Use of Population Health Data and Qualitative Analysis to Guide Local Planning and Implementation of Supplemental Nutrition Assistance Program Education

Abstract

Purpose

The purpose is to describe how local quantitative and qualitative data were used to assess the progress of the Supplemental Nutrition Assistance Program Education (SNAP-Ed) interventions in Los Angeles County, California.

Approach

Data from the California Health Interview Survey informed the geographical concentration of program resources during the planning phase. At the end of the program, semi-structured interviews with stakeholders were conducted to assess factors that facilitated SNAP-Ed implementation.

Setting

Los Angeles County, California.

Participants

Twenty-four project coordinators were interviewed.

Intervention

From 2016 to 2020, 24 organizations across Los Angeles County delivered nutrition education, reaching an estimated 2 million people. Two-hundred policy, systems, and environmental change interventions reached an estimated 1.2 million people.

Method

Semi-structured interview data were analyzed using a form of both inductive and deductive content analysis. A codebook was developed based on themes identified in these interviews. Each interview was coded by 2 team members; discrepancies (if they arose) were resolved by a 5-member group.

Results

Two facilitators—support for capacity building from a local health department and presence of community partnerships—were identified as critical factors that contributed to the success of SNAP-Ed implementation.

Conclusion

A local health department can increase SNAP-Ed intervention reach and uptake by assisting funded partners with further capacity building, helping them to develop feasible work plans, foster evaluation skills, and engage in sustainability planning.

Keywords

Supplemental Nutrition Assistance Program Education capacity building community partnerships nutrition program planning

Purpose

The obesity epidemic and the increase in chronic disease prevalence across the United States (US) have disproportionately impacted low-income communities and communities of color,¹ contributing to poor health outcomes and a rise in expenses for safety net programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP).² The educational arm of the latter entity—SNAP Education (SNAP-Ed)—is an evidence-based nutrition education program that helps SNAP eligible households eat better and take better advantage of available food resources and opportunities for physical activity. The program accomplishes this by delivering nutrition education, promoting physical activity, and implementing complementary policy, systems, and environmental change interventions (PSEs) in the community. The PSEs often take the form of food and built environment modifications or policy changes. In prior studies, SNAP-Ed has been linked to improved dietary outcomes.^3,4

From 2016 to 2020, the Los Angeles County Department of Public Health (DPH) implemented its version of the local SNAP-Ed program using several evidence-based, community-oriented interventions; they targeted obesity risk factors including unhealthy eating and physical inactivity. Twenty-four funded partner organizations (hereafter ‘partners’) were selected through a competitive contract solicitation process and asked to deliver nutrition education, support coalition building, and implement PSEs. These partners were given flexibility to select a range of PSEs from a menu of strategies provided by DPH. The menu offered such evidence-based or informed interventions as the smarter lunchroom movement and community edible gardens.

The present program assessment describes the planning and implementation processes employed during the prior SNAP-Ed funding cycle in Los Angeles County (LAC), 2016–2020. The assessment sought to explain the program structure established in LAC and illustrate how local population health data were used to inform the geographical concentration of program resources. Results from 24 qualitative interviews with funded partners were used to document lessons learned from implementing SNAP-Ed in LAC. These results also offered insights into ways in which LAC’s effort could be improved to better address obesity, nutrition, and overall health among the underserved in this county.

Approach

Throughout 2016–2020, SNAP-Ed in LAC utilized data from the California Health Interview Survey (CHIS) to inform the geographical concentration of program resources during the initial and subsequent planning phases of the program. At the end of the 3-year project, the program commissioned a series of semi-structured interviews with funded partners’ (their project coordinators) to assess factors that facilitated the successful implementation of the program locally.

Setting

There are approximately 10 million residents in LAC. During the time of the 2016–2020 program, an estimated 3.5 million of LAC residents qualified for the SNAP-Ed program with household incomes at or below 185% of the Federal Poverty Level (FPL).

