86 | Educational Pathways of Delaware Dentists: An Investigative Review of Dental Educational Records Dating Over 85 Years
Matt McNeill, B.S.; Timothy E. Gibbs, M.P.H.; Katherine Smith, M.D., M.P.H.
94 | Resources
97 | Index of Advertisers
98 | Delaware Journal of Public Health Submission Guidelines
The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine and Public Health (Academy).
Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome.
Questions? Contact managingeditor@djph.org
Advertising: Please contact ksmith@delamed.org for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products.
Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages are not be photocopied, except in limited quantities, or posted online, without permission of the Academy/DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to managingeditor@djph.org
Nutrition and Malnutrition as a Determinant of Health
In October 2025, the Delaware Academy of Medicine / Delaware Public Health Association finalized its rebranding as the Delaware Academy of Medicine and Public Health. This process, supported by our board, advisory council, and members, helped the Academy pivot from a ‘double name’ to one with clear intentions, and reflects our commitment to both medicine and public health as essential, interlinked aspects of keeping our community healthy. Although our name changed, our mission remains the same:
To enhance the well-being of our community through education, the promotion of public health, research, and targeted investments.
The Academy runs several programs of great benefit to our state, including the Immunization Coalition of Delaware, Delaware Mini-Medical School, and Delaware Health Force. And of course, we publish the Delaware Journal of Public Health, Delaware’s only PubMed-indexed, dual Open Access health sciences journal.
The issue topics of the DJPH are generally chosen in the previous calendar year, after discussion on possible topics by the Academy’s Public Health Advisory Council, and this issue on Nutrition and Malnutrition as a Social Determinant of Health was no different. With the federal government in a recent shut down, and federally funded programs like the Supplemental Nutrition Assistance Program (SNAP) at risk of being unable to meet the requirements of feeding children, the elderly, those with disabilities, and pregnant individuals, it seems like a coincidence, but also an opportunity. Public Health impacts all areas, and nutrition is fundamental to health & well-being of our community.
Our guest editors, Dr. Allison Karpyn (Professor of Human Development and Family Sciences, and CoDirector of the Center for Research Education and Social Policy at the University of Delaware) and Dr. Katelyn Fritzges (Internal Medicine Physician at ChristianaCare) have included articles about culinary medicine, mitigating food insecurity stigma, the Delaware Food Farmacy, and how food insecurity becomes a social determinant of health in college students. There are also articles to be found on the role of nutrition and malnutrition as determinants of cancer development, abstracts from the ACCEL CTR Conference on nutrition research, and research into Delaware dentists.
We hope you enjoy this issue of the Journal, and as always, reach out if you have any questions!
Omar A. Khan, M.D., M.H.S. Editor-in-Chief, Delaware Journal of Public Health
Katherine Smith, M.D., M.P.H. Publisher, Delaware Journal of Public Health
Guest Editors
Finding Dignity in Hard Times: Normalizing Support and Confronting Food Insecurity in Delaware
Allison Karpyn, Ph.D. Professor, Human Development and Family Sciences, Co-Director, Center for Research in Education and Social Policy, Director, Collaborative for Data Driven Action, University of Delaware
We are living through a critical time in public health history, a time when the livelihoods, and identities of many are threatened while compounding financial constrictions, pressures on the healthcare system, and increasing costs of goods—including food—are threatening public health. When it comes to nutrition, this convergence of rising food costs and unprecedented federal nutrition program cuts, impacted further by government shut downs, makes real the potential for skyrocketing rates of food security for Delawareans.
In our region the cost of poultry, fish meat and eggs has increased by 8.7% in the past year alone. For families in lower income brackets, who often spend 32% of their household budget on food, inflation can become the difference between having enough food for the family or going without. While our state has long maintained a strong emergency food system network, the reality is that food pantries are no substitute for functional government. These infrastructures, too, are dependent on a functioning Emergency Food Assistance Programs run by the USDA, as well as an active supply of day old and donated food from retailers, manufacturers, and distributors. As the economy contracts, these sources also begin to dry up.
Our research on stigma has shown that as challenges manifest, many experience shame, embarrassment, and blame, among other stigmatizing experiences. Parents report devastating selfjudgement, feeling like a bad parent for not being able to feed their children, seeing the challenge as a personal (not structural) failure. As neighbors, colleagues, and practitioners we must keep these realities at the forefront of our interactions. No one should experience embarrassment for needing food and we must be mindful of the systems and stereotypes that perpetuate blame.
Here are a few small steps you can take:
1. Change your language. Those eligible to receive food at pantries or through a federal program are “participants” not “program users.”
2. Many families struggle with the idea that they are taking more than their share – and that there are people who need it more than they do, even if it’s clear they qualify and have need. Be prepared to counter this prevailing thought. When talking about food program participation with someone, clarify that:
a. Many families you know participate. If you participated yourself, tell them!
b. That they have already paid into these programs through taxes.
c. It’s not about needing help forever, rather, it’s helpf available now when we need it.
d. Everyone should take as much of the resource as they need.
Together, by using compassionate language, challenging harmful assumptions, and affirming that access to food is a right (not a privilege), we can help ensure that every Delawarean feels supported, respected, and nourished during these uncertain times.
Culinary Medicine: A Necessary Public Health Intervention
Katelyn Fritzges, M.D., C.C.M.S. Primary Care Physician, ChristianaCare
Poor diet is a major public health crisis in the US, with over 529,000 deaths in the US in 20161 being associated with dietary risks --- and this was before the COVID-19 pandemic ushered in a rise in rates of obesity, type 2 diabetes, and hypertension across the country.
Meanwhile, our physician trainees consistently report lack of knowledge and skill in providing nutritional counseling, with only 14% of internal medicine residents reporting confidence in their ability to counsel patients about diet.2 It follows as no surprise that only about 40% of patients endorse receiving nutritional recommendations from their doctors,3 leaving millions of patients to seek guidance from alternate resources, which inevitably include wellness influencers on social media who may not be touting evidence-based recommendations.
Enter culinary medicine: a new, evidence-based field in medicine that blends the art of food and cooking with the science of medicine.4 It seeks to address this knowledge gap for healthcare providers by teaching both nutritional and culinary principles with the goal that providers can guide patients to make better food choices to both manage and prevent chronic disease. In a perfect world, healthcare providers might share a favorite recipe or a healthy swap within a recipe to suit the patient’s needs. This culinary guidance is key: providers should be able to advise patients on how to make healthy food that tastes delicious.
Culinary medicine does not seek to erase our registered dietician (RD) colleagues whose dedication to providing nutritional guidance to our patients is invaluable. In fact, many certified culinary medicine specialists are dieticians who have sought the additional culinary training. However, with increasing rates of diet-related chronic disease, frequent delays in care in the overburdened healthcare system, and insurance limitations in coverage of RD visits, our patients don’t always have access to RD visits. Training other healthcare professionals in nutrition and culinary medicine allows more contact points for patients to access this guidance and helps amplify the messages from our RD team.
However, educating healthcare professionals is just the beginning. An effective intervention will also require input and action from policymakers and the food industry. Addressing the epidemic of poor diet in our country will require interventions targeting food insecurity and the systems that allow ultra-processed, caloriedense, nutrient-poor foods to be the most abundant, affordable, and accessible options. It will also require us to address the complexities of disordered eating and weight-related stigma, both of which complicate discussions around healthy eating.
It is an honor to serve as a guest editor for this nutrition-focused issue of the Delaware Journal of Public Health, and I hope that as you read these articles, you are inspired to consider how you might play a role in addressing this crisis… even if that starts with adding an extra vegetable to your own plate.
REFERENCES
1 Mokdad, A. H., Ballestros, K., Echko, M., Glenn, S., Olsen, H. E., Mullany, E., Murray, C. J. L., & the US Burden of Disease Collaborators. (2018, April 10). The state of US health, 1990-2016: Burden of diseases, injuries, and risk factors among US states. JAMA, 319(14), 1444–1472. https://doi.org/10.1001/jama.2018.0158
2 Aspry, K. E., Van Horn, L., Carson, J. A. S., Wylie-Rosett, J., Kushner, R. F., Lichtenstein, A. H., . . . Kris-Etherton, P., & the American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; and Stroke Council. (2018, June 5). Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: A science advisory from the American Heart Association. Circulation, 137(23), e821–e841 https://doi.org/10.1161/CIR.0000000000000563
3 Greaney, M. L., Cohen, S. A., Xu, F., Ward-Ritacco, C. L., & Riebe, D. (2020, November 23). Healthcare provider counselling for weight management behaviours among adults with overweight or obesity: A cross-sectional analysis of National Health and Nutrition Examination Survey, 2011-2018. BMJ Open, 10(11), e039295 https://doi.org/10.1136/bmjopen-2020-039295
4. La Puma, J. (2016, February). What is culinary medicine and what does it do? Population Health Management, 19(1), 1–3 https://doi.org/10.1089/pop.2015.0003
Heart disease is the number one cause of death in the U.S., claiming more lives than all forms of cancer combined. Stroke is the number five cause of death in the U.S. and in Delaware.
The fourth annual Delaware Stroke Summit will feature a series of presentations to educate and inform local residents and healthcare professionals on the risk factors of stroke, the warning signs of stroke, the latest in prevention, research initiatives underway and more. There will be two educational tracks, one for community residents and one for healthcare professionals *This activity has been
E.
AGENDA
Registration and Breakfast 8am– 9am
Registration, Breakfast Free Health Screenings, Beebe Healthcare’s Community Outreach Team
Welcome 9am
Brief Welcome: Jim Murphy, Executive Director, American Heart Association Delaware
Chair, Stroke Summit : David Tam, MD, President & CEO, Beebe Healthcare
Host , Stroke Summit : E Thomas Har vey, III, Chairman & CEO, Har vey, Hanna & Associates, American Heart Association Delaware Board of Directors Leadership Chair
Chair, Stroke Summit Steering Committee: Thomas Trobiano, DNP, Executive Director, Ser vice Line Strategy & Partnerships, Beebe Healthcare
Franziska Herpich, MD, Neurology, Neurocritical Care, ChristianaCare Her personal sur vivor story.
10:30am -10:45am Break
Community Track (30 minutes each) 10:45 am
Shilpi Mittal , MD, Division Chief, Teleneurology & Telestroke, Clinical Associate Professor, Jefferson Ischemic Stroke
Bridget DiMaio, Speech-language Pathologist , Bridget Callahan, Occupational Therapist , ChristianaCare With Everett Lacey, Sur vivor Lauren Grieder, Director of Therapy Operations, Encompass Health With sur vivor Karen Wey and her husband Joe Wey Sur vivor Panel
Monica Javadian, MD, Beebe Healthcare R Randall Rollins Center for Medical Education, Family Medicine Residency Perspective on Stroke of a 3 Year Resident rd 12:15 pm Lunch 12:30pm
Shaista Alam, MD, Neurologist , Jefferson Health Brain Hemorrhage
Kim Gannon, MD, Medical Director, Comprehensive Stroke Program and Medical Director, ChristianaCare
What happens after you leave the hospital – the full recovery journey
Sean Connolly, DO, Cardiologist , Nemours Children’s Health
Sudden Cardiac Arrest & CPR – with a focus on schools and in the community Clinician Track (30 minutes each) 10:45 am
Kate Smith, MD, Executive Director of the Delaware Academy of Medicine/ Delaware Public Health Association Public Health Impact of Stroke
Andrew Foy, MD, Cardiologist , Beebe Healthcare Hypertension & Stroke
David Turkel-Parrella, MD, Medical Director, Neurointer ventional Surgery, Bayhealth Mechanical Thrombectomy in Acute Stroke
12:15 pm Lunch 12:30pm
Abraham John MD, MHA , Jefferson Health Life after Stroke, post-stroke mental health
Susanne M Morton, PT, PhD, Associate Professor, Physical Therapy Department , University of Delaware
Use of brain stimulation methods (primarily tDCS) to enhance post-stroke rehabilitation
Katie Johnson, DO, Medical Director of the Palliative Care Program, Beebe Healthcare Stroke & Palliative Care
Mitigating Food Insecurity-Related Stigma: A Review of Intervention Strategies
Evyn Y. Appel, B.S.
Center for Research in Education and Social Policy, University of Delaware
McKenna M. Halverson, Ph.D.
Center for Research in Education and Social Policy, University of Delaware
Valerie A. Earnshaw, Ph.D.
Department of Human Development and Family Sciences, University of Delaware
Tania Cruz Cordero, Ph.D.
Center for Research in Education and Social Policy, University of Delaware
Maya Rozin, M.A.
Center for Research in Education and Social Policy, University of Delaware
Raquelle Powell, B.A.
Center for Research in Education and Social Policy, University of Delaware
ABSTRACT
Grace Sands, B.A.
Center for Research in Education and Social Policy, University of Delaware
Nithila Chrisostam, B.A.
Center for Research in Education and Social Policy, University of Delaware
Sarah E. Katz, M.S.
Library, Museums, and Press, University of Delaware
Shreela V. Sharma, Ph.D., R.D.N., L.D.
Center for Health Equity, School of Public Health, The University of Texas Health Science Center at Houston
Allison Karpyn, Ph.D.
Center for Research in Education and Social Policy, University of Delaware
Objective: To characterize intervention strategies addressing food insecurity-related stigma implemented in federal nutrition programs (e.g. SNAP, WIC) and emergency food programs (e.g. food pantries, food cupboards) within high income countries. Methods: Six databases (PubMed, PsychINFO, Web of Science, CINAHL, Sociological Abstracts, Dissertations and Theses Global) and the Internet were searched through September 2024. Data on study characteristics and stigma intervention characteristics were extracted with a structured template. Descriptive statistics and thematic analysis were used. Results: The review found 46 intervention strategies across 18 articles. The majority of articles were based in the United States (89.9%) with the remaining portion from the United Kingdom (11.1%). Interventions most frequently targeted emergency food (44.4% of articles, 70.3% of interventions). Interventions were most often operating at the structural level (89.1%).
Conclusion: This review demonstrates the frequency of structural level interventions, particularly within the emergency food setting, and the need to implement strategies that address the everyday interactions between staff/volunteers and those seeking food assistance.
INTRODUCTION
Food insecurity, defined as the lack of reliable access to a sufficient quantity of affordable and nutritious food, has been on the rise or persisted globally since 2019.1 Individuals who face food insecurity are at an increased risk of deleterious physical and mental health outcomes including increased risk for diabetes, obesity, as well as anxiety and depression.2 For children in families experiencing food insecurity, even very mild levels of food insecurity have been found to impact their behavioral, emotional, and academic outcomes.3
In response to this persistent challenge, federal food assistance and emergency food programs, such as the Supplemental Nutrition Assistance Program (SNAP), the Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC), and food pantries and banks, play a critical role in addressing gaps in access.4–6 Yet, despite the evident need for supplemental and emergency food, many programs remain underutilized. For example, a 2019 report by the United States Department of Agriculture’s (USDA) Food and Nutrition Service reported that 18% of individuals eligible for SNAP nationwide are not enrolled. In WIC, this gap increases to 49% of eligible people not participating.7
Stigma is frequently cited to be a contributing factor to this underutilization.8 Stigma, in this context, can be defined as a social process where individuals are marked, judged, and devalued based on their food insecurity status or use of assistance
programs.9,10 Stigma makes it difficult for individuals to seek and ask for help,11 internal feelings of shame,12 self-consciousness,13 and unworthiness.8 In addition to being a stressor on mental health,14 stigma has also been found to increase a person’s risk for cardiovascular disease,15 and negatively impact overall physical health and wellbeing.16
STIGMA/INTERVENTION FRAMEWORKS
The Stigma and Food Inequity Framework
The Stigma and Food Inequity Framework (figure 1), 9 describes how stigma is manifested, articulates factors that mediate experiences of stigma, and highlights moderating contextual factors that influence its impact. Specifically, this framework helps to clarify that at the individual level, stigma manifests for targets, that is the individuals who carry a stigmatized identity and face mistreatment (e.g., a person who is experiencing food insecurity or utilizing nutrition assistance programs), and for perceivers, individuals who perpetuate stigma by holding prejudice or mistreating those with stigmatized identities (e.g., a grocery store cashier, volunteer at a food pantry). Perceivers and targets experience stigma as a result of a multi-level, social process that exists when labeling, separation, status loss, discrimination and stereotyping occur within a power context and result in some groups being socially devalued and discredited. It also recognizes that structural stigma happens at the systems level where policies, systems, and environments perpetuate stigma.
Stigma and Interventions: Characterizing Strategies
Recognizing that stigma occurs at multiple levels, public health researchers have developed a framework that characterizes interventions to address stigma. Interventions can be grouped into three main categories: structural, interpersonal, and intrapersonal.17
Structural level interventions aim to change the societal, and institutional conditions that create stigmatizing environments.17 Interventions at the structural level attempt to improve access and/or quality of the program or service.18 An intervention may seek to change a state policy that imposes SNAP eligibility restrictions or address a food pantry offering expired goods.19,20
Interpersonal level interventions reduce stigma by addressing the interactions between targets and perceivers.17 These interventions aim to increase intergroup contact and improve the quality of interactions, ensuring they are respectful, often through training and education.17,21
Intrapersonal level interventions address the way individuals think, feel, or behave. These interventions can be geared towards targets or perceivers and often involve education,22 counseling,17 or expressive and reflective writing.23
Research Objective
As research about the ways in which food insecurity and stigma manifest and intersect emerges, there is an increasing interest in characterizing the interventions and strategies currently underway or available which specifically intend to address food insecurity-related stigma. The goal of the current study is to characterize interventions of food insecurity-related stigma implemented in federal nutrition programs (e.g. SNAP, WIC) and emergency food programs (e.g. food pantries, food cupboards) within high income countries.
METHODS
Data Sources
A search of six bibliographic databases including PubMed, APA PsycINFO (ProQuest), CINAHL Plus with Full Text, Sociological Abstracts, and Dissertations and Theses Global (ProQuest) was undertaken for this study. In partnership with a librarian, the team refined search terms and formatting in PubMed. The formatting of subsequent searches in other databases were adjusted based on the database-specific parameters, but included terms to best match the PubMed search. Search terms were categorized into three groups: 1) stigma-related terms (e.g., social stigma, shame, embarrassment), 2) food insecurity and assistance terms (e.g., SNAP, emergency food, food insecurity), and 3) intervention terms (e.g., intervention, strategy, program, evaluation). Complete search queries can be found in Appendix A. Additionally, the research team searched for gray literature by combining keywords into search engines (e.g. food insecurity stigma, SNAP stigma). The research team also conducted a snowball search of articles identified from databases and search engines.
Inclusion and Exclusion Criteria
Articles were included if they met the following criteria: (a) peer-reviewed or gray literature; (b) published in or before September 2024; (c) publication in the English language; (d) articles from high-income countries, as defined by the World Bank in 2024; and (e) article details an explicit and implemented intervention strategy specifically intended to address food insecurity-related stigma. Articles were excluded if they were: (a) a measure development, commentary, or review; (b) conducted in a mid- or low-income country; (c) lacking a detailed description of the intervention; (d) interventions not implemented to reduce food insecurity and food insecurity-related stigma; (e) examined a pediatric population; (f) lacking data associated with intervention and/or outcomes closely related to food insecurity and food insecurity-related stigma were not included.
Data Extraction
Articles identified through databases were imported into Covidence for de-duplication and screening. Two research team members independently reviewed title/abstracts and full texts and resolved conflicts periodically through consensus and the input of a third team member. Articles identified through the gray literature (i.e., search engines) and snowball (i.e., citations) searches were unable to be entered into Covidence, and instead were reviewed by two team members, resolving conflicts by consensus. Data on study/article attributes and intervention characteristics were extracted using a structured template.
Data Synthesis
The structured template captured descriptive statistics and thematic analysis to summarize intervention characteristics and identify themes. The location, program of intervention (e.g., SNAP, WIC, emergency food), and study design (i.e., qualitative, quantitative, mixed-methods) were recorded. Interventions were coded according to the level of stigma addressed (i.e., structural, interpersonal, intrapersonal) and further grouped into categories (e.g., technology, training, service model).
RESULTS
Search Results
The initial database search produced 2,251 results, 1,964 of which were screened after duplicates were identified and removed (figure 2). Sixty-six results remained after title/abstract screening and ten results were included after full text screening. Another 49 articles were identified via internet and citation searching, eight of which remained after full text screening. In total, 18 articles were included in this review.
Study Characteristics
A majority of the included articles (n=16) originated in the United States of America, with the remainder (n=2) from the United Kingdom. Half of the articles (n=9) used mixed methods designs, seven articles used qualitative designs, and two articles used quantitative designs. Many articles (n=8) detailed an intervention in the emergency food setting. Interventions for future health/helping professionals (n=3) and general food insecurity (n=3) were the next most frequently identified. Three articles reported on interventions for WIC participants, and two articles considered SNAP interventions. One article examined both WIC and SNAP and was counted in both categories. The majority of articles (n=12) were published in the past five years, but date as far back as 2004 (n=1). Characteristics of articles included in the review can be found in Appendix B.
Intervention Levels and Categories
The 18 included articles detailed a total of 46 food insecurity-related stigma intervention strategies. Intervention levels and categories with examples are presented in Table 1. The frequencies of each intervention level and category can be found in Table 2. The complete list of interventions can be found in Appendix C. Structural level interventions were much more frequently implemented (n=41, 89.1%) than intrapersonal level interventions (n=3, 6.5%) or interpersonal level interventions (n=2, 4.3%).
Table 1. Food Insecurity-Related Stigma Intervention Categories and Definitions with Examples
Intervention Category Definition
Structural Level
Technology
New technology, whether physical or online, is utilized to reduce feelings of discomfort and shame involved in receiving food.
Messaging/ Communication Spoken, posted, or displayed words are chosen with intention to reduce stigma.
Examples
Electronic Benefit Transfer (EBT) cards were provided in place of paper vouchers to alleviate discomfort and reduce stigma at checkou25t.25–28
Open Food Network is a food hub that hosts an open-source software connecting local producers and consumers to provide a less stigmatizing experience to lower income communities when compared to traditional food banks.29
U.S. Hunger’s Full Cart uses artificial intelligence to objectively review emergency food applications and provide recommended services, removing judgement and potential shame.30
Classroom materials presented by professors (e.g. course syllabi, slide decks) make information about campus food resources widely available, not just to students determined to be “in need,” to reduce othering/singling out.31
Food bank communication strategies use social media to emphasize fulfilling a duty to prevent food from being sent to a landfill, rather than taking advantage of a service or system.32
Services are rebranded and referred to as markets and cafes, rather than food pantries or soup kitchens to avoid negative connotations.33
Service Model A food assistance program alters how their service is traditionally/commonly provided to improve the client experience.
Environment
The space inside the food assistance program is designed in a way to reduce stigma.
Feeding Tampa Bay’s Trinity Cafe redesigned their food distribution warehouse to feel like a public market where clients can choose what items they would like to take.34
The food hub avoided internalized stigma by o ering clients a choice of what items they wanted, overcoming connotations that clients are “receivers” rather than “purchasers” of food.29
Clients could receive food 24/7/365 with no questions asked and no proof of need in attempts to eliminate structural and social inhibitors to participation.35
SuperShelf connected a food bank to funding that upgraded food displays with culturally and visually appealing signage and artwork, creating a space where clients feel respected.21
The North East of England Independent Community Food Hub was designed to look like a community cafe rather than a typical food pantry.32
Location The physical location of the food resource is positioned to o er convenience and/or privacy.
Food Selection / Quality Food options provided strive to match the tastes and preferences of clients.
Policy Federal or state policies amend how a food program is administered to reduce stigma.
Sta ng
The food program selects sta and volunteers (perceivers) with intention to ensure the client (target) experience is welcoming and accommodating.
Interpersonal Level
Training
Intrapersonal Level
Food program sta and volunteers (perceivers) participate in a formal training to improve client (target) interactions and experiences.
Training Perceivers participate in an educational experience that intervenes on their personal perceptions of what food insecurity is like.
A hospital fully integrates their on-site food pantry into public use areas to normalize food pantry use within the community.35
The food pantry was moved to a central location to demonstrate that it is a resource for the whole community, which over time may reduce the stigma.36
When the food bank learned that peanut butter was not something Hispanic families wanted it was swapped for greater quantities of rice and beans.34
Boise State’s food pantry reduces stigma by providing food and supplies that patrons want. They gather information by sending out surveys.31
Implement policies that address SNAP eligibility restrictions by allowing SNAP access to unemployed and underemployed people, college students, and formerly incarcerated individuals.27
Volunteers were commonly ex-food bank users who had lived experiences of the stigma and shame that are often felt when accessing food resources.32
The Samaritan Community Center focused on recruiting and hiring bilingual volunteers and sta members to accommodate the large Spanish and Marshallese speaking population.33
Managers and volunteers were trained in cultural humility, client choice, and being both welcoming and respectful to pantry clients.21
Students enrolled in a community nutrition course participated in a food insecurity experience where they could not spend more than $3 per day on food for five days to build empathy and reflect on a SNAP-user’s experience.23
Researchers used an online animated simulation to increase cultural competence of emerging health professionals.37
Interventions were tailored to specific target programs (i.e. SNAP, WIC, emergency food, future health/helping professionals, other/ general food insecurity). Therefore, the following results are organized by program of intervention and further grouped by intervention level (i.e. structural, interpersonal, intrapersonal).
Table 2. Food Insecurity-Related Intervention Program of Focus and Intervention Type by Frequency
Messaging/Communication Interventions. The most frequently mentioned intervention strategy to reduce stigma involved altering messaging and communication related to emergency food programs. In total, eight messaging/communication interventions were described within six articles.29,31–35 To increase awareness of emergency food resources, food pantries placed advertisements in the local paper,34 grocery stores,29 and on social media.32 Additionally, professors at the University of California disclosed information about their campus’s pantry on the first day of classes or in the syllabus.31 In addition to these advertising interventions, emergency food programs altered the contents of their outreach materials to improve program accessibility. For example, food pantries made various changes to their messaging including referring to their resources as markets and cafes instead of food pantries or soup kitchens,33 publicly displaying signs that read “Food for Everyone” to encourage broad participation, and altering their advertisements to clarify program administrative requirements (e.g., no paperwork).34
Service Model Interventions. Another common intervention strategy involved modifying emergency food program service models. Seven service model interventions were described within four articles.29,33–35 In particular, pantries switched from standardized, pre-packaged bags of items to a “choice” or “client choice” model where clients have a more grocery store-like experience, hand selecting the items that best meet their dietary preferences and nutritional needs. Another article additionally described an innovative café experience where guests are served a three-course, sit-down meal by volunteers. Furthermore, a hospital food pantry designed its service model to allow clients to access food 24-hours a day, 7 days a week, 365 days a year and reduced administrative burden by eliminating proof of need, identification, and screenings or assessments.35
Environment Interventions. Five interventions altered the food pantry environments to improve client experiences.21,32–34,36 Two articles displayed the food in a desirable way to make the food options look more appealing21,34 and ensured the space had visually pleasing signage and artwork to add color to the space.21 In another study, a college food pantry covered their windows with large branded decals that would block views to the clients inside, ensuring anonymity.36 For a food pantry that had a large non-English speaking population, all signs and materials were translated in English, Spanish, and Marshallese, ensuring all clients could navigate the facilities.33 In addition to the details that make food pantries more appealing, one article described an operation that looked more similar to a café than a food pantry, with tables and chairs, computers and fridges for client use.32
Emergency Food Program Interventions
Eight articles described intervention strategies within emergency food environments (44.4%).21,29,31–36 Within these eight articles, 32 interventions were mentioned, comprising 69.6% of all interventions in this review. Most of these interventions were at the structural level (n=30, 65.2%), and two (4.3%) were at the interpersonal level.
Structural-Level Interventions
Seven types of structural level interventions were identified within emergency food settings including messaging/communication, service model, environment, location, food selection/quality, staff/ volunteers, and technology.
Location Interventions. Four interventions altered the physical location of the emergency food resource.32,35,36 Intervention goals were split between preserving food pantry clients’ sense of anonymity and integrating the food pantry with the public to normalize and desensitize the community. One article described a community hub’s food bank whose location was out of sight to people passing by.32 The food bank’s location near other services, however, maintained a sense of anonymity for clients, where it was difficult to tell if someone was there for the food bank, or a game night. The opposite approach was also found in the literature. A college food pantry intentionally relocated the pantry from a more secluded location to a central one, hoping that with greater visibility and a location that demonstrates it’s a resource
for the whole community, stigma would eventually be reduced.36 Additionally, a series of food pantries established within a hospital prioritized location for similar reasons by placing them in break rooms, elevator waiting areas, and public passageways to make food obviously available to all and easily accessible so family members could quickly return to visiting loved ones.35
Food Selection/Quality Interventions. Three interventions on food selection were implemented across three articles.21,31,34 All three interventions revolved around a commitment to offer food items that the community genuinely wanted. One article described a food bank in a Hispanic community that sought advice about food selection from a neighboring emergency food operation. In response to their guidance, the food bank stopped offering peanut butter, and provided more fresh and prepared foods.34 Boise State University surveys clients asking for feedback and suggestions regarding food selection.31 Food shelf managers consulted with SNAP-Ed educators to help source more culturally desirable foods and increase the variety of fresh produce provided.21
Staffing Interventions. Two interventions focused on staff hiring/volunteer onboarding practices.32,33 One article emphasized that the community food hub was both run by and for the community.32 As such, the volunteers were typically exfood bank users who had first-hand lived experiences with what it was like to be on the receiving end of services. Additionally, a food pantry within a community center that served many nonEnglish speaking clients focused their recruitment efforts on hiring staff and finding volunteers who were bilingual to best accommodate patrons.33
Technology Intervention. One article introduced a technologybased intervention in the emergency food space. A food hub’s online platform sought to streamline connections between producers and consumers via a single aggregated site. The open-source software was developed specifically for this online marketplace and aimed to create an alternative, less stigmatizing pathway to obtain food resources.29
Interpersonal Interventions
Training Interventions. Two articles discussed interpersonal interventions, both of which focused on training the staff and volunteers at the emergency food program.21,34 One food pantry has coined the phrase “The Grow Code” that is displayed on their website, discussed in their interviewing process, and weaved throughout training. This unifying agreement ensures that staff and volunteers prioritize service with respect and dignity.34 Another food pantry noted that managers and volunteers were trained specifically in cultural humility, client choice, and creating a welcoming and respectful environment.21
SNAP Interventions
Four interventions in SNAP were described in two articles.27,28 All four (8.7%) interventions were at the structural level. SNAP interventions included two policy-related interventions and two technology-based interventions.
Policy Interventions. Policy-based interventions were implemented by federal and state governments to alter SNAP administration. The first policy sought to expand SNAP eligibility and inclusiveness by eliminating restrictions for certain populations, such as people who are underemployed,
formerly incarcerated, or are college students. The second policy approach involved rejecting proposals aiming to restrict SNAP-eligible foods, thereby protecting SNAP customer’s food.27
Technology Interventions. Both of the technology-based SNAP interventions included transitioning from paper food stamps to an electronic benefit transfer (EBT) card. These interventions sought to reduce administrative costs, fraud and theft of benefits, and social stigma.28 The use of an EBT card, compared to paper food stamps, has increased SNAP enrollment.27
Other/General Food Insecurity Interventions
Three articles examined intervention strategies that did not target a specific program or population, but rather, food insecurity in general, and the negative emotions that are often coupled with it.26,30,38 Four (8.7%) structural interventions were described across the three articles including three (6.5%) technology interventions and one (2.2%) service model intervention.
Technology Interventions. In one of the technology interventions, a college campus aimed to mitigate stigma and administrative burdens by switching from paper meal tickets to a debit card that could fund students’ meals three to four times each week.26 In another instance, a technology intervention was implemented to maintain anonymity with an online food assistance application. This strategy eliminates any judgement or shame experienced when filling out a food assistance application in person and allows applicants to provide sensitive information in the privacy of their own home. The same article discussed the use of human-centric artificial intelligence (AI) and machine learning to remove subjectivity from evaluating people’s lived experiences.30
Service Model Interventions. The service model intervention delivered weekly meal kits to rural and suburban low-income families containing the ingredients and recipes to make three meals. Meal delivery services provide convenience that many food insecure families could benefit from, but otherwise could not afford. Rather than measure the meal kit’s effect on food security, researchers analyzed if receiving the service improved people’s subjective social status, and indication of both mental and physical health.38
WIC Interventions
Three articles detailed intervention strategies within WIC settings.25,27,39 All three of these articles discussed a structural level technology intervention (n=3, 6.5%).
Technology Interventions. Two of the technology-based interventions looked at the effects of WIC enrollment/ participation after the program’s transition from redemption using paper vouchers to an EBT card.25,27 The third intervention targeted the Cash-Value Benefit amount WIC participants receive for fresh fruit and vegetable purchases. While other goods are redeemed via WIC on a quantity basis, produce is redeemed according to its cost. Individual grocery store codes and WIC authorized product codes may not align, and the difficulty of redemption has left significant amounts of WIC dollars unclaimed. The study found that a more flexible, mixed generic code mapping leads to the fewest erroneous rejections.39
Future Health/Helping Professionals Interventions
Three intervention strategies targeting current students on career paths that may connect people experiencing food insecurity to nutrition assistance programs were described in three articles.23,37,40 Each of these articles described one intrapersonal intervention (n=3, 6.5%).
Training Interventions. Two interventions were budget restriction experiences assigned to students enrolled in a class or specific program. Students taking a community nutrition course at a land-grant university in the Northwest were required to spend no more than $3 per day on food for five days to simulate a SNAP participant’s budget for 5 days. Journaled reflections about the experience were analyzed and given empathy scores.23 Social work master’s students were instructed to spend no more than $6.10 per day on food for six days and could supplement their diets with free food obtained from family, friends, or food pantries. Discussion board posts were analyzed qualitatively.40 A study piloted an online animated simulation with focus groups of emerging health professionals.37 The simulation followed a character deciding whether to apply for public assistance and interacted with viewers by prompting them to select choices/make decisions to change the narrative. The goal of the simulation was to increase participant’s cultural competence and empathy.
