survey response count was reached within two weeks, so planned reminders were not sent. A total of 2,923 surveys were received, and 847 respondents opted out of the gift card. This study was approved by the Tufts University Institutional Review Board.

Measures

To design the NHWS, domains of interest for HS educators were identified, including perceived health status, need for health and wellness programming, available worksite wellness programs, and participation in those programs, among others. Validated instruments were identified from evidence-based sources (CDC, NHANES, BRFSS) and additional questions were developed to address specifics like the number of daily breaks, visits to a dentist, frequency of participation in WWPs, and barriers to participation. The survey included questions on sociodemographic and employment characteristics, workplace health and wellness support, and health and wellbeing measures. The study team pretested the survey with three HS educators, who participated in an interviewer-administered, four-question conversation, specifically asking about the length of the survey, the clarity of the survey questions, and technology challenges with completing the survey. Their feedback was positive about length, wording of questions, and ease of use, including one participant who stated, “if my center director gave me this survey, I would feel like they cared about my health and wellness.” According to the PIR, the two most prominent languages spoken by HS educators are English and Spanish, so the final electronic survey was offered in both (translated by a bilingual study team member and reviewed by a bilingual HS educator) via Qualtrics (a secure electronic platform for data collection). The expected respondent burden was 15 minutes.

Data Analysis

The analytic sample included 2,611 respondents who completed more than 60% of the survey, including educators from all 50 states, DC, and US territories. Seven percent of respondents completed the survey in Spanish. Respondents were similar to those in the PIR list with regards to the distribution of race/ethnicity and education attainment; educators from AIAN and migrant HS programs were under-represented in the survey responses. Educators on the NHSA list may be associated with PIR grantees on the primary or reserve sample list, therefore, response rates were not calculated.

Survey responses were tabulated and summarized as frequencies for categorical data and means and standard deviations for continuous data. Pearson’s chi-square tests were used to assess availability, participation (if available), satisfaction (if participated), and interest (if not currently available) in WWPs. Item response to the question on barriers to participating in WWP was low, and reasons for this are not clear.

Multivariate logistic regression was used to examine the association between sociodemographic and workplace characteristics and participation in any WWP. Respondent characteristics included in the model were age, education attainment, race/ethnicity, general health, household size, participation in Supplemental Nutrition Assistance Program (SNAP), reliance on community food assistance programs, role at HS, and program type (AIAN and Migrant HS programs were not included in the regression analysis due to small counts). These sociodemographic characteristics were included in the regression model as they have been associated with participation in workplace health promotion programs.⁷ For example, younger employees may have different needs than older employees.⁷ Similarly, those with higher income levels may be more likely to engage in wellness programs, and those with lower incomes may be focused on basic needs, which could reduce participation.⁷ Workplace characteristics were included in the model as they reflect the culture within the workplace. Including these variables in the model helps identify which factors are most significant, allowing for targeted interventions to improve participation rates. All variables were added simultaneously to each model, and p-value <0.05 was considered significant. Data were analyzed using SAS (version 9.4).

Results

Sample

Almost all respondents identified as female (97%); about 40% were 30–44 years of age, and 40% were 45–64 years of age. Just over half (53%) of respondents identified as nonHispanic White, 16% as nonHispanic Black, and 26% as Hispanic; three-quarters (76%) spoke English at home. About 40% of respondents were college-educated, and 70% lived in a two-to-four-person household. Nearly two-thirds perceived their health to be excellent or good, nearly one-fourth perceived it as fair (23%), and about 2% perceived it as poor. Overall, 42% of respondents reported participation in at least one Federal, State, or local assistance program (such as SNAP, WIC, HS, free school meals, community food assistance, employment training, etc.); 12% of respondents participated specifically in SNAP, and 7% relied on community food assistance programs (Table 1).

Table 1.