Participants

Twenty-four project coordinators were interviewed by DPH’s program assessment team. These coordinators of funded partners represented nonprofit organizations (n = 17), healthcare systems (n = 3), academic institutions (n = 2), a faith-based organization (n = 1), and a school district (n = 1). All interviewees were familiar with the day-to-day SNAP-Ed operation of their organization. All had prior experience working with populations that are food insecure, had >5 years of experience in community outreach, and were part of prior SNAP-Ed programming.

Methods

Department of public health staff utilized health behavior prevalence estimates from CHIS 2013–2015—a random-digit dial telephone survey in California⁵—to guide LAC-specific SNAP-Ed priorities. These data were used to inform the selection of the 24 funded partners and to identify where to concentrate SNAP-Ed resources. For example, analyses using CHIS data⁵ allowed DPH to locate and target adults with household incomes ≤185% of the Federal Poverty Level (SNAP-Ed eligibility criterion) by geography (e.g., by Service Planning Area [SPA]). Once identified, resources were strategically allocated to these areas with the highest need and greatest number of SNAP-Ed eligible households. Throughout 2016–2020, funded partners reported on their ongoing work in these areas, documenting the following in a federal reporting system: estimates of population reach; direct project activities (e.g., nutrition education), indirect project activities (e.g., distribution of educational materials), information about PSE interventions, and any progress made by the community partnerships.

At the end of the program cycle in 2020, 24 semi-structured, in-depth interviews were completed with funded partners to document lessons learned during the 3-year project. All project coordinators of the 24 funded partners (interviewees) were asked to participate; they gave verbal consent prior to enrollment in the program assessment. An interview guide was developed to elicit the interviewees’ reflections about their project, for example, experiences with coalition building, lessons learned about barriers and facilitators, and others. It also had a protocol (series of question probes) to solicit recommendations about ways in which SNAP-Ed implementation could be improved (see Supplementary File 1). All 24 interviews were conducted and recorded by one of the program assessment team members and transcribed verbatim by 4 others. Each of the interviews were conducted by an experienced interviewer.

After completing the interviews, all transcripts were uploaded to Dedoose (a qualitative data software) to facilitate qualitative content management and analysis. A codebook was then developed based on pre-identified domains of the interview guide and on the themes identified in the data collected.⁶ A hierarchical organizational strategy was employed to organize the content, for example, subthemes were captured to reflect coherent variations of a given, larger theme. Each transcript was coded by 2 team members to ensure acceptable reliability. Discrepancies in coding (if any) were resolved via consensus by a 5-member group. For example, in a sample of 3 interviews, the initial reliability was calculated as .69, but after reconciliation with the group (which included further testing in 2 additional interviews), the reliability score was rescored to .80. Coders worked simultaneously on the Dedoose platform, building coding hierarchies, communicating about the coding process, and contributing to coding definitions. A framework analysis (i.e., themes were indexed in an Excel spreadsheet by interviewee role for review), combining with deductive and inductive techniques,⁷ was conducted to identify and better understand the various themes and subthemes identified in the interview data. This pragmatic combination of post-positivist and interpretivist approaches was used because each of these approaches addresses different aspects of our research questions that neither approaches addresses alone: organizational experiences with the SNAP-Ed grant and how experiences may vary by interviewee role.⁸ The coders were trained in qualitative methods in the context of health services research, and had prior exposure to interview data on food insecurity. Therefore, the analytic process may have occasionally drawn on assumptions and expectations associated with prior work. Other metrics such as percent saturation were not included in the process, because we had fixed pool of interviewees and saturation metrics could not have been leveraged to increase recruitment or data collection. All program assessment materials were reviewed and approved by the DPH Institutional Review Board.

Intervention

In California, the California Department of Social Services administers the SNAP-Ed program, with 4 State Implementing Agencies tasked with implementing the program on the ground. Of the 4, the California Department of Public Health (CDPH) is the State Implementing Agency that coordinates with local health departments (LHDs) to scale SNAP-Ed interventions. At the local level, LHDs serve as the local lead agency (LLA) and SNAP-Ed resources (including direct funding) are further allocated to key partners to assist with program implementation. As a LLA, DPH developed a request for proposals⁹ in 2016 to solicit and select 24 partners for this purpose.