Intervention Efficacy
The majority of interventions reported to have a positive effect on food service utilization. The data to support these claims varied by article, ranging from quantitative statistics,21,23,25,28,37–40 such as SNAP/WIC usage or increased empathy scores, to qualitative data based on observations, testimonies, or firsthand experience.26,27,30–36 One article found an intervention on service model from a food pantry to a local food hub was unable to address food insecurity-related stigma, and recommended broader societal-level changes were necessary.29
DISCUSSION
This review uses a multi-level approach to categorize intervention strategies aiming to address food insecurity-related stigma17 with the language and context of the Stigma and Food Inequity Framework.9 Across 18 included articles identified from scholarly databases and reputable Internet sources, 46 interventions and strategies were described. Our findings demonstrate that a majority of interventions operate at the structural level (n=41, 89.1%), as opposed to the interpersonal level (n=2, 4.3%) or intrapersonal level (n=3, 6.5%). Additionally, most interventions occurred within emergency food program environments (n=32, 69.6%). Structural level interventions most frequently utilized technology (n=9, 19.6%), often in the form of an EBT card for food purchases,25–28 innovated operations through an alternative service model (n=8, 17.4%), offering pantry clients a choicebased, “shopping”-like experience,28,33–35 or made changes to how the food program was messaging and communicating services (n=8, 17.4%) through signage and language/word choice.29,31–35 Messaging has been emphasized in other literature expressing the need to normalize the use of food banks and pantries,41 and regard it as a way to care for one’s family, rather than a sign of weakness.42 These strategies substantiate findings in a 2018 article describing a sense of shared community identity can humanize the emergency food experience.43
The degree of structural level interventions is encouraging as these typically result in the broadest impact.17 However, accounts
of negative individual-level stigma manifestations are extremely common, especially within the emergency food setting and warrant greater intervention.8 Of the 46 total interventions, only two described interpersonal strategies to support staff or volunteers working with clients/customers.21,34 This relative lack of interpersonal strategies contradicts recommendations found in other studies to increase training for grocery store staff,44 university faculty,45 and SNAP/WIC caseworkers.46 Three studies described interventions to help increase awareness among students with an intention of working in the social services sector.23,37,40 We observed a lack of interpersonal level interventions, a need that parallels other stigma reduction fields 15-20 years ago.47,48 However, these fields have begun to recognize and close the gap by putting greater emphasis on interpersonal interventions.49 Similarly to our study, other articles have reported an emphasis on college students as the study population.8,50
Stigma does not manifest itself within a vacuum, and intervention approaches should be multi-layered and recognize stigma’s intersectionality. Food insecurity-related stigma often exacerbates or originates from other negative social dynamics such as racism,51 and social isolation52 in addition to physical barriers that targets may face such as physical mobility limitations.53,54 Food insecurity-related stigma overlaps with weight stigma55 and discrimination against low-income populations referred to as welfare stigma or poverty stigma.56 This complexity suggests that future interventions must address the dynamic dimensions of stigma and the discrimination it perpetuates. The overlap additionally may explain why the majority (89.1%) of strategies uncovered in this review focused on structural level interventions that encouraged broad organizational-level changes. It may also represent an opportunity however to dovetail training efforts around stigma with interconnected topics such as racism, substance use disorder, or mental health.
Strengths and Limitations
Our database search spanned six databases to identify relevant articles across health sciences, psychology, sociology, and other social sciences. Further sources were identified from a wide Internet search and the reference sections of included articles. However, there is a possibility that some articles were missed if they were published in a database we did not search, were located beyond our keyword search, or were not available in English. Additionally, our search did not include articles focused on child nutrition programs (e.g., school meals) where there has been an emphasis on lunchroom stigma.57,58 Future research could apply a similar methodology of this review to exclusively focus on interventions of lunchroom stigma. Finally, due to the inconsistent style of writing between gray literature and scholarly sources and even within the gray literature, it is possible that our review excluded interventions that in practice were relevant but were not adequately described or were presented as ideas but not active interventions with any associated data. Of note, there is not a common measure of food insecurity-related stigma, perhaps contributing to this gap and a lack of definitive causality that would link an intervention to an increased utilization of services. Future research to design and apply such a tool is warranted. Lastly, articles reviewed presented a myriad of recommendations for those implementing federal and emergency food programs, based on their article’s findings. We did not categorize these suggestions to maintain the scope of our review, however, future researchers and food program professionals may find them beneficial.
CONCLUSION
Our review emphasizes the need for greater interpersonal and intrapersonal level interventions to address food insecurityrelated stigma, especially those that consider these overlapping forms of discrimination. The inclusion of stigma-specific knowledge and relevant examples functions to expose and intervene on normalized, yet discriminatory, practices and could be incorporated into existing training on cultural awareness and inclusion at emergency food sites, in medical settings, and grocery stores, as an example.
Ms. Appel may be contacted at evyn@udel.edu .
FUNDING
This research was funded by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation.
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APPENDIX A.
SEARCH QUERIES AND ARTICLE QUANTITIES BY DATABASE
Database Search Articles
PubMed ((((“Social Stigma”[Mesh] OR “Social Discrimination”[Mesh] OR “Perceived Discrimination”[Mesh] OR “Stereotyping”[Mesh] OR “Prejudice”[Mesh] OR “Rejection, Psychology”[Mesh] OR “Social Status”[Mesh] OR “Social Isolation”[Mesh] OR “Guilt”[Mesh] OR “Shame”[Mesh] OR “Embarrassment”[Mesh] OR “Disclosure”[Mesh] OR “Truth Disclosure”[Mesh] OR “Self Disclosure”[Mesh] OR “Coping Skills”[Mesh] OR “Social Segregation”[Mesh] OR Discrimination[Title/Abstract] OR prejudice[Title/Abstract] OR stereotyping[Title/Abstract] OR stigma[Title/Abstract] OR Perceived Discrimination[Title/Abstract] OR Self-stigmatization[Title/Abstract] OR Shame[Title/Abstract] OR Stereotype[Title/Abstract] OR Respect[Title/Abstract] OR Othering[Title/Abstract] OR Exclusion[Title/Abstract] OR “Social Status Hierarchies”[Title/Abstract] OR “Social Rejection”[Title/Abstract] OR “Social Status Loss”[Title/Abstract]))) AND (((“Food Assistance”[Mesh] OR “Public Assistance”[Mesh] OR “Food Insecurity”[Mesh] OR “Access to Healthy Foods”[Mesh] OR “Food Security”[Mesh] OR SNAP[Title/Abstract] OR WIC[Title/Abstract] OR food assistance[Title/Abstract] OR food bank*[Title/Abstract] OR food pantr*[Title/Abstract] OR Supplemental Nutrition Assistance Program[Title/ Abstract] OR “Special Supplemental Nutrition Program for Women, Infants, and Children”[Title/Abstract] OR Food Assistance Program*[Title/ Abstract] OR Food Aid Program*[Title/Abstract] OR Food Stamp Program*[Title/Abstract] OR Food Stamp*[Title/Abstract] OR SNAP Program*[Title/Abstract] OR “Women, Infants, and Children Program”[Title/Abstract] OR WIC Program[Title/Abstract] OR “Special Supplemental Nutrition Program for Women, Infants, and Children”[Title/Abstract] OR food cupboard*[Title/Abstract] OR emergency food*[Title/Abstract])))) AND (((“Program Evaluation”[Mesh] OR “Policy”[Mesh] OR “Evidence-Based Practice”[Mesh] OR Intervention[Title/Abstract] OR Program[Title/ Abstract] OR Strateg*[Title/Abstract] OR Programme[Title/Abstract] OR Evaluation[Title/Abstract])))
PsychINFO
(MAINSUBJECT.EXACT(“Stigma”) OR MAINSUBJECT.EXACT(“Discrimination”) OR MAINSUBJECT.EXACT(“Visual Discrimination”) OR MAINSUBJECT. EXACT(“Social Discrimination”) OR MAINSUBJECT.EXACT(“Perceptual Discrimination”) OR MAINSUBJECT.EXACT(“Stereotyped Attitudes”) OR MAINSUBJECT.EXACT(“Shame”) OR MAINSUBJECT.EXACT(“Embarrassment”) OR MAINSUBJECT.EXACT(“Self-Disclosure”) OR tiab(Discrimination OR prejudice OR stereotyping OR stigma OR Perceived Discrimination OR Self-stigmatization OR Shame OR Stereotype OR Respect) MAINSUBJECT.EXACT(“Prejudice”) OR MAINSUBJECT.EXACT(“Social Acceptance”) OR MAINSUBJECT.EXACT(“Social Status”) OR MAINSUBJECT. EXACT(“Social Isolation”) OR MAINSUBJECT.EXACT(“Guilt”)) AND (MAINSUBJECT.EXACT(“Social Services”) OR MAINSUBJECT.EXACT(“Community Services”) OR MAINSUBJECT.EXACT(“Community Welfare Services”) OR MAINSUBJECT.EXACT(“Food Insecurity”) OR MAINSUBJECT.EXACT(“Food”) OR MAINSUBJECT.EXACT(“Nutrition”) OR MAINSUBJECT.EXACT(“Government Programs”) OR tiab(SNAP OR WIC OR food assistance OR food bank* OR food pantr* OR Supplemental Nutrition Assistance Program OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR Food Assistance Program* OR Food Aid Program* OR Food Stamp Program* OR Food Stamp* OR SNAP Program* OR “Women, Infants, and Children Program” OR WIC Program OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR food cupboard*)) AND ((MAINSUBJECT.EXACT(“Intervention”) OR MAINSUBJECT.EXACT(“Program Evaluation”) OR MAINSUBJECT.EXACT(“Evidence Based Practice”)) OR tiab(program OR policy OR programme OR evaluation OR strateg*))
Web of Science ((TS=(Discrimination OR prejudice OR stereotyping OR stigma OR “Perceived Discrimination” OR “Self-stigmatization” OR Shame OR Stereotype OR Respect)) AND (TS=(SNAP OR WIC OR “food assistance” OR “food bank*” OR “food pantr*” OR “Supplemental Nutrition Assistance Program” OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR “Food Assistance Program*” OR “Food Aid Program*” OR “Food Stamp Program*” OR “Food Stamp*” OR “SNAP Program*” OR “Women, Infants, and Children Program” OR “WIC Program” OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR “food cupboard*”)) AND (TS=(“Intervention” OR “Program Evaluation” OR “Program” OR “Policy” OR “Programme” OR “evaluation” OR “evidence-based practice” OR “strateg*”)))
CINAHL ((MH “Stigma”) OR (MH “Discrimination”) OR (MH “Perceived Discrimination”) OR (MH “Stereotyping”) OR (MH “Prejudice”) OR (MH “Social Status”) OR (MH “Social Isolation”) OR (MH “Guilt”) OR (MH “Shame”) OR (MH “Embarrassment”) OR (MH “Truth Disclosure”) OR (MH “Self Disclosure”) OR (MH “Coping”)) OR (Discrimination OR prejudice OR stereotyping OR stigma OR Perceived Discrimination OR Self-stigmatization OR Shame OR Stereotype OR Respect) AND ((MH “Food Assistance”) OR (MH “Public Assistance”) OR (MH “Food Security”) OR (MH “Access to Healthy Foods”)) OR (SNAP OR WIC OR food assistance OR food bank* OR food pantr* OR Supplemental Nutrition Assistance Program OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR Food Assistance Program* OR Food Aid Program* OR Food Stamp Program* OR Food Stamp* OR SNAP Program* OR “Women, Infants, and Children Program” OR WIC Program OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR food cupboard*) AND ((MH “Program Evaluation”) OR (MH “Public Policy”)) OR (Intervention OR program OR programme OR evaluation OR “evidence-based practice” OR strateg*) N
Sociological
Abstracts
(MAINSUBJECT.EXACT(“Stigma”) OR MAINSUBJECT.EXACT(“Discrimination”) OR MAINSUBJECT.EXACT(“Stereotypes”) OR MAINSUBJECT. EXACT(“Social rejection”) MAINSUBJECT.EXACT(“Social isolation”) OR MAINSUBJECT.EXACT(“Shame”) OR MAINSUBJECT.EXACT(“Self disclosure”) OR MAINSUBJECT.EXACT(“Social status”) OR MAINSUBJECT.EXACT(“Guilt”) OR MAINSUBJECT.EXACT(“Coping”) OR MAINSUBJECT. EXACT(“Prejudice”) OR MAINSUBJECT.EXACT(“Embarrassment”) OR abstract(Discrimination OR prejudice OR stereotyping OR stigma OR Perceived Discrimination OR Self-stigmatization OR Shame OR Stereotype OR Respect)) AND (MAINSUBJECT.EXACT(“Food security”) OR MAINSUBJECT.EXACT(“Food stamps”) OR abstract(SNAP OR WIC OR food assistance OR food bank* OR food pantr* OR Supplemental Nutrition Assistance Program OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR Food Assistance Program* OR Food Aid Program* OR Food Stamp Program* OR Food Stamp* OR SNAP Program* OR “Women, Infants, and Children Program” OR WIC Program OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR food cupboard*)) AND (MAINSUBJECT.EXACT(“Intervention”) OR MAINSUBJECT.EXACT(“Program evaluation”) OR MAINSUBJECT.EXACT(“Public policy”) OR MAINSUBJECT.EXACT(“Evidence-based practice”) OR abstract(program OR programme OR evaluation OR strateg*))
Dissertations and Theses Global (MAINSUBJECT.EXACT(“Stigma”) OR MAINSUBJECT.EXACT(“Discrimination”) OR MAINSUBJECT.EXACT(“Visual Discrimination”) OR MAINSUBJECT. EXACT(“Social Discrimination”) OR MAINSUBJECT.EXACT(“Perceptual Discrimination”) OR MAINSUBJECT.EXACT(“Stereotyped Attitudes”) OR MAINSUBJECT.EXACT(“Shame”) OR MAINSUBJECT.EXACT(“Embarrassment”) OR MAINSUBJECT.EXACT(“Self-Disclosure”) OR tiab(Discrimination OR prejudice OR stereotyping OR stigma OR Perceived Discrimination OR Self-stigmatization OR Shame OR Stereotype OR Respect) MAINSUBJECT.EXACT(“Prejudice”) OR MAINSUBJECT.EXACT(“Social Acceptance”) OR MAINSUBJECT.EXACT(“Social Status”) OR MAINSUBJECT. EXACT(“Social Isolation”) OR MAINSUBJECT.EXACT(“Guilt”)) AND (MAINSUBJECT.EXACT(“Social Services”) OR MAINSUBJECT.EXACT(“Community Services”) OR MAINSUBJECT.EXACT(“Community Welfare Services”) OR MAINSUBJECT.EXACT(“Food Insecurity”) OR MAINSUBJECT.EXACT(“Food”) OR MAINSUBJECT.EXACT(“Nutrition”) OR MAINSUBJECT.EXACT(“Government Programs”) OR tiab(SNAP OR WIC OR food assistance OR food bank* OR food pantr* OR Supplemental Nutrition Assistance Program OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR Food Assistance Program* OR Food Aid Program* OR Food Stamp Program* OR Food Stamp* OR SNAP Program* OR “Women, Infants, and Children Program” OR WIC Program OR “Special Supplemental Nutrition Program for Women, Infants, and Children” OR food cupboard*)) AND (MAINSUBJECT.EXACT(“Intervention”) OR MAINSUBJECT.EXACT(“Program Evaluation”) OR MAINSUBJECT.EXACT(“Evidence Based Practice”) OR tiab(program OR policy OR programme OR evaluation OR strateg*))
N=314
APPENDIX B.
CHARACTERISTICS OF INCLUDED ARTICLES
Ali, A. (2022, April 12). Fighting stigma in hunger relief, one small step at a time. Food Bank News. foodbanknews.org/fighting-stigma-in-hunger-relief-one-small-step-at-a-time/
Bai, Y., & Ciecierski, A. (2023). Participants’ underlying beliefs of using WIC electronic benefit transfer (EBT) cards in stores in New Jersey. Journal of Community Health, 48(6), 1038-1043. https://doi.org/10.1007/s10900-023-01262-0
Boise State University. (2021, March 29). Reducing the stigma of food Insecurity on college campuses. https://www.boisestate.edu/deanofstudents/2021/03/29/reducing-the-stigmaof-food-insecurity-on-college-campuses/
Brennan-Tovey, K., Board, E. M., & Fulton, J. (2023). Counteracting stigma-power: An Ethnographic case study of an independent community food hub. Journal of Contemporary Ethnography, 52(6), 778-798. https://doi.org/10.1177/08912416231199095
Brinston, T., Phipps, S., Stratten, M., McGee-Brown, J., & Purry, A. (2023). SuperShelf transformation: Centering equity in a predominantly African American community. Journal of Nutrition Education and Behavior, 55(7), 6.
Broton, K. M., Mohebali, M., & Goldrick-Rab, S. (2022). Deconstructing assumptions about college students with basic needs insecurity: Insights from a meal voucher program. Journal of College Student Development, 63(2), 229-234. https://doi.org/10.1353/csd.2022.0018
Feed1st. (2024). Pantry program toolkit. UChicago Medicine. https://www.keepandshare.com/doc21/117209/feed1st-toolkit-2024?da=y
Fernandez, H. (2020, February 4). Tackling the challenge (and the stigma) of student food insecurity. Academic Impressions. https://www.academicimpressions.com/tackling-thechallenge-and-the-stigma-of-student-food-insecurity/
Guardia, L. & Lacko, A. (2021, December 1). To end hunger, we must end stigma. Food Research & Action Center. https://frac.org/blog/endhungerendstigma
Harmon, A., Landolfi, K., Shanks, C. B., Hansen, L., Iverson, L., & Anacker, M. (2017). Food insecurity experience: Building empathy in future food and nutrition professionals. Journal of Nutrition Education and Behavior, 49(3), 218-227. https://doi.org/10.1016/j.jneb.2016.10.023
FL, WA
WIC
MT Early health
APPENDIX B. CHARACTERISTICS OF INCLUDED ARTICLES (continued)
Johnson, K. E., Fleck, M., & Pantazes, T. (2019). “It’s the story”: Online animated simulation of cultural competence of poverty--A pilot study. Internet Journal of Allied Health Sciences and Practice, 17(2), 10. https://doi.org/10.46743/1540-580X/2019.1766
Kenney, J. L., & Young, S. R. (2019). Using experiential learning to help students understand the impact of food insecurity. Journal of Social Work Education, 55(1), 64-74. https://doi.org/10.1080/10437797.2018.1491356 USA, A large urban university in the Northeast
Psarikidou, K., Kaloudis, H., Fielden, A. & Reynolds, C. (2019). Local food hubs in deprived areas: destigmatising food poverty. Local Environment, 24(6). 525-538. https://doi.org/10.1080/13549839
Raymond, C., & Rouzier, A. (2023, April 18). Shame and hunger: Breaking the stigma through lived experiences. Behavioral Health News. behavioralhealthnews.org/shame-and-hunger-breaking-the-stigma-through-lived-experiences/
Rowland, B., Mayes, K., Faitak, B., Stephens, R. M., Long, C. R., & McElfish, P. A. (2018). Improving health while alleviating hunger: Best practices of a successful hunger relief organization. Current Developments in Nutrition, 2(9). https://doi.org/10.1093/cdn/nzy057
Yarborough, J., Chambers, K. A., Sierra, I. R., House, L. A., Mathews, A. E., & Shelnutt, K. (2022). P144 A Heathy meal kit intervention improves subjective social status of rural and suburban participants with low-income. Journal of Nutrition Education and Behavior, 54(7), S86-S87. https://doi.org/10.1016/j.jneb.2022.04.185
Zekeri, A. A. (2004). The adoption of electronic benefit transfer card for delivering food stamp benefits in Alabama: perceptions of college students participating in the food stamp program. College Student Journal, 38(4), 602-607.
Zhang, J., Zhang, Q., Tang, C., Park, K., Harrison, K., McLaughlin, P. W., & Stacy, B. (2022). The role of generic price look-up code in WIC benefit redemptions. Journal of Public Policy & Marketing, 41(3), 237-253. https://doi.org/10.1177/07439156221092418
FOOD INSECURITY-RELATED INTERVENTION STRATEGIES: LEVELS AND CATEGORIES
1. Technology
2. Technology
3.
Benefit Transfer (EBT) cards were provided in place of paper vouchers to alleviate discomfort for WIC participants at check out.25
Students received a debit card rather than paper meal tickets to reduce stigma and administrative burdens.26
Benefit Transfer (EBT) cards provided in place of paper vouchers reduces stigma for SNAP participants.27 4.
(EBT) cards provided in place of paper vouchers reduces stigma for WIC participants.27
5. Technology The novelty of the Open Food Network’s food hub was its online platform.29
6. Technology
7. Technology
The food assistance application can be completed online, allowing users to share information in a private, judgement-free space.30
The use of human-centric artificial intelligence and machine learning on the food assistance application is another way to combat stigma using an objective method to evaluate people’s lived experiences, removing negative emotions such as shame.30
8. Technology Electronic Benefit Transfer (EBT) cards were provided to SNAP participants in place of paper vouchers to reduce embarrassment and social stigma felt at check out.28
9. Technology
10. Messaging/communication
11.
Messaging/communication
Using a generic price lookup number for fruits and vegetables purchased with WIC can lower the probability of a rejected transaction which can be an extremely frustrating and stigmatizing experience.39
The food bank runs ads in the local paper, promoting that no paperwork is needed to receive food, phrasing their services as an act of food justice rather than a handout.34
Many food pantry clients respond more positively when they feel the food they are receiving is an outcome of paying taxes over the years.34
Messaging/communication Clients also feel more comforted knowing that their receiving of benefits is not excluding someone else from doing the same.34
The community food hub tried to change the narrative around food aid users through its social media account.32
sign reads “Food for Everyone” to encourage people to take the food they need and decrease feelings of stigma.35
The food hub has tried to destigmatize its services by advertising in adjacent spaces as well such as at the social supermarket and the food co-op, as well to the attendees of the center’s health and cooking classes.29
Messaging/communication Rather than refer to their services as food pantries or soup kitchens, the Samaritan Community Center rebranded to call them markets and cafes.33
Tampa Bay’s Trinity Cafe redesigned their food distribution warehouse to feel like a public market where clients can choose what items they would like to take.34
model
food pantry was available and open 24/7/365.35
model Clients could receive food with no prescription, proof of need, or questioning.35
The Feed1st model promotes dignity by operating as a client-choice pantry.35
The food hub avoided internalized stigma by o ering clients a choice of what items they wanted, overcoming connotations that clients are “receivers” rather than “purchasers” of food.29
The Samaritan Community Center made the decision to switch from a traditional food distribution mode to a client-choice model.33
model Low income families received a delivery of three meal kits each week for six consecutive weeks and were asked to rank their social status in relation to society.38
APPENDIX C.
FOOD INSECURITY-RELATED INTERVENTION STRATEGIES: LEVELS AND CATEGORIES (continued)
26. Environment
27. Environment
Orcas Island Food Bank reduces stigma by displaying fresh food in an inviting way.34
The North East of England Independent Community Food Hub did not look like a typical food pantry, but rather a community café.32
28. Environment SuperShelf connected the food bank to funding to display foods with culturally and visually appealing signage and artwork.21
29. Environment
The college food pantry’s windows are covered in large branded decals to both call attention to the pantry but also create a sense of privacy for those inside.36
30. Environment Samaritan Community Center translated all of their signs to include English, Spanish, and Marshallese to ensure all clients could navigate their facilities.33
31. Location The North East of England Independent Community Food Hub was well hidden to o er clients a sense of privacy.32
32. Location
The North East of England Independent Community Food Hub o ered a range of services (game nights, children’s clubs) so it wasn’t obvious which services people were accessing.32
33. Location A hospital fully integrates their on site food pantry into public use areas to alleviate the stigma of food insecurity.35
34. Location
35. Food selection/quality
The food pantry was moved to a central location to make it a resource for the whole community, which over time may reduce the stigma.36
The food bank recently learned that peanut butter was not something Hispanic families wanted so they swapped it out for greater quantities of rice and beans. They also learned that many clients preferred to get cooked food over raw ingredients, since many members work multiple jobs and do not have much time to cook.34
36. Food selection/quality Boise State’s food pantry reduces stigma by providing food and supplies that patrons want. They gather information by sending out surveys.31
37. Food selection/quality SNAP-Ed Educators worked with managers to identify and obtain more culturally desirable foods, and to increase the variety of fresh produce.21
38. Policy
39. Policy
40. Sta ng
41. Sta ng
Interpersonal-
SNAP eligibility restrictions perpetuate stigma and poverty by restricting access to unemployed and underemployed people, college students, and formerly incarcerated individuals.27
Proposals that restrict SNAP customer’s food choice create additional points of frustration at check out and ignore the research that shows the diets of SNAP and nonSNAP participants are similar.27
Volunteers were commonly ex-food bank users who had lived experiences of the stigma and shame that are often felt when accessing food resources.32
The Samaritan Community Center focused on recruiting and hiring bilingual volunteers and sta members to accommodate the large Spanish and Marshallese speaking population.33
1. Training Sta and volunteers are trained using The Grow Code, a set of principles introduced during each interview that vows to “honor all.” Anyone on the team is consequently chosen by the food bank, but also choses to respect the culture of the organization.34
2. Training Managers and volunteers were trained in cultural humility, client choice, and being both welcoming and respectful to pantry clients.21
Intrapersonal-
1. Training Students enrolled in a community nutrition course participated in a food insecurity experience where they could not spend more than $3 per day on food for five days to build empathy and reflect on a SNAP-user’s experience.23
2. Training Researchers used an online animated simulation to increase cultural competence of emerging health professionals.37
3. Training Social work masters students were assigned to spend no more than $6.10 per day on food to increase insight and empathy regarding receiving SNAP benefits.40
2025 Delawar e Planning Conference and Annual Meeting
Healthy by Design: Planning Communities for All
Wednesday, December 3, 2025
8:30 AM to 4:30 PM - Followed by Social Hour
Location:
Bally’s Dover Casino Resort Rollins Center 1131 N. Dupont Hwy, Dover, DE 19901
Brought to you by:
This Conference is made possible with help from our sponsors:
Conference and Meeting Agenda
8:30 AM Registration, Continental Breakfast, & Networking
9:00 AM Welcome & Opening Remarks: Michael Tholstrup, AICP, DE-APA Chapter President; Tricia K. Arndt, AICP, Councilwoman, City of Dover
9:15 AM Keynote Address: Rita Landgraf . Managerial Strategic Advisor for Healthy Communities Delaware (.5 CM)
10 :00 AM Session 1: Health, Wellness, and Planning Vital Conditions Framework in Planning (1 CM)
12:15 PM Lunch, Annual Meeting, Awards featuring guest speaker Nikko Brady, Deputy Chief of Staff for Climate, Food Systems, and Planning, Office of the Governor (.5 CM)
2:15 PM Session 3: Delaware Law Review: Max Walton , Attorney and Partner at Connolly Gallagher (1 CM -Law)
3:30 PM Session 4: Advancing Affordable Housing in Delaware: Policy, Zoning, and Action (1 CM)
4:30 PM Social Hour
The Delaware Food Farmacy: Integrating Medically Tailored Groceries and Community Health Workers into Chronic Disease Management
Michelle Axe, M.S.
Manager, Food is Medicine, Community Health Impact, ChristianaCare
Kathleen McCallops, Ph.D.
Senior Research Associate, Community Health Impact, ChristianaCare
John Oluwadero,
M.A.
Doctoral Fellow, Center for Research in Education and Social Policy, University of Delaware
Allison Karpyn, Ph.D.
Co-Director,
Center for Research in Education and Social Policy, University of Delaware
ABSTRACT
Objective: This study evaluates whether a medically tailored grocery intervention supported by community health workers improves clinical, behavioral, and social outcomes among patients with diet-related chronic conditions. The Delaware Food Farmacy (DFF), a six-month program implemented by ChristianaCare, targeted adults with diabetes, hypertension, or heart failure. Methods: This retrospective pre-post quasi-experimental study analyzed intake and six-month data for 185 participants enrolled between 2021 and 2024. Participants received weekly home deliveries of groceries aligned with the DASH diet, cooking tools, and ongoing support from community health workers (CHWs). Outcomes included food security, depression (PHQ-9), anxiety (GAD-7), BMI, blood pressure, and HbA1c. Results: Results indicated significant improvements in food security (p = 0.008), depression (–2.19 points, p < 0.001), anxiety (–1.76 points, p = 0.001), BMI (–1.44 kg/m2, p = 0.020), and HbA1c (–0.52%, p = 0.027). Goal completion averaged 84%, and satisfaction exceeded 90% across all program components. Conclusions: Findings demonstrate that medically tailored grocery programs supported by community health workers can produce measurable improvements in health and social outcomes among medically complex, low-income adults, offering a scalable, equity-oriented model to address chronic disease and inform value-based reimbursement pathways.
INTRODUCTION
Suboptimal diets and food insecurity contribute to more than $1.1 trillion in US healthcare spending and lost productivity each year.1,2 Six in ten adults live with one chronic condition, and four in ten experience two or more.3,4 Half of all adults live with diabetes or pre-diabetes and three in four adults are overweight or obese.
Delaware mirrors these national trends, with 61% of deaths in 2020 attributable to chronic diseases.5 The state ranks fifth nationally in per capita healthcare spending at $12,899 per resident.6 Nearly 12% of adults (approximately 95,100 individuals) have been diagnosed with diabetes, contributing to $1.1 billion in annual costs, and 37.9% of adults (approximately 311,000) live with obesity.7 These data highlight the urgent need for upstream strategies that integrate nutrition into healthcare delivery. The emerging field of Food is Medicine (FIM) offers a pathway to better align diet with healthcare. Defined by the American Heart Association as the “provision of healthy foods prescribed within a healthcare setting to prevent, manage, and treat diet-related chronic conditions,” FIM interventions include medically tailored meals, medically tailored groceries, produce prescriptions, and culinary medicine education.8 Research demonstrates that healthy food subsidies through Medicare and Medicaid could prevent
3.28 million cardiovascular events and 120,000 diabetes cases while saving $100.2 billion in healthcare costs.9 Medically tailored meals alone could avert 1.6 million hospitalizations each year and generate $13.6 billion in savings.10 Available studies have reported up to 1.5 percentage points decrease in HbA1c reductions,11,12 with each 1-point decrease associated with $500–$950 lower medical spending per patient per year.13 Individual programs have documented HbA1c reductions of up to three points, translating to roughly $24,000 in healthcare cost savings per patient.14
Despite growing evidence and investment, payers have not yet institutionalized the provision of healthy foods as a routine component of care for patients with diet-related chronic conditions. This study adds to the evidence base by evaluating a regional healthcare system’s implementation of a medically tailored grocery intervention designed to improve health outcomes and reduce hospital utilization.
The Delaware Food Farmacy (DFF) is a six-month program administered by ChristianaCare, a northeast regional health system. The intervention provides weekly home deliveries of medically tailored groceries through a partnership with community-based organization Lutheran Community Services (LCS), guided by the evidence-based Dietary Approaches to Stop Hypertension (DASH) eating plan and complemented by Community Health Worker (CHW) support. Each delivery
includes enough food to prepare approximately 10 meals per week for both the participant and their household members. Eligible participants are ChristianaCare primary or specialty care patients aged 18 or older with diabetes, hypertension, or congestive heart failure who are Medicaid-insured or uninsured residents of New Castle County, Delaware.
Serve-safe certified CHWs conduct initial kitchen assessments to identify barriers to food preparation and safety, such as limited access to basic cooking tools or storage capacity. Based on individual needs, participants receive essential kitchen equipment such as pots, pans, measuring cups, or blenders to support safe and effective meal preparation. CHWs engage weekly with participants to complete menus, set goals, address social needs, and strengthen nutrition knowledge and cooking skills. Participants could also receive self-monitoring tools such as blood pressure cuffs and scales and may access additional support from pharmacists, dietitians, and behavioral health consultants.
This study evaluates whether participation in a medically tailored grocery intervention supported by CHWs improves health outcomes and reduces food insecurity among patients with diet-related chronic conditions. Specifically, the research examines changes in glycemic control, blood pressure, body mass index, behavioral health symptoms, and food security status, along with patient centered goals achievement, and program satisfaction among participants in the DFF program over a six-month period.
METHODS
This pre-post study employed a retrospective quasi-experimental evaluation design to assess the impact of the DFF program among its first 150 graduates. Participants were enrolled between March 2021 and March 2024 and followed for six months. The study utilized intake and post-intervention assessments to measure changes in food security, behavioral health, biometric outcomes, and patient satisfaction.
Eligible participants were ChristianaCare patients aged 18 or older with at least one of the following chronic conditions: diabetes, hypertension, or congestive heart failure. Participants were required to be either Medicaid-insured or uninsured and residing in New Castle County, Delaware. Patients were referred to the program by their clinical care team, through ChristianaCare’s care coordination system.
Program data were extracted from ChristianaCare’s REDCap system and included participant enrollment, declination, retention, and completion information. Patient-centered goals and goal achievement were obtained from REDCap and ChristianaCare’s healthcare electronic health record (EHR) platform. Biometric outcomes (BMI, HbA1c, blood pressure) were extracted from the EHR at baseline and approximately six months post-enrollment. Behavioral health screenings and food security assessments were administered by the program coordinator and recorded in REDCap.
Participant satisfaction and self-reported behavior changes were assessed through a post-program survey administered by program staff and entered into REDCap. All data were de-identified prior to analysis. The study protocol was reviewed and approved by the ChristianaCare Institutional Review Board (IRB).
MEASURES
Biometric Outcomes. Hemoglobin A1c (HbA1c), blood pressure (systolic and diastolic), and body mass index (BMI) were extracted from participants’ EHRs at baseline (within 90 days prior to enrollment) and post-intervention (within 90 days following program completion). HbA1c values were analyzed for participants with diabetes; blood pressure values were analyzed for participants with hypertension.