Demographic Characteristics of Survey Respondents

Characteristic	%	Characteristic	%
Gender	n = 2,555	Household size	n = 2,552
Female	96.87	1 (live alone)	9.99
Male	1.92	2–4 people	71.12
nonBinary	0.31	5–6 people	16.38
Prefer not to answer	0.90	7–10 people	2.43
Age	n = 2,554	10 or more people	0.08
18–29 years	18.32	Languages spoken at home	n = 2,555
30–44 years	38.68	English	75.66
45–64 years	39.62	English, Spanish	14.56
65 or older	3.37	English, Spanish, Other	0.43
Race/Ethnicity	n = 2,550	English, Other	1.68
NonHispanic White	52.55	Spanish	6.14
Hispanic	26.16	Other^a	1.53
NonHispanic Black	15.57	Would you say your general health is …	n = 2,611
NonHispanic Asian, Native Hawaiian and Pacific Islander	1.96	Excellent	11.76
NonHispanic Multi-Racial	1.57	Good	63.69
NonHispanic American Indian or Alaska Native	1.41	Fair	22.56
NonHispanic Other	0.78	Participation in any federal, state, or local support program^a,b	n = 2,611
Highest level of education completed	n = 2,555	Yes	42.35
HS Diploma/GED	13.07	Participation in Supplemental Nutrition Assistance Programs	n = 2,611
Some college	20.63	Yes	12.29
Associate degree	25.56	Receipt of Community Food Assistance Programsb	n = 2,611
Bachelor’s degree or higher	40.74	Yes	7.39

Includes SNAP; Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Head Start or other child care program where children got free meals; free or reduced-price school breakfast or lunch; community food assistance programs; senior nutrition programs; or employment and training to get a job, new skills or school degree. SNAP, Supplemental Nutrition Assistance Program.

Community food assistance program includes food from churches, food banks, food pantry, or other community organizations.

Source: National Health and Wellness Survey, April 2023.

NOTES: 2,611 Teachers and Assistant Teachers were included in the analyses; item count may be lower due to nonresponse.

The majority (85%) of respondents had more than one year of experience at HS; 34% had a tenure of more than 10 years. Most respondents indicated that their workplace provided them paid time off (84%) and health insurance (86%), and half (51%) indicated their workplace provided them access to health and wellness programs. While 16% strongly agreed and 58% agreed that their workplace is committed to employee health and wellbeing, the remaining disagreed (21%) or strongly disagreed (4%) that their workplace was committed to employee health and wellbeing (Table 2).

Table 2.

Years of Head Start Experience, Benefits Provided, and Perceived Workplace Commitment to Employee Health and Wellbeing

Characteristic	%
Years of head start experience	n = 2,608
Less than one year	15.41
2 to 5 years	32.78
6 to 10 years	17.83
More than 10 years	33.97
Benefits provided by workplace	n = 2,540
Paid time off	84.20
Health insurance	85.70
Access to health and wellness programs	51.30
None	3.00
My workplace is committed to employee health and wellbeing	n = 2,601
Strongly agree	16.84
Agree	58.02
Disagree	21.11
Strongly disagree	4.04

Source: National Health and Wellness Survey, April 2023.

NOTES: 2,611 Teachers and Assistant Teachers completed the survey, item count may be lower due to nonresponse.

Availability of and Interest in Workplace Wellness Programs

Overall, about 71% of respondents reported having access to one or more WWPs. Among those with access, about 72% participated in one or more WWPs. Fifty percent of respondents had access to health education and promotion programs, 25% had access to stress management, and 20% had access to healthy lunch and snack options. Twelve percent of respondents had access to fitness centers or gym memberships, and fewer than 10% had access to common space or activity hubs, weight management programs, alcohol and substance use programs, or smoking cessation programs (Table 3).

Table 3.