As described above, local SNAP-Ed priorities were established using population health data from CHIS 2013–2015 (restricted data file).⁵ Community needs and places marked for receipt of these resources were identified by geography, for example, both the Metro SPA 4 (Downtown and Hollywood) and the South SPA 6 (Compton and Crenshaw) were ranked among the areas with the worst key health indicators and had the most SNAP-Ed eligible households. In SPA 6, SNAP-Ed eligible adults consumed on average 3.2 servings of soda and 2.3 servings of fast food per week, both numbers were higher than the overall county estimates. Not too surprisingly, of the 24 selected partners, nearly half were located in the 2 SPAs—5 in SPA 4, 5 in SPA 6 (Table 1).

Table 1.

California Health Interview Survey, Supplemental Nutrition Assistance Program Education Eligible Participants, Los Angeles County, 2013–2015.

	SNAP-Ed Eligible (≤185% FPL)
	Overall LAC Non-SNAP-Ed Eligible (>185% FPL)	SPA 1 Antelope Valley	SPA 2 San Fernando Valley	SPA 3 San Gabriel	SPA 4 Metro	SPA 5 West	SPA 6 South	SPA 7 East	SPA 8 South Bay
	Estimate	Estimate	Estimate	Estimate	Estimate	Estimate	Estimate	Estimate	Estimate
	SE	SE	SE	SE	SE	SE	SE	SE	SE
Physical activity
Number of times walking for transportation more than 10 min in the past week	2.7	2.1	2.3	2.1	3.8	3.3	3.0	2.9	3.2
	(.1)	(.3)	(.2)	(.2)	(.3)	(.4)	(.2)	(.3)	(.3)
Number of times walking for leisure more than 10 min in the past week	2.9	2.1	3.0	2.4	2.5	3.1	2.2	2.6	2.6
	(.1)	(.3)	(.4)	(.2)	(.2)	(.5)	(.2)	(.2)	(.2)
Dietary intake
Number of times drank soda in the past week	1.5	3.2	2.2	2.3	2.6	1.9	3.2	2.9	2.3
Number of times drank soda in the past week	(.1)	(.7)	(.3)	(.3)	(.6)	(.7)	(.5)	(.5)	(.3)
Number of times drank sweetened fruit drink in the past month	5.8	12.3	7.3	5.6	9.9	7.2	12.0	8.0	7.6
	(.3)	(4.3)	(1.0)	(.6)	(1.6)	(2.1)	(1.6)	(1.0)	(1.0)
Number of times ate fast food past week	1.8	1.6	1.9	1.8	1.8	1.3	2.3	1.9	1.7
Number of times ate fast food past week	(.1)	(.2)	(.2)	(.1)	(.2)	(.3)	(.2)	(.1)	(.1)
Environment
How often can you find fresh fruits and vegetables in your neighborhood?
Always or usually	89.5%	81.8%	83.6%	83.6%	76.4%	92.8%	74.1%	81.9%	74.7%
Sometimes	7.6%	14.1%	12.6%	11.6%	18.1%	6.3%	18.0%	16.2%	20.8%
Never	3.0%	4.2%	3.8%	4.8%	5.5%	.9%	7.9%	1.9%	4.5%
How often are the fresh fruits and vegetables you find in your neighborhood affordable?
Always or usually	82.2%	49.6%	73.3%	68.7%	62.9%	79.4%	63.6%	62.5%	64.3%
Sometimes	16.9%	44.5%	26.1%	28.6%	35.3%	19.5%	35.5%	34.8%	34.2%
Never	9.0%	6.0%	.6%	2.8%	1.9%	1.1%	1.0%	2.6%	1.5%
BMI
BMI	26.9	29.3	28.9	28.1	28.1	26.2	29.0	29.5	28.0
BMI	(.1)	(1.0)	(.7)	(.4)	(.6)	(.7)	(.5)	(.6)	(.4)
Obese	23.9%	30.8%	30.9%	27.7%	27.8%	18.6%	35.9%	37.1%	32.7%
Overweight or obese	59.3%	71.7%	69.9%	63.0%	66.3%	55.6%	77.7%	73.6%	65.3%
Health status
Overall health (5 categories with higher being worse health)	2.4	3.1	2.9	3.0	3.2	2.8	3.1	3.2	2.9
	(.0)	(.2)	(.1)	(.1)	(.1)	(.2)	(.1)	(.1)	(.1)
Psychological distress (K-6)	3.3	4.8	4.5	4.4	5.5	4.7	4.9	5.0	4.8
Psychological distress (K-6)	(.1)	(.7)	(.3)	(.3)	(.4)	(.7)	(.4)	(.4)	(.4)
Chronic conditions
Lifetime diagnosis of diabetes	8.0%	13.8%	12.8%	13.6%	13.3%	13.2%	16.2%	15.5%	16.1%
Lifetime diagnosis of pre-diabetes	9.9%	7.2%	8.0%	7.1%	9.2%	11.8%	9.4%	10.9%	11.7%
Lifetime diagnosis of high blood pressure	26.1%	26.6%	31.0%	26.3%	32.0%	38.4%	35.7%	29.2%	34.1%
Lifetime diagnosis of heart disease	4.7%	10.4%	7.6%	6.2%	3.6%	5.5%	4.4%	7.1%	6.8%
N	7238	217	573	763	625	130	580	485	541
Number of community based organization contracts		1	3	2	5	1	5	4	3