Behavioral Health. Depression symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), a self-administered 9-item screener that scores patients on a scale from 0 (not at all) to 3 (nearly every day).15 Total scores range from 0 to 27, with scores categorized into five severity levels: none-to-minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27). A reduction of 5 points or more is considered clinically meaningful.15,16
Anxiety symptoms were assessed using the Generalized Anxiety Disorder-7 (GAD-7), a self-administered 7-item screener scored on the same 0–3 scale.17 Total scores range from 0 to 21 and are categorized into four severity levels: minimal (0–4), mild (5–9), moderate (10–14), and severe (15–21). A reduction of 4 points or more is considered clinically meaningful.
Food Security. The 2-item Hunger Vital Sign (HVS) was used to assess food insecurity.18 The HVS is derived from the 18-item USDA U.S. Household Food Security Survey Module. Each item is scored as “often true,” “sometimes true,” or “never true” in reference to the past 12 months. Participants who respond “often true” or “sometimes true” to either item are categorized as at risk for food insecurity, while those responding “never true” to both items are categorized as food secure.
Social Determinants of Health. CHWs conducted structured assessments to identify social care needs across domains including food access, transportation, housing, and utilities. The number of reported needs was summed for each participant at baseline.
Goal Setting and Achievement. CHWs worked with participants to establish individualized health goals related to nutrition, chronic disease management, and health behaviors. Goals and completion status were documented in the EHR and REDCap throughout the six-month program period.
Patient Satisfaction. A post-program satisfaction survey assessed participants’ experiences across four domains: food quality, satisfaction with the partnering organization (i.e., LCS), satisfaction with CHWs, and overall program satisfaction. Each item was rated on a 5-point Likert scale: very satisfied, satisfied, neutral, dissatisfied, or very dissatisfied.
STATISTICAL ANALYSIS
Descriptive statistics were calculated for participant characteristics, program reach, and satisfaction outcomes. Paired t-tests were used to assess pre-post changes in continuous outcomes (i.e., HbA1c, blood pressure, BMI, PHQ-9, and GAD-7). McNemar’s test was used to evaluate changes in the dichotomous food security outcome. Statistical significance was set at p < 0.05. To control for multiple comparisons, the Benjamini–Hochberg false discovery rate correction was applied to primary outcome analyses. All analyses were conducted using appropriate statistical software.
RESULTS
A total of 307 patients were referred to DFF between March 2021 and March 2024. Of those referred, 230 patients (75%) were successfully contacted, and 200 (87%) consented to participate in the program. Among those who consented, 15 participants (8%) did not engage with their assigned community health worker prior to the first grocery delivery and were classified as early dropouts. The final analytic sample included 185 participants. Table 1 presents all participant characteristics.
Most participants identified as Black or African American (59%), followed by White (26%), and smaller proportions identified as Other (8.6%), multiple races (3.8%), American Indian or Alaska Native (0.5%), or Asian or Asian American (0.5%). Nearly one in five participants (18%) identified as Hispanic or Latino. English was the primary home language for most participants (87%), with 11% reporting Spanish and 2% another language.
The majority of participants identified as female (60%), while 40% identified as male. Almost half were single (46%), with
smaller proportions reporting they were divorced (15%), married (15%), living with a partner (9.9%), separated (8.8%), or widowed (5.5%). Educational attainment varied, with 43% reporting a high school diploma or GED, 21% having some college or an associate degree, and 18% having some high school education. A smaller number had completed a four-year degree (6%) or held a trade or technical certificate (4%).
Employment rates were low, with 58% not employed and not seeking work (such as retirees, students, homemakers, or those living with disabilities). Seventeen percent were unemployed but seeking work, while 24% reported part- or full-time employment. Most participants were Medicaid beneficiaries, either as their primary or secondary insurance (97%). Among Medicaid recipients, the largest share were enrolled in Highmark Health Options (50%) or AmeriHealth Caritas (30.6%), with a smaller number covered under Delaware Traditional Medicaid (15.5%), or other plans (3.9%). The remaining participants were uninsured (3%).
All participants had at least one chronic condition, with half (50%) managing both diabetes and hypertension. An additional 17% had diabetes alone, 14% had hypertension alone, and 10% had all three conditions: diabetes, hypertension, and heart failure. Smaller proportions had combinations of hypertension and heart failure (6.5%), heart failure alone (2.7%), or diabetes and heart failure (1.1%).
These data indicate that DFF primarily served low-income, medically complex adults managing multiple chronic conditions, most of whom were insured through Medicaid and identified as Black or African American. The demographic profile underscores the program’s focus on addressing health inequities and supporting populations disproportionately affected by diet-related chronic diseases. A total of 307 patients were referred to DFF between March 2021 and March 2024. Of those referred, 230 patients (75%) were successfully contacted, and 200 (87% of those contacted) consented to participate in the program. Among those who consented, 15 participants (8%) did not engage with their assigned CHW, never completing their menu prior to first grocery delivery and were classified as early dropouts. The final analytic sample included 185 participants who completed the six-month program.
CHRONIC CONDITIONS
All participants had at least one chronic condition, with half (50%) managing both diabetes and hypertension. An additional 17% had diabetes alone, 14% had hypertension alone, and 10% had all three conditions: diabetes, hypertension, and heart failure. Smaller proportions had combinations of hypertension and heart failure (6.5%), heart failure alone (2.7%), or diabetes and heart failure (1.1%).
PROGRAM REACH AND SATISFACTION
Across 185 households, DFF served a total of 473 individuals, including patients and household members, providing enough food for 115,560 meals over the course of the six-month intervention. Overall satisfaction was consistently high across all assessed domains (n=185). Regarding food quality, 135 participants (73%) reported being very satisfied, 33 (18%) satisfied, 17 (9%) neutral, and 2 (1%) dissatisfied. Satisfaction with the partnering organization (LCS) was similarly strong, with
167 participants (90%) very satisfied, 15 (8%) satisfied, and 3 (2%) neutral. For community health workers (CHWs), 176 participants (95%) were very satisfied, 9 (5%) satisfied, and 1 (<1%) neutral. Overall program satisfaction remained high, with 172 participants (93%) very satisfied, 11 (6%) satisfied, and 2 (1%) neutral. No participants reported being dissatisfied with LCS, CHWs, or the overall program experience.
GOAL SETTING AND COMPLETION
Of 150 participants with recorded health goals, a total of 344 goals were established and 290 were completed, yielding an overall goal completion rate of 84.3%. When analyzed at the individual level (n=147, excluding three participants with zero recorded goals), graduates established an average of 2.34 goals and completed 1.97, resulting in an average completion rate of 83%. The majority of participants (74%) achieved full completion of their goals.
HEALTH AND SOCIAL OUTCOMES.
Health and social outcomes data is presented in Table 2
Food Security. Among the 105 participants with paired data, food insecurity decreased significantly from 80% at baseline to 65% at six months (χ2=7.03, df=1, p=0.008). Correspondingly, foodsecure participants increased from 20% to 35%, representing a 15 percentage point improvement in household food access.
Behavioral Health. At baseline, 166 participants completed the GAD-7, with the majority presenting with minimal (36%) or mild (31%) anxiety, while 17% reported moderate and 16% severe anxiety symptoms. Among the 98 participants with paired data, mean GAD-7 scores decreased from 7.16 at baseline to 5.41 at six months (t=3.34, p=0.001), a reduction of 1.76 points. Among the 33 participants presenting with moderate or greater anxiety at baseline (GAD-7 ≥10), 61% achieved clinically significant improvement of at least four points, with a mean reduction of 5.03 points.
One hundred sixty-three (163) participants completed the PHQ-9 at baseline, with more than one-third (36%) reporting noneto-minimal symptoms, 29% mild depression, 14% moderate, 13% moderately severe, and 8% severe depression. Among the 96 participants with paired data, mean PHQ-9 scores decreased from 7.80 at baseline to 5.61 at six months (t=3.85, p<0.001), a reduction of 2.19 points. Among 31 participants with moderate or greater depression at baseline (PHQ-9 ≥10), 62% achieved clinically meaningful improvement of five points or more, with a mean reduction of 6.74 points. Only one participant (3%) experienced worsening symptoms.
Glycemic Control. Among participants with diabetes and paired laboratory data (n=63), mean hemoglobin A1c decreased from 9.16% at baseline to 8.64% at six months (t=2.27, p=0.027), representing a 0.52 percentage point reduction.
Body Mass Index. Baseline BMI data were available for 149 participants, with 66% meeting clinical criteria for obesity, 22% classified as overweight, and 12% as healthy weight. Among the 84 participants with paired BMI data, mean BMI decreased from 35.95 at baseline to 34.51 at six months (t=2.37, p=0.020), a reduction of 1.44 kg/m2. Among all participants with complete weight data (n=108), 55% lost weight during the intervention, with an average loss of 15.3 pounds among those who experienced weight reduction.
Blood Pressure. For participants with hypertension and paired data (n=84), mean systolic blood pressure decreased from 136.5 mmHg at baseline to 133.4 mmHg at six months, a reduction of 3.1 mmHg. Mean diastolic pressure decreased from 80.9 mmHg to 78.5 mmHg, a reduction of 2.4 mmHg. Changes did not reach statistical significance.
Social Determinants of Health. At baseline, participants reported an average of 3.68 social care needs across domains including food access, transportation, housing, and utilities. CHWs provided referrals and support to address these needs throughout the intervention.
STATISTICAL ADJUSTMENT FOR MULTIPLE COMPARISONS.
After applying the Benjamini–Hochberg false discovery rate correction to control for multiple comparisons, improvements in food insecurity, depression (PHQ-9), anxiety (GAD-7), BMI, and HbA1c remained statistically significant (adjusted p<0.05). Blood pressure reductions did not reach significance following adjustment.
DISCUSSION
The Delaware Food Farmacy (DFF) evaluation adds meaningful evidence to the emerging science on healthcare system-integrated, medically tailored grocery interventions. Results indicate that participation in the DFF program, grounded in the Food Is Medicine framework, was associated with improvements in food security, glycemic control, body mass index, and psychological well-being among patients with chronic conditions. These findings reinforce and extend prior studies demonstrating that structured nutrition interventions embedded in clinical care can improve diet-related outcomes and mitigate health disparities.9,19,20 Similar to other Delaware-based Food Is Medicine initiatives, such as the Feeding Families program at Westside Family Healthcare,21 the DFF findings suggest that pairing medically tailored groceries with behavioral and care coordination support create measurable benefits in dietary behaviors and overall health status. The DFF’s incorporation of community health workers (CHWs) as key facilitators reflects growing recognition that CHWs enhance patient engagement, adherence,
and self-efficacy in nutrition and chronic disease management interventions.22,23 This approach also highlights the value of culturally responsive coaching in building healthy eating skills, reducing key participation barriers, and extending the benefits of the intervention to the entire household.
Recent systematic reviews and scientific statements reinforce that medically tailored meals (MTMs), groceries (MTGs), and produce prescriptions improve critical prerequisites for health including diet quality and food security, which are foundational to chronic disease prevention.10,19,20,24,25 The American Heart Association’s (AHA) 2025 synthesis of Food Is Medicine randomized controlled trials found consistent support for improved nutrition and food security, with favorable trends in biomarker outcomes such as hemoglobin A1c and blood pressure, although effect sizes vary by study duration and sample size.26 The growing portfolio of pragmatic trials, state Medicaid demonstrations, and implementation-science projects led by Health Care by Food™ exemplifies the field’s maturation and commitment to closing evidence gaps.26,27
Economic analyses further strengthen the case for FIM integration as a health equity and cost-containment strategy. Massachusetts Medicaid data demonstrated a 23% reduction in inpatient admissions and a 13% reduction in emergency department utilization among MTM participants, delivering net healthcare savings exceeding program costs.28 National modeling extrapolates that widespread implementation could prevent over 1.6 million hospitalizations per year, generating upwards of $13 billion in savings while improving health equity.29 These findings align with Delaware’s current Food Is Medicine Task Force goals and Medicaid 1115 waiver reforms, which contemplate valuebased reimbursement mechanisms like “In Lieu of Services” (ILOS) to expand sustainable nutrition interventions.
Recent state-level analyses indicate that medically tailored meals are cost-saving interventions across 49 of 50 U.S. states, with estimated savings per patient ranging from $6,299 in some states to several hundred dollars in others.30 Given Delaware’s high per capita healthcare spending and chronic disease burden, expanding MTM programs could provide substantial fiscal and clinical benefits locally, reinforcing the state’s commitment to upstream nutrition-based care models.
*Benjamini–Hochberg correction applied;
Table 2. Summary of Health and Social Outcomes
Although the effectiveness of MTMs, MTGs, and produce prescriptions as Food is Medicine interventions has been established, implementation success increasingly depends on how these interventions are embedded within clinical systems rather than on the intervention content alone. DFF’s hybrid grocery-based design, emphasizing patient autonomy through skills-building within the household environment, distinguishes it from conventional MTM models reliant on fully prepared meals. This distinction between MTG and MTM models matters because grocery-based design can build durable self-efficacy and household-level habits that persist after program end, potentially reducing relapse and improving long-run HbA1c and diet quality without continuous subsidy. The model’s integration of CHWs delivering tailored coaching, home kitchen assessments, and essential culinary resources facilitates actionable behavior change and addresses practical barriers to healthy eating.22,31 Embedding these services in a regional health system serving primarily Medicaid recipients illustrates the feasibility of scaling community-nutrition interventions that address both clinical outcomes and social determinants of health. This systems-based approach further supports the argument within the Food is Medicine framework that the complementary combination of program design, implementation mechanisms, and resource allocation, operationalized through an integrative policy approach rather than food access alone, drives adherence and sustained behavior change in Food is Medicine initiatives.32
LIMITATIONS AND NEXT STEPS
The pre–post evaluation design limits causal inference, and reliance on electronic health record data introduces variability in biometric timing. However, the directionality of observed improvements is congruent with evidence synthesized in rigorous reviews.26 Planned quasi-experimental analyses incorporating propensity score–matched comparison groups and differencein-differences methods are underway to bolster causal inference, assess intervention dose-response, and evaluate long-term sustainability. Return-on-investment analyses are also planned to quantify economic value and inform payer engagement strategies.
CONCLUSION
The Delaware Food Farmacy represents a scalable and systemintegrated FIM model that leverages MTGs and CHW support to advance nutrition security, chronic disease self-management, and health equity within a Medicaid-insured population. While larger, controlled studies are needed to fully establish comparative effectiveness, current evidence from Delaware and nationwide demonstrates that FIM approaches are an essential component of value-based, prevention-focused healthcare. Continued rigorous evaluation and policy alignment remain critical to realizing the full potential of Food Is Medicine as a foundational health intervention. Ms. Axe may be contacted at michelle.axe@christianacare.org .
REFERENCES
1 Centers for Disease Control and Prevention. (2023). Healthcare spending and lost productivity due to poor diet. https://www.cdc.gov/nutrition/health-spending
2 Ridberg, R. A., Lee, H., & Seligman, H. K. (2022). Economic impacts of medically tailored food interventions in the United States: A systematic review. Nutrition Reviews, 80(9), 1959–1973. https://doi.org/10.1093/nutrit/nuac017
3. Task Force on Hunger, Nutrition, and Health. (2022). Building on the evidence: Food is medicine and its role in US health equity. U.S. Department of Agriculture. https://www.usda.gov/food-is-medicine-taskforce
4 Centers for Disease Control and Prevention. (2024). Chronic disease prevalence in adults. https://www.cdc.gov/chronicdisease/data
5 Delaware Division of Public Health. (2024). Burden of chronic disease report 2024. https://myhealthycommunity.dhss.delaware.gov
6 Centers for Medicare & Medicaid Services. (2020). Health expenditures by state of residence, 1991-2020. Office of the Actuary, National Health Statistics Group. https://www.cms.gov/data-research/statistics-trends-and-reports/nationalhealth-expenditure-data/state-residence
7 Delaware Department of Health and Social Services. (2023). Delaware state health assessment. https://dhss.delaware.gov/dhss/dph/files/health_assessment2023.pdf
8. Volpp, K. G., Berkowitz, S. A., Sharma, S. V., Anderson, C. A. M., Brewer, L. C., Elkind, M. S. V., . . . Zachariah, J. P. V., & the American Heart Association. (2023, October 31). Food is medicine: A presidential advisory from the American Heart Association. Circulation, 148(18), 1417–1439 https://doi.org/10.1161/CIR.0000000000001182
9 Lee, Y., Mozaffarian, D., Sy, S., Huang, Y., Liu, J., Wilde, P. E., Micha, R. (2019, March 19). Cost-effectiveness of financial incentives for improving diet and health through Medicare and Medicaid: A microsimulation study. PLoS Medicine, 16(3), e1002761 https://doi.org/10.1371/journal.pmed.1002761
10 Hager, K., Cudhea, F. P., Wong, J. B., Berkowitz, S. A., Downer, S., Lauren, B. N., & Mozaffarian, D. (2022, October 3). Association of national expansion of insurance coverage of medically tailored meals with estimated hospitalizations and health care expenditures in the US. JAMA Network Open, 5(10), e2236898. Retrieved from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2797397?utm https://doi.org/10.1001/jamanetworkopen.2022.36898
11. Berkowitz, S. A., Terranova, J., Randall, L., Cranston, K., Waters, D. B., & Hsu, J. (2019, June 1). Association between receipt of a medically tailored meal program and health care use. JAMA Internal Medicine, 179(6), 786–793 https://doi.org/10.1001/jamainternmed.2019.0198
12 Lage, M. J., & Boye, K. S. (2020, September). The relationship between HbA1c reduction and healthcare costs among patients with type 2 diabetes: Evidence from a U.S. claims database. Current Medical Research and Opinion, 36(9), 1441–1447 https://doi.org/10.1080/03007995.2020.1787971
13 Wagner, E. H., Sandhu, N., Newton, K. M., McCulloch, D. K., Ramsey, S. D., & Grothaus, L. C. (2001, January 10). Effect of improved glycemic control on health care costs and utilization. JAMA, 285(2), 182–189 https://doi.org/10.1001/jama.285.2.182
14 Hess, A., Passaretti, M., & Coolbaugh, S. (2019, June). Fresh food farmacy. Am J Health Promot, 33(5), 830–832 https://doi.org/10.1177/0890117119845711d
15 Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001, September). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613 https://doi.org/10.1046/j.1525-1497.2001.016009606.x
16 Löwe, B., Unützer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004, December). Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 42(12), 1194–1201. https://doi.org/10.1097/00005650-200412000-00006
17 Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006, May 22). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097 https://doi.org/10.1001/archinte.166.10.1092
18 Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., Frank, D. A. (2010, July). Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics, 126(1), e26–e32 https://doi.org/10.1542/peds.2009-3146
19 Gao, Y., Yang, A., Zurbau, A., & Gucciardi, E. (2023, March). The effect of food is medicine interventions on diabetes-related health outcomes among low-income and food-insecure individuals: A systematic review and meta-analysis. Canadian Journal of Diabetes, 47(2), 143–152 https://doi.org/10.1016/j.jcjd.2022.11.001
20 Rabaut, L. J. (2019, April 29). Medically tailored meals as a prescription for treatment of food-insecure type 2 diabetics. Journal of Patient-Centered Research and Reviews, 6(2), 179–183. https://doi.org/10.17294/2330-0698.1693
21. Oluwadero, J., De Leon, L., Falgowski, M., Holman, E., Kennedy, N., NorrisBent, M., Karpyn, A. (2025, April 30). Food is medicine: The effectiveness of Delaware’s Feeding Families program in managing chronic conditions. Delaware Journal of Public Health, 11(1), 10–18 10.32481/djph.2025.04.04 https://pubmed.ncbi.nlm.nih.gov/40331171
22 Centers for Disease Control and Prevention. (2025, July 27). Resources for community health workers: Chronic disease. U.S. Department of Health and Human Services. https://www.cdc.gov/chronic-disease/php/community-health-worker-resources
23 Salud, M. H. P. (2024). Community health worker interventions for chronic disease. https://mhpsalud.org/community-health-worker-resources/chronic-disease
24 Aiyer, J. N., Raber, M., Bello, R. S., Brewster, A., Caballero, E., Chennisi, C., Sharma, S. V. (2019, October 1). A pilot food prescription program promotes produce intake and decreases food insecurity. Translational Behavioral Medicine, 9(5), 922–930 https://doi.org/10.1093/tbm/ibz112
25 Palar, K., Sheira, L. A., Frongillo, E. A., O’Donnell, A. A., Nápoles, T. M., Ryle, M., Weiser, S. D. (2025, March 17). Food is medicine for human immunodeficiency virus: Improved health and hospitalizations in the changing health through food support (CHEFS-HIV) pragmatic randomized trial. The Journal of Infectious Diseases, 231(3), 573–582. https://doi.org/10.1093/infdis/jiae195
26 Seligman, H. K., Duncan, A. K., & Hager, E. R. (2025). A systematic review of Food Is Medicine evidence and clinical integration pathways. Circulation: Cardiovascular Quality and Outcomes, 18(7), e001612. 10.1161/CIR.001612
27 Health Care by Food. (2025). Advances in the Food Is Medicine field: Annual report 2025. Health Care by Food™ Initiative. https://www.healthcarexfood.org
28 Berkowitz, S. A., Seligman, H. K., & Basu, S. (2024). Health care utilization and savings associated with medically tailored meal programs. JAMA Internal Medicine, 184(3), 412–422 10.1001/jamainternmed.2024.0142
29. Dornfeld, J. M., Go, K. W., & White, M. N. (2025). Modeling the value of “Food Is Medicine” interventions: Population health and cost implications. Health Affairs, 44(4), 406–412 https://doi.org/10.1377/hlthaff.2024.01343
30 Deng, S., Mozaffarian, D., Shieh, S., & Lee, M. (2025). State-level cost savings of medically tailored meals in the United States. Health Affairs, 44(4), 433–442 https://doi.org/10.1377/hlthaff.2024.01307
31 Anderson, C. M., Ferrer, M., Doyle, L., & Kwan, A. (2023). Behavior change mechanisms in food assistance interventions: Evidence from community nutrition trials. Journal of Nutrition Education and Behavior, 55(9), 811–820 https://doi.org/10.1016/j.jneb.2023.06.004
32 Volpp, K. G., Troxel, A. B., & Asch, D. A. (2023). Implementing healthy food subsidies through Medicare and Medicaid: Potential impacts on chronic disease outcomes and health care costs. Health Affairs, 42(2), 162–171 https://doi.org/10.1377/hlthaff.2022.01083
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The NATION’S HEALTH
November/December 2025
The Nation’s Health headlines
Online-only news from The Nation’s Health newspaper
Surge in US poverty would ignite public health crisis, experts warn Sophia Meador
The Nation’s Health November/December 2025, 55 (9) 1-12;
Public health communicators finding promise in AI tools
Teddi Nicolaus
The Nation’s Health November/December 2025, 55 (9) 1-19;
Mississippi calls for emergency action as infant deaths soar
Sophia Meador
The Nation’s Health November/December 2025, 55 (9) 9;
Resilience helps people cope with climate-driven weather disasters
Natalie McGill
The Nation’s Health November/December 2025, 55 (9) 6;
Step into safety: How to be a smarter pedestrian
Teddi Nicolaus
The Nation’s Health November/December 2025, 55 (9) 24;
APHA 2025 to celebrate public health, educate field in November
Mark Barna
The Nation’s Health November/December 2025, 55 (9) 1-15;
APHA 2025 attendees can support youth mental health through Help Us Help Them campaign
Mark Barna
The Nation’s Health November/December 2025, 55 (9) 14;
APHA Press book takes systems approach to racial injustice
Mark Barna
The Nation’s Health November/December 2025, 55 (9) 23;
Newsmakers: November/December 2025
Sophia Meador
The Nation’s Health November/December 2025, 55 (9) e10;
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The Role of Food Security as a Social Determinant of Mental Health in College Students
Amy Gootee-Ash, Ph.D., M.S.W., M.S. Director, Masters of Public Health Program, Public & Allied Health Sciences Department, Delaware State University
ABSTRACT
Objective: This study examined the prevalence of food insecurity and its association with anxiety and depression among students at Delaware State University (DSU). Methods: A cross-sectional survey was administered to 117 students via classroom distribution, social media, campus events, and within the campus food pantry. Food insecurity was assessed using the USDA Six-Item Short Form, anxiety levels were determined using the GAD7 survey tool, and depression scored with the PHQ-9 survey tool. Descriptive statistics were used to describe the population and the chi square test to analyze relationships between food security status and mental health outcomes. Results: Among respondents (n = 117), 97% were classified as food insecure (n = 113), and of those, 17% (n = 20) reported moderate-to-severe anxiety and 32% (n = 37) reporting moderate-to-severe depression. Only 37% (n = 43) of the students surveyed (n = 117) accessed mental health services within the past year and only 6% (n = 7) participated in food assistance programs. Although notable proportions of students experiencing food insecurity presented with elevated mental health symptoms, there was no statistically significant association between food security status and levels of depression or anxiety. Conclusions: The lack of statistical significance does not rule out a meaningful relationship between food and psychological distress. Larger sample sizes, longitudinal studies, and the inclusion of impacting variables such as financial supports are warranted to get an accurate assessment of our current student needs. Developing targeted interventions addressing both nutrition and mental health are essential to improve student well-being at a critical “gateway” period—habits and health challenges that emerge in this life stage often influence lifelong health trajectories.
INTRODUCTION
FOOD INSECURITY AS A SOCIAL DETERMINANT OF HEALTH
Food security is widely recognized as a critical social determinant of health (SDOH), as it not only shapes individuals’ access to adequate nutrition but also directly influences their capacity to maintain both physical and mental well-being.1 Food insecurity, defined as a deficiency in the quantity or quality of food, constitutes a critical nutritional risk that disrupts dietary adequacy and quality, contributing to various forms of malnutrition, including undernutrition as well as overnutrition, as evidenced by overweight and obesity.2 According to the U.S. Department of Agriculture, 13.5% of the U.S. population experienced food insecurity, representing a statistically significant increase from 2022.3 Among college students, food insecurity has emerged as a growing public health concern, with increasing evidence suggesting that limited or unstable access to food is associated with heightened levels of stress, anxiety, and depressive symptoms.4,5 As this population navigates academic pressures, financial strain, and transitional life stages, understanding the intersection between food security status and mental health outcomes becomes vital for developing effective campusbased interventions and support systems. This study examines food insecurity and its association with psychological distress, including symptoms of anxiety and depression within young adults at a minority-serving institution.
FOOD INSECURITY PREVALENCE AND MENTAL HEALTH IMPLICATIONS
Food insecurity has been widely documented as a determinant of poorer mental health outcomes, with associations observed across diverse global regions regardless of socioeconomic status.4 Beyond its direct impact on nutrition, food insecurity functions as a chronic stressor, exacerbating psychosocial strain and increasing vulnerability to depression, anxiety, and other common mental disorders.4,5 These effects are not solely explained by food deprivation; they also operate through multiple pathways, including the psychological burden of uncertainty, diminished perceived self-efficacy, and cultural expectations related to food provision and family care.4 Jones conducted a comprehensive global analysis examining the relationship between food insecurity and mental health using cross-sectional data from individuals in 149 countries.4 The study revealed a clear dose-response relationship, demonstrating that as food insecurity increased in severity—from mild to moderate to severe—mental health outcomes correspondingly declined.4 These findings underscore the pervasive impact of food insecurity on psychological well-being across diverse cultural and socioeconomic contexts, highlighting the importance of addressing food insecurity not only as a nutritional concern but also as a critical determinant of mental health. Understanding this relationship is essential for informing public health policies and interventions aimed at mitigating both food insecurity and its associated mental health burdens.
FOOD INSECURITY AND MENTAL HEALTH RELATED TO YOUNG ADULTS
Research has also increasingly explored the relationship between food insecurity and psychological distress in younger populations, including young adults.5,6 These investigations have employed both primary data collection and secondary data analyses across countries. Using data from the U.S. National Health and Nutrition Examination Survey (NHANES), Maynard et al. examined the association between food insecurity and perceived anxiety among adolescents aged 12 to 17 years.5 Maynard’s findings suggest that the relationship between food insecurity and mental health may be bidirectional, with food insecurity both contributing to and being exacerbated by psychological distress.5 The experience of food insecurity is inherently tied to ongoing worry and anxiety about meeting basic nutritional needs, which can induce a persistent state of psychological strain.5 The concept of toxic stress—defined as chronic, unmitigated stress in the absence of adequate social or structural support—offers a relevant explanatory framework for understanding how repeated or prolonged episodes of food insecurity may erode mental well-being.5 Meza et al. conducted in-depth, semi-structured interviews with undergraduate students to investigate the psychosocial impacts of food insecurity.6 They identified multiple psychosocial themes emerging from students’ lived experiences with food insecurity, including the constant stress of securing food interfering with daily functioning, fear of disappointing family expectations, and feelings of resentment toward peers with greater financial stability.6 Participants also described difficulty forming meaningful social connections due to foodrelated shame, alongside emotional responses such as sadness, hopelessness, and feeling undeserving of assistance.6 Additionally, there was a notable sense of frustration directed toward academic institutions for their perceived lack of structural support and acknowledgment of student food insecurity.6
NUTRITIONAL PATHWAYS AND MENTAL HEALTH OUTCOMES
One male student in Meza’s study specifically noted the stress associated with consuming “trans-fat and unhealthy food” due to financial limitations, which adversely affected his physical health and further exacerbated his anxiety.6 Food insecurity among college students has been consistently linked to both nutritional and mental health challenges.5–8 Students experiencing food insecurity often report lower dietary quality, including reduced intake of fruits, vegetables, and fiber, and higher consumption of added sugars, which can compromise physical health.7,8
Inadequate fiber intake may contribute to negative mental health outcomes, as fiber-rich fruits and vegetables have been associated with reductions in stress, depression, and mood disturbances, as well as improvements in overall quality of life.8 Beyond nutritional consequences, food insecurity is also associated with increased psychosocial stress, manifesting as poor sleep quality, anxiety, and depression.8 These findings highlight the multifaceted consequences of limited food access, illustrating that inadequate food security not only affects dietary intake but also contributes to substantial behavioral and mental health outcomes.6,8 Additionally, the gut microbiome represents an important and increasingly explored biological pathway through which food insecurity may influence
mental health, as disruptions in dietary quality can alter gut-brain signaling mechanisms associated with anxiety and emotional regulation.9 Emerging evidence from nutritional neuroscience indicates that inadequate or poor-quality food intake does not only affect physical health but also disrupts critical brain processes involved in mood regulation and stress response.9 Given that the brain consumes approximately 20–25% of the body’s total energy and depends on consistent nutrient availability to support neurotransmitter production, neuroplasticity, and gut-brain communication, food insecurity can disrupt these pathways and contribute to heightened anxiety symptoms.9
Understanding these relationships is critical for the development of comprehensive interventions that address both the nutritional and psychological needs of food-insecure student populations.
GAP IN LITERATURE
A key gap in knowledge lies in the limited understanding of how food insecurity specifically affects the mental health— particularly anxiety and depression levels—of college students, a population experiencing a unique developmental and life transition. While food insecurity has been widely studied in general adult populations and low-income households, much less is known about how it manifests in young adults pursuing higher education, who are often perceived as relatively privileged compared to other at-risk groups.
College students face distinct stressors such as academic pressure, unstable employment, limited financial independence, and social expectations, which may intensify the psychological impact of food insecurity. However, current research often fails to differentiate their experiences from broader adult populations or to examine anxiety and depression as distinct outcomes rather than grouping them under general psychological distress.
Additionally, food-insecure college students may not qualify for traditional safety net programs, leaving a gap in both support and surveillance. This makes it difficult for institutions to design effective interventions without first understanding how food insecurity contributes to anxiety and depression in this demographic. Therefore, exploring these specific relationships are essential for developing targeted campus-based strategies that address not only hunger but also the associated emotional and psychological burdens that may hinder academic performance, retention, and overall well-being.
METHODS
This study employed a quantitative, cross-sectional research design. Surveys (n = 117) were distributed through multiple channels, including in-class administration, social media, campus events, and participation in the campus food pantry at Delaware State University (DSU), representing approximately 2.5% of the total student population (N = 4,581).8 DSU is a Historically Black College and University (HBCU) located in Dover, Delaware, with an enrollment composed of 76% African American students.10 Data was collected over a six month period from January to June of 2025.
MEASURES
Ethical procedures for the collection of student data included approval from the Institutional Review Board –Human Subjects Protection Committee. An exemption was granted under Category 3, and all information was recorded in a manner that prevented the identification of individual participants, either directly or through linked identifiers. Data were collected using validated survey instruments. Food insecurity was assessed with the U.S. Household Food Security Survey Module: Six-Item Short Form (USDA), multiple responses were coded as binary with affirmative responses collapsed to determine overall food insecurity levels, scores 2 and over labeled as food insecure.11 Affirmative responses included “often” or “sometimes” for questions HH3 and HH4, and “yes” for questions AD1, AD2, and AD3.11 Responses of “almost every month” or “some months but not every month” on AD1a were also coded as affirmative.11 The sum of affirmative responses across the six questions constituted each survey respondant’s raw score. Food security status was then assigned as follows:
• 0–1: High or marginal food security (raw score 1 may be considered marginal).
• 2–4: Low food security
• 5–6: Very low food security
For reporting purposes, raw scores of 0–1 were categorized as food secure, while the combined categories of low and very low food security were considered food insecure.11
Anxiety was measured using the Generalized Anxiety Disorder 7-item scale (GAD-7), the instrument was scored through the tally of the numbers of all checked responses under each heading (not at all=0, several days=1, more than half the days=2, and nearly every day=3) a score of 10 or more indicated a preliminary diagnosis of Generalized Anxiety Disorder (GAD).12 Depression was assessed with the Patient Health Questionnaire 9-item scale (PHQ9), the instrument was scored through the tally of the numbers of all checked responses under each heading (not at all=0, several days=1, more than half the days=2, and nearly every day=3) scores of 10 and higher indicated a preliminary diagnosis of moderate to severe depressive symptoms.13 Surveys were administered via the online platform Anthology with a total of n = 117 students through in-class sessions, campus events, social media campaigns, and participation in the campus food pantry.