Availability of and Participation in Workplace Wellness Programs

WWP	Program availability (n = 2,565)	If available: frequency of participation^a
WWP	%	N	All the time	Frequently	Occasionally	Never
Health education and promotion	50.18	12,89	7.84	13.65	40.65	37.86
Stress management	24.80	651	5.07	12.29	37.79	44.85
Access to healthy lunch and snack options	20.04	513	40.16	32.36	20.47	7.02
Onsite fitness center or gym membership discounts	12.16	319	5.64	13.8	25.71	54.86
Common spaces or activity hubs	10.60	272	10.66	23.16	38.6	27.57
Weight management	6.39	164	6.10	6.71	28.05	59.15
Alcohol and substance use	6.00	154	1.3	1.3	2.6	94.8
Smoking cessation	5.22	134	1.5	1.5	3.0	94.0
Other^b	3.20	34	5.88	5.88	20.59	67.65

Response count for WWP participation may be lower than response count for WWP availability due to item nonresponse.

Examples of other programs include financial education and support, child care, and cultural opportunities.

Source: National Health and Wellness Survey, April 2023.

NOTES: 2,611 Teachers and Assistant Teachers completed the survey; item responses may be lower due to nonresponse.

% does not add up to 100 as respondents could select all WWPs available to them.

WWP, Workplace Wellness Program.

Respondents who did not report access to specific WWPs were asked, “If your workplace offered <program name>, how interested would you be in participating?” As seen, interest was high for all programs except smoking cessation and alcohol and substance use reduction programs. Only 15% of those with no access to smoking cessation or alcohol and substance use reduction programs expressed interest in these programs (Table 4).

Table 4.

Level of Interest in Workplace Wellness Programs (WWPs) Among Educators Without WWP Access

WWP (n with no program access)	If your workplace offered … program, how interested would you be in participating?
	Not at all	Slightly	Moderately	Very
	%
Access to healthy lunch and snack options (n = 2,015)	7.0	12.7	24.1	56.3
Onsite fitness centers or gym membership discounts (n = 2,256)	7.9	15.1	25.4	51.7
Health education and promotion programs (n = 1,294)	8.2	25.0	32.9	33.9
Stress management programs (n = 1,889)	10.6	20.6	28.4	40.4
Common spaces or activity hubs (n = 2,271)	10.7	20.2	30.9	38.1
Weight management (n = 2,337)	14.8	16.1	24.3	44.9
Smoking cessation programs (n = 2,319)	85.9	5.4	4.4	4.4
Alcohol and substance use reduction programs (n = 2,287)	87.0	6.1	3.7	3.2

Source: National Health and Wellness Survey, April 2023.

NOTES: 2,611 Teachers and Assistant Teachers completed the survey; item counts may be lower due to nonresponse.

% does not add up to 100 as respondents could select more than one WWP.

Participation and Satisfaction with Workplace Wellness Programs

Among those who had access to WWPs, program participation was the highest for healthy lunch and snack options (83%), followed by use of common space and activity hubs (73%), health education and promotion (68%), and stress management (55%). Fewer than 5% of educators participated in smoking cessation and alcohol and substance use programs (Table 3). Educators who participated in the WWPs available to them generally indicated that the program(s) matched or exceeded their expectations (Fig. 1).

Figure 1.

Level of satisfaction with WWP among those who participated¹. Source: National Health and Wellness Survey, April 2023. NOTES: 2,611 Teachers and Assistant Teachers completed the survey. ¹Level of satisfaction with the program was asked only if educators participated in the program (all the time, frequently, or occasionally); response count for satisfaction may be less than participation count due to item nonresponse. WWP, Workplace Wellness Program.

Results of multivariate logistic regression show that respondent characteristics associated with participation varied by program type. Age and job satisfaction were significantly associated with WWP participation: being younger (18–29 years) and being dissatisfied with their job were associated with lower odds of participating in health education and wellness programs. Not receiving community food assistance and being in poor health were associated with lower odds of participating in nutrition programs, and not receiving community food assistance was associated with lower odds of participating in stress management programs (Table 5).

Table 5.