Abbreviations: BMI, body mass index; CHIS, California Health Interview Survey; FPL, federal poverty level; LAC, Los Angeles County; SE, standard error; SNAP, Supplemental Nutrition Assistance Program (also known as CalFresh in California); SNAP-Ed, Supplemental Nutrition Assistance Program Education (also known as CalFresh Healthy Living Program in California); SPA, Service Planning Area.

Note: Means are weighted using CHIS sampling weights. Standard errors in parentheses. SNAP-Ed eligibility is defined as those households with incomes at or below 185% of the FPL.

Intervention Selection

For the LAC SNAP-Ed program, funded partners were tasked with carrying out 3 required implementation actions: (1) nutrition education and physical activity promotion, (2) coalition and partnership building, and (3) scale and spread of complementary PSEs. Recognizing that these partner organizations knew their target populations very well, DPH gave them tremendous latitude and flexibility when it came to prioritizing and selecting the best interventions that work for their communities. The partners also were given access to 5 DPH analysts who provided technical support and assistance to help them comply with CDPH expectations and state-contractual requirements.

Results

Most funded partners were able to freely choose their target populations (e.g., youth or adults) and select the curricula from a state-approved list for the nutrition education component of the SNAP-Ed program. Over the 3-year project, these partners delivered nearly 20,000 nutrition education and community classes, reaching an estimated 2 million people (data from the federal reporting system). All partners were asked to convene community coalitions to facilitate discussions about implementation issues (e.g., outreach, troubleshoot transportation barriers, education methods). For PSEs, there was a broad range of interventions selected by the partners. Figure 1 shows the most frequently selected PSEs along with the delivery sites. Overall, >200 PSEs were implemented to varying degrees over the 3-year timeframe, reaching approximately 1.2 million people.

Figure 1.

Most common policy, systems, and environmental change interventions (PSEs) and number of sites implementing them in Los Angeles county.

Table 2 shows the 2 facilitators—capacity building and community partnerships—that were identified by the interviewees as key contributors to the successful implementation of SNAP-Ed. Many of the interviewees stated that a strong factor conducive to successful intervention implementation was the capacity building support provided by DPH. For example, a capacity building strategy, themed workgroups known as “learning collaboratives”, provided a regular, monthly platform that provided a common place to learn about best practices and allowed for rich discussions of approaches that could be implemented in the field, including ways in which nutrition education delivery or PSEs could be improved. In all, there were 5 learning collaboratives, formed around 5 subject areas as identified by the partners themselves: (Group 1) nutrition/physical activity, (Group 2) smarter lunchroom movement, (Group 3) food insecurity screenings, (Group 4) food pantries/food banks, and (Group 5) school gardens. Meetings for each of these collaboratives were organized in an interactive way, typically starting with a topic specific lecture, followed by dedicated time for small breakout sessions where partners shared experiences and success stories. Another benefit of these collaboratives was the opportunity for partners to identify other capacity building needs which were not initially apparent at the start of the program, for example, developing feasible work plans for their projects, evaluating the impact of PSEs that have been implemented, and engaging in sustainability planning for the future. Seven partners, for instance, described that, in hindsight, they may have been too ambitious with their project goals from the start. If given another chance, they indicated they would have optimized their scope of work and time by asking for more of DPH’s technical assistance on organizational capacity building and strategy alignment (Table 2).