DATA ANALYSIS
Descriptive statistics were used to summarize food insecurity, anxiety (GAD-7), and depression (PHQ-9) scores. Data were analyzed in Excel using counts and percentages for survey responses. Food security status was then assigned through the sum of affirmative responses across the six questions which constituted each student’s raw score. For the GAD-7 and PHQ-9 measures, responses were scored using standard procedures. Each item was coded as follows: “Several days” = 1, “More than half the days” = 2, and “Nearly every day” = 3. Total scores were obtained by summing item responses, and results were interpreted using the corresponding scoring guidelines for each scale.12,13
The chi square test was used to provide insight to the relationship between food insecurity and anxiety levels of students as well as food insecurity and depressant levels of the students surveyed. Students received their individual results along with contact information for campus counseling services and the campus food pantries.
Additionally, counts of demographic characteristics, including gender, race, class standing, living arrangement, meal plan participation, food assistance and mental health utilization were calculated. This descriptive analysis identified patterns and trends within the data, providing a more comprehensive understanding of the study population.
RESULTS
A total of n = 117 students completed the survey. The majority of respondents identified as black, indigenous and people of color (BIPOC) (95%, n = 111) and female (92%, n = 108), with 8% identifying as male (n = 9). Most participants were upperclassmen, including 43% juniors (n = 50) and 46% seniors (n = 54). Regarding employment, 23% of students reported working full-time (n = 27), while 56% worked more than 20 hours per week (n = 65).
Living arrangements indicated that 58% of students resided on campus (n = 68), whereas 37% lived offcampus with roommates, parents, or a spouse (n = 43). Meal plan participation varied: 22% of students had a plan with 19 meals per week and $200 in Flex dollars (n = 26), 15% received 125 block meals with $150 Flex dollars (n = 17), and 9% had 200 block meals with $225 Flex dollars (n = 11). Nearly half of respondents (47%, n = 55) did not have a meal plan.
Most students reported not participating in food assistance programs (86%, n = 110), which included SNAP, emergency food from churches, food pantries, food banks, emergency kitchens, or private organizations. Only 6% (n = 7) reported using any of the aforementioned food assistance programs. Regarding food security, 94% of students were classified as having low food security (n = 110), with an additional 3% experiencing very low food security (n = 3). Characteristics of the sample regarding responses discussed: food insecurity, GAD-7, and PHQ-9 can be found in Table 1. Among students with low or very low food security, 17% exhibited moderate-to-severe anxiety (n = 20) and 32% exhibited moderate-to-severe depression (n = 37). While 1.7% (n = 2) of food secure students (n = 7) exhibited moderate-to-severe anxiety and moderate-to-severe depression levels. Despite these findings, only 33% of students (n = 39) reported participating in any mental health services within the past year and 6% (n = 7) utilized food assistance programs over the past year. The Chi-Square test (p < .05) indicated no statistically significant association between food security status and levels of anxiety (p = 0.596); in addition, no statistical significant association was found between food security status and levels of depression (p = .0865). The relationship of the food security and food insecurity variables as related to anxiety (GAD-7), and depression (PHQ-9) can be found in Table 2 and Table 3 respectively.
BIPOC
White
Student Class
Freshman
Sophomore
Junior
Senior
Other
Living Arrangements
On Campus
Off Campus (w/others)
Other
Meal Plan
19 meals + $200 Flex
125 block + $150 Flex
200 block + $225 Flex
No Meal Plan
Other
DISCUSSION
In a sample of 117 students, 17% (n = 20) reported moderate to severe anxiety and 32% of those identified as food insecure reported moderate to severe depression (n = 37). Although notable proportions of students experiencing food insecurity presented with elevated mental health symptoms, the chi-square test indicated no statistically significant association between food security status and levels of anxiety or depression. This suggests that while the trend is clinically relevant, food insecurity alone may not be
a strong independent predictor of moderate to severe mental health symptoms in this sample, or the sample size may lack sufficient power to detect significance. The lack of statistical significance does not rule out a meaningful relationship but may reflect limitations such as sample size, distribution imbalance, or unmeasured confounding variables (e.g., social support, financial aid, living situation). Given that over onethird of food insecure students reported high depression levels, this still represents a public health concern warranting intervention, regardless of statistical significance. This study highlights the high prevalence of food insecurity among college students at Delaware State University, with 94% (n = 110) experiencing low food security and 3% experiencing very low food security (n = 3). These rates exceed national average of 13.5%, which may be reflective of a disproportionate burden of food insecurity in student populations at Historically Black Colleges and Universities (HBCUs).2 Racial disparities within food access report that black, non-Hispanic households levels of food insecurity was almost double the national average at 23.3%.3 These factors could also mirror the complex interplay between academic demands, financial constraints, and limited access to nutritious food. Despite a higher prevalence of anxiety and depression in those surveyed, only 33% of these students accessed mental health services in the past year, underscoring a critical need for exploring enhanced supports. These findings emphasize the necessity of comprehensive interventions addressing both nutritional and psychological needs. Campus strategies, such as expanding food pantry access, meal plan support, and nutrition education, coupled with improved availability and connection to mental health services, may mitigate the negative consequences of food insecurity. Future research should explore larger population studies and longitudinal associations with the role of other social determinants of health to help guide policies and interventions promoting student well-being.
PUBLIC HEALTH IMPLICATIONS
The findings of this study underscore the urgent need for additional research as well as targeted public health interventions addressing both food insecurity and mental health among college students. High prevalence of food insecurity, coupled with significant rates of anxiety and depression, highlights a dual burden that threatens academic success, physical well-being, and overall quality of life. Campus-level strategies can improve food security and dietary quality. Simultaneously, increasing awareness and accessibility of mental health services—including counseling, stress management workshops, and peer support programs— is critical to mitigate the psychological consequences of food insecurity. Policies and programs that integrate nutritional support with mental health interventions can provide a holistic approach, addressing both immediate needs and long-term student well-being. Furthermore, these findings can inform broader public health planning to reduce disparities in food access and mental health outcomes in higher education populations.
Dr. Gootee-Ash
Table 1. Population Characteristics of the Sample
Table 2: DSU Food Insecurity and Anxiety Levels (GAD-7)
Table 3: DSU Food Insecurity and Depression Levels (PHQ-9)
REFERENCES
1 World Health Organization. (2024, October 4). Determinants of health. https://www.who.int/news-room/questions-and-answers/item/determinants-of-health
2. Coleman-Jensen, A., Rabbitt, M. P., Gregory, C. A., & Singh, A. (2019). household food security in the United States in 2018: United States Department of Agriculture.
3. U.S. Department of Agriculture, Economic Research Service. (n.d.). Food security in the U.S.: Key statistics and graphics. http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-theus/key-statistics-graphics.aspx#foodsecure
4 Jones, A. D. (2017, August). Food insecurity and mental health status: A global analysis of 149 countries. American Journal of Preventive Medicine, 53(2), 264–273 https://doi.org/10.1016/j.amepre.2017.04.008
5 Maynard, M. S., Perlman, C. M., & Kirkpatrick, S. I. (2019). Food insecurity and perceived anxiety among adolescents: An analysis of data from the 2009–2010 National Health and Nutrition Examination Survey (NHANES). Journal of Hunger & Environmental Nutrition, 14(3), 339–351 https://doi.org/10.1080/19320248.2017.1393363
6 Meza, A., Altman, E., Martinez, S., & Leung, C. W. (2019, October). “It’s a feeling that one is not worth food”: A qualitative study exploring the psychosocial experience and academic consequences of food insecurity among college students. Journal of the Academy of Nutrition and Dietetics, 119(10), 1713–1721. e1. https://doi.org/10.1016/j.jand.2018.09.006
7 Slotnick, M. J., Ansari, S., Parnarouskis, L., Gearhardt, A. N., Wolfson, J. A., & Leung, C. W. (2024, May). Persistent and changing food insecurity among students at a Midwestern university is associated with behavioral and mental health outcomes. Am J Health Promot, 38(4), 483–491 https://doi.org/10.1177/08901171231224102
8 Jandaghian-Bidgoli, M., Kazemian, E., Shaterian, N., & Abdi, F. (2024, September 6). Focusing attention on the important association between food insecurity and psychological distress: A systematic review and meta-analysis. BMC Nutrition, 10(1), 118 https://doi.org/10.1186/s40795-024-00922-1
9 Merlo, G., Bachtel, G., & Sugden, S. G. (2024, February 9). Gut microbiota, nutrition, and mental health. Frontiers in Nutrition, 11, 1337889 https://doi.org/10.3389/fnut.2024.1337889
10. U.S. News & World Report. (n.d.). Delaware State University. U.S. News & World Report. Retrieved September 30, 2025, from https://www.usnews.com/best-colleges/delaware-state-university-1428
11 United States Department of Agriculture, Economic Research Service. (2024). USDA six-item short form food security survey module: Questions and scoring. https://ers.usda.gov/sites/default/files/_laserfiche/DataFiles/50764/short2024. pdf?v=77152
12 Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006, May 22). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097 https://doi.org/10.1001/archinte.166.10.1092
13 Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001, September). The PHQ9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613 https://doi.org/10.1046/j.1525-1497.2001.016009606.x
2025 IMMUNIZATION SUMMIT
CTC Conference Room 400
Delaware Tech - Terry Campus
100 Campus Drive, Dover 11:30 - 4:10 pm
Navigating Vaccine Recommendations in the Current Political Climate Agenda
Structural-Level Stigma Within Emergency Food Assistance Programs: Perspectives from Delaware and Pennsylvania
McKenna M. Halverson, Ph.D.
Center for Research in Education and Social Policy, University of Delaware
Evyn Y. Appel, B.S.
Center for Research in Education and Social Policy, University of Delaware
Valerie A. Earnshaw, Ph.D.
Department of Human Development and Family Sciences, University of Delaware
Raquelle Powell, B.A.
Center for Research in Education and Social Policy, University of Delaware
ABSTRACT
Grace Sands, B.A.
Center for Research in Education and Social Policy, University of Delaware
Nithila Chrisostam
Center for Research in Education and Social Policy, University of Delaware
Shreela V. Sharma, Ph.D.
Center for Health Equity, School of Public Health, the University of Texas Science Center at Houston
Allison Karpyn, Ph.D.
Center for Research in Education and Social Policy, University of Delaware
Objective: To characterize the ways in which structural stigma manifests within emergency food program settings. Methods: We conducted 30-minute semi-structured interviews with 18 emergency food program clients in Pennsylvania and Delaware between August and December of 2024. The discussion guide included open-ended questions regarding client experiences of structural stigma, with an emphasis on issues of access and quality. Demographic data and household food insecurity (Hunger Vital Sign) were also captured. A hybrid inductive and deductive coding approach was used to analyze the data. Results: Structural stigma is a persistent issue within emergency food program environments, impacting both participant access and quality. Access constraints included long wait times, limited agency over food choice, and accessibility challenges for individuals with physical disabilities, whereas quality constraints included receiving expired/spoiled foods or foods not aligned with participants’ nutritional needs. These issues led to the erosion of autonomy and dignity and perpetuated clients’ feelings of shame, frustration, and discomfort. Conclusions: Intervention strategies such as routinely assessing structural stigma, implementing and monitoring quality standards, increasing infrastructure funding for pantries, creating direct distribution channels with local growers, and revising tax incentive policies show promise for reducing structural stigma within emergency food program settings. Implications: Findings indicate the importance of addressing structural barriers related to accessibility and quality to reduce stigma and create more equitable and inclusive food assistance systems.
INTRODUCTION
Food insecurity continues to pose a significant challenge in the United States, affecting 13.5% of households in 2023.1 This pervasive issue has far-reaching consequences for individuals, families, and communities, contributing to detrimental physical and mental health outcomes, as well as impairing educational attainment for children and economic stability across generations.2–5 While federal safety net programs such as the Supplemental Nutrition Assistance Program (SNAP) aim to reduce food insecurity, they often struggle to meet the needs of all households.6 As a result, philanthropic and non-profit organizations step in to fill these gaps, providing emergency food assistance through food banks, pantries, and other charitable efforts. In 2022, approximately 49 million individuals relied on the emergency food system, with one in six Americans accessing resources provided by organizations such as Feeding America, the largest hunger-relief network in the country.7,8 However, despite the critical role of these systems, stigma remains a persistent barrier, preventing many individuals from accessing the resources they need.9–11
Stigma, broadly defined as a social process involving labeling, stereotyping, discrimination, and status loss, operates across multiple levels, including individual/ intrapersonal (i.e., self-stigma), interpersonal, and structural domains.12–15 While much of the existing literature focuses on the individual and interpersonal dimensions of stigma, structural stigma, which refers to the societal-level conditions, cultural norms, and institutional or organizational policies that systematically limit access to resources and opportunities for specific groups,14 has received comparatively little attention, particularly in the context of food insecurity.11,14,16
Literature on structural stigma within public health settings is burgeoning and has focused on two key issues: access and quality.17 Inequitable access occurs when policies and practices lead to the systematic de-prioritization or mistreatment of those attempting to seek assistance, such as forcing individuals to endure long wait times or complete onerous administrative tasks.17,18 These access inequities, which often stem from discriminatory laws, cultural norms,
and institutional practices, have also been linked to health disparities in other fields, such as LGBTQ+ research.16 In addition to inequitable access, structural stigma can also be manifested when individuals systematically receive lower quality care or services, which may result from underfunding or the devaluing of certain stigmatized statuses. Ultimately, inequitable access and low quality of care have both been shown to delay help seeking or deter assistance receipt amongst individuals in need.17
In the realm of food insecurity, structural stigma similarly manifests through implicit and explicit actions that impact food access and quality.13 Prior research in this area is limited, but has shown that complex and time-consuming enrollment processes requiring extensive paperwork or administrative tasks discourage participation in food assistance programs.9,13,19,20 For example, one study found that SNAP participation was 2.9 percent lower among individuals living in states with applicant fingerprinting requirements.19 Involved administrative processes that require extensive personal information or police checkpoints have also been shown to reduce food assistance participation among immigrant populations as they perpetuate fear of legal consequences associated with the use of public resources.21–23 Structural stigma is also manifested through the distribution of poor
Table 1 Representative Interview Questions
Representative Interview Questions
quality food within emergency food assistance settings.11,24,25 By promoting veiled messages of worthlessness and dehumanization, these access and quality barriers reinforce inequality and shame amongst emergency food program clients, leading to internalized stigma and discouraging helpseeking behaviors.11
Guided by the Stigma and Food Inequity Framework,13 this qualitative study explores the ways in which structural stigma manifests and shapes the experiences of individuals relying on emergency food assistance. By shedding light on these dynamics, this paper aims to contribute to a deeper understanding of structural stigma in the context of food insecurity and to inform the development of more equitable and effective food systems.
METHODS
Participants and Procedure
Participants were 18 emergency food program clients recruited from emergency food program sites (i.e., food bank, food pantries) in Pennsylvania and Delaware between August and December of 2024. We used purposive and snowball sampling methods to recruit participants. Study eligibility criteria were as follows: be at least 18 years of age, have received emergency
1. I’d like you to start by imagining a scenario where you find yourself low on food and have decided to go to a food bank/pantry/ cupboard. How would you decide which one to choose?
2. What is your typical experience like when you visit a food pantry to get food? Please describe the process from start to finish. Probes:
1. Do you need to make an appointment?
2. What paperwork do you need to fill out?
3. Do you need to bring any required documentation (e.g., driver’s license)?
4. Are there any rules around how frequently you can obtain food?
5. How do you get to the food bank/pantry/cupboard?
6. Where do you wait to get your food (car, in line outside, inside)?
3. Please tell us about the types of food you typically receive from the pantry.
4. Do you have a choice in the items you get? Probes:
1. If there is food you don’t want, do you have to take it?
2. Is there anything you have received that you haven’t been able to use? If so, why?
5. Describe the overall quality of the food, including its nutritional value, taste, and freshness. Probes:
1. Have you ever been concerned about the quality of food items? If so, please explain.
2. Does the food available fit your typical diet?
3. Does the food available meet your health needs?
4. If participant has a chronic health condition (e.g., diabetes) - “How does the food you receive from the food bank/pantry/ cupboard fit with your needs for managing diabetes? Do you find that the food options support your dietary requirements, or are there challenges you face in maintaining your diet?”
6. How does the process of getting food, such as the layout of the space, paperwork, or interactions with staff, influence your experience at the food bank?
7. If you could change anything about your experience at the food bank, what would it be?
food assistance from a food bank, cupboard, or pantry in the last year, be a resident of Delaware or Pennsylvania, and be fluent in speaking English or Spanish.
Participants completed semi-structured phone or Zoom interviews lasting approximately 30- to 45-minutes. The semistructured interview guide, which inquired about participants’ experiences of structural stigma, was created in partnership with the stigma subgroup of the Health Equity Collective, a multi-sector effort with more than 200 organizations and 800 members in Greater Houston operated by the UTHealth Houston Center for Health equity. See Table 1 for representative interview questions. As compensation for their participation in the study, participants received a $50 ShopRite or GIANT grocery store gift card. The University of Delaware Institutional Review Board approved study procedures.
MEASURES
Demographics
Participants completed the following socio-demographic questions: age, gender, race, ethnicity, educational level, income level, employment status, relationship status, housing status, household size, SNAP participation over the last year, and WIC participation over the last year.
Hunger Vital Sign
Household food insecurity risk was assessed using the twoitem Hunger Vital Sign screener.26 The screener includes the following questions: (1) “Within the past 12 months, we worried whether our food would run out before we got money to buy more,” and (2) “Within the past 12 months, the food we bought just didn’t last, and we didn’t have money to get more.” Response options for both items are “often true,” “sometimes true,” and “never true.” Participants were categorized as food insecure if they selected “often true” or “sometimes true” for either question. This measure has been shown to align closely with the 18-item U.S. Household Food Security Scale, exhibiting strong convergent validity and demonstrating high sensitivity (97%) and specificity (83%).26
Structural Stigma Interview Questions
Participants answered a series of open-ended interview questions (see Supplemental Material) to explore clients’ experiences of structural stigma. The research team implemented measures to minimize participant discomfort and potential re-traumatization, such as including positive closing questions to conclude interviews and reassuring participants of their discretion for sensitive issues.
DATA ANALYSIS
Interviews were audio-recorded, and transcripts were generated using Zoom. Data were analyzed using Dedoose software, and participant demographic data were incorporated into the analyses to provide interpretive context. In addition, a descriptive analysis of participant characteristics was completed. Interview data were examined using a hybrid deductive and inductive thematic approach.27 The deductive phase included codes informed by the semi-structured interview guide to understand participants’ experiences and perceptions of stigma. Subsequently, in the inductive phase, themes that emerged organically from the data were identified. The coding process was
conducted by the lead author,
and depth in identifying patterns and themes. To further
the rigor of the analysis, all codes were
by a second author. Coding discrepancies were resolved through consultation with the larger research team, and as necessary, external experts. All codes are described in table format with exemplar quotes, and themes are discussed in the context of the larger literature on this topic.
Table 2 Sample Characteristics (n = 18)
RESULTS
The socio-demographic characteristics of the participants are detailed in Table 2. The sample was predominantly female (78%), White (56%), and single (78%). A significant proportion of participants were unable to work or on disability (33%), and half reported having a high school diploma as their highest level of education. The majority of participants (83%) reported annual incomes below $30,000.
Most participants relied on a single food pantry at the time of the interview (67%), while a smaller percentage reported attending two (28%) or four (6%) pantries. A majority of participants walked (40%) or drove (40%) to the pantry, whereas others took the bus (10%), and rode with a caretaker (10%).
Qualitative data analysis of participants’ experiences with structural stigma in emergency food program environments identified three key themes (See Table 3): (1) accessibility constraints, (2) quality constraints, and (3) supportive pantry operations and structures.
THEME #1: ACCESSIBILITY CONSTRAINTS
The first way structural stigma manifested in this study was through accessibility constraints including long wait times, agency over food choices, and accessibility challenges for individuals with physical disabilities. Sub-themes presented below are ordered from most to least frequently mentioned.
Long Wait Times
Participants reported experiencing long wait times in pantry lines, sometimes waiting multiple hours to receive their food. To get the best food selection and attempt to avoid these long lines, several participants reported arriving at the pantry early. For example, Respondent 8 (63, White, Female, PA) said,
“The [pantry] at the church gets [...] a pretty long line. [...] The [pantry] starts at 10:30am, but I usually get there around 9:30am, [...] I [...] grab a chair, and I sit there. [...] I like getting there early, because I like getting the best selection, especially when it comes to the proteins and stuff. [..] By the time 10:30am rolls around, there’s a lot of people behind me. [...] The only problem with it is that [...] I want to be one of the first ones there and that does require me to sit there for an hour. But, [...] I put my headphones on [and] I listen to something on Youtube or I call one of my daughters and I talk to them for an hour. [...] It’s worth it to me in the long run for what it helps me with.”
Another respondent reiterated the need to line up early for pantry services, despite pantry staffs’ resistance. Specifically, Respondent 2 (64, Black, Female, PA) stated,
“I try to get there as early as I can. I don’t wanna be like 20th in line. I like to be in the top five. Some people get there really really early. I ain’t gonna bother to try and beat them. They’re like camping out for concert tickets for something. It’s unbelievable how early they got there. [...] I try to get there a little after 9am, so [I wait for] an hour and a half. [...] They don’t like everybody going there early. They really don’t like that. They just can’t stop us, because we all want to be first.”
A couple of participants also noted that they were forced to endure poor weather conditions without appropriate accommodations while waiting in long pantry lines. For example, Respondent 2 (64, Black, Female, PA) stated,
“There’s always a line that you have to wait [in], and during the summer it was very hot. Now it’s getting cold, and they don’t have anything for you [to] stand underneath to get warm. But I just thank God that I’m able to get food so I’m blessed with that. [....] They give you seven minutes to shop, so it’s a waiting game. [...] The line is just outrageous. I guess so many people in today’s world need that help. [...] I guess the [other clients] just don’t like the fact that they have to wait in this long line. [...] Where I live, I can look out my window, and the line is from here to [name of nearby town], I swear, and people are lined up at 6 o’clock in the morning, and they don’t open until 10am. [...] Everybody’s going through hard times, and people feel like that’s the only way that they can live these days [is] if they go to the pantry.” - Respondent 2 (64, Black, Female, PA)
Another participant shared that they became a pantry volunteer because they could not afford to waste gas by idling their car in long pantry lines. Respondent 18 (46, White, Female, DE) said,
“Well, because I can’t afford to waste gas, I go early, so I’m usually in the front of the line. I would say, usually within the first five-six cars. I tend to go at least an hour to an hour and a half before the start time and wait. [...] [At one pantry] I actually go and volunteer first. I sit at one of the tables and sort stuff into bags for the people to take once the event starts. That way, I don’t have to idle my car. I just sit there with a blanket if it’s winter, or in summer when windows are down, but the lines tend to be pretty long consistently at all of them.”
Agency Over Food Choices
Participants often commented on pantries’ distribution approaches, noting their preference for models that provided them with a choice in the foods they receive versus pre-packaged bags. Specifically, choice pantries allowed participants to avoid wasting unwanted food items, ensuring there is enough food for others. Respondent 18 (46, White, Female, DE) stated,
“I definitely prefer choosing my own [items versus the prepackaged drive through] because you’re grateful for what you get, but there’s always going to be stuff that you can’t use. I don’t like to waste anything or throw anything away, because I know it’s hard enough for me to get food, other people can use this stuff. [...] So definitely picking and choosing is much more preferred”
“I like to see what I’m getting [and shop for myself]. [...] In some pantries I’ve heard that you just go and drive by, and they just put it in your car so you don’t know what you’re getting until you get home. Whereas for [the pantry I go to], you know what you’re getting. If you don’t want it, you don’t have to get it. [...]”
Table 3 Qualitative Themes and Exemplar Quotes
Theme #1: Accessibility Constraints
Honestly, I usually try to get there like two hours before because the line could go around the whole block. [...] I’ll wait in my car. [...] It’s a drive through. - Respondent 15 (54, Hispanic, Female, DE)
Long Wait Times
Okay, so they start to give out the food at 10:30am, but if you want a chance at getting something you will get in line early. [...] Even when I get there at 10 o’clock, people are already in line. Probably by like a quarter of it’s already four or five people in front of me. They’re in line for at least 45 minutes to an hour. [...] I usually get in line 30 minutes early, so I’m in line by 10am [...] So I’m assuming the [people in front of me] got there, probably 45 minutes ahead of time. - Respondent 4 (46, Black, Female, PA)
I don’t want to take stuff that I’m not going to eat, so I don’t let nobody else shop for me [or go to drive through pantries]. Because they may get stuff that I don’t like, and then I have to throw that away. So that’s just really wasted food that somebody else could have got. - Respondent 5 (65, Black, Male, PA)
Agency Over Food Choices
Accessibility Challenges (Physical Disabilities)
I would say I would rather just go in there and get it myself, because when I got all that extra stuff it was extra work because they gave you things that you didn’t really want. So I think that it’s better just to go in yourself. - Respondent 3 (75, White, Female, PA)
So one [pantry] I went [to], I only went once. And the reason I only went once was because they don’t really have the help to bring the food. I can’t carry this stuff [due to my physical disability]. [...] It was all really great; however, I can’t go back because I can’t freaking carry this stuff. [...] Respondent 18 (46, White, Female, DE)
My problem is, I can’t stand in line [due to my physical disability]. So what happens is, when I get there, things are pretty well wiped out. The lines are pretty long in the morning when they open up, so by the time I’m able to get there in the afternoon it’s very limited as to what I can get. Maybe some bread, and I might luck out and get another item that I want, but none of the main products. [...] It’s all kind of gone. [...] - Respondent 17 (79, White, Male, PA)
Theme #2: Quality Constraints
Expired/Spoiled Foods
The fruit sometimes is bad, and sometimes [...] they get mad at me that I’m looking at it because [they] think I’m holding the line up. But I don’t want to bring home rotten freaking grapes, or rotted strawberries, or rotted blueberries. [...] I don’t know why they even bring that stuff out. Like, don’t they look at it? [...] [Sometimes] they’re already mildewed or rotted. [...] I just throw them out [...] when I get home. That’s the first thing I do is throw them out. So that’s a little insulting. And I don’t understand why they don’t double check that stuff. They really ought to double check it, open up the little boxes, and make sure that everything is actually edible before they decide to serve it to poor people. [...] - Respondent 8 (63, White, Female, PA)
I would just say [if I could change anything about the pantry it would be] less expired food. - Respondent 4 (46, Black, Female, PA)
Differences in Food Quality/ Sufficiency by Location
Food Options
Not Aligned with Participants’ Nutritional Needs
[At the other pantries] I’ve gotten bad stuff and I’ve had to throw it out. [...] I’ve had people say I went [to a different pantry], and I was really dissatisfied with their stuff. [...] When [my girlfriend] goes each week, she’s had to throw so much stuff out because [the pantry is] giving her bad stuff. I wish she could come down here and go here, but she can’t, because she’s in [county name]. But I’ve seen some of the stuff that she’s [gotten], and I’m glad I got this one down here. [...] She takes it home, but then she said, “Look at this, I go here, and I have to throw this out because it’s no good.” I feel so bad. I don’t know what to say because you can’t come to the [county name] one [...]. So I try to help her out. [...] - Respondent 1 (58, White, Female, PA)
The [pantry] gives out better meat [...], desserts, and vegetables [than the other pantry]. [Another pantry] gives out good everything, [...] more meat and vegetables [...]. - Respondent 12 (62, Black, Female, DE)
They have a lot of canned goods, but I can’t eat a lot of canned stuff because of my gallbladder. I can’t take whatever they put in there, preservatives, or whatever it is, it bothers me. But the only thing that I can eat is the corn that they give you. The corn is salt free. They give you salt free corn and salt free peas, and I can mix it in with my ground meat and I make myself some kind of [meal]. - Respondent 3 (75, White, Female, PA)
Theme #3: Supportive Pantry Operations and Structures
Simple Administrative Processes
Helpful Accommodations
Made by Pantry Staff
We get a food pantry card and they stamp it each week you go. We keep it and just have to bring it with us when we come. If we forget it, they’ll tell us to make sure we bring it next week. But they don’t take your name down. [...] The paperwork was very easy. [...] I do [show] my ID to show that I lived in this county area because I guess they only serve so many areas. - Respondent 1 (58, White, Female, PA)
No, [we don’t have to sign anything]. We have a colored card. It has your information on it, members of your family. When you go there to get your bags they ask you what your number is, and that’s how many members are in your family. You tell them that and they get the appropriate bag that’s already preloaded with stuff. Pretty simple. [...]Respondent 6 (57, White, Male, PA)
There are very helpful people there. Very, very nice and very helpful. [...] I feel good [when I visit the pantry] because they greet you sitting in the door there, and they always [...] call me by first name. [...] The [staff ] greet you very nicely. If they see me with my cane they say “Would you like us to help you pick things out?” - Respondent 17 (79, White, Male, PA)
In another case, a participant provided an example of their experience at drive through pantries in which they received foods they do not want, despite specifying their preferences at the time of pickup. In particular, they drew attention to the fact that they felt bad throwing away the unused food items, many of which do not align with certain clients’ cultural needs.
“When you go to the [pantries] that you pull up to, you’ll say, “[...] I don’t want pork, and I don’t want this.” When you get home you open up the bag,[...] and it’s pork and beans, but you don’t know until you got home. So now you’re home, and you could throw this stuff away if you don’t got nobody to give it to. Then you feel bad to throw away food that can be used because they gave you specific stuff that your family don’t eat. That’s what happens. You pretty much just take what they give you. So imagine you [are], Muslim and they even gave you some pork and beans, or something like that. Or they’ll throw stuff like [...] Vienna sausages in the bag. Like that’s prison food. That’s the type of stuff that they’ll throw at them.” - Respondent 4 (46, Black, Female, PA)
Several participants stated that they made efforts to ensure the food they received from the pantry was not going to waste, often offering the unwanted items to others. For example, Respondent 12 (62, Black, Female, PA) stated,
“Yeah, sometimes I do [receive items I don’t want]. But [I] just go to the side after I get my stuff and take out what I know I’m gonna use. Then I ask people in the line if they will want it, or I would just leave it right there for somebody else to get, because I don’t want to take anything that I’m not going to use. [...] I would prefer to just go through and just get to pick out what I’m gonna use because somebody else can use that, and if I’m not going to use it, then why take it?” - Respondent 12 (62, Black, Female, PA)
Accessibility Challenges (Physical Disabilities)
Physical disabilities hindered many participants’ ability to obtain food at pantries. For example, one participant stated that they were unable to stand for long periods of time, so they had to wait until the afternoon when the lines subsided to attend the pantry. However, by the time they arrived, most of the food was gone, leaving them with only a few items each week.
“[I can’t stand in line, so I go in the afternoon because it’s not as busy]. I call them and they say “There’s no line, but sir, there’s a limited supply of what we have left. [...] I can’t stand with my sciatic problem. I walk with a cane. I can stand for two or three minutes, and then I kind of lock up. [...] They’re willing to help [shop] if I’d like to, but by the time I get there, there isn’t very much at all. I can get ground turkey, or something like that every once in a while. Other than that, things are really pretty well wiped out, so I’m very limited as to when I can go and what I can get.” - Respondent 17 (79, White, Male, PA)
Another participant noted that they could not attend choice pantries in which they shopped for themselves unless they had assistance due to their inability to lift food items on their own.
“So, all of the [pantries] that I go to, except for the [pantry name], are drive-up because I am disabled. [...] COVID did a number on me, and I got some immune diseases. So, I have no strength, and I cannot lift many things anymore, which is limiting. I’ve gone to [pantries] where they do have you [shop on] your own, and I don’t go back, because it’s already embarrassing to go, and then without help, it just makes it worse because I’m struggling in front of everybody. [...] [At the pantry without a drive-up], I go with somebody who helps me. [...] She helps me carry and put everything away for me.” - Respondent 18 (46, White, Female, DE)
To address these accessibility barriers to pantry usage, participants made several recommendations regarding pantry operations including offering shopping assistance, online shopping options, and seats at the pantry so clients don’t have to stand in line for extended periods of time. For example, Respondent 18 (46, White, Female, DE) said,
“I guess, [I would recommend that the pantry] [...] offer [shopping] assistance ahead of time, in either writing or when you come up, letting people know, “If you need help, let us know.” Because obviously I need the help, and I also don’t like feeling singled out.”
Respondent 7 (72, White, Female, PA) said that they preferred the online ordering system, which mitigated long wait times and allowed for food order pickups by clients’ family or friends.
“I would have to say [I preferred] the [pantry name] system, only because they had the online [ordering] system. They also had terminals in there, [so if] people didn’t have a computer they could come in there [and] order right there on the computer. [...] Then [the staff] will put it all together for them. [...] I’m a mile or two away, [so] I order online, I set up a pickup time, [and] either I picked it up or my sister went in and picked up. There was no overcrowding. There’s no waiting. [...] Here, it’s okay, but [...] [I’m about to] have another foot surgery, [so] I’m not going to be able to get there, whereas [if] I had it be the other way where I could order online and have a family member pick it up, I would never be without it. [...] Unless I get a knee scooter or something, I’m not gonna be able to get up there, there’s no way.” - Respondent 7 (72, White, Female, PA)
A few participants noted that it would be helpful if pantries offered seating accommodations for clients while they were waiting in line for food.