Respondent Characteristics Significantly Associated with Participation in WWPs

Dependent variable	Independent variable	Odds ratio (95% CI)	p-value
Participate in any WWP	Job satisfaction (no vs. yes)	0.57 (0.400–0.809)	0.002
Participate health education and wellness programs	Age (18–29 yrs vs. 30–44 yrs)	0.63 (0.446–0.887)	0.008
Participate health education and wellness programs	Job satisfaction (no vs. yes)	0.54 (0.359–0.808)	0.003
Participate nutrition programs (access to healthy lunch and snacks or weight management)	Receive community food assistance (no vs. yes)	0.18 (0.042–0.754)	0.019
	General health (fair/poor)	0.39 (0.151–0.990)	0.048
Participate in stress management (stress management or mental health)	Receive community food assistance (no vs. yes)	0.50 (0.282–2.019)	0.019

Source: National Health and Wellness Survey, April 2023.

NOTES: 2,611 Teachers and Assistant Teachers completed the survey.

Logistic regression included the following independent variables: age, education attainment, race/ethnicity, general health, household size, participation in SNAP, receipt of community food assistance, program type (HS vs. Early HS), and role at HS.

HS, Head Start; WWP, Workplace Wellness Program.

Discussion

Among NHWS participants, 71% of center-based HS educators reported access to one or more WWPs. Questions in the survey assessed “current” availability of various WWPs and did not ask about the duration over which these programs were available or how long they lasted. Among those with access, participation rates varied by program type and were highest for access to healthy lunch and snack options, followed by common spaces or activity hubs and health and education programs. All HS educators have access to healthy meals and snacks through the Child and Adult Food Program (CACFP), so it is possible that educators may have reported “access to healthy meals and snacks” that were provided by CACFP.

Respondent characteristics associated with participation in WWPs varied by program type. Job dissatisfaction was associated with lower odds of participating in any WWP, particularly health education and wellness programs. Not receiving community food assistance was associated with lower odds of participating in nutrition and stress management programs. Both job satisfaction and receipt of community food assistance likely reflect a range of economic stressors experienced by low-wage HS educators. Additionally, younger educators were less likely to participate in health education and wellness. While respondent characteristics associated with participation in WWPs offered at HS programs have not been previously reported, younger age and lower income are associated with lower participation rates in workplace health promotion programs across all occupational categories in the United States.^7,12

While item nonresponse was high, the NHWS findings suggest that the location and/or timing of sessions posed barriers to participation. Previous research has identified several factors contributing to lower participation rates, including lack of perceived relevance, time constraints, setting challenging goals, difficulty tracking progress, and lower prioritization of personal health needs, particularly among low-wage workers and minority subpopulations.^11,12Additionally, focus groups conducted by Child Care Aware of America with ECE educators identified money, time, and access as the primary barriers to adopting a healthy lifestyle. Participants suggested potential solutions, including designated break rooms, simple exercise equipment, maintaining a safe location for walking, partnering with a gym or fitness center close to the child care program, and conducting regular on-site instruction and classes related to health and wellness.¹³

Our findings indicate that among educators who lacked access to certain WWPS, interest in participating in WWP (that are currently not available to them) generally exceeded participation rates for those that were accessible. However, we did not explore the reasons for the gap between interest and actual participation. These findings highlight a previously undocumented disconnect between interest in participation and actual participation in WWPs and provide important insights for policymakers and center directors seeking to develop engaging and effective WWPs at HS centers. Further, NHWS findings support the value of consulting with participating educators both before and during the implementation of a WWP to ensure the programs are adaptable and meet their needs.

Strengths and Limitations

The study has several strengths. It is the first national survey to examine the landscape of WWPs among HS educators, focusing on availability, participation, satisfaction, and interest. This comprehensive approach allows for a broad understanding of factors that influence program engagement. Second, the survey included HS educators from all 50 states, DC, and U.S. territories, and, enhancing the geographic diversity and generalizability of findings. Additionally, respondents were demographically similar to those in the PIR list, which bolstered the representativeness of the sample.

The study also examined a broad range of factors that affect participation in WWPs, providing insights into the various types of programs available to HS educators. Additionally, the survey was fielded in April 2023 with an expected data collection period of eight weeks. The target number of responses were reached in two weeks, and the data collection concluded when the budget limit was reached. Our ability to reach the target sample size in a two-week data collection period reflects the successful recruitment efforts in collaboration with the NHSA and underscores the high value that educators place on health and wellness.