Table 2.

Salient Quotes for Themes Emerging From Interviews With Supplemental Nutrition Assistance Program Education Funded Partners, Los Angeles County, California.

Capacity Building
Training
“Definitely the [county] trainings are super helpful. My favorite one was the facilitation training. And being just in the community, there is a certain way to conduct classes to your clientele, and so, I felt like the facilitation training really provided those tools so that they could be more effective in their training. Rather than just going in there with the curriculum and just kind of talking at people, I think the facilitation training really helped in my health educators learning more how to integrate the audience into their classes. And so, it makes it more enjoyable when they know how to conduct the class.”
“Part of our scope of work involves us to attend trainings that specifically the Dept of Public Health has offered. They have different trainings such as food safety, ensuring that we have those specific guidelines for whenever we are handling food. Demonstration techniques for how to captivate an audience, facilitation techniques, video, or social media. Training techniques as well. We have different trainings on different curriculums. We have a curriculum that specifically focuses on gardening and fun activities you can do with kids in the gardens. So the trainings really kind of encompass all the different things that we do and it helps us achieve them to a higher degree, higher efficacy. They give us the tools we need for sure!”
Themed workgroups
“I think another thing to mention is that they have started some sub-groups, so depending on what type of work you’re doing, the county has provided support in a sub-group to be a part of, which is like a working group so that you can learn best practices from others that are doing the same work you’re doing.”
Evaluation
“For the county it’s important to look at what assessments are available for the PSE strategies, and then really educating and guiding us on that because for example, for the food insecurity work there hasn’t been a clear assessment from the beginning, you know. As we’re doing the work over the three years, the year two assessment might be something we needed to do from the beginning but we didn’t know about it and even the community survey that we’re implementing right now, that should have been done in the beginning, as well.”
Recommendations for capacity building
“[Y]ou do have these nonprofits who are not necessarily experts in this field. We’re more of a social service nonprofit. […] I don’t think I had enough knowledge from the outset to be realistic to create a plan that was realistic, so I really needed somebody to do an overview of it to say ‘Hey, this is great if you had 10 years, but being that you only have 3 years, let’s scale it down.’ So, that would have been helpful, too, from the beginning to have that outside perspective, just to really say, ‘I think this is really ambitious, and let’s narrow it down.’”
Community Partnerships
Partnerships with local government agencies and initiatives
“Another example is the city created an umbrella initiative, in which they address 5 core initiatives, which are: education, community safety, health, economic development, and community engagement. So, we were invited to attend a welcoming session as a new partner in the community through the health section of the initiative and in that particular section, you have a University, you have a Medical Center, you have everyone involved in health attends those particular workgroup meetings. So, we were also able to connect with several agencies and nonprofits that otherwise we may have not have known because the city is pretty busy.”
How partnerships help with data collection
“We were sharing data because each partner was collecting health data but from different perspectives. So, a lot of the discussion is about how do we tell the story of our city using the data that we are collecting already instead of creating another survey to survey the community. We also talked about policies, like active transportation. We talked about implementing heal zones, like places like a farmer’s market or green parks, where we can create a map and disseminate it to the community members so that they know where they can go and where it’s safe to go. It’s a fairly large group, and a lot of topics are covered, but it’s a really great way to know what is going on, as well as propose something.”
Networking
“I’m part of several coalitions, and through these coalitions, I meet healthcare partners. I meet partners from other community-based organizations. A lot of them have helped with these efforts. They may know someone that is interested in replicating, or not replicating, but implementing projects like ours, then that’s how I find out about other stakeholders. And so, being part of these coalitions and work groups allows me to network and to establish nutrition education and also it helps with our PSE efforts.”
Coalitions facilitate communication
“I know, especially through the grant, being able to share our stories and learn from other agencies who have been doing food distributions, there’s a lot of interest in our community for this program, but agencies just don’t have the capacity for it because it’s a hugely intensive process. So, we’re trying to build relationships and work collectively with other agencies to try and make this a little more of a reality in other places. So, that includes the LA Food Policy Council, Food Waste Recovery and Prevention Working Group, as well as the DPH Food Waste and Recovery Coalition or Working Group.”
Shortcomings of partnerships
“There’s a lot of work to be done because the barriers are that there’s low participant turnout, there isn’t enough marketing or outreach effort to the community. I think the only effort is to mail the catalog to the members of [our city], the residents, but there hasn’t been anything like an open house for the Health Hub. There hasn’t been anything like that. Parks and Rec, which are the people that are supporting this effort, they don’t follow up with us, letting us know how many people are attending beforehand, set up of the classroom, or even follow up after the date. So those are huge barriers there.”