“Yeah, [if they offered seats at the pantry that would be helpful]. Since I walk with a cane, if there were benches on the outside of the community [center] where I could sit and work my way down the line that would be absolutely great.” - Respondent 17 (79, White, Male, PA)
Respondent 7 (72, White, Female, PA) echoed this sentiment, and also suggested that pantries offer specific hours for individuals with physical disabilities.
“Maybe for people with [disabilities], I know there’s a lot of people standing in line with walkers. If they don’t have a walker with a seat, it’s hard for them. [...] Other than something like that [...], maybe let all those people in first or give them a certain time to come in [...]. At the pantry, if a person has to either take a caregiver [...] or can’t stand, it is hard. I see people having a hard time. I can’t stand, so I carry a little tripod seat with me. If I’m moving, I’m kind of all right, but anymore, I can’t stand in place [with] my one foot the way it is. [...]” - Respondent 7 (72, White, Female, PA)
THEME #2: QUALITY CONSTRAINTS
The second way structural stigma manifested in this study was through quality constraints including receipt of expired or spoiled foods, differences in food quality and sufficiency by location, and food options not aligned with participants’ nutritional needs. Sub-themes are presented below from most to least frequently mentioned.
Expired/Spoiled Foods
Participants frequently reported receiving expired or spoiled or rotten foods from pantries. They expressed frustration with the poor food quality, which prevented some individuals from returning to certain pantries. For example, Respondent 18 (46, White, Female, DE) stated,
“All of them are pretty much short-date or past-date foods. When you get stuff from the Food Bank, they tell you on the boxes with that little print-out from the USDA talking about past-date foods, and when they’re still good and stuff. [...] I used to go to [pantry name], but I stopped going because their vegetables are all rotten. [...] I’ve gotten used to [the past-date items], so as long as they still taste good and smell good, I’m fine with it. But when they’re just rotten, it’s very disappointing. [It’s] kind of insulting because sometimes I’ve gotten things that are completely moldy or just completely mush and really stink. And it’s like, we can’t eat this. Why did you even give it to us? That’s one of the reasons why I love the [pantry name], because, like I said, when I go in, and I volunteer, I sit at the table [and] we actually sort out all the bad stuff. Where[as] most of the other [pantries], you just get what you get.”
Another participant referred to the expired items as “trash” and stated that she had to become more vigilant when choosing food at the pantry after accidentally feeding her daughter an expired item.
“[The expired items] were the ones that we got to pick, so basically we’re picking the trash. It’s like “Oh, well, we got this or we got that.” And I’m like, okay, no wonder we can take what we want, because a lot of this stuff is expired. Last week I noticed that [the] boxes of pasta I had took [were expired]. I [also] got a bag of Veggie Straws, [...] [and] my daughter ate them. I didn’t look at the date, so I just put them in [her] room [...]. And she texted me and was like, “Mommy, these veggie chips expired two years ago.” I’m like “What?” [...] So now, I have to watch.”Respondent 4 (46, Black, Female, PA)
In one case, a participant noted that they wished pantry staff would ensure the food they are distributing is not expired. However, they had not raised this complaint to pantry staff as they felt they must be grateful to receive food, regardless of quality.
“[Receiving expired items] happens a lot. [...] I think as many people as they have over there working, I think the [expired foods] should have been taken off the shelf. [...] They try to get [rid of] stuff that’s dated, but sometimes it’s so congested in there and maybe they forget to take it off [the shelf]. The stuff that I have gotten, many of the items were [expired], and I never brought it to their attention, because I was just blessed to have gone in there to get something for the day [...]” - Respondent 2 (64, Black, Female, PA)
A few participants expressed concerns about the safety of the food items they received from the pantry. For instance, Respondent 4 (46, Black, Female, PA) said,
“[The expired foods] kinda freak me out. [...] Like [...] the cans of the chicken breasts in water. Those were expired, so when I saw that it made me say, “Oh, I got to go back home and check everything that I ever got there to make sure that I didn’t pick up expired stuff before.” And I didn’t know, right? Because you can get botulism from the stuff that’s in those cans. [...] So now I got to be careful. I didn’t know they get down like that [with the expired food]. So now [that] I know that, I gotta watch [for] it. [...] I know some people don’t mind, but [...] I don’t like when you go, and they have a bunch of expired food. Last week I went, and it was some things that was from early March 2023. That freaks me out. That made me realize that I really had to start watching what I was picking up, [...] You know, we’re going into 2025, and [this stuff] has a 2023 date on it. [...] It’d be one thing if it was a week old or the months just switched, but when it’s almost two years old, that’s a problem. [...] I’ll be taking [the expired item] home to throw it in the trash.”
Similarly, Respondent 2 (64, Black, Female, PA) stated, “I’ve gotten meat that was maybe a month expired, but I still use it because I was desperate. [...] Yeah, I do worry about [food safety] if it’s expired and they’re letting you have it. But it was frozen. Will I get sick? But I haven’t gotten sick there.”
Although several participants expressed frustration with their receipt of expired or spoiled foods at pantries, a few participants reported that the pantries they attended made concerted efforts to ensure the foods they were distributing were high-quality, brand name, and not expired. For example, Respondent 3 (75, White, Female, PA) said,
“They monitor [the food]. [...] When you get meat there, it’s usually really good. When I went through, I was looking at all the dates of everything, and the lady that ran it came, she said “we check the dates.” [...] Like yesterday I went, and they always have spaghetti and they had the
name brand San Giorgio spaghetti. It was thin spaghetti, and I just grabbed this [thing], and I didn’t really look at it. I just went through and then when I came home, I said, “Oh, my God! I didn’t check the dates.” I checked them, and they were all like 2026. It was all good stuff, like it wasn’t outdated.”
Another participant expressed surprise at the high-quality of food they received from the pantry, stating they expected it to be lowquality foods that individuals or organizations wanted to write off.
“I think everything’s very good. It’s never out of date.[...] The current dates on cans are good. [...] I was actually surprised, because I figured they want to get rid of that stuff, but they probably just write it off, anyway. [...] No [I have not been concerned about the quality of the food or spoilage].” - Respondent 6 (57, White, Male, PA)
Differences in Food Quality/Sufficiency by Location Participants also highlighted differences in food quality and sufficiency by pantry location. One participant noted that wealthier neighborhoods tended to have higher-quality food items than lower-income neighborhoods. Respondent 4 (46, Black, Female, PA) expressed,
“So I will say that because I’m in a township and the cost of living here is higher, that the donations that they get is better. [...] But my friend lives in [town name], and she said that she gets rotten stuff all the time. Especially if you grab meat, you need to hurry up and cook it. But they’ve never given me something rotten [here]. She said [...] in [town name], which is 20 minutes from me, they get rotten vegetables, rotten food, rotten turkeys, because she said they care less. [...] Out here, they will be more mindful of how long it’s sitting out. It’s not in the refrigerator there, it could have been out for hours, or something like that. So, like I said, it kind of depends, the better the area you live in, the better the food. No matter the donations.”
Respondent 18 (46, White, Female, DE) also commented on the differences in food quality and sufficiency by pantry, noting that some pantries distributed mostly canned and pre-packaged items whereas others offered more fresh options.
“Okay, so [the types of food] differ at different times [and by different pantries]. Sometimes all of them tend to be very meager, and then sometimes they have more than you can take. I want to say the [pantry name] has the biggest swing in stuff that you get from them. Sometimes, the majority of everything is canned stuff. They’ll have maybe a can of salmon and a can of chicken instead of anything frozen or fresh. The other places, like the [pantry name], their stuff is all short date or post date foods, but there, [...] it’s usually a bag of bacon and then a random array of all fresh or pantry items, not really any cans. And then the [pantry name] is basically all fresh stuff which I love. That’s great, because a lot of that canned and prepackaged stuff is just not healthy for you.” - Respondent 18 (46, White, Female, DE)
Food Options Not Aligned with Participants’ Nutritional Needs
Participants reported that the foods distributed at pantries do not always meet their health needs. Specifically, participants expressed concerns about the high concentration of sodium in many of the canned options distributed by food pantries, stating they would prefer healthier options. For example, Respondent 18 (46, White, Female, DE) expressed,
“They do give you a lot of stuff that’s loaded in sodium. [...] Obviously they do have some low sodium cans, but most canned and prepackaged stuff is very high in sodium, preservatives, and things like that. I try to limit how many preservatives, colorings, and stuff because diabetes does run in my family, and I am overweight. So it’s a concern that I try to stay away from. [...] But unfortunately, the low sodium stuff just tastes awful. [...] [...] I’m not the healthiest person in the world, and I don’t eat the healthiest diet, but I think most people, in general, want to eat more fresh foods, and can’t. I mean, canned foods are just when you don’t feel like doing anything, and/or you don’t have the energy to do anything, so you go pop open a can and heat it up. But in general, most people want something that looks like food.”
THEME #3: SUPPORTIVE PANTRY OPERATIONS AND STRUCTURES
Although several participants reported experiences of structural stigma at emergency food sites, many others mentioned supportive pantry operations and structures that made their experience more positive including simple administrative processes and helpful accommodations made by pantry staff.
Simple
Administrative Processes
Participants’ perceptions of administrative processes were predominantly positive. Participants were particularly grateful for administrative processes that were simple and that minimized paperwork or ID requirements.
“Fortunately, when I signed up for the Church [food pantry], I just had a very, very quick form to fill out that just said I would like to access this food [pantry] and sign my name. I didn’t have to provide any income which is really really good, because that’s very embarrassing and [...] I didn’t have to do any of that. You just had to self report that you were under whatever the income was and that’s all you did. And just signed it and then they give you a little [card].” - Respondent 8 (63, White, Female, PA)
“You sign your name on a paper/tablet. No [we don’t have to show an ID or any other documentation, so I am satisfied with the model].”
Respondent 16 (22, Black, Female, DE) echoed,
“I think the simplicity behind the order form and the process that our [pantry] has is really important [for making it a positive experience].”
Although most participants reported positive perceptions of pantry administrative processes, one participant expressed that the collection of personal information made them uncomfortable, as they feared it would be used against them in the future. Respondent 18 (46, White, Female, DE) stated,
“I wasn’t happy about the [pantry name] doing the whole registration thing because you feel like it’s going to be used against you. [...] At that time, it was literally just your information, your name, your address, whatever. I don’t typically like that, but I was just like, okay, whatever because you feel like maybe they’re going to use this against you at some point. It just feels some type of way. [...] For example, say that somehow my health gets better and I am able to participate again in society to the point that I did before or more, and things change. You just feel like you might be singled out or that information is going to get out and people are gonna talk about you. Or [it may] limit your chances for things. Like if I were to go with a company and they just show discrimination basically. [...] What I really liked about [the other pantry] was that they told you upfront before you went that no ID, no identifying information was needed other than just asking your first name. That’s it, so that was really great.”
Helpful Accommodations Made by Pantry Staff
A few participants noted that pantry staff made helpful accommodations to ensure a more positive experience such as offering shopping assistance if they had a physical disability or making accommodations so participants could avoid harsh weather conditions. Respondent 1 (58, White, Female, PA) said,
“I’m very satisfied with the staff. [...] I really like a lot of things [...]. Now it’s been cold out, and there’s a gentleman that helps at the food entry. He always lets us go in and sit like in the hall in a chair to keep us out of the cold. It’s very helpful. [...] Tonight, he was telling us when it starts getting colder they’re going to start opening up the churches at 3:30pm for the food pantry, and then you have to wait until 5pm. But at least they’ll let you in to sit where it’s warm so that you’re not out in the cold. And they said when it’s poor weather they’re gonna try to accommodate people who walk and don’t have transportation. They’ll tell you what they have, and you can get it delivered. Like me, because I don’t drive, and in really bad weather, they don’t want us walking.”
DISCUSSION
This qualitative study found that structural stigma is a persistent issue within emergency food program environments impacting both participant access and quality. Regarding inequitable access, participants reported common issues such as long wait times, limited agency over food choices, and accessibility challenges for individuals with physical disabilities. Further, participants described situations where long wait times, which could occur in harsh weather conditions, and a lack of accommodations for individuals with physical disabilities, implicitly communicated that their time and needs were not valued, and contributed to frustration and discomfort. The data presented provides important insight into how these logistical challenges, sometimes
unintentionally, contribute to unwelcoming and difficult to navigate environments, which in turn deter participants from returning to pantries. Findings also suggest important opportunities for helping to guide pantries and support policy efforts to address limitations.
Findings also align with broader research on the role of structural stigma in public health, which demonstrates the ways in which systemic access barriers lead to the de-prioritization of those seeking assistance, amplifying feelings of exclusion and perpetuating health inequities.16,17 As the field begins to advance its awareness of the significance of structural stigma and the factors driving participant experiences within emergency food environments, specific approaches to intervention and measurement are needed. Recent studies show that within healthcare settings, for example, there is a recognition of the importance of routinely monitoring structural stigma with audit tools, scales, or checklists to gauge progress and advance equity.17 Adapting these tools or developing aligned measures for use in emergency food assistance settings would improve program administrators’ ability to understand and modify infrastructure and operations (i.e., wait times, accessibility of facilities, need for assistive technology) to better support the needs of all clients, while also advancing the field through measurement alignment.
The erosion of autonomy is another mechanism of structural stigma often described in this study. Choice-based food pantry models, which allow for agency in selecting foods aligned with dietary needs and preferences and counteract the disempowerment associated with rigid, pre-packaged distributions, are articulated here, and have been established in the literature, as a preferred strategy for clients.28,29 Despite the use of one common term (i.e., choice), the actual approach to providing choice in food selection varies considerably across pantries. For example, the Akron-Canton Regional Foodbank highlights four primary types of choice pantry models: 1) supermarket model, 2) table model, 3) window model, and 4) inventory list model.30 On the surface, supermarket and table models offer the most agency of the choice models as they allow clients to walk through the pantry and choose their own food items off of shelving units or tables. Window models allow participants to select the items they would like by pointing to items for staff to package from outside of the pantry. Inventory list models, in which clients select items off of a list of available food options and pantry staff assemble the order, potentially offer the least agency of the choice models. These variations give rise to additional considerations regarding the ways in which choice pantries are applied, and if some approaches may do a better job than others at addressing structural stigma.
A majority of participants in this study described a preference for full choice models (i.e., supermarket and table models) as they allowed clients to choose foods that best aligned with their cultural and religious preferences, food allergies, and nutritional needs. However, a few participants noted that other choice models (e.g., inventory list) or traditional pantry models (e.g., pre-packaged drive through pantries) are better suited to meet the needs of clients with physical mobility limitations. It is also worth noting that “choice” pantries became recognized as a best practice over the past 20 years, and today are widely adopted.28,29 Studies which help to describe the process by which choice pantry methods were communicated nationally, and ultimately adopted
as a best practice, may also help to inform similar next steps in the area of structural stigma.
In addition to inequitable access, structural stigma was also manifested through quality constraints. For example, many participants reported receiving expired or spoiled foods, which they described as frustrating, insulting, and dismissive of their dignity. Food safety concerns were also raised by participants. These results are buttressed by similar research demonstrating that receiving poor-quality or undesirable food from pantries reinforces feelings of shame and unworthiness among recipients.11,24,25,31,32
Efforts to address quality constraints have been undertaken nationally through a variety of methods, including through the implementation of quality standards, such as nutrition policies and food safety plans, which can be disseminated to donors to emphasize the dedication to food quality for clients.33,34 It is unclear, however, how such standards are monitored, and whether emergency food boards, for example, have adequate knowledge or resources to measure progress toward standards, or identify areas of critical need. Another way in which states have addressed food quality is through efforts to prioritize policies and funding streams that create direct distribution channels between local growers and pantries, thereby improving the freshness of pantry foods by decreasing transportation and storage time.34 Statelevel funding has also been allocated toward grants for pantries, ensuring they have access to appropriate infrastructure (e.g., cold storage) to ensure limited spoilage of non-shelf-stable foods. Tax incentive policies for food processors, retailers and distributors are another potentially important approach to ensuring a steady flow of healthier foods; however, many do not currently consider food freshness or quality, and may need to be re-evaluated with this lens.34,35
Finally, administrative processes are a long-standing issue within many social service areas, including emergency food. Simple sign-up and sign-in processes, along with welcoming, supportive, and accommodating staff, are critical to reduce usage barriers. Prior research demonstrates that extensive verification requirements (e.g., ID requirement, proof of employment, residence, or poverty) dissuade many individuals from seeking needed food assistance, particularly among the most vulnerable populations, such as immigrants.9,11 To mitigate these burdens, efforts to reduce or eliminate verification requirements have been recommended.9
LIMITATIONS AND FUTURE DIRECTIONS
Despite the potential utility of findings regarding structural stigma within emergency food assistance settings, our study is not without limitations. The study sample was small and included predominantly English-speaking women in Pennsylvania and Delaware who actively participated in emergency food assistance at the time of the interview, thus limiting the generalizability of study findings. It is likely that newer immigrant families, and those who speak languages other than English or Spanish have different experiences which are not fully captured here. In addition, our study is limited to emergency food pantries in community settings, where participant experiences are likely very different from pantries in other settings such as hospitals or schools. Additionally, although this study captures important
qualitative data, further research is needed to quantify the impact of structural stigma on food insecurity outcomes, perhaps with the development and testing of a measurement tool enabling the assessment of scores for specific criteria. Longitudinal studies could also evaluate the impact of changes to pantry systems and policies on diet, mental health and food insecurity as well as other social determinants of health which may be closely related to issues of food security or dietary quality.
PUBLIC HEALTH IMPLICATIONS
The findings from this study underscore the urgent need to address structural stigma within emergency food systems. Interventions such as adopting full-choice pantry models that maximize client agency, developing and routinely using structural stigma measurement tools, implementing accessible, participant-centered infrastructure, and enforcing food quality standards are imperative for reducing structural stigma. Additionally, policy initiatives that prioritize infrastructure improvements (e.g., cold storage grants), direct partnerships with local growers, and revisions to tax incentives to emphasize food freshness and quality could further strengthen emergency food programs.
Simplifying administrative enrollment processes and eliminating unnecessary verification requirements are also essential for reducing access barriers, particularly among marginalized populations. Beyond research and policy action, these findings highlight opportunities for community engagement. Local stakeholders, including volunteers, donors, and community organizations, play a vital role in advancing equity within emergency food systems. Partnering with or contributing to local food banks—through donations of time, funds, or fresh produce—can help strengthen infrastructure, improve food quality, and support client-centered practices that uphold dignity and reduce stigma. Beyond research and policy action, these findings highlight opportunities for community engagement. Local stakeholders, including volunteers, donors, and community organizations, play a vital role in advancing equity within emergency food systems. Partnering with or contributing to local food banks, through donations of time, funds, or fresh produce, can help strengthen infrastructure, improve food quality, and support client-centered practices that uphold dignity and reduce stigma. By addressing structural barriers related to accessibility and quality, emergency food assistance programs can improve participant dignity, support health equity, and ultimately advance the public health impact of food assistance programs.
Dr. Halverson may be contacted at mmhalverson21@gmail.com .
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4 Morales, M. E., & Berkowitz, S. A. (2016, March). The relationship between food insecurity, dietary patterns, and obesity. Current Nutrition Reports, 5(1), 54–60. https://doi.org/10.1007/s13668-016-0153-y
5 Seligman, H. K., Bindman, A. B., Vittinghoff, E., Kanaya, A. M., & Kushel, M. B. (2007, July). Food insecurity is associated with diabetes mellitus: Results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999-2002. Journal of General Internal Medicine, 22(7), 1018–1023 https://doi.org/10.1007/s11606-007-0192-6 PubMed
6 Vigil, A., & Rahimi, N. (2024). Trends in Supplemental Nutrition Assistance Program participation rates: Fiscal year 2020 and fiscal year 2022. https://fns-prod.azureedge.us/sites/default/files/resource-files/ops-snap-trendsfy20-fy22-report.pdf
7 Feeding America. (2023). 1 in 6 people received help from charitable food sector in 2022.
9 Bruckner, H. K., Westbrook, M., Loberg, L., Teig, E., & Schaefbauer, C. (2021). “Free” food with a side of shame? Combating stigma in emergency food assistance programs in the quest for food justice. Geoforum, 123, 99–106 https://doi.org/10.1016/j.geoforum.2021.04.021
10 de Souza, R. (2023). Communication, carcerality, and neoliberal stigma: The case of hunger and food assistance in the United States. Journal of Applied Communication Research, 51(3), 225–242 https://doi.org/10.1080/00909882.2022.2079954
11. Halverson, M. M., Appel, E. Y., Earnshaw, V. A., Sands, G., Powell, R., Rozin, M., Cruz, T., Chrisostam, N., Kennedy, N., Katz, S., Sharma, S., & Karpyn, A. (Under Review, 2025). Food insecurity-related stigma in the United States: A scoping review.
12. Cook, J. E., Purdie-Vaughns, V., Meyer, I. H., & Busch, J. T. A. (2014, February). Intervening within and across levels: A multilevel approach to stigma and public health. Soc Sci Med, 103, 101–109. https://doi.org/10.1016/j.socscimed.2013.09.023
13. Earnshaw, V. A., & Karpyn, A. (2020, December 31). Understanding stigma and food inequity: A conceptual framework to inform research, intervention, and policy. Translational Behavioral Medicine, 10(6), 1350–1357. https://doi.org/10.1093/tbm/ibaa087
14. Hatzenbuehler, M. L., & Link, B. G. (2014, February). Introduction to the special issue on structural stigma and health. Soc Sci Med, 103, 1–6. https://doi.org/10.1016/j.socscimed.2013.12.017
15. Hatzenbuehler, M. L. (2017). Structural stigma and health. In B. Major, J. F. Dovidio, & B. G. Link (Eds.), The Oxford handbook of stigma, discrimination, and health (p. 105). Oxford University Press.
16. Hatzenbuehler, M. L., Lattanner, M. R., McKetta, S., & Pachankis, J. E. (2024, February). Structural stigma and LGBTQ+ health: A narrative review of quantitative studies. The Lancet. Public Health, 9(2), e109–e127. https://doi.org/10.1016/S2468-2667(23)00312-2
17. Livingston, J. D. (2020). Structural stigma in health-care contexts for people with mental health and substance use issues: A literature review. Mental Health Commission of Canada. https://doi.org/10.13140/RG.2.2.21168.17929
18. Ross, L. E., Vigod, S., Wishart, J., Waese, M., Spence, J. D., Oliver, J., . . . Shields, R. (2015, October 13). Barriers and facilitators to primary care for people with mental health and/or substance use issues: A qualitative study. BMC Family Practice, 16, 135. https://doi.org/10.1186/s12875-015-0353-3
19. Jones, J. W., Courtemanche, C., Denteh, A., Marton, J., & Tchernis, R. (2022). Do state Supplemental Nutrition Assistance Program policies influence program participation among seniors? Applied Economic Perspectives and Policy, 44(2), 591–608. https://doi.org/10.1002/aepp.13231
20. Villegas, P. E., McGrath, C., Enriquez-Johnson, A., Hudgens, R., Flores, N., & Felix, R. (2024). Food insecurity stigma, neoliberalization, and college students in California’s Inland Empire. Food, Culture, & Society, 27(3), 696–713. https://doi.org/10.1080/15528014.2022.2130658
21. Bowen, S., Hardison-Moody, A., Cordero Oceguera, E., & Elliott, S. (2023). Beyond dietary acculturation: How Latina immigrants navigate exclusionary systems to feed their families. Social Problems; Advance online publication. https://doi.org/10.1093/socpro/spad013
22. Payán, D. D., Perez-Lua, F., Goldman-Mellor, S., & Young, M. T. (2022, July 5). Rural household food insecurity among Latino immigrants during the COVID-19 pandemic. Nutrients, 14(13), 2772. https://doi.org/10.3390/nu14132772
23. Varela, E. G., McVay, M. A., Shelnutt, K. P., & Mobley, A. R. (2023, January). The determinants of food insecurity among Hispanic/Latinx households with young children: A narrative review. Advances in Nutrition, 14(1), 190–210. https://doi.org/10.1016/j.advnut.2022.12.001
24. Fong, K., Wright, R. A., & Wimer, C. (2016). The cost of free assistance: Why lowincome individuals do not access food pantries. Journal of Sociology and Social Welfare, 43, 71. https://doi.org/10.15453/0191-5096.3999
25. Lindow, P., Yen, I. H., Xiao, M., & Leung, C. W. (2022, April). ‘You run out of hope’: An exploration of low-income parents’ experiences with food insecurity using Photovoice. Public Health Nutrition, 25(4), 987–993. https://doi.org/10.1017/S1368980021002743
26. Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., . . . Frank, D. A. (2010, July). Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics, 126(1), e26–e32. https://doi.org/10.1542/peds.2009-3146
27. Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5(1), 80–92. https://doi.org/10.1177/160940690600500107
28. Jia, J., Anderson, C., Romero, E., Kandula, N. R., Caspi, C. E., Beidas, R. S., & O’Brien, M. J. (2024). Improving client experience and charitable food reach and access at food pantries: A qualitative study. Journal of Health Care for the Poor and Underserved, 35(4S), 147–165.
https://doi.org/10.1353/hpu.2024.a942874
29. Schrum, J. E. (2023). Self-Determination Theory and food insecurity: A mixedmethods study of a client choice food pantry (Doctoral dissertation, Rutgers The State University of New Jersey, School of Graduate Studies).
31. Garthwaite, K. (2016). Stigma, shame and ‘people like us’: An ethnographic study of foodbank use in the UK. The Journal of Poverty and Social Justice : Research, Policy, Practice, 24(3), 277–289. https://doi.org/10.1332/175982716X14721954314922
32. Long, C. R., Bailey, M. M., Cascante, D., Purvis, R., Rowland, B., Faitak, B., . . . McElfish, P. A. (2023). Food pantry clients’ needs, preferences, and recommendations for food pantries: A qualitative study. Journal of Hunger & Environmental Nutrition, 18(2), 245–260. https://doi.org/10.1080/19320248.2022.2058334
33. Hendrickson, A. (2019). Reduce food waste: A resource of food banks and food pantries. Extension Winnebago County, University of Wisconsin-Madison. https://winnebago.extension.wisc.edu/2019/12/30/reduce-food-waste-a-resource-of-food-banksand-food-pantries/
34. Huang, J., Acevedo, S., Bejster, M., Kownacki, C., Kehr, D., McCaffrey, J., & Nguyen, C. J. (2023, July 7). Distribution of fresh foods in food pantries: Challenges and opportunities in Illinois during the COVID-19 pandemic. BMC Public Health, 23(1), 1307. https://doi.org/10.1186/s12889-023-16215-4
35. Hudak, K. M., Friedman, E., Johnson, J., & Benjamin-Neelon, S. E. (2022, March 15). US state variations in food bank donation policy and implications for nutrition. Preventive Medicine Reports, 27, 101737. https://doi.org/10.1016/j.pmedr.2022.101737
FOOD BANK OF DELAWARE
MOST NEEDED ITEMS
High Fiber, Low Sugar, Low Sodium
HOT & COLD CEREAL
In Light Syrup or in its Own Juices (if possible)
Oatmeal
Cheerios
Corn Flakes
Raisin Bran
Low-Sodium (if possible)
Low-Sodium No Salt Added (if possible)
GRAINS
100% whole-grain or whole grain as first ingredient (if possible) In Water (no oil or broth if possible)
Brown and White Rice
Pasta
Macaroni & Cheese
Low-Sodium No Salt Added (if possible)
First ingredient whole-grain (if possible)
All Sizes, Including Juice Boxes
The Food Bank of Delaware is creating access to good, healthy food in every community, and we couldn’t do it without your generous donations! Our new Foods to Encourage policy ensures that we procure the healthiest foods available for Delawareans in need.
Unfortunately, many low-income Delawareans suffer from health conditions such as diabetes, high blood pressure, and other diet-related illnesses. Ensuring access to healthy foods helps mitigate these health conditions. By choosing items on this “most wanted” list, you’re contributing to the health and wellness of the neighbors we serve. Thank you for your generous donations!
Tuna Salmon Chicken
Raisins
Granola Bars
FOCUS Fogarty-supported researchers use food as medicine to address tuberculosis & type 2 diabetes
NATIONAL
PROFILE
Gwenyth Lee, PhD, works at the intersection of infectious disease & nutrition
Q & A
Christine Sizemore, PhD, provides a pragmatic perspective on global health
NEWS
LAUNCH orientation presentations address capacity building and career development
INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES
Global Health Matters
FOGARTY INTERNATIONAL CENTER
Dietitians in Benin develop meal plans tailored to local culture and local tastes.
BUILDING CAPACITY FOR Research on Sexually Transmitted Infections
IN LOW- AND MIDDLE-INCOME COUNTRIES
By providing funding and protected time for both mentors and trainees, Fogarty has played and continues to play a crucial role in the development of research capabilities worldwide.
I STARTED MY FEDERAL GOVERNMENT CAREER three decades ago in the CDC Division of Sexually Transmitted Disease Prevention, so I was excited to travel to Montreal in July for the World Congress of the International Society for Sexually Transmitted Diseases Research and the International Union against Sexually Transmitted Infections.
For the convention, I’d organized a symposium that emphasized how the burden of sexually transmitted infections (STIs) in low- and middle-income countries (LMICs) is eight-fold higher than in high-income countries. This means the need for STI research in LMICs is substantially higher, yet opportunities are increased as well. Research priorities include developing affordable pointof-care diagnostics as well as novel antibiotics, antivirals, and vaccines; investigating antibiotic resistance; optimizing behavioral interventions; integrating STI services with other
health programs; using digital health solutions; and conducting research of at-risk groups such as teens, sex workers, men who have sex with men, and people living with HIV.
The symposium attracted a standing-room-only crowd and began with a presentation by Dr. Le Minh Giang and his mentee, Dr. Bùi Thị Minh Hảo, from Hanoi Medical University in Vietnam. Their Fogarty D43 research training grant is building on the national HIV prevention program (with support from PEPFAR).
Next, Dr. Jenell Stewart from Hennepin Healthcare in Minnesota spoke on behalf of herself and Dr. Elizabeth Bukusi, a former Fogarty trainee and current Fogarty grantee. They’ve been building research capacity in Kisumu, Kenya, based on the work of the late Dr. King Holmes, a former Fogarty grantee and board member and an early leader in AIDS care and research.
Next up was Dr. Patty Garcia, a
former Fogarty trainee and grantee from Universidad Peruana Cayetano Heredia, Peru, who spoke about her own early research as a mentee of Holmes. Their work led to the development of a robust HIV and STI clinical care and research infrastructure in Peru. The final presenter, Dr. Álisson Bigolin, described how, with the support of mentors, he now leads STI diagnostics development in the Brazilian Ministry of Health.
Co-moderator Dr. Francis Ndowa, director of the Skin & Genito-Urinary Medicine Clinic in Zimbabwe, underscored the need for translating evidence-based research findings into practice, while co-moderator Dr. Kees Reitmeijer, an editor of the journal Sexually Transmitted Diseases, highlighted the role of journals in supporting early-career researchers worldwide.
Perhaps surprisingly, these various presenters from Asia, Africa, and Latin America shared commonalities. Notably, they all started by developing public health and clinical infrastructure and later added a research component, which could then support research training. All believe the commitment of both U.S. and LMIC mentors as well as the dedication of their mentees has been instrumental for growth.
By providing funding and protected time for both mentors and
trainees, Fogarty has played and continues to play a crucial role in the development of research capabilities worldwide.
Undoubtedly, STI research conducted by former Fogarty trainees in all corners of the globe has improved health not only worldwide, but also in the United States, where it has informed STI prevention and treatment guidelines and practices and contributed to the development of STI diagnostics and vaccines that benefit all humanity.
Afterwards, Bigolin introduced me to his mentor, Dr. Angelica Espinosa Miranda, STI Unit Coordinator in the Brazilian Ministry of Health, who mentioned that she is also a former Fogarty trainee. Later, I met Dr. Sunil Sethi, a professor at the Post Graduate Institute of Medical Education and Research in Chandigarh, India. He’ll be hosting the 2027 World STI & HIV Congress and we discussed including a day-long session on research capacity building. He is also a former Fogarty trainee!
Such chance conversations underscore the ways in which Fogarty, by pursuing its vision of capacity building, has extended the frontiers of health research and disseminated scientific advances across the globe. I expect more former Fogarty trainees will be attending the 2027 World STI & HIV Congress in India.
Fogarty International Center
National Institutes of Health Department of Health and Human Services
July/August 2025
Volume 25, Issue 4
ISSN: 1938-5935
Publishing Director Andrey Kuzmichev
Editor-in-Chief
Susan Scutti
Contributing Writers/Editors
Mariah Felipe-Velasquez Amanda Stearns
Digital Analyst Merrijoy Vicente
Graphic Designer Carla Conway
CONNECT WITH US
The Fogarty International Center is dedicated to advancing the mission of the National Institutes of Health by supporting and facilitating global health research conducted by U.S. and international investigators, building partnerships between health research institutions in the United States and abroad, and training the next generation of scientists to address global health needs.
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IQUITOS,
PERU,
IS OFTEN DESCRIBED AS THE LARGEST CITY IN THE WORLD THAT’S INACCESSIBLE BY ROAD,
says Gwenyth Lee, PhD, assistant professor in the Department of Biostatistics and Epidemiology at the Rutgers School of Public Health.
“So if you take a big boat up the Amazon, Iquitos is about as far as you can go before the river gets a lot shallower and you have to switch to a small boat.” Situated east of the Andes in Loreto province, it is home to more than 150,000 people and served as a major port for the global
4
4 GLOBAL HEALTH MATTERS
rubber trade during the 19th Century.
“All of my formative research— master’s, PhD, postdoc—has been in the general area of early child health,” says Lee, who lived in Iquitos on and off for more than two years while working on her PhD. “Spending that amount of time there allowed me to
Gwenyth Lee PhD, MPH
Fogarty Fellow 2014-2015
U.S. institution
Johns Hopkins Bloomberg School of Public Health
Foreign institution
Asociacion Benefica Prisma (NGO)
Project
Impact of enteric infections on the growth and development of children living in the Peruvian Amazon
Current affiliation
Rutgers School of Public Health
make certain connections to child health and become interested in questions based on observations or discussions with people.”