The study had some limitations. First, educators may have received the survey from the study team and/or from the NHSA. This survey distribution methodology prevented us from estimating the number of teachers who received the survey. As a result, we are unable to calculate the response rate, which limits our ability to assess potential nonresponse bias. Second, the survey was offered in English and Spanish, which may have excluded educators who were not fluent in either language. Given that 29% of nonsupervisory education and child development staff are proficient in a language other than English (with Spanish being the most common at 79%), this may have limited participation among bilingual or nonEnglish speaking educators. Additionally, the electronic format may have led to the underrepresentation of educators without reliable internet access or those uncomfortable with technology. To mitigate this, we collaborated with grantees to ensure that interested educators could have access to HS center-based technology to participate.

Another limitation is the high item nonresponse to the question regarding barriers to participating in WWPs. As noted in the results, high item nonresponse could undermine the reliability of the results, particularly in assessing barriers to participation. Among those who did respond, location and timing of programs were identified as key barriers, which align with findings from other studies.^2,11 Lastly, the NHWS did not ask about participation in wellness programs outside of work, and educators who reported lack of interest in WWPs may be engaged in their own fitness/wellness programs outside of work.

Conclusions

This study offers the first comprehensive characterization of WWP availability, participation, and interest among HS educators in the United States. It underscores significant variability in program availability, participation, and interest, pointing to the need for educator engagement in the decision-making process for selecting WWPs. Given the emphasis on staff wellness in HS settings and the new HSPPS rule, it is important to ensure ongoing availability and participation in WWPs. Engaging educators in decision-making for program selection is a key step in fostering meaningful participation.

While this study identifies a gap between interest and actual participation, it does not explore the reasons for this disconnect. Understanding the specific barriers that prevent educators from engaging in programs would be useful for addressing this gap and in creating more inclusive and effective programs.

Impact Statement

The findings from this study contribute to an ongoing effort to improve the health of HS educators through the implementation of WWPs. Adopting a more inclusive approach to program design that incorporates educator input and prioritizes flexible, accessible offerings may improve participation and overall wellbeing of HS educators.

Footnotes

Acknowledgments

The authors dedicate this article in memory of Dr. Dianne Stanton-Ward. They also thank: (1) Drs. Dianne Stanton-Ward, Caree Cortwright, and Danielle Krobath for their contribution to the overall study design; (2) The National Head Start Association Research Committee for guidance and feedback on the survey design and assistance with survey distribution to educators; (3) Head Start educators from MN who participated in the cognitive testing of the survey; (4) Graduate students from Friedman School of Nutrition Science and Policy who supported survey development and distribution; with special thanks to Monica Mutinda and Sora Johnson who assisted with the research and development of the survey. Portions of this article were presented at the 2023 and 2024 SNEB Conferences; the 2024 National Head Start Association Conference and NOPREN Workforce Wellness group meeting (September 2024).

Authors’ Contributions

S.D.J. as the research manager for the study, she co-led in survey development, data collection, analysis, and writing of the article. K. S. as the project manager for the study, she led the survey development and data collection and co-led the writing the article; P.W. — 5, 7 as coinvestigators on the study, they helped conceive the initial grant and the study design, assisted with the methods and discussion sections, and edited the entire article. P.B. as the statistician and data manager on the study, he created the sampling frame, selected the sample, ran the statistical analyses and assisted with the results and statistical methods sections of the article. K.A. as a graduate student on the grant, she assisted with literature review, data analysis, and edited the entire article. C. D. E. as the PI of the study, she was involved in all aspects of the study and edited the entire article. All authors read and approved the final article.

Author Disclosure Statement

The authors confirm that they have no conflicts of interest.

Funding Information

This work is supported by the Agriculture and Food Research Initiative Diet, Nutrition, and Prevention of Chronic Diseases, project award number 2022-68015-36282, from the U.S. Department of Agriculture's National Institute of Food and Agriculture.

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