Another key facilitator identified by interviewees during the interviews was the value of having robust community partnerships (Table 2). Stipulated by DPH, the establishment and use of community partnerships (coalition building) turned out to be both uniformly accepted and pragmatically beneficial for troubleshooting implementation challenges, especially for PSEs. The partnerships facilitated sharing of data, networking, and learning of key lessons that became a staple part of the problem-solving process for partners, especially when it came to logistical issues. The partnerships led to the establishment of several infrastructures that were larger than originally imagined. As an example, many partners wanted to deliver free fruits and vegetables to participants of their nutrition education classes but were not able to do so due to the cost and lack of infrastructure to transport produce. Through these community partnerships, strategies were devised to overcome the challenge, that is, several organizations stepped up to provide transport for the delivery of free produce to target class sites while others offered large-scale storage for the produce.

Discussion

During 2016–2020, DPH and its 24 funded partners were successful in delivering SNAP-Ed nutrition education and implementing PSEs in LAC, reaching millions of county households. Although previous research has documented the promise of multi-level public health programming for addressing conditions like obesity¹⁰ and hunger, only a few have described the nuances of planning and implementing such a large-scale safety net program as SNAP-Ed. Results from the present program assessment sought to do just this, revealing 2 key lessons that were learned during the 3-year project which helped to scale and spread SNAP-Ed strategies to better reach populations disproportionately impacted by chronic disease. First, local health departments can plan and prioritize for centralized capacity building support for partner organizations to learn and develop skills and best practices in the field. Second, local health departments can facilitate community partnerships to increase communication, collaboration, and to troubleshoot implementation challenges, especially for PSEs.

In California, the SNAP-Ed LHD model has provided numerous opportunities for LLAs to tailor their planning and program delivery to fit the needs of the underserved populations they serve.¹¹ Among the benefits of the CDPH’s flexibility is the ability of LHDs to subcontract out SNAP-Ed interventions, choosing only high need cities within a supervisorial district or funding projects through a superintendent of schools. In LAC, use of local data helped prioritize the jurisdiction’s intervention selection and development, and concentrated resources in geographical areas (i.e., certain SPAs) where they were needed most.

Department of public health’s decision to partner with organizations that had on-the-ground experience resulted in a unique set of assets and learning opportunities that facilitated further capacity building and advancement of SNAP-Ed PSEs.^12,13 DPH’s decision to rely strictly on population-level health data to prioritize resource allocation, however, did not fare as well. Too much emphasis on SPA geographies, in some instances, created artificial boundaries and other inflexible, structural/system barriers that slowed services delivery and PSE implementation. Although reliance on data is often seen as the first step to traditional program planning¹⁴ and is usually well-intended, approaches grounded or driven primarily by data frequently miss the nuances of implementation and of how complex community contexts and capacity can be when it comes to implementation of a combination of individual and community-level interventions.