Iquitos, then, was a natural setting for her Fogarty LAUNCH Fellowship.
Investigative independence
Lee’s project examined the impact of enteric (intestinal) infections on the growth and development of a cohort of children in Iquitos. Specifically, she looked at how enteric infections, and other exposures related to nutrition, impact child growth and development. Her work used social network analysis to evaluate how social ties within communities function to improve food security.
The project allowed her to continue her research in a familiar field, yet it also enabled her to transition to nutritional epidemiology, which examines child development in relation to diet, a field of interest to Lee. “My fellowship was very much a building block, scientifically, to the projects that I work on now.”
Photo courtesy of Gwenyth Lee
Gwyneth Lee gathers with her colleagues while working on the EcoMiD project in Ecuador.
Her Fogarty project also pushed her towards independence. “Field work wasn’t completely new to me, but what was new is that, increasingly, I was left to figure out what I wanted to do and then run with it.” She also managed her own administrative paperwork, a significant advance. “It was the first project where I had a large number of people working directly for me—during my PhD, I had two people helping me collect data, for the Fogarty project, eight or 10. My mentors started to, in an appropriate way, step back and make me responsible as a project manager.”
Results of her fellowship year also include publications, presentations, and landing a post-doctoral position.
“Being in-country was very helpful for finding those opportunities and networking and disseminating my research more readily.” She continued working with her Peruvian colleagues at UPCH during her postdoc training funded by Fogarty’s Inter-American Training for Innovations in Emerging Infectious Diseases program.
Subsequently, she began a research faculty position at University of Michigan School of Public Health, where she received a K01 award from the National Institute of Allergy and Infectious Diseases. Her Ecuadorbased project, Dynamic modeling of antagonism between enteric infection and undernutrition in infancy, officially ended in May but continues under a no-cost extension.
“I work as a co-investigator with Dr. Joseph Eisenberg and Dr. Karen Levy for Enteropatógenos,
Crecimiento, Microbioma, y Diarrea (EcoMiD), a pediatric cohort study that looks at environmental exposures and child health outcomes with a specific focus on the microbiome across rural and urban communities in Ecuador.” (The microbiome is the community of microorganisms that can be found living together in your gut.) Offered a position at Rutgers University, Lee transferred and began working with another early career investigator, Shauna Downs, an associate professor in the Department of Health Behavior, Society and Policy. Combining interests, they received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development for a project in Kenya that aims to reduce teen malnutrition.
One year into that project, Lee has begun to steer students and colleagues to apply for LAUNCH fellowships. “It’s invaluable for people interested in research, especially global health research, but even research in general.”
Traditional diets
The fruits of global health research recompense Americans in two ways, says Lee. “It provides training
opportunities for American students while advancing general scientific knowledge.”
One example of this is her Ecuador project. “It’s increasingly understood that the American microbiome is affected by our diets and exposures to our environment. Now that is not necessarily representative of the way humans have lived for thousands of years, right?” Researchers who study the microbiome in Ecuador encounter an urban-to-rural gradient, with part of the population eating a more westernized diet and living a more westernized lifestyle, while the diet and lifestyle of river communities, including residents of Iquitos, reflect regional traditions.
“ SO THERE’S A VARIETY THERE THAT WOULD BE HARD TO FIND IN THE U.S. AND WE CAN LEARN FROM THAT AND POTENTIALLY APPLY LESSONS LEARNED BACK IN THE STATES.”
Gwenyth Lee’s global work focuses on infectious disease and nutrition.
(Left) Lee outside Hospital Esmeraldas in Ecuador (Right) Lee (in front, writing) contributes to sample collection for the EcoMiD project in Ecuador.
FOCUS I NUTRITION
Mon plan de repas OSanDiaBé
RESEARCH EXPLORES FOOD AS MEDICINE
GLOBALLY & IN THE U.S.
“My meal plan” is a dietary guide tailored to the tastes and preferences of patients in Benin. Courtesy of Halimatou Alaofè
Good nutrition is crucial for maintaining health. A balanced diet fuels the body and also lowers the risk of illness, including type 2 diabetes, heart disease, and infectious diseases.
Earlier this year, the U.S. Department of Health and Human Services (HHS) crafted a plan for ending chronic disease in the U.S. The Make Make America Healthy Again (MAHA) initiative aims to ensure that all
Americans live longer, healthier lives, supported by systems that prioritize prevention, wellbeing, and resilience.
In particular, the HHS’ report, Make Our Children Healthy Again: Assessment, summarizes the decline in children’s health and identifies potential drivers of rising disease where progress is most likely. First among these is “poor diet.”
In light of the MAHA agenda, this
CULTURALLY RELEVANT MEAL PLANS LEAD TO BETTER HEALTH
STANDARD NUTRITION ADVICE OFTEN FAILS TO RESONATE WITH LOCAL PREFERENCES AND PRACTICES IN LOWER-INCOME NATIONS. Unfortunately, this leads to poor diet adherence and suboptimal health outcomes, says Halimatou Alaofè, PhD, associate professor at the University of Arizona. Her International Research Scientist Development Award (IRSDA) Program project in her native Benin aims to “bridge that gap between advice and practice by designing a culturally relevant, sustainable nutrition intervention that can empower patients in low resource settings to improve their dietary adherence.”
Specifically, her research focuses on long-term nutritional management of type 2 diabetes, which develops when the body cannot use insulin correctly, leading to excess sugar in the blood, in turn causing damage to the eyes, kidneys, nerves and heart.
Tailored plans
An alarming increase in type 2 diabetes-related illness and mortality is occurring in Benin, a west African country that borders Nigeria and sits just south of the Sahara. Diabetes prevalence has quadrupled in this French-speaking country of 14.7 million people, from 3% to 12.4% over the last decade, reaching as high as 22% in some regions. The negative effects impact not only those who live with the condition, but also their families and the healthcare system, says Alaofè.
Small scale studies of nutritional interventions for type 2 diabetes conducted in Benin have found very low adherence to the recommended diet. “Just 20%, but it might be even lower,” says Alaofè, who suspects that the suggested food plans are difficult to adhere to or unacceptable for patients. When developing a dietary intervention, researchers need to include general guidelines yet also consider the many
issue’s FOCUS: Nutrition spotlights two Fogarty-supported projects centered on using food as medicine—one seeking to improve the health of patients with type 2 diabetes in Benin, the other aiming to prevent and treat tuberculosis in Tanzania.
The researchers believe that these nutritional studies, despite their far-off locations, have direct implications for Americans.
Dietitians learn how to measure blood pressure.
additional factors that encourage uptake of an eating plan.
For example, medical nutrition therapy, which is formulated by a registered dietitian or nutritionist, helps patients manage specific health conditions. The evidence based process begins with a clinical assessment, followed by a diagnosis and intervention plan, and then requires monitoring. For this to work, personalization is required.
“Culturally tailored nutrition therapy has proven particularly effective with type 2 diabetes. It recognizes the connection between food, dietary habits and culture, and understands that effective behavior change necessitates that an intervention be both meaningful and relevant to each patient,” says Alaofè.
Courtesy of Halimatou Alaofè
In short, food preferences and cultural beliefs are baked into each individual plan.
Challenges
Alaofè sees a chasm between the official guidelines and actual patient behavior. When listening to people, she often hears a “lack of awareness at the patient level, but also at the healthcare provider level.”
Before beginning her IRSDA project, she conducted formative research which included focus group interviews with stakeholders. She found that nutritionists often “present the idea that Benin doesn’t have good local resources. But it’s not true. We have seasonal fruits and vegetables and many of our national dishes are vegetable-based.”
Her formative research also showed that patients don’t want to participate in projects delivered via healthcare systems because “healthcare means death. Can you imagine? If you provide a service at the healthcare level, the population will never come and listen to you,”
FOCUS
In turn insufficient patient interaction leads to out-of-touch recommendations. “We still say, ‘eat five portions of fruit and vegetables.’ We still say, ‘one spoon of oil.’ What does that even mean, when in Africa the food is shared?”
Alaofè asked one patient focus group: Why don’t you eat more fruits and vegetables?
The answer: “Fruits and vegetables are for the poor. When you have a guest, you have to put out a rice dish or spaghetti.” Carb-based, westernized food confers prestige, she notes.
“In the media, everywhere, nutritionists talk about obesity and a good diet, but how do you convince people to eat good food, when they believe that eating a particular carb means they belong to a higher status?”
Having examined perceptions of obesity, she found that people reject the negative connotations of “obesity” because for them, weight “is related to wealth and to attraction and to fertility. Women say, ‘I have to gain weight when I’m pregnant,’ so how do I convince those who are overweight to lose pounds to help with glycemic control [lowering blood sugar]?”
Nutritional communication strategies need to change, says Alaofè. “We need to adjust so our patients don’t run from us.”
Family matters
Alaofè, who previously worked as a lab technician in both rural and urban areas of Benin, saw first-hand how nutrition intersects with disease prevention and long-term health outcomes. Overall she hopes to better understand the biological,
“ MOST PEOPLE DIE DUE TO UNDERNUTRITION, NOT BECAUSE OF THE DIABETES—THEY DIE BECAUSE THEY DON’T KNOW WHAT TO EAT.”
social and policy dimensions of diet, while contributing to evidence based solutions to improve population health.
Alaofè believes her project will be relevant to many U.S. citizens on whose behalf her research is funded.
“We have low health literacy and under-resourced communities facing food insecurity who need help to access adequate and nutritious food.”
Although her project is not yet complete—it will end in 2027—Alaofè has already published three papers. One paper examines best practices for engaging social networks in nutrition interventions. Another shows how both culture and family relate to diets.
“Most people die due to undernutrition, not because of the diabetes—they die because they don’t know what to eat. Families don’t know how to support the patient, so we have to help them do that.”
It’s not necessary to require the entire family’s constant participation, but family members need to be invited along whenever there’s crucial information to be shared, says Alaofè. “People become isolated when they have diabetes. They feel they have to solve it alone, when, really, they need the support of their families.”
Halimatou Alaofè, PhD.
NUTRITIONAL RESEARCH IN TANZANIA MAY HELP COAL MINERS
IN THE U.S.
Chronic respiratory disease, including asthma, is a common diagnosis in the United States—in fact, it’s the fifth most common cause of death. By contrast, tuberculosis (TB) is an unusual diagnosis in the U.S.
Yet TB research conducted in Tanzania will likely prove very beneficial for Americans, say Dr. Scott Heysell, a professor of international medicine at University of Virginia (UVA), and Dr. Stellah Mpagama, a physician-scientist at Kibong’oto Infectious Diseases Institute in Tanzania. They are co-principal investigators of a Fogarty Global Infectious Diseases Research Training Program project.
“In the U.S. and where I work in Appalachia, there’s a lot of coal mining,” explains Heysell. In Tanzania, there’s a roughly equal rate of mining as in Appalachia (though for different commodities), and so people develop lung disease from silicosis or other environmental aspects of the industry just as they do in the U.S.
This shared history of similar environmental exposures and chronic lung disability suggests Tanzanian research will likely translate to the American context. Studying how a targeted nutritional intervention, given either before or during a TB episode, impacts chronic lung disease “will possibly have direct implications for any nation where chronic lung disease is common,” says Heysell.
Learning by doing
Ancient in origin, tuberculosis is a serious infectious illness affecting the lungs. It’s caused by bacteria that spreads via droplets propelled into the air when an ill person coughs or sneezes.
Some people who inhale TB germs have strong immune systems, so their bodies successfully fight off disease. Others have weaker systems and so disease develops, leading to weight loss and possibly wasting.
“Malnutrition is a consequence yet also a cause of tuberculosis—it is the leading risk factor for developing tuberculosis,” says Heysell. People who are undernourished lack a healthy immune response, so, following exposure to germs, they’re likely to progress to disease, which leads to a worsening of their famished condition.
This bidirectional relationship
between sustenance and disease is where Heysell and Mpagama center their TB project.
Mpagama says, “Our research explores all forms of nutritional status in TB patients to understand how nutrition influences disease outcomes.” Undernutrition and poor nutrition are closely related but distinct, she explains. Undernutrition is defined as inadequate food intake that leads to deficiencies in essential nutrients and then presents as wasting, stunting, or being underweight.
“Malnutrition is a consequence yet also a cause of tuberculosis—it is the leading risk factor for developing tuberculosis.”
Photos courtesy of Scott Heysell
Drs. Stellah Mpagama & Scott Heysell
Grant writing workshop and data science bootcamp, Moshi, Tanzania 2024
Courtesy of Scott Heysell
“Malnutrition is a broader term that includes both undernutrition and overnutrition—where excessive or imbalanced intake (such as too much sugar, salt, or fat), often without meeting essential nutrient needs, leads to overweight and obesity.”
Overnutrition can lead to diabetes, where high levels of blood sugar affect immune cell function, impairing the body’s ability to defeat infections.
Heysell’s and Mpagama’s project will train six post-doctoral candidates to become independent researchers at leading institutions across the country including Kibong’oto Infectious Diseases Hospital, the Kilimanjaro Christian Medical University College and Kilimanjaro Clinical Research Institute, Muhimbili University of Health and Allied Sciences, and the University of Dodoma. Pursuing separate research plans, each trainee will investigate how the gut microbiome, nutritional interventions, pulmonary rehabilitation, chronic lung disease, and the bacterial infection of TB interact and intertwine.
“Our role is to provide guidance, mentorship, and encouragement to help them build confidence and pursue their professional goals,” says Mpagama.
Why Tanzania?
Mpagama’s and Heysell’s training grant began in March 2022 and ends in February 2027, by which time each
FOCUS
trainee should be capable of competing for National Institutes of Health grants and other global funding, setting research agendas, and overall contributing to policymaking and to the community. “Two of the six total postdocs in the earliest cohort are just finishing their projects and the latest cohort just started,” says Heysell.
Metrics of success include academic promotion, development of a research team, and grant submission and receipt. Heysell says, “So we’ve had a fair amount of success; those who started at the beginning have been academically promoted and their research teams have grown. They’ve published scientific papers and submitted research grant proposals to NIH and other funders. They haven’t yet received word back, so it’s too early to determine the success of those grants.”
Training in Tanzania, a country with a high burden of TB, is crucial because TB needs to be studied in endemic areas (where it’s most common). “While tuberculosis exists in the United States—for instance, a little over 10,000 people were diagnosed with the disease in 2024—we need a much greater scale of impact and severity of disease presentation to really understand scientifically how to intervene,” says Heysell.
Tanzania is also a country with high rates of undernutrition. “We need to understand how undernutrition leads to TB disease, and then how we might target and treat undernutrition either before tuberculosis develops or during the disease course itself,” Heysell explains.
Building the research workforce in Tanzania is an equally important goal. “The approaches, findings, and the
frameworks we develop are designed to be transferable and applicable to other diseases, including pandemics and other health threats on and outside the continent,” Mpagama says.
Conducting research in Tanzania provides opportunities not found in the U.S., but there are snags as well, says Heysell. “Getting the timeline right is one challenge. For instance, we think we’ll be able to do this in two months when in fact it takes six because of the regulatory environment or getting something shipped and having it arrive on time with the proper paperwork.”
“The long-term relationship that UVA has established with partners in the region facilitates a lot of the work that would be more difficult if we were starting from scratch,” says Heysell.
Nutritional challenges
Mpagama says the current U.S. administration is addressing poor nutrition as a national health concern, “so the methodologies and key insights generated from our work may be applicable—either directly or indirectly—in the American context.”
She adds, “There is also an opportunity to expand this research to the U.S. to address its own malnutrition challenges. This would produce valuable cross-country comparisons that help reveal common, underlying mechanisms and inform more effective strategies for addressing malnutrition in both local and global settings.”
Heysell concludes, “Through the work we’re doing in Tanzania, we’ll be able to understand how a nutritional intervention affects the immune system in an important way.”
10 GLOBAL HEALTH
Scott Heysell at a Tanzanian research symposium.
Christine F. Sizemore, PhD
Q A&
A pragmatic perspective on global health
Christine Sizemore retired from her position as the director of Fogarty’s Division of International Relations (DIR) on April 30. Her career began in the biopharmaceutical industry, where she worked in drug discovery and development. Prior to joining Fogarty in 2018, she spent 18 years at the National Institute of Allergy and Infectious Diseases (NIAID) as chief of the Tuberculosis, Leprosy and Other Mycobacterial Diseases section. Sizemore received her Master’s degree in Biology and her Ph.D. in Bacterial Genetics from the Friedrich Alexander Universität in Erlangen, Germany.
What was your first job at NIH?
AI started as a program officer in the tuberculosis (TB) program at the National Institute of Allergy and Infectious Diseases (NIAID) in 2000. It was an opportunity to work on a much larger scale and on the full spectrum of research and product development for TB and other mycobacterial diseases. The job fit me to a T. Along with being practical, I’m a big picture person. I like seeing and making connections and figuring out strategy to fill gaps in knowledge in the most straightforward and practical way. At first, there were just two of us, but once we began to strategically grow the program and more program officers and medical officers joined the team, we became a Section within the Division of Microbiology and Infectious Diseases and I was named Section Chief. I remained in that role until I became the director of DIR in 2018.
Do Americans benefit from NIHfunded research in low- and middle- income countries (LMICs)?
When I was at NIAID, I worked a lot with LMICs, because TB is a
disease of poverty. I learned very quickly that the way scientists from lower resource countries think and the way they approach challenges is more pragmatic and often more outcome-oriented. What we call “neglected diseases” are very real for them and any solutions they can develop will have real impact for their communities. They see interventions or programs that work at the local level as worthwhile even if they do not scale globally. This has been a challenge for some very innovative projects criticized for not being “global enough” despite making a huge difference for local communities.
This practical thinking is a great complement to the science that is conducted in richer countries where doing research is not uncommon.
If we want to crack the hard nuts in research, then the two sides must work together—the pragmatists and the technologists. Collaborations between low- and high- income countries give investigators a lot of technological access, including large data centers and large infrastructure,
all of which are necessary to holistically tackle a problem. But when it comes to direct patient outcomes and impact, you need to start with the pragmatism of LMIC researchers who have the experience and insights into what is needed to make prevention, diagnosis or cure a reality.
What do you tell global health researchers?
We would do well by communicating outside a narrowly-focused cluster of like-minded individuals. For example, try to explain the relevance of your scientific work to your non-scientific neighbors and take their questions seriously. If you can’t answer, “Why does that matter?” in a way that resonates with them, then more introspection may be needed.
To really understand a disease and what it means, you need to go to where it is. My first trip to Africa showed me what it means to have TB as a patient, as a community and what TB means for healthcare providers— what infrastructure is available, what it takes to get your drugs and finish months’ worth of treatment, and what nurses and doctors, as well as community health workers and families do, to help patients. That immediately puts a different perspective on the utility of a fancy, sensitive diagnostic machine vs. a low tech, easy to use, fast diagnostic test. After that trip, I never thought about my job the same way again.
NEWS&Updates
Resolute
vision:
Caring for casualties in low-resource conflict settings
“When people think of military trauma care, they often think of what existed in Iraq and Afghanistan. But that paradigm has shifted,” says Hannah Binzen Wild, a former Fogarty fellow whose project in Burkina Faso focused on improving casualty care for patients with conflict-related injuries.
Unlike the wars in the Middle East, irregular warfare as well as large-scale combat operations between great powers will not be characterized by air superiority or intact echelons of care. Instead, U.S. military trauma care personnel may face conditions resembling those seen in Burkina Faso: specifically, prolonged transportation times, restricted supply chains, and severe resource limitations.
Solutions devised by trauma care personnel in Burkina Faso reflect long years of experience with warfare in a context that might more closely resemble what the U.S. may face in the future. “It would be ideal to synthesize these lessons, which can be beneficial to the U.S. for the planning and preparedness of its military, while also providing more resources and technical advisory support to personnel in lowresource conflict settings,” says Wild. Providing care during conflicts Wild, now a general surgery resident at the University of Washington, spoke at July’s orientation for Fogarty’s Launching Future Leaders in Global Health Research Training Program. As part of her own Fogarty fellowship in Burkina Faso, she worked on a range of proposals, all focused on trying to
improve casualty care for patients with conflict-related injuries.
“The formal project was piloting integration of explosive ordnance risk education with community first aid responder training in communities affected by the threat of IEDs (improvised explosive devices),” says Wild.
Led by Dr. Nicolas Meda, a professor at University of Ouagadougou in Burkina Faso, Wild’s team conducted this pilot through a collaboration with the Mines Advisory Group, a global advocacy group. (Mine action generally comprises explosive ordnance detection and clearance, risk education, and victim assistance.)
With their networks of community liaisons, charitable mine action programs already possess a platform to deliver community first-responder training in conflict and post-conflict settings. Programs like the Burkina Faso pilot are now underway in Syria, Afghanistan, and Mozambique. The Antipersonnel Mine Ban Convention recognized the value of merging community first responder training with explosive ordnance risk education and added an integrated program to its most recent action plan.
During her Fogarty fellowship Wild also collaborated closely with local military surgeons including Dr. Yves Sanou and Dr. Yves Aziz Nacanabo. The team conducted one of the largest analyses of local casualties in the Sahel to date (roughly 1,400), filling a longstanding evidence gap on casualty care within local health systems.
The team is also studying other key casualty care problems such as tourniquet application and blood availability.
One life’s mission
Wild discovered her passion in life at a young age and never wavered from it.
“I was five years old during the Rwandan genocide and, being an early reader, I learned about it and could not comprehend how people knew that this was happening in the world and moved on with their lives.” As she grew older, Wild read about conflicts taking place in Bosnia and in the Middle East. “I decided to spend my life trying to be useful in this type of setting.”
Though her passion places her in harm’s way, Wild does not dwell on this. “I calculate and moderate risk as much as I can. But the purpose of my existence is making a contribution in this environment, so when you’re lucky enough to be doing exactly what you’re built to do and want to do, personal risk factors differently.” She notes that her colleagues in low-resource conflict settings provide care for the wounded under extraordinarily challenging conditions with little recognition. “I follow the path that I think will make me most effective in mitigating human suffering,” says Wild.
Courtesy of Hannah Binzen Wild
Wild and Colonel Bassinga in the operating room
NEWS&Updates
What do you mean when you say capacity building?
“I didn’t know what capacity building meant until I went to Uganda, and then someone said that phrase to me every hour,” says Dr. Yukari Manabe, a professor of medicine at Johns Hopkins University School of Medicine. Between 2007 and 2012, she served as head of research at the fledgling Infectious Diseases Institute (IDI), founded in Kampala in 2002.
“The research capacity building pyramid became the focus and the guide of everything that occurred at the institute when I worked there,” says Manabe. At the top are the easy things to accomplish, such as bringing in tools, equipment, and research money. The next step on the pyramid is skills. “So equip the person, right? We all know how to do that with courses and training,” says Manabe. Harder tasks to complete—such as developing a core staff, infrastructure and systems—requires the help of international faculty to fill specific gaps and to provide mentorship. The final step encompasses the most difficult goals, including comprehending and interpreting local context (to appropriately assist the country’s Ministry of Health) and building enduring partnerships.
As it matured, the institute necessarily updated its strategic plan, says Manabe. The first plan reflects “the era of dependence. It’s narrowly focused. You’re still trying to build a critical mass of talent and training key staff abroad. Grants are led by external partners.”
The second strategic plan reflects a new era, that of independence. “We
could replicate most things in-country. We’d partnered with policymakers. We had key staff and a larger group of funders. We started to disseminate knowledge to others on the continent.” With its third strategic plan, the institute entered the era of interdependence. “We’ve become a national node within continental networks. We have global and regional links and sustainable funding. We get major grants directly. Talent comes to us.”
Today, IDI is considered a true center of excellence able to foster independent researchers, says Manabe, who spoke to Fogarty fellows attending the Fogarty’s Launching Future Leaders in Global Health Research Training Program orientation in July. “Now people try to steal [talent] from us, which is the surest sign of success.”
Cascade effect
U.S. research dollars go farther in places where things happen at a much higher frequency, says Manabe. For example, congenital syphilis has risen precipitously over the last decade in the U.S., still it’s more efficient and less expensive to study syphilis in a hot spot where the prevalence is up to 30% compared to 0.01% in the U.S. “Money going overseas actually comes back to benefit people in the U.S. afterwards.”
Currently, as director of Johns Hopkins’ Center for Innovative Diagnostics for Infectious Diseases, Manabe focuses on point-of-care diagnostics, which enable health
care providers to test and treat patients within a single visit, rather than waiting days for test results (with patients needing to make additional visits).
Point of care diagnostics “exploded” during COVID, says Manabe. (The NIH’s Rapid Acceleration of Diagnostics program was a multi-billion-dollar investment in COVID-19 testing methods.) She now urges companies to consider using the platforms created during the pandemic when creating new diagnostics for other diseases instead of wasting “this investment that American taxpayers have already made.”
So how does Manabe define capacity building today? “It means friends and colleagues—cultivating your network through training. It also means just getting things done and having a public health impact. You train a few who go on and train 10 and that leads to hundreds of people trained who have an impact on thousands.”
This cascade effect is the joy of capacity building, she says.
“IN SOME PLACES, THEY NO LONGER NEED US AS MUCH AS THEY USED TO, AND THAT MAY BE DIFFICULT EGOTISTICALLY, BUT MAYBE THE SIGN OF REALLY HAVING MADE A DIFFERENCE IS WHEN YOU TEACH YOURSELF OUT OF A JOB.”
Courtesy of Yukari Manabe
Yukari Manabe, MD
The Infectious Diseases Institute in Kampala, Uganda, used this capacity building pyramid as a guide.
people
Community
Adnan Hyder tapped by BU School of Public Health
Boston University has appointed Dr. Adnan Hyder the Robert A. Knox Professor and next dean of its School of Public Health beginning fall 2025. Hyder’s Fogarty- and National Institutes of Health-funded research has contributed to the global understanding of the epidemiological burden, risk factors, potential interventions, economic impact, and socio-cultural correlates of noncommunicable diseases and injuries globally. Currently, Hyder is senior associate dean for research and innovation and professor of global health at The George Washington University Milken Institute School of Public Health.
Simone Badal honored with a Sabga Award
The Anthony N. Sabga Caribbean Awards for Excellence has selected Simone Badal, MD, for this year’s Science & Technology laureate. Badal, a senior lecturer at The University of the West Indies, Mona, has been recognized for her work in developing Caribbean-specific cancer cell lines. Her research led to the creation of the first prostate cancer cell line derived from a Caribbean man, addressing a gap in cancer research, where models have historically focused on Caucasian populations. Badal, a Fogarty Emerging Global Leader, has more than 45 peer-reviewed publications.
Katherine O’Brien wins Albert B. Sabin Gold Medal
The 2025 recipient of the Albert B. Sabin Gold Medal is Katherine O’Brien, MD, for her work in the licensure and global introduction of vaccines against pneumococcal disease, rotavirus, and respiratory syncytial virus. O’Brien is widely considered a pioneering global health leader whose innovative work in vaccine access and policy has transformed immunization programs worldwide. Previously, she served as an Epidemic Intelligence Service officer at the U.S. Centers for Disease Control and Prevention and led vaccine research and development initiatives at the Johns Hopkins Bloomberg School of Public Health. Her past work includes large-scale vaccine impact studies and clinical trials.
Abdoulaye Djimdé wins Hideyo Noguchi Africa Prize
The Hideyo Noguchi Africa Prize in Medical Research has been awarded to Abdoulaye Djimdé, MD, director of the Parasites & Microbes Research & Training Center at the University of Science, Techniques and Technologies of Bamako, Republic of Mali. Djimdé is a Fogarty grantee who has also been supported by the National Institute of Allergy and Infectious Diseases for his efforts to combat infectious and other diseases in Africa. The award recognizes his work in the areas of treatment and control of malaria as well as training of young researchers in African countries.
Barbara Sina secures bioethics leadership award
The 2025 Oxford Global Health & Bioethics International Conference honored Barbara Sina, PhD, with a Global Health Ethics Leadership Award. Sina serves as acting director of Fogarty’s Division of International Training and Research. This annual award recognizes a member of the bioethics community who has made immense contributions to the advancement of the field, often under challenging circumstances. The selection committee noted that Sina’s efforts have shepherded vital initiatives across the training, research and policy/practice spectrum while also yielding lasting benefits for many.
HEALTH Briefs Global
Gut microbiome study includes previously under-sampled populations
In 2007, the Human Microbiome Project (HMP) set the goal of characterizing the human microbiome and measuring its contribution to disease. Large cohorts in high income countries have been well represented in HMP studies, yet low- and middle-income nations, which account for nearly 84% of total population, have been under-represented; this reduces the generalizability of HMP’s conclusions. To help rectify this, Stanford’s Dr. Dylan G. Maghini conducted a cross-sectional gut microbiome study sampling 1,801 women from Burkina Faso, Ghana, Kenya, and South Africa for her Fogarty fellowship project. Using shotgun metagenomic sequencing—a technique that enables microbiologists to detect both the bacterial diversity and the abundance of microbes in the gut—Maghini’s team identified taxa (hierarchical groups of microbes) with geographic and lifestyle associations and also an HIV infection signature defined by taxa not previously linked to HIV. The study is published in Nature.
How do newly approved vaccines affect RSV hospitalizations?
Each year respiratory syncytial virus (RSV), which usually causes mild, cold-like symptoms, leads to 1,500 to 2,800 hospitalizations per 100,000 infants in the U.S.
A research team, led by Fogarty’s Chelsea Hansen, used mathematical modeling to examine impacts of newly introduced immunization strategies on RSV hospitalizations in King County, Washington. (Beginning in 2023, the CDC’s Advisory Committee on Immunization Practices recommended a monoclonal antibody or passive vaccine, nirsevimab, for routine use in infants and a single dose of either one of the two approved active vaccines for older adults.) The team estimate that vaccination cut RSV hospitalizations by two-thirds in babies less than 6 months old and by a third in seniors over age 75 during the 2024-25 season (when compared to no vaccination). Fogarty’s Dr. Cécile Viboud is senior author of the paper published in JAMA Network Open.
Researchers identify a new diabetes subtype in sub-Saharan Africa
Type 1 diabetes results from autoimmune destruction of insulin-secreting cells— according to studies of mostly European populations. Now a new study published in Lancet Diabetes and Endocrinology provides evidence that many young people in Africa, and some in the U.S., may have a non-autoimmune form of type 1 diabetes. Dr. Dana Dabelea of University of Colorado, who receives funding from the National Institute of Diabetes and Digestive and Kidney Diseases, participated in this project. The researchers enrolled 894 participants with young-onset diabetes from Cameroon, Uganda, and South Africa and assessed their blood levels of antibodies against insulinproducing cells and calculated their genetic risk of developing diabetes. Next, the team compared findings with similar, age-matched studies performed in the U.S. Discovery of a form of type 1 diabetes that is not caused by immune system dysregulation could change how diabetes is diagnosed, treated and managed, while paving the way for more effective medicines and better outcomes.
Fogarty alumnus co-leads study of cardiovascular health in southeast U.S.
Each year, rural areas in the U.S. experience 60,000 more cardiovascular-disease related deaths than urban areas due, in part, to a lack of specialists and cardiac imaging machines that are required to detect, diagnose, and manage cardiovascular disease. The RURAL (Risk Underlying Rural Areas Longitudinal) Cohort Study aims to address critical gaps in awareness and knowledge related to heart and lung disorders in several southeastern states. RURAL mobile exam units, which are outfitted with a lab, private exam rooms, and cardiovascular assessment and imaging tools, travel to the counties where the study’s more than 3,000 enrolled participants live. Dr. Gerald Bloomfield, a former Fogarty fellow and associate professor at Duke University School of Medicine, is co-lead of the study’s Imaging Core, which is responsible for obtaining CT scans and also storing, processing, and accessing the images.
All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated. In rare cases when a correction is needed after an issue’s printed version has been finalized, the change will be made and explained in the online version of the article.
FUNDING NEWS
On behalf of the Fogarty International Center at the U.S. National Institutes of Health (NIH), the following funding opportunities, notices and announcements may be of interest to those working in the field of global health research.
Funding Announcement
International Research Scientist Development Award (IRSDA) (K01 Independent Clinical Trial Not Allowed) (K01 Independent Clinical Trial Required)
Mobile Health: Technology and Outcomes in Low and Middle Income Countries (R21/R33 Clinical Trial Optional)
Global Infectious Disease Research Training Program (D43 Clinical Trial Optional)
Deadline Details
March 9, 2026
March 9, 2026
August 6, 2026
Fogarty fellows gather in Bethesda
Once again, Fogarty welcomes trainees from across the U.S. and the globe!
Orientation for Fogarty’s Launching Future Leaders in Global Health (LAUNCH) Research Training Program took place on July 7-11 at the Hyatt Regency in Bethesda, Maryland, near the National Institutes of Health (NIH) campus.
LAUNCH supports one-year mentored research training opportunities
for U.S. and international scholars at biomedical research institutions and established project sites in low- and middle-income countries.
The orientation included workshops, presentations, lectures, and panel discussions featuring global health leaders and experts as well as NIH leadership, including NIH Director Dr. Jay Bhattacharya. This year’s trainees are supported by 24 NIH Institutes, Centers, and Offices.
Fogarty International Center
National Institutes of Health
31 Center Drive
Bethesda, MD 20892
NIH Director Dr. Jay Bhattacharya talks with a scientist following his fireside chat.
Speakers, left to right: Ellie Dehoney (Research!America); Dr. Wafaie Fawzi (Harvard T.H. Chan School of Public Health); Jane Simoni, PhD (NIH); Fred Ssewamala, PhD (Washington University School of Medicine); and Dr. Magaly Blas (Universidad Peruana Cayetano Heredia)
Photos courtesy of Fogarty staff
THE FIRST STATE HEALTH LEADERS ALLIANCE
Delaware and our country are facing uncertain times, which is why partnership and collaboration have never been more important. In our work, we have the privilege of helping individuals navigate complex health challenges and put them on the path to thriving. With looming federal funding cuts, we are closely monitoring the landscape and the trickle-down effect to Delaware.