In LAC, community partnerships were generally perceived as very useful vehicles for partners to network, share resources, and receive logistical support. However, despite these advantages,^15,16 there is growing research that suggest partnerships, particularly for implementing PSEs, can become particularly time- and labor-intensive.¹³

Limitations

The results of the program assessment should be interpreted carefully and used with several limitations in mind. The qualitative data, for instance, may not be generalizable to other jurisdictions or communities. While other LHDs across California have similarly subcontracted SNAP-Ed services or resources out to partners, their circumstances, and the counties they serve may not be comparable to DPH’s. LAC’s geography is enormous and is substantially more diverse than 42 other states in the United States, suggesting that lessons learned in LAC may not be translatable elsewhere.

Conclusion

Planning and implementing a large government program such as SNAP-Ed at the local level requires strategic balance between meeting community-driven needs and adhering to federal and state requirements for the program. In LAC, implementing SNAP-Ed was a challenge because of the county’s sheer size, that is, SNAP-Ed eligible people likely exceeded 3.5 million during 2016–2020. Unfortunately, this number will likely continue to grow, especially as the economic toll from the coronavirus disease 2019 pandemic becomes more apparent in the upcoming years. Nonetheless, LAC will be more prepared for this increase in food insecure households, as lessons learned from 2016 to 2020 point to ways in which implementation challenges can be mitigated effectively. That is, a cohesive network of local partners has been established and can work to create opportunities for further capacity building and for fostering relationships between different sectors to solve issues that are mutually inclusive. Similarly, LHDs are well-positioned to leverage other large obesity and diet-related chronic disease prevention programs to complement the efforts of local SNAP-Ed interventions, further creating and strengthening systems of institutions and agencies that can collectively advance system-level determinants of health at a faster pace, with the goal of achieving health equity for the underserved in LAC and across the United States.

So What?

What is already known about this topic? Although Supplemental Nutrition Assistance Program Education (SNAP-Ed) has been linked to improved dietary outcomes, there is limited research on the nuances related to its planning and implementation.

What does this article add?

The present program assessment showed that capacity building support from a local health department and the use of community partnerships to problem-solve implementation challenges can be useful approaches to scaling SNAP-Ed nutrition education and policy, systems, and environmental change interventions locally.

What are the implications for health promotion practice?

Supplemental Material

sj-pdf-1-ahp-10.1177_08901171211069128 – Supplemental Material for Use of Population Health Data and Qualitative Analysis to Guide Local Planning and Implementation of Supplemental Nutrition Assistance Program Education

Supplemental Material, sj-pdf-1-ahp-10.1177_08901171211069128 for Use of Population Health Data and Qualitative Analysis to Guide Local Planning and Implementation of Supplemental Nutrition Assistance Program Education by Julia I. Caldwell, Alina Palimaru, Deborah Cohen, Daniel Rizik-Baer, Dipa Shah-Patel and Tony Kuo in American Journal of Health Promotion

Footnotes

Author’s Note

This article describes the process of planning and implementation of SNAP-Ed at the local level in Los Angeles County from 2016 to 2020. SNAP-Ed includes nutrition education, physical activity promotion, and complementary policy, systems, and environmental change interventions (PSEs). Findings from 24 semi-structured interviews with project coordinators indicate that capacity building facilitated by the county health department and community partnerships were important in successfully implementing SNAP-Ed. Findings have practical implications for local-level entities to initiate and scale large obesity and other chronic disease prevention programs.

Author’s Contributions

All authors contributed to the conceptualization, data interpretation, and manuscript preparation. All authors have approved the final version for publication. Interpretation of the data are those of the authors and do not necessarily represent the views of the Los Angeles County Department of Public Health or any other organization mentioned in the text.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported in part by a contract from the California Department of Public Health to the Los Angeles County Department of Public Health (#16-10148) for work related to the United States Department of Agriculture’s Supplemental Nutrition Assistance Program Education.

Ethical Approval

This project received IRB approval from the Los Angeles County Department of Public Health Institutional Review Board (2014-09-535) prior to field implementation.

ORCID iDs

Tony Kuo

Supplemental Material

Supplemental material for this article is available online.

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