To that end, we want to introduce our new partnership. Our key advocacy groups for hospitals, nurses, physicians, home care, long-term care facilities, pharmacists, community-based disability services, care givers, and public health practitioners have joined forces as the First State Health Leaders Alliance (FSHLA) to champion issues that will strengthen healthcare in our state. We recently announced our first-ever joint agenda, an eight-point plan that focuses on policy efforts to address health workforce development, insurance reform, public health, emergency preparedness, workplace violence, and community needs driven by the social determinants of health. The tenets include:
• Advance health workforce development to address shortages across professions.
• Advocate for adequate reimbursement rates to ensure healthcare sustainability.
• Fight for prior authorization reform to ease patient access to care and reduce the burden on the health workforce.
• Invest in public health and emergency preparedness to support health workers and our most vulnerable.
• Create a culture of safety for health workers free of workplace violence.
• Remove healthcare barriers and promote health literacy to ensure care for all.
• Enhance transitions of care to improve a patient’s care coordination across all health settings.
• Champion affordable housing solutions that support aging in place, health promotion and success, health workforce recruitment and retention, and community living for those with disabilities.
Delaware is home to the sixth oldest and eighth-fastest-growing population in the nation, which will continue to increase the demand for a robust healthcare infrastructure. We need collaboration and coordination across all sectors of the healthcare system to meet the moment and advocate for solutions that are shared not siloed.
Our members bring deep expertise from across the healthcare continuum and are eager to partner with all Delawareans to build a stronger, more resilient healthcare system for Delaware. We look forward to partnering with you as we make Delaware a national model for healthcare.
The Role of Nutrition and Malnutrition as Determinants of Cancer Development, Prevention, and Survivorship
Dawn Hollinger, M.S., M.A.
Bureau Chief, Cancer Prevention and Control, Health Promotion and Disease Prevention, Delaware Division of Public Health, Delaware Department of Health and Social Services
Lauren Butscher, C.H.E.S.
Program Administrator, Physical Activity, Nutrition, and Obesity Prevention, Health Promotion and Disease Prevention, Delaware Division of Public Health, Delaware Department of Health and Social Services
Stephanie Belinske, M.P.H.
Chronic Disease Epidemiologist, Bureau of Chronic Disease, Delaware Division of Public Health, Delaware Department of Health and Social Services
Helen Arthur, M.H.A.
Section Chief, Health Promotion and Disease Prevention, Division of Public Health, Delaware Department of Health and Social Services
Sumitha Nagarajan, M.P.H.
Cancer Epidemiologist, Bureau of Cancer Prevention and Control, Health Promotion and Disease Prevention, Delaware Division of Public Health, Delaware Department of Health and Social Services
ABSTRACT
Nutrition and malnutrition are highly influential yet often under recognized determinants in the development, progression, and survivorship of cancer. Poor dietary patterns and nutritional deficiencies are leading modifiable risk factors for several types of cancers. These issues disproportionately affect vulnerable populations, intensifying existing health disparities. In Delaware, the Bureau of Cancer Prevention and Control addresses cancer across the continuum from education and prevention to screening, diagnosis, treatment, and survivorship. This is done through integrated programs such as the Delaware Comprehensive Cancer Control Program, Screening for Life, the Physical Activity, Nutrition and Obesity Prevention Program, and the Delaware Cancer Treatment Program.
This article explores the complex interplay between nutrition and malnutrition, and their impact on cancer. Highlighted are both the biological mechanisms linking dietary patterns to carcinogenesis and the socioeconomic factors that drive nutritional inequities. It also presents Delaware-specific cancer and nutrition data, highlighting how state-led efforts are evolving to incorporate nutrition education, food access partnerships, and communitybased interventions into cancer prevention and control strategies. By aligning clinical, public health, and community resources, Delaware is creating a more holistic and equitable approach to reducing cancer incidence and improving outcomes. This article underscores the urgent need to treat nutrition as a foundational element of cancer prevention and presents opportunities for policy and practice to address malnutrition across the cancer care continuum.
The authors would like to acknowledge Diane Ng, M.P.H. (Research Associate, Westat) for assistance with the data collection and analysis referenced in this article.
INTRODUCTION
Nutritional status is both a cause and consequence of disease. Deficiencies in dietary quality contribute to the onset of numerous cancers. Meanwhile, malnutrition increases treatment complications, weakens treatment outcomes, and leads to poorer survivorship.1 This article will examine how the health determinants of nutrition and malnutrition function across the cancer continuum, highlighting both biological and structural drivers of disease. Drawing on Delaware’s state-specific experience and programs led by the Bureau of Cancer Prevention and Control and the Physical Activity, Nutrition, and Obesity Prevention Program, a case for deeper investment in nutrition-based interventions spanning from prevention to survivorship care is presented. Strategies for health equity, access to healthy food, and integration with existing cancer infrastructure are emphasized.
Cancer remains one of the leading causes of death in the United States, yet much of its burden is preventable. Among the most modifiable risk factors for cancer are poor diet and nutritional deficiency. According to the Centers for Disease Control and Prevention (CDC), nearly one in five cancers is associated with lifestyle-related risk factors, including unhealthy eating patterns. On the opposite end of the continuum, malnutrition, characterized by the inadequate consumption of calories, proteins, and essential nutrients, furthers treatment complications, increases hospitalizations, and compromises survivorship.1,2 Nutrition and malnutrition form a crossroad with other social determinants of health, such as poverty, race, geography, and education. These disparities affect cancer risk, diagnosis, treatment, and long-term outcomes. Detailed in this article is the central role nutrition plays in cancer prevention, treatment, and survivorship. It draws upon national data and Delaware’s statespecific experience to illustrate how nutrition-based interventions can promote more equitable cancer outcomes.
METHODS
This article is based on a synthesis of a variety of literature, secondary data sources, and internal program-specific data. A thorough review of current peer-reviewed literature was conducted via the Delaware Department of Health and Social Services Library access to EBSCO, PubMed, and Sage databases using the key terms cancer and nutrition, oncology dietician, and malnutrition in cancer. Delaware-specific public health reports were reviewed for current state-related obesity, nutrition, and cancer related state findings. These reports are publicly available on the State of Delaware website.
Data Sources
The Behavioral Risk Factor Surveillance System is the longest running random-digit dial telephone survey in the U.S. capturing health outcomes and associated risk factor data in all 50 states and four territories. Approximately 4,000 Delaware adults respond to the survey each year. These results are used to create prevalence estimates for a variety of health outcomes and risk factors.
CDC PLACES is a publicly available dataset in which small area estimates (SAE) are calculated for counties, census tracts, and ZIP Code Tabulation Areas. Crude prevalence SAEs for selected chronic disease indicators are available as a geodatabase and in tabular format.
The Social Vulnerability Index (SVI) is a composite measure aiming to determine social vulnerability by compiling 17 different indicators into four themes. These themes include socioeconomic status, household characteristics, racial and ethnic minority status, and transportation. This composite measure is developed and maintained by the CDC and the Agency for Toxic Substances and Disease Registry. SVI allows researchers to identify census tracts with high social needs and allows programs to provide a targeted approach to resource allocation.
Relevant state programs, including the Delaware Comprehensive Cancer Control Program (CCCP), Screening for Life (SFL), the Physical Activity, Nutrition, and Obesity Prevention Program (PANO), and the Delaware Cancer Treatment Program, were reviewed to identify initiatives addressing nutrition and malnutrition across the cancer continuum.
DATA ANALYSIS
SAS 9.4 was used to analyze Delaware-specific BRFSS data for obesity, smoking, and nutrition trends, and identify disparities in these indicators among selected demographic factors. ArcGIS Pro v. 3.3.1 was used to visualize crude obesity prevalence and SVI by census tract. Shape files were obtained from the U.S. Census Bureau’s 2020 TIGER/Line download website.
RESULTS
Nutrition, Obesity, and Cancer Risk
One of the greatest public health successes in Delaware is the decrease in cigarette smoking prevalence over the past three decades. In 1995, 25.5% of Delaware adults reported smoking cigarettes, compared to 10.1% of Delaware adults in 2024.3 However, most of the decrease in current cigarette smoking prevalence has been made within the past 13 years. In 2011, 21.2% of Delaware adults reported smoking cigarettes.3 The change in prevalence between 1995 and 2011 was a 16.9% decrease. From 2011 through 2024, Delaware experienced a 52.4% decrease.3
Although progress has been made in cigarette smoking among Delaware adults, weight gain and increased body mass index (BMI) among Delaware adults has become a public health concern. Obesity is defined as having a BMI of 30.0 or more. In 2024, 36.6% of Delaware adults reported being obese, compared to 17.1% of Delaware adults in 1995.3 This change in reported adult obesity is a 43.5% increase in the past three decades. While, not statistically different, a higher percentage of Delaware adult women have consistently reported having obesity, compared to Delaware men, since 2012.3 Likewise, a higher proportion of non-Hispanic Black adults have consistently reported having obesity, compared to nonHispanic White adults since 2011.3
Figure 1 shows the distribution of crude prevalence of obesity and SVI by census tract in Delaware in 2020. Census tracts in and surrounding the City of Wilmington indicate a high crude obesity prevalence and a high SVI in New Castle County. Western Sussex County shows areas of high crude prevalence and higher SVI. All but four census tracts in Kent County are in the top quintile for crude obesity prevalence.
Note: The model-based estimates were generated using BRFSS 2020, Census 2010 population counts, or census county population estimates of 2020 or 2019, and ACS 2015-2019. Estimates are not available for areas shaded in gray. For more information visit https://www.cdc.gov/places. Credit: Centers for Disease Control and Prevention, National Center for Chronic Disease and Health Promotion, Division of Population Health, Atlanta, GA
Obesity is recognized as a risk factor for at least 13 different cancers including breast, colon and rectum, ovarian, and stomach. Delaware experiences a higher cancer burden related to obesity compared to the United States. In 2022, Delaware’s obesity-associated cancer rate was 174.6 per 100,000 population which is higher than the comparable rate in the United States which was 170.1 per 100,000 population during the same period.6 Additionally, in 2023, only 9% of Delaware adults consume the recommended daily intake of vegetables, and just 12% meet fruit intake guidelines.3 These gaps underscore systemic barriers to healthy eating, especially among low-income households and communities.
Nutrition as a Determinant of Cancer
Development
Nutrition plays a critical role in preventing obesity and maintaining a healthy weight. Excess caloric intake can lead to weight gain, increasing the risk of overweight and obesity, a well-established risk factor for cancer development. Scientific evidence also increasingly confirms the link between the dietary patterns and cancer incidence.7 Diets high in processed meats, added sugars, and refined carbohydrates are associated with elevated risks for breast and colorectal cancers.7 Conversely, diets rich in fruits, vegetables, fiber, and whole grains are protective factors against the development of cancer.7 Nutritional status directly influences cancer risk through mechanisms including inflammation, stress, hormone regulation, and immune function. High glycemic diets promote insulin resistance and chronic inflammation. Both conditions are conducive for tumor growth. Diets
lacking in antioxidants and phytochemicals fail to counteract DNA damage from environmental exposures. However, food insecurity heavily influences an individual’s ability to make healthy food choices. Limited access to affordable, nutritious food often forces individuals to rely on calorie-dense, nutrientpoor options, which can contribute to the development of obesity, and further highlights the complex relationship between nutrition, obesity, and cancer development.
Structural Drivers of Nutritional Disparities
The lack of access to healthy food is shaped by structural inequities. Delaware’s urban and rural regions face food insecurity in rates exceeding 11% with even higher prevalence in Black and Hispanic communities. Statewide, 42% of Delaware adults have low food access, defined as living beyond 1 mile in an urban setting, or 10 miles in a rural setting, of a supermarket.8 Socioeconomic status, transportation barriers, and lack of food retail infrastructure contribute to these disparities. Food deserts, or areas where access to affordable, healthy food is limited, exist in both the city of Wilmington and throughout Sussex County. These inequities intersect with and influence cancer outcomes. Research shows that cancer patients from low-income households experience worse treatment outcomes and are more likely to be diagnosed with cancer at later stages. Malnutrition may also delay treatment initiation or result in dose reductions, further worsening cancer prognosis.
DISCUSSION
Malnutrition in Oncology Care
Malnutrition affects up to 80% of cancer patients during the course of their treatment.2 Consequences of malnutrition during cancer treatment include decreased tolerance to chemotherapy and radiation; increased risk of infection and delayed wound healing; longer hospital stays and higher readmission rates; and diminished quality of life and survival rates.2 During treatment, adequate nutrition is essential for maintaining strength, mitigating side effects, and supporting immune response. Despite its prevalence, malnutrition is frequently underdiagnosed in oncological settings. Screening tools such as the Malnutrition Screening Tool (MST) and Patient-Generated Subjective Global Assessment (PG-SGA) are available but are not universally applied. Assessing a cancer patient’s nutrition status and designing personalized early nutritional therapy to meet individual needs can help prevent or manage malnutrition, reduce its adverse effects, and potentially improve overall outcomes.9 Addressing malnutrition requires early screening, interdisciplinary care, and access to food assistance. Increased use of MST and PG-SGA as part of an integrated comprehensive cancer care plan should include nutritional interventions by oncology dieticians.
In Delaware, oncology dieticians are present at major cancer centers but lack integration into broader care teams. There is a growing push to embed nutrition support into standard oncology protocols, particularly for underserved populations. Throughout
the course of cancer care, oncology dietitians help to support and maintain patient quality of life by offering individualized nutrition guidance aimed at reducing eating-related discomfort.10 While undergoing cancer treatment, every patient requires an individualized nutrition plan to address their specific disease and dietary circumstances to ensure the best possible treatment outcome and longest survivorship.11 Lower-income cancer patients are more at risk of experiencing malnutrition and its associated effects of reduced quality of life and increased risk of mortality but are least likely to have access to nutrition-related services and one-on-one dietary counseling.11 Including oncology dieticians in cancer care teams can optimize nutrition and improve health outcomes in individuals with cancer.
Survivorship and Long-Term Outcomes
The importance of proper nutrition continues beyond prevention and treatment, and into survivorship. There are over 16 million cancer survivors in the United States. As survivorship grows, nutrition remains vital for reducing recurrence risk and managing comorbidities like cardiovascular disease and diabetes. A recent study published in the JAMA Health Forum conducted by researchers at the University of Pennsylvania Perelman School of Medicine investigated the impact of food insecurity on mortality rates in cancer survivors.12 The study found that those experiencing food insecurity had a 28% higher mortality risk compared to those who were food secure.12 Although this is the first study of its kind, it highlights the need for improved systems and comprehensive care plans that address the food and nutrition needs of cancer survivors throughout remission. However, many survivors lack post-treatment guidance. Efforts to provide this type of guidance, such as integrating Registered Dietitian Nutritionists (RDNs) into survivorship care plans, are underutilized strategies.
Delaware’s Response: Integrating Nutrition into Cancer Care
Delaware has taken meaningful steps to bridge nutrition and cancer care. Key programs include Screening for Life, which offers free screening for breast, cervical, colorectal, lung, and prostate cancer, and follow-up for eligible individuals. Efforts are underway to integrate nutrition counseling. The PANO Program implements community-based interventions promoting healthy eating and physical activity through the Advancing Healthy Lifestyles (AHL) Initiative, an effort supported by the Delaware Cancer Consortium (DCC).
In 2021, the DCC’s Cancer Risk Reduction Committee’s Healthy Lifestyles Subcommittee (HLSC) was tasked with studying and recommending policies aimed at improving healthy lifestyles for Delawareans across the life course. The AHL Initiative was subsequently developed to facilitate implementation of these recommendations. Through this Initiative, the PANO Program has aided the development of healthy eating initiatives through state-funded projects such as healthy corner stores, community gardens, and nutrition education in schools. The Initiative has strengthened health system-community partnerships, notably through support of community-based programming and policy, systems, and environmental change initiatives spearheaded by hospital systems, Federally Qualified Health Centers, and community health workers. These programs, such as culinary medicine and nutrition education for healthcare providers, hybrid
nutrition education programs for individuals at risk for breast cancer and other chronic diseases, food pharmacies, and produce prescription programs, have highlighted and addressed the connection between nutrition, food access, and health outcomes. They have laid the foundation for comprehensive, integrated care models that can be sustained and scaled statewide.
Concurrently, the Delaware Cancer Treatment Program covers cancer treatment costs for eligible Delaware residents with plans to integrate social determinants screening to include food insecurity during the application review process. One proposed pilot collaboration is between the Delaware CCCP and a local food bank to offer medically tailored food boxes to newly diagnosed cancer patients. This proposed project seeks improvements in patient-reported energy, reduction in emergency department visits during cancer treatment cycles, and increased adherence to treatment plans. Delaware’s Bureau of Cancer Prevention and Control and PANO Program continue to work collaboratively to identify needs and integrate healthy lifestyle programming with cancer prevention, care, and survivorship.
Public Health Implications
Recognizing nutrition as a cornerstone of cancer prevention and survivorship is a public health imperative. Delaware’s experience illustrates how cross-sector collaboration between healthcare providers, public health agencies, food systems, and community organizations can improve cancer outcomes. The Centers for Disease Control and Prevention has a menu of evidencebased strategies and approaches public health practitioners can implement to support access to healthy foods and beverages. Fruit and vegetable voucher incentive programs and produce prescription programs, such as Food is Medicine initiatives, are proven to improve affordability of, access to, and consumption of healthy foods, and showcase the impact of coordinated partnerships between health systems, public health professionals, and community-based organization.13 The Food is Medicine movement, which includes medically tailored meals, produce prescription programs, culinary medicine, and integration of nutrition into Medicaid and Medicare reimbursement, is gaining momentum nationwide. The movement aligns with a nationwide public health shift to better support food security by focusing on nutrition security, defined by the USDA as consistent access, availability, and affordability of foods and beverages that promote well-being, prevent disease, and, if needed, treat disease, particularly among racial/ethnic minority populations, lower income populations, and rural and remote populations including Tribal communities and Insular areas.14 The shift in focus highlights the role proper nutrition plays in disease prevention, treatment, and maintenance, and further exemplifies the need for integrated, interdisciplinary cancer care teams. Delaware has the infrastructure to become a regional leader in this space. Policy priorities should include reimbursable nutrition counseling in oncology; integration of food insecurity screening in cancer centers; expansion of medically tailored meal programs; investment in community-based nutrition education and food access; and incentives for grocery store development in underserved areas.
CONCLUSION
Nutrition and malnutrition are fundamental determinants of cancer development, treatment, and recovery. They intersect with socioeconomic disparities, structural barriers, and healthcare
access. Delaware has demonstrated promising models that integrate nutrition into cancer control through clinical, social, and community-based partnerships, but more work is needed to develop a system to integrate these efforts nationwide and develop an interdisciplinary standard of care. To reduce cancer incidence and improve survivorship, we must treat nutritional health as public health and improve nutrition security for all Delawareans. Addressing dietary deficiencies at the biological and structural levels can disrupt disease pathways and create a more equitable future for cancer care.
REFERENCES
1 Arends, J. (2024, May). Malnutrition in cancer patients: Causes, consequences and treatment options. Eur J Surg Oncol, 50(5), 107074 https://doi.org/10.1016/j.ejso.2023.107074
2 Hoobler, R., Herrera, M., Woodruff, K., Sanchez, A., Coletta, A. M., Chaix, A., Playdon, M. C. (2025, September). Malnutrition risk is associated with all-cause mortality and chemotherapy complications among adults diagnosed with diverse cancer types: A retrospective cohort study. Journal of the Academy of Nutrition and Dietetics, 125(9), 1242–1255.e10 https://doi.org/10.1016/j.jand.2025.04.014
3 Delaware Health and Social Services, Division of Public Health. (1995-2024). Behavioral Risk Factor Survey [Data set]
4 Centers for Disease Control and Prevention. (n.d.) PLACES: local data for better health, census tract data 2022 release. National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. https://chronicdata.cdc.gov/500-Cities-Places/PLACES-Local-Data-for-BetterHealth-Census-Tract-D/cwsq-ngmh
5 Centers for Disease Control and Prevention. (n.d.). Social vulnerability index. Agency for Toxic Substances and Disease Registry/ Geospatial Research, Analysis, and Services Program, 2020 Database Delaware. https://www.atsdr.cdc.gov/placeandhealth/svi/data_documentation_download.html
6 U.S. Cancer Statistics Working Group. (2025). U.S. cancer statistics data visualizations tool. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; https://www.cdc.gov/cancer/dataviz
7 English, L. K., Raghavan, R., Obbagy, J. E., Callahan, E. H., Fultz, A. K., Nevins, J. E. H., … Stoody, E. E. (2024, January). Dietary patterns and health: Insights from NESR systematic reviews to inform the dietary guidelines for Americans. Journal of Nutrition Education and Behavior, 56(1), 75–87 https://doi.org/10.1016/j.jneb.2023.10.001
8. Healthy Communities Delaware. (2025). Data dashboard. https://healthycommunitiesde.org/data-dashboard
9 Reber, E., Schönenberger, K. A., Vasiloglou, M. F., & Stanga, Z. (2021, April 7). Nutritional risk screening in cancer patients: The first step toward better clinical outcome. Frontiers in Nutrition, 8, 603936. Retrieved from https://pubmed.ncbi.nlm.nih.gov/33898493/ https://doi.org/10.3389/fnut.2021.603936
10. Koshimoto, S., Amano, K., Mori, N., Imai, A., Sasaki, M., Miyajima, M., & Takeuchi, T. (2025, May 12). The role of registered dietitians in cancer palliative care: Responsibilities, challenges, and interdisciplinary collaboration-a crosssectional survey. Current Oncology (Toronto, Ont.), 32(5), 275. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC12109665/ https://doi.org/10.3390/curroncol32050275
11 Rozga, M., Moloney, L., & Handu, D. (2025). Dietitian-provided interventions for adults with cancer: An umbrella review of systematic reviews. Nutrition and Cancer, 77(6), 575–589. Retrieved from https://www.tandfonline.com/doi/full/10.1080/01635581.2025.2480317 https://doi.org/10.1080/01635581.2025.2480317
12. Penn Medicine. (2023, Oct). Food insecurity affects mortality risk among cancer survivors. https://www.pennmedicine.org/news/food-insecurity-affects-mortality-riskamong-cancer-survivors
13 Centers for Disease Control and Prevention. (2024, May 15). Healthy food environments. U.S. Department of Health & Human Services. https://www.cdc.gov/nutrition/php/healthy-food-environments/index.html
14 U.S. Department of Agriculture. (2022). USDA actions on nutrition security.
Integrating Food and Care: Evaluating Impacts of Delaware Food Farmacy, a Food is Medicine Pilot for Maternal Health
Allison Karpyn, Ph.D.
Professor, Human Development and Family Sciences; Co-Director, Center for Research in Education & Social Policy, University of Delaware
Vandeka Eze
Doctoral Student, Education and Social Policy, University of Delaware
Michelle Axe, M.S., C.H.E.S.
Program Manager, Community Health, ChristianaCare
ABSTRACT
Objective: The study examined participant experiences in a community-based Food is Medicine (FIM) program for pregnant women in Delaware, focusing on program structure, support services, health impacts, and perceived dignity and respect. Methods: Using a qualitative design, 7 postpartum participants who completed the FIM pilot during pregnancy participated in semi-structured interviews that were transcribed and analyzed using thematic analysis, generating five conceptual categories and 25 themes. Results: Participants described substantial benefits, including improved food security, healthier eating behaviors, and emotional well-being supported through Community Health Workers and Case Management. They valued the program’s respectful delivery, high food quality, convenient home delivery, and personalized dietary guidance. Reported challenges included limited program duration, restricted snack variety, and communication gaps related to goal-setting and resource navigation. Conclusions: Findings suggest that FIM programs tailored to pregnant women can have multidimensional effects that extend beyond nutrition to encompass economic stability, mental health, and access to social supports. The integration of Community Health Workers and participant-centered service delivery emerged as key strengths, underscoring the potential of FIM models to enhance perinatal health outcomes and equity.
FUNDING
This research was supported by the Administration for Children and Families, Office of Planning, Research, and Evaluation, as part of the ACF Congressionally Directed Community Projects initiative. We thank the participants who generously shared their experiences and the program staff who facilitated recruitment. We acknowledge the contributions of the interview team and transcription services. The authors declare no conflicts of interest.
INTRODUCTION
Poor nutrition and food insecurity during pregnancy poses significant risks to maternal and infant health outcomes. Approximately 10-15% of pregnant women in the United States experience food insecurity, defined as limited or uncertain access to adequate, nutritious food.1 Food-insecure pregnant women face elevated risks for gestational diabetes, preeclampsia, preterm birth, low birthweight infants, and postpartum depression.2,3 The physiological demands of pregnancy increase nutritional requirements precisely when economic constraints may limit dietary quality, creating a critical vulnerability period.4
Traditional food assistance programs, including the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), provide essential support but may not fully address the complex needs of food-insecure pregnant women.5 These programs often require recipients to shop independently, which may present barriers related to transportation, time, knowledge of healthy food preparation, and physical limitations
during pregnancy. Additionally, benefit levels may be insufficient to ensure consistent access to nutrient-dense foods throughout the month.6
Food is Medicine (FIM) programs have emerged as innovative interventions designed to address food insecurity among vulnerable populations through medically tailored food provision.7 These programs typically integrate food delivery or distribution with healthcare settings, often including nutrition education, culinary instruction, and wraparound support services.8 The medically tailored approach recognizes that nutrition plays a therapeutic role in preventing and managing chronic conditions, positioning food access as a health intervention rather than solely a social service.9
Recent evidence suggests FIM programs can improve dietary quality, reduce food insecurity, and potentially decrease healthcare utilization and costs.8,10 A randomized controlled trial of medically tailored meals for patients with chronic conditions demonstrated reduced healthcare costs and improved clinical outcomes.11 Similarly, produce prescription programs have shown improvements in fruit and vegetable consumption, body mass index, and blood glucose control.12,13 However, most FIM research has focused on individuals with diagnosed chronic diseases such as diabetes, cardiovascular disease, or cancer.7
Limited research has specifically examined FIM programs targeting pregnant women, despite pregnancy representing a critical window for nutritional intervention.14 Pregnancy offers unique opportunities for health behavior change, as women are often highly motivated to optimize outcomes for their infants.15
Moreover, nutritional interventions during pregnancy can have intergenerational effects, influencing offspring metabolic programming and long-term health trajectories.16
Beyond direct nutritional benefits, FIM programs may address multiple social determinants of health by connecting participants with CHWs who can provide resource navigation, and community support.17 For pregnant women facing economic instability, the perinatal period often coincides with compounded challenges including housing insecurity, transportation barriers, employment disruptions, and social isolation.18 Comprehensive FIM programs incorporating CHWs may be particularly wellsuited to addressing these intersecting needs.
Qualitative research is essential for understanding participant experiences with FIM programs, including perceived benefits, barriers, program strengths, and areas for improvement.19 Participant perspectives can illuminate how program design elements, such as delivery mechanisms, food selection processes, case management support, and interpersonal interactions, influence engagement, satisfaction, and outcomes.20 Furthermore, qualitative inquiry can reveal whether FIM programs respect participant dignity and autonomy, critical considerations for programs serving economically vulnerable populations who may have experienced stigma in other assistance contexts.21
The present study aimed to conduct an in-depth qualitative examination of participant experiences in a FIM pilot program targeting pregnant women in Delaware. Through individual interviews with program graduates, we sought to: (1) understand participant perceptions of program structure and operations; (2) explore the role of Community Health Workers and Community Health Workers and Case Management and support services; (3) examine perceived health and behavioral impacts; (4) assess economic and material benefits; and (5) investigate participant experiences related to dignity, respect, and stigma. This research addresses a critical gap in the FIM literature by centering the voices of pregnant women and providing actionable insights for program refinement and expansion.
METHODS
Design
This qualitative study employed individual semi-structured interviews to explore participant experiences with a FIM pilot program for pregnant women. The study design was approved by the Institutional Review Board at the University of Delaware. A qualitative approach was selected to enable rich, detailed exploration of participant perspectives and to generate insights that could inform program improvement and scalability.22
Setting and Program Description
The study was conducted in Delaware in partnership with ChristianaCare, a hospital-based Food is Medicine (FIM) program serving pregnant women. The Women’s Health Delaware Food Farmacy (DFF) operated as a pilot initiative testing the feasibility and acceptability of providing medically tailored groceries to pregnant women experiencing high risk pregnancies. The over-arching study was implemented as a randomized controlled trial, with eligible participants assigned to either an intervention group receiving the full program or a control group receiving standard care. Data presented here is from a purposeful sample of participants.
Eligible participants were ChristianaCare Women’s Health patients who were 18 years or older and between 4 to 14 weeks pregnant at enrollment with a singleton pregnancy. Additional requirements included having Medicaid insurance, a Body Mass Index (BMI) of 30 or higher, and residence in New Castle County, Delaware. Exclusion criteria included Type I or II diabetes, multiple pregnancy, already being enrolled in a CHW program, inability to store and prepare meals, severe medical comorbidities that might interfere with program participation, and inability to communicate effectively in English or Spanish.
The intervention included three main components: 1) weekly food delivery of medically tailored food boxes containing fresh produce, proteins including poultry, fish, and meat options, whole grains, dairy products, cooking staples such as oils and seasonings, and shelf-stable items (enough food for approximately 10 meals per person in the household, and participants could select food preferences from a menu distributed in advance by their Community Health Worker); 2) Community Health Worker support via a dedicated CHW who provided resource navigation and connections to community services such as SNAP, WIC, and financial assistance programs as well as special support pertaining to family-specific situations, was assigned to each participant. The CHW conducted weekly check-ins and monthly in-person visits and assisted participants with goal setting; 3) Nutrition education included recipes tailored to the foods available on their weekly menu, cooking demonstrations including some in-home meal preparation sessions, and educational nutrition videos. Participants also received welcome kits with cooking equipment including measuring cups, spoons, and other supplies to support meal preparation at home; when needed, participants could also access clinical services with pharmacists, registered dieticians, and behavioral health consultants to address additional health needs that arose during their pregnancy.
The program incorporated culturally responsive elements including culturally relevant foods, recipes, and cooking equipment. All materials and support were available in English and Spanish, with certified interpreters serving Spanish-speaking participants. A community advisory board provided ongoing input on food selections and educational materials to ensure cultural appropriateness and community acceptability.
Participants
The program enrolled participants during early pregnancy, specifically between 4- and 14-weeks gestation, and continued through delivery and one month postpartum. This meant participants received approximately 22 to 42 weeks of support depending on their gestational age at enrollment and the length of their pregnancy. The program was implemented in partnership with Lutheran Community Services (LCS), a nonprofit organization with 61 years of experience providing food assistance. LCS managed food sourcing, box preparation, and delivery logistics.
Seven postpartum women who had completed the FIM program were recruited for interviews. All participants had received program services during pregnancy and had delivered healthy infants 1-14 months prior to interviews. Recruitment occurred through program staff outreach to former participants via phone and email. Purposive sampling was employed to ensure representation of diverse experiences within the program.
Participants responded to a survey, post interview, providing self-identifying demographic characteristics. Response data reflected socioeconomic diversity. The age range of mothers were late 20’s to late 30’s (27 to 38 years old). Roughly four lived with a partner or spouse, while three identified as single, reflecting a mix of family compositions. The sample was racially diverse, with a majority identifying as Black (n=4), alongside White, Hispanic/ Latina, and a North African respondent. Educational attainment skewed with six of seven having a high school degree or some college, and one individual who did not complete high school. Correspondingly, household incomes were concentrated below $30,000 while there was one reported family income earning less than $60,000. Employment was unstable, with no participants working full-time but were either self-employed (n=1), part-time (n=2), stay-at-home (n=2), or unemployed (n=2).
While experiences of homelessness were discussed during program participation, housing stability varied slightly at the time of the interview. Six women rented homes or apartments, while only one reported living with family or friends without paying rent. Typical household sizes ranged from two to five people, and all respondents were caregivers for one to three children under 18. There was one participant who reported living with a senior household member.
Food insecurity was a shared concern. Five participants said it was “sometimes true” that they worried food would run out, and four participants noted that it was ”sometimes true” that the food they bought just didn’t last with no money to get more. Nearly all participants received public assistance during their pregnancy, including SNAP (5 of 7) and WIC (6 of 7), with one also on Medicaid.
Data Collection
Individual interviews were conducted between July and September 2025 via video conference platform for participant convenience. Interviews lasted approximately 30-60 minutes and were conducted by a trained graduate research assistant or faculty investigator with expertise in qualitative methods. An interview guide was developed based on program evaluation goals and focused on: Program structure and operations (delivery, food selection, quantity, quality); Food preparation and utilization; Community Health Workers and Community Health Workers and Case Management experiences and support services; Health and behavioral impacts; Economic impacts and food security; Experiences with dignity, respect, and stigma; and Recommendations for program improvement.
The interview guide employed open-ended questions with probing follow-up questions to elicit detailed narratives. For example, participants were asked: “Can you describe how the program worked from your perspective?” and “Did you feel supported or respected while receiving food through the program?” All interviews were audio-recorded with participant consent and transcribed verbatim by a professional transcription service. Transcripts were de-identified to protect participant confidentiality, with all personal names and identifying information removed or replaced with generic placeholders.
Data Analysis
Transcripts were analyzed using thematic analysis following the approach outlined by Braun and Clarke.23 The analysis proceeded through six phases: familiarization, initial coding; theme
development; theme review; theme definition and conceptual organization where ultimately, themes were organized into five overarching conceptual categories representing distinct domains of program experience: (1) Program Structure & Operations, (2) Community Health Workers and Community Health Workers and Case Management & Support Services, (3) Health & Behavioral Impacts, (4) Economic & Material Impacts, and (5) Dignity, Respect & Stigma-related Constructs.
Researcher Positionality
The research team included investigators with backgrounds in public health, human development and health equity. None of the researchers were involved in program delivery, ensuring independence in data collection and analysis. Team members engaged in reflexive practices to examine how their own assumptions and experiences might influence interpretation of participant narratives.
RESULTS
The thematic analysis yielded 15 distinct themes organized into five conceptual categories: (1) Program Structure & Operations, (2) Community Health Worker Support & Case Management, (3) Health & Behavioral Impacts, (4) Economic & Material Impacts, and (5) Dignity, Respect & Stigma-related Constructs (table 1). Below we present each category with constituent themes and illustrative quotations.
Category 1: Program Structure & Operations
Theme 1.1: Accessibility and Convenience
The home delivery aspect was consistently highlighted, particularly for pregnant women managing multiple responsibilities. One participant with twins emphasized: “I also have twins, so at the time when I was pregnant, my twins were, like, one... just getting to the grocery store while pregnant with twins was just not the easiest thing to do” (Participant 2). Another mother expressed similar relief: “I didn’t want to go anywhere. I was big, I didn’t want to walk, I didn’t want to do anything, so it was just love just to have everything delivered to the house” (Participant 1). An additional participant noted the flexibility: “Mine’s was delivered at first, and then when I moved, I started picking it up (Participant 7)
Theme 1.2: Food Quality, Variety, and Selection
Participants were pleasantly surprised by the consistently high quality of food provided and valued having autonomy in selecting foods that matched their preferences and needs. One mother shared her surprise: “when I hear food bank, I think of, like, rotten, spoiled food. I never had a bad experience with my produce being bad, the food being expired” (Participant 1). Another confirmed: “I think everything was fresh... I would say 99% of the time, everything was fresh. The salmon and everything was always frozen. So I never had any issues” (Participant 2).
Participants appreciated the ability to customize selections: “I could change them each month. So, that was good, too... I love the quantity. Like, they gave us so much” (Participant 1). Another noted: “They’ll send a message of the list of what you could pick for... I thought that was really nice, because then I can look through it, and then... Be like, here we go” (Participant 6). However, some noted limitations: “I guess one of the only other things that I would change is, like, the options as far as, like, the food... I had food aversions. So, there were certain things that I couldn’t stomach. For example, poultry” (Participant 7).
Theme 1.3: Cooking Support and Practical Resources
The program provided practical cooking assistance, recipes, and essential ingredients that empowered participants. One unique experience was described: “She would come to my house as well, and, like, help me cook, or, like, help come up with recipes... we basically, like, meal prep some of the, groceries. So we made, like, salmon and, we made potatoes in the air fryer, and we did some overnight oats” (Participant 2).
Specific items like cooking oils, seasonings, and versatile ingredients were highly valued. Participants enthusiastically discussed favorites: “They also gave seasonings, I like that as well... I think I’ve just started running out, like, the canned oils, can spray they... they gave for cooking” and “That was my favorite!... They just were piling up, and like, I just ran out, and I’m like, dang, this last time” (Participant 7). Additional participants valued the recipes: “There’s also, like, little things that the lady gave me to, like, what you can make with all these things that you’re provided with... I got a bunch of those in the folder every time” (Participant 6). One mother received additional support: “I needed the air fryer, and they came through with one for me... [my CHW/CHW], she will send me some, like, some recipes... I tried out some recipes, that was really good, and then I mainly meal prep every week” (Participant 5).
Theme 1.4: Program Customization and Recommendations
The program demonstrated flexibility in adapting to individual needs while participants also suggested improvements. One participant explained: “I had food aversions... they did, accommodate by giving me, like. For example, more salmon instead of poultry” (Participant 2). Another appreciated: “I loved the options. It was... I had got ground turkey, I got fish, salmon, so I, I, I enjoyed that, that aspect of it” (Participant 1). A third noted: “if I didn’t like it, I would just tell her, like, I don’t want that anymore, and she just takes it off” (Participant 5).
Participants requested more snack items to complement meal ingredients: “I would probably include, like, snacks... like, a not-salted, like, chip, or, like, low-sodium, anything like a chip, like, I love a chip” (Participant 1). Another added: “granola bars would be good... Nutri-Green, maybe?” and “Crackers would be nice to go with the cheese” (Participant 1). Regarding beans, multiple participants suggested: “The beans, the dried beans... I didn’t really know what to do with them... it would have been nice if, like, they were canned beans versus the dried beans” (Participant 3) and “I think that would have been a little easier. So then you don’t have to wait to prep it” (Participant 6).
Theme 1.5:
Desire for Program Extension
Participants consistently wished the program lasted longer. One mother stated directly: “only thing I would change is I wish, like, the foreground was a little longer. That’s probably the only thing I would change” (Participant 1). Another recommended: “I would recommend, like, say if the program was to go on longer after we, like, you know, give birth, like the [nurse home visiting program] ... Healthy options for babies, or giving us, you know, more, like, menus or, like, recipes for babies when they’re born” (Participant 7). A third noted appreciation for the transition: “I thought it was nice that they reached out and let me know, like, hey, next week is gonna be your last week” (Participant 6).
Category 2: Community Health Worker Support & Case Management
Theme 2.1:
Comprehensive, Holistic Support
The assigned Community Health Workers (CHWs) provided support that extended far beyond food delivery, addressing multiple needs simultaneously. One participant detailed: “she had resources for him [husband]... it was, like, another lady, I forget her name, she would call and check on me, like, I think, like, every month... that helped me. It opened me to be more vocal about my feelings and how I’m doing mentally, not only physically” (Participant 1). Another mother described practical assistance: “she would actually, like, meet me at my doctor’s appointment, help me get the kids in with me, and, like, kind of keep them entertained while I was getting the ultrasound done” (Participant 2). Additional support included: “[my CHW] got, got funds approved to have a [support service provider] ... and had gotten me set up with [them], and had gotten funds approved to pay for it, so that I got most of my laundry done” (Participant 3).
Participants gained access to a network of resources they wouldn’t have known about otherwise. One mother explained: “even the nurse program I’m in today, the nurse, I think it’s called [nurse home visiting program], where you... they give you the nurse up until you’re... the baby’s two years old... even after the program, they said we could still come up there every Friday and get us a food package” (Participant 1). Another emphasized the breadth of support: “resources for that, housing resource, so it’s so many... The diaper bank, resources for that, housing resource, so it’s so many, those could go on” (Participant 5).
Theme 2.2:
Strong Relationships with Community Health Workers
Deep, trusting relationships developed between participants and their assigned workers. One mother expressed: “[my CHW], [my CHW], [my CHW]! Like, she was just so helpful. And she ended up being in the hospital, like, she was, like, working there, so I invited her... I’ve seen, like. The program is like a family, pretty much” (Participant 1). Another stated: “I don’t know where I would be without the program or her” (Participant 5). A third praised their worker during face to face meetings, but struggled a bit connecting via phone: “She was really cool, but there was times where I did reach out, and she wouldn’t reach out to, like. Maybe, like, a week or two... But whenever she would see me face-to-face, I’ll, like, ask her” (Participant 6).
Theme 2.3: Material Needs Support: Housing and Transportation
The program addressed critical housing and transportation needs for participants. One mother shared: “when I first got in the program, I was staying at the motel” and received help finding permanent housing within “maybe, like, 4 months? 4 or 5 months?” through connection with the CHW who helped me connect with “this lady to help me find housing” (Participant 5). Another faced eviction: “I was going through eviction... Eventually, I did, I was able to fight my eviction. I just got the full commitment to the back payment, actually, on Monday... I made $1,600 off their [gig work service]. And I was able to put it on towards the rent” (Participant 4).
Transportation barriers were also addressed. One participant explained: “I had issues dealing with [transportation service], the transportation company with [insurance program], and
they would just give me a hard time every time I was trying to schedule... so there were often times where I was taking the bus... [my CHW] was setting up transportation, because I think there was transportation allowed through the program as well... the bus passes, the rides were definitely a huge relief” (Participant 3).
Theme 2.4: Community Building and Social Connection
The program helped address social isolation during pregnancy. One participant shared that her CHW wanted to create connection: “I told her I didn’t have any friends in Delaware. She’s like, oh man, I have to put together, like, a mommy program for us, like, in the program, so you guys could, you know, get out and talk... I think that would have helped, you know, some of us get out the house and be more hands-on” (Participant 1). Another mentioned community events: “they had, like. Get-togethers at the hospital... I went to one... I thought it was cool. There’s, like. People from the library that are there... they would, like, help you get a library card for your baby” (Participant 6).
Theme 2.5: Communication and Navigation Challenges
Some participants identified gaps in communication, followthrough on goals, and difficulties navigating resources. One mother explained: “I feel like it should be, like, more communication... about how I am meeting my goals? Because they have to, like, set goals for the week. (Participant 5). Resource navigation also posed challenges for one mother. As she described: “when I’m reaching out to [referral hotline], they’re telling me, well, who referred you, or what people told you, like, to reach out for these programs... and they would just be, like, smack at square one.” She explained the coordinator “knew, but she didn’t know, like, all the details, like, she didn’t maybe know, like, where to, like, point me at, or who to point me to, she just had the general help line.” (Participant 4).
Category 3: Health & Behavioral Impacts
Theme 3.1: Sustained Behavior Change and Healthier Eating Habits
Participants reported lasting changes in their approach to nutrition and meal planning. One mother described becoming “more mindful of what you eat... when I go shopping, I definitely am more mindful of what I pick up” (Participant 1). Another participant noted considerable health outcomes: “I do feel like, health-wise, for sure, ever since the program, I haven’t really reverted back to eating out a lot like I used to... I’ve lost 60 pounds or so since I had my baby” (Participant 2). A third emphasized the shift: “it would have probably been, like, [fast food restaurant] or something, but with the box, it’s a lot healthier... It was nice to have healthier options, instead of, like, oh, I’m gonna eat out” (Participant 6).
Theme 3.2: Maternal Health Outcomes
Participants connected the healthy food to better health outcomes during and after pregnancy. One mother reflected on the consequences when she stopped eating program foods: “I ended up getting high blood pressure... It’s really, you know, what I’m eating. It wasn’t even the stress... I end up going into labor two weeks early... I should have stuck to my, you know, recipes and what I learned from the program” (Participant 1). Another noted positive impacts: “I would say that definitely, as far as mentally, I was happy, because I could always know that something... it was
like security... I’m definitely, I was 235, When, I had the baby, I’m now down to 210” (Participant 4).
The program provided tailored dietary guidance for pregnancyrelated health issues. One mother explained: “I was sick a lot throughout my pregnancy. So, it was like, I was barely eating anything, honestly... she was like, oh, you should try this, and then every week when we were selected... we were selecting the food. It was, like, more so encouraging me to try different stuff so I won’t be stuck, like, eating the same thing all the time” (Participant 5). Another noted: “me being, like, a high-risk pregnant person... the list options was like, okay, this is probably good, because they got, like, all the healthier options that I need” (Participant 7).
Theme 3.3: Family Nutrition and Child Health
The program positively influenced children’s eating habits and family nutrition patterns. One mother observed: “She loves vegetables. She loves yams, it’s her favorite, but yeah, vegetables is a thing in our house now. Thanks because of the program” (Participant 1). Another noted: “My daughter, I need a snack and some oranges in there... everything came in handy” (Participant 1). A third participant shared: “They gave you enough for your household. So it was like, everybody is incorporating, like, this healthiness into their diet” (Participant 5).
Theme
3.4:
Emotional and Mental Health Support
The program provided crucial emotional support during a vulnerable time. One participant shared: “my pregnancy. I was very emotional... my CHW was very patient with me, like, when I didn’t want to be bothered, she was just, like, so gentle with me” (Participant 1). Another described opening up about mental health: “with my postpartum, and prepartum, I’ll call it, too she really helped me. It opened me to be more vocal about my feelings and how I’m doing mentally, not only physically” (Participant 7). An additional mother explained: “Having that extra support really helped, you know, helped me stay on track, because it was motivation to, you know, get up and go to my therapy appointment” (Participant 3).
Category 4: Economic & Material Impacts
Theme 4.1: Food Security and Financial Relief
Participants described significant financial relief from receiving regular food deliveries, which allowed them to redirect limited resources to other household necessities. As one mother explained, the timing was crucial: “I wasn’t working, so… and I was going through a lot financially, so I wasn’t really able to afford a lot of food while I was, you know, in the beginning of my pregnancy” (Participant 1). The program’s support with food provision alleviated other burdens as another participant noted how “it came towards, like, the end of the month, and running low on food, knowing that I don’t have to spend cash on it. Then I could definitely go put gas in my car, or put it towards an extra bill” (Participant 7). A third mother emphasized: “[benefits programs] doesn’t cover your full month... it’s a supplement. And, you know, since I wasn’t working, I didn’t have anything to supplement the supplement. So, the food farmacy program kind of stepped in and was that supplement” (Participant 3).
Theme 4.2: Superiority to Other Food Assistance Programs
Participants consistently rated this program superior to alternatives. One mother contrasted: “the [alternative meal
delivery program] ... the food came busted sometimes, some of the food was old... Compared to other programs, I definitely would put this at the top” (Participant 1). Another noted: “no other food program, [nutrition assistance program] or anything like that has ever delivered food to my home. So, from a convenience standpoint, it was very, very helpful” (Participant 2). A third participant emphasized: “This is not like a food giveaway, oh, like, yeah, we just fed the homeless, leave them, they’re good, they just ate. It’s deeper than that with this program” (Participant 4).
Participants consistently described feeling respected and valued throughout their program experience. One mother stated: “I felt respected every time I went to go get my food, or every time I needed help... [my CHW] always was attentive... I felt respected throughout the whole program” (Participant 1). Another emphasized the lack of stigma: “The program made me feel no shame, how comfortable I was in it, in expressing myself and my concerns and my resources that were offered to me” (Participant 7). A third participant noted: “I felt like I was treated with respect... I, at first, I was, like, nervous about joining it, because I was like, oh, like, are people gonna judge me…?” (Participant 6).
Theme 5.2: Overcoming Stigma and Advocacy
Many participants described initial nervousness that was overcome through positive experiences, leading to active word-ofmouth recommendations. One mother explained: “I... I get where some people are probably like. I don’t want to feel embarrassed, or, you know, like, oh, are they gonna look at me or treat me different because I’m in a program? Or something, but I... I was like that at first, but then I really... I needed it. I thought it was very nice to have” (Participant 6).
Following positive experiences, participants actively wanted to share the program with others. One mother lamented: “I had two mommies, I’m like, I want to recommend the program but … I’m like, I can’t even recommend it, because it’s just a study” (Participant 1). Another told friends: “I actually offered them to come live out here with me, so they could get all these, like, resources out here” (Participant 7). A third shared: “After I was done, I was trying to get a bunch of other girls to, like, hey, you should look into it, because, like, it’s really useful.” (Participant 6).
DISCUSSION
This qualitative study provides rich, detailed insights into pregnant women’s experiences with a FIM pilot program, revealing multi-dimensional benefits extending beyond nutrition to encompass economic stability (and housing), mental health support, and dignified service provision. Our findings align with and extend prior FIM research while highlighting unique considerations for programs serving pregnant women.
Our findings corroborate previous research demonstrating that FIM programs effectively reduce food insecurity and improve dietary quality.8,13 Similar to Berkowitz et al.’s study of medically tailored meals for patients with chronic conditions, participants in our study reported sustained behavior change, with multiple mothers describing continued healthy eating patterns postpartum, including substantial weight loss and mindful food purchasing.11 This suggests FIM programs may catalyze lasting dietary
improvements that extend beyond program participation. The convenience of home delivery emerged as a critical program element, consistent with findings from other FIM evaluations.12,19 For pregnant women managing physical discomfort, childcare responsibilities often with other young children to care for, and transportation barriers, eliminating the need for grocery shopping represented substantial burden reduction. This finding underscores the importance of delivery-based models for populations facing mobility limitations.
A distinctive finding was the exceptional quality and freshness of food provided, which contrasted sharply with participants’ expectations and prior experiences with food assistance. Multiple participants expressed surprise that food bank items were not “rotten” or “expired,” highlighting persistent stigma surrounding charitable food distribution.21,24 The provision of high-quality, fresh produce and proteins challenged deficit narratives about food assistance recipients and affirmed participants’ worthiness of nutritious food. This aligns with emerging FIM scholarship emphasizing the therapeutic and dignifying potential of food provision.25
Community Health Workers and Case Management as Core Program Component
A particularly salient finding was the critical role of CHWs in shaping participant experiences and outcomes. Participants described support from CHWs who addressed housing crises, secured transportation, arranged laundry services for one family where this was a particular challenge, attended medical appointments, and provided emotional support services far exceeding traditional nutrition program scope. This holistic support model resonates with social determinants of health frameworks recognizing that food insecurity rarely occurs in isolation but rather intertwines with other hardships.26 Indeed, participants described the value of getting help with needs beyond food, including for participants facing homelessness, eviction, and transportation barriers. However, we also identified gaps in Community Health Workers and Case Management implementation, including a few reports of inconsistent communication responsiveness and incomplete resource knowledge relating to referred resources.
Mental Health and Emotional Support
Another frequently reported program benefit was the emotional and mental health support participants received through the program. Multiple women described feeling comfortable disclosing mental health struggles, with one participant noting the program “opened me to be more vocal about my feelings and how I’m doing mentally, not only physically.” This finding aligns with research on the mental health impacts of food insecurity and the potential for food assistance programs to provide psychological relief.27,28
Pregnancy is a period of heightened vulnerability for mental health concerns including depression and anxiety.18 The emotional support participants received, which here was characterized by patience, gentleness, and non-judgment, appeared to create psychological safety that facilitated disclosure and connection. This finding suggests FIM programs for pregnant women should explicitly incorporate mental health screening and support, potentially through partnerships with perinatal mental health providers.
Table
Category Theme Quote 1
Program Structure & Operations
Accessibility and convenience
Food quality, variety, and selection
Cooking support and practical resources
Program customization and recommendations
Program extension
Community Health Worker Support & Case Management
“I didn’t want to go anywhere. I was big, I didn’t want to walk, I didn’t want to do anything, so it was just love just to have everything delivered to the house.” (P1)
“When I hear food bank, I think of, like, rotten, spoiled food. I never had a bad experience with my produce being bad, the food being expired.” (P1)
“She would come to my house as well, and, like, help me cook, or, like, help come up with recipes... we basically, like, meal prep.” (P2)
“I had food aversions... they did, accommodate by giving me, like. For example, more salmon instead.” (P2)
“Only thing I would change is I wish, like, the program was a little longer. That’s probably the only thing I would change.” (P1)
Quote 2
“You’re getting, like, the fruits, the vegetables, the protein, the sides, you’re getting everything that you really needed.” (P5)
“I could change them each month. So, that was good, too... I love the quantity. Like, they gave us so much.” (P1)
“They also gave seasonings, I like that as well... the canned oils, can spray they gave for cooking... That was my favorite!” (P1)
“Granola bars would be good... Crackers would be nice to go with the cheese.” (P1)
“I thought it was nice that they reached out and let me know, like, hey, next week is gonna be your last week, but it was still too short.” (P6)
Health & Behavioral Impacts
Comprehensive, holistic support
CHW relationships
Material needs support: housing and transportation
Community building and social connection
Communication and navigation challenges
Sustained behavior change and healthier eating habits
Maternal health outcomes
Family nutrition and child health
Emotional and mental health support
Economic & Material Impacts
Food security and financial relief
Superiority to other food assistance programs
Dignity & Stigmarelated Constructs
Respectful and dignified treatment
Overcoming stigma and advocacy
“She had resources for him... she would call and check on me... It opened me to be more vocal about my feelings and how I’m doing mentally, not only physically.” (P1)
“[My CHW], [my CHW], [my CHW]! Like, she was just so helpful... I’ve seen, like. The program like a family.” (P1)
“When I first got in the program, I was staying at the motel... She connected me with this lady to help me find housing.” (P5)
“I told her I didn’t have any friends in Delaware. She’s like, oh man, I have to put together, like, a mommy program for us.” (P1)
“I feel like it should be, like, more of a communication thing, like, hey, was your goals met for the week?” (P5)
“I do feel like, health-wise, for sure, ever since the program, I haven’t really reverted back to eating out a lot like I used to... I’ve lost 60 pounds.” (P2)
“I end up getting high blood pressure... I end up going into labor two weeks early... I should have stuck to my recipes.” (P1)
“She loves vegetables. She loves yams, it’s her favorite, but yeah, vegetables is a thing in our house now, because of the program.” (P1)
“My pregnancy. I was very emotional... my CHW was very patient with me, like, when I didn’t want to be bothered, she was just, like, so gentle with me.” (P1)
“I wasn’t working, so... and I was going through a lot financially, so I wasn’t really able to a ord a lot of food.” (P1)
“Compared to other programs, I definitely would put this at the top.” (P1)
“I felt respected every time I went to go get my food, or every time I needed help... I felt respected throughout the whole program.” (P1)
“I, at first, I was, like, nervous about joining it, because I was like, oh, like, are people gonna judge me for, like, reaching out for help?” (P6)
“[My CHW] got funds approved to have a [support service]... so that I got most of my laundry done, which was really a problem in our house..” (P3)
“She was really cool, but there was times where I did reach out, and she wouldn’t reach out to, like maybe, like, a week or two.” (P6)
“[My CHW] was setting up transportation... the bus passes, the rides, and the laundry part were definitely a huge relief.” (P3)
“They had, like get-togethers at the hospital... People from the library... help you get a library card for your baby.” (P6)
“When I’m reaching out to [referral hotline], they’re telling me, well, who referred you... and they would just be, like, smack at square one.” (P4)
“It would have probably been, like, [fast food] or something, but with the box, it’s a lot healthier.” (P6)
“I was sick a lot throughout my pregnancy... she was like, oh, you should try this... encouraging me to try di erent stu .” (P5)
“They gave you enough for your household. So it was like, everybody is incorporating, like, this healthiness into their diet.” (P5)
“Having that extra support really helped... it was motivation to, you know, get up and go to my therapy appointment.” (P3)
“[Benefits program] doesn’t cover your full month... it’s a supplement... the food farmacy program kind of stepped in and was that supplement.” (P3)
“This is not like a food giveaway... we just fed the homeless, leave them... It’s deeper than that with this program.” (P4)
“I felt like I was treated with respect.” (P6)
“After I was done. I was trying to get a bunch of other girls to, like, hey, you should look into it, because, like. It’s really useful.” (P6)
Note. P = Participant. Quotes have been lightly edited for clarity while preserving participant voice and meaning.
Dignity and Respect in Service Delivery
Participants universally described feeling respected throughout program participation, a finding with important implications given documented experiences of stigma in traditional food assistance contexts.21,24 Several participants initially hesitated to enroll due to anticipated judgment but were pleasantly surprised by respectful treatment. The program’s structure which allows food choice, delivering to homes, providing high-quality items, appeared to communicate respect for participant autonomy and dignity. This finding resonates with person-centered care principles emphasizing collaboration, respect, and recognition of individual preferences.29 The contrast participants drew between this program and other food assistance experiences (e.g., describing the program as “not like a food giveaway... It’s deeper than that”) suggests FIM programs have potential to reimagine food assistance delivery in ways that center dignity and partnership rather than charity and dependence.30
Economic Impact and Supplementation of Existing Benefits
Participants described significant financial relief, with food boxes enabling them to redirect limited funds toward utilities, transportation, and household necessities. This finding quantifies qualitatively what other research has demonstrated numerically, that FIM programs can reduce household food expenditures and free resources for other essential needs.10,12 Notably, all participants were receiving SNAP and/or WIC benefits, yet still experienced food insecurity and valued FIM program participation. This aligns with research documenting that SNAP benefits, while essential, may not fully meet household food needs, particularly toward monthend.6 One participant explicitly described the FIM program as “a supplement to the supplement,” highlighting how FIM programs can fill gaps left by traditional assistance.
This finding has policy implications, suggesting FIM programs function not as SNAP/WIC replacements but as complementary interventions addressing limitations of existing programs. The combination of SNAP (providing purchasing flexibility), WIC (offering specific nutritious items), and FIM (delivering ready-to-use fresh foods with Community Health Workers and Community Health Workers and Case Management) appeared synergistic in meeting participants’ needs.
Food
Quality Issues and Program Refinements
While overwhelmingly positive, participants identified areas for improvement. Quality concerns emerged around specific items, particularly salmon which they found inedible. Though participants understood this as a salmon-related issue rather than program negligence, the experience caused distress during pregnancy when food safety concerns are heightened. This finding underscores the importance of rigorous quality assurance protocols for FIM programs providing perishable items.
Participants also recommended food modifications including: (1) replacing dried beans with canned alternatives to reduce preparation time; (2) providing beans less frequently or in smaller quantities; (3) adding more snack options including crackers, low-sodium chips, and granola bars; and (4) moderating peanut butter/nut quantities, particularly for
participants also receiving WIC. These concrete suggestions offer actionable guidance for program refinement.
The preference for convenient, ready-to-use items (canned vs. dried beans) reflects time poverty many pregnant women face, particularly those managing other children, employment, and pregnancy-related fatigue.31 FIM programs should balance nutrition optimization with practical feasibility, recognizing that foods requiring extensive preparation may go unused despite nutritional value.
Program Duration and Postpartum Extension
Participants universally desired longer program participation, with several recommending extension through postpartum and early infancy. This finding aligns with growing recognition that the “fourth trimester” represents a critical but under-supported period requiring intensive postpartum care.32 The transition off the program coincided with new parenting demands precisely when nutritional support might remain beneficial.
One participant recommended the program include infant feeding guidance and recipes for introducing solids, noting she was “clueless to what I’m doing. Like, I’ve been putting stuff in the blender.” This suggests FIM programs could extend impact by incorporating early childhood nutrition education, supporting optimal infant feeding practices that shape lifelong dietary patterns.33
Strengths, Limitations, and Future Directions
This study’s strengths include rich qualitative data from diverse participants, systematic thematic analysis, and focus on an understudied population (pregnant women) within FIM research. However, limitations warrant consideration. First, the small sample size (n=7), while appropriate for qualitative inquiry, limits transferability to other contexts. Second, all participants completed the program, introducing potential selection bias if program drop-outs had systematically different experiences. Third, interviews occurred postpartum (1-14 months after delivery), potentially subject to recall bias. Fourth, all participants received care from the same program in one geographic region, limiting generalizability.
Future research should employ mixed-methods approaches combining qualitative depth with quantitative outcome assessment, including clinical indicators (gestational weight gain, birth outcomes), behavioral measures (dietary quality), economic outcomes (healthcare utilization, food security scores), and mental health assessments. Longitudinal designs tracking participants through pregnancy, delivery, and postpartum would illuminate how program impact evolves across the perinatal continuum. Comparative studies examining different FIM models (e.g., medically tailored meals vs. produce prescriptions vs. comprehensive food boxes) could identify which approaches optimize outcomes for pregnant women.
Additionally, research should examine implementation factors affecting program effectiveness, including Community Health Workers and Case Management ratios, staff training approaches, partnership structures, and cost-effectiveness. Understanding the “active ingredients” of successful FIM programs will enable replication and scaling.
Implications for Practice and Policy
Our findings suggest several implications for FIM program design and policy:
1. Prioritize Home Delivery: Delivery-based models remove critical barriers for pregnant women and should be standard practice.
2. Embed Community Health Workers and Case Management: FIM programs should incorporate trained CHWs with capacity for holistic support addressing housing, transportation, mental health, and social needs, not nutrition alone.
3. Ensure Food Quality and Choice: High-quality, fresh foods and meaningful choice opportunities are essential for program acceptability and dignity.
4. Extend Duration: Programs should consider extending through postpartum and early infancy, potentially including infant nutrition support.
5. Provide Practical Foods: Balance nutrition optimization with convenience by offering readyto-use options requiring minimal preparation, considering too offerings provided by WIC to create variety and balance in provisions.
6. Create Communication Protocols: Systematic goalsetting, follow-up, and responsive communication enhance Community Health Workers and Case Management effectiveness.
7. Build Resource Knowledge: Staff require thorough training on available community resources and referral processes to effectively navigate participants.
8. Address Mental Health: Programs should screen for and support perinatal mental health needs, potentially through partnerships with mental health providers. At the policy level, our findings support expanded funding for FIM programs targeting pregnant women. With growing evidence of multi-dimensional benefits, policymakers should consider FIM programs as cost-effective interventions potentially reducing healthcare costs through improved maternal-child health outcomes. Several states have begun Medicaid reimbursement for medically tailored meals34; expanding such policies to include pregnant women could improve access and sustainability.
CONCLUSION
This qualitative study reveals that FIM programs for pregnant women deliver multi-dimensional benefits extending far beyond nutrition to encompass economic relief, comprehensive support services, mental health benefits, and dignified care provision. Participants described experiences characterized by reduced food insecurity, healthier eating behaviors, financial flexibility, holistic support for complex needs, and respectful interactions that honored their dignity and autonomy. While identifying areas for refinement, including program duration, specific food modifications, participants overwhelmingly endorsed the program and advocated for its expansion. These findings contribute to the growing evidence base supporting FIM programs as promising interventions for improving maternalchild health and addressing social determinants during the critical perinatal period.
Dr. Karpyn may be contacted at . karpyn@udel.edu
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25 Lê-Scherban, F., Ballester, L., Castro, J., Cohen, A., Castillo, R., Olson, E. C., . Garg, A. (2021). Identifying families with complex needs after screening for social determinants of health. Academic Pediatrics, 21(5), 930–938. https://doi.org/10.1016/j.acap.2021.01.014
26. Marmot, M., & Allen, J. J. (2014, September). Social determinants of health equity. American Journal of Public Health, 104(Suppl 4, Suppl 4), S517–S519 https://doi.org/10.2105/AJPH.2014.302200
27. Knowles, M., Rabinowich, J., Ettinger de Cuba, S., Cutts, D. B., & Chilton, M. (2016, January). “Do you wanna breathe or eat?”: Parent perspectives on child health consequences of food insecurity, trade-offs, and toxic stress. Maternal and Child Health Journal, 20(1), 25–32 https://doi.org/10.1007/s10995-015-1797-8
28 Maynard, M., Andrade, L., Packull-McCormick, S., Perlman, C. M., Leos-Toro, C., & Kirkpatrick, S. I. (2018, July 6). Food insecurity and mental health among females in high-income countries. International Journal of Environmental Research and Public Health, 15(7), 1424 https://doi.org/10.3390/ijerph15071424
29 Epstein, R. M., & Street, R. L., Jr. (2011, Mar-Apr). The values and value of patient-centered care. Annals of Family Medicine, 9(2), 100–103 https://doi.org/10.1370/afm.1239
30 Poppendieck, J. (1999). Sweet charity?: Emergency food and the end of entitlement Penguin Books.
31 De Henau, J., & Himmelweit, S. (2020). Unpacking within-household gender differences in partners’ subjective benefits from household income. Review of Income and Wealth, 66(4), 783–809 https://doi.org/10.1111/roiw.12457
32 Stuebe, A. M., & Bonuck, K. (2011, December). What predicts intent to breastfeed exclusively? Breastfeeding knowledge, attitudes, and beliefs in a diverse urban population. Breastfeed Med, 6(6), 413–420. https://doi.org/10.1089/bfm.2010.0088
33 Birch, L. L., & Doub, A. E. (2014, March). Learning to eat: Birth to age 2 y. The American Journal of Clinical Nutrition, 99(3), 723S–728S. https://doi.org/10.3945/ajcn.113.069047
34. Stenmark, S. H., Steiner, J. F., Marpadga, S., Debor, M., Underhill, K., & Seligman, H. (2018). Lessons Learned from Implementation of the Food Insecurity Screening and Referral Program at Kaiser Permanente Colorado. The Permanente Journal, 22, 18–093 https://doi.org/10.7812/TPP/18-093
Adults Need Protection During Respiratory Virus Season
Respiratory viruses like respiratory syncytial virus (RSV), flu and COVID-19 typically circulate in the fall and winter and share similar symptoms, risk factors, and prevention strategies. Symptoms from these viruses can range from mild to severe and some people are at increased risk for serious illness and hospitalization like older adults, people who are pregnant and those living with certain chronic medical conditions.
Certain chronic medical conditions put you at higher risk for serious illness:
• Chronic lung disease (like asthma or COPD)
• Heart disease
• Diabetes
• Weakened immune system
Vaccines Work!
Did you know?
Up to 160,000 older adults in the United States are hospitalized due to RSV each year.
Vaccination is the best form of protection against respiratory illness. Vaccines help prevent respiratory diseases by helping your body develop immunity and learn how to fight off a disease before getting infected.
A vaccine works by imitating an infection. It causes your immune system to start producing the same antibodies you would make if you were exposed to the real disease. This helps your body learn to recognize and fight an invasion of that virus or bacteria. Vaccination is the safest and most effective way to protect yourself.
Vaccination Recommendations
• Flu – Flu vaccination is recommended for everyone 6 months and older, every fall.
• COVID-19 – It is recommended that everyone 6 months and older receive an updated 2024-2025 COVID-19 vaccine.
• RSV – An RSV vaccine is recommended for:
• All adults aged 75 and older
• Adults aged 50-74 living with certain chronic medical conditions, like asthma, COPD and chronic heart disease
• Adults aged 50-74 living in nursing homes
If you’ve previously received an RSV vaccine, you do not need another one at this time.
Daily Actions to Prevent Respiratory Viruses
Staying up to date on your recommended vaccines is the best way to prevent complications and hospitalization from respiratory viruses like RSV, the flu and COVID-19. You can also take daily actions to help protect yourself, your family and your loved ones against serious illness, including:
Washing your hands with soap and water (or use hand sanitizer containing 60% alcohol).
Cleaning frequently touched surfaces.
Filtering indoor air or opening windows to bring outdoor air inside.
Covering coughs and sneezes with a tissue or your elbow.
Avoiding close contact with people who are sick.
Staying at home while you are sick.
Talk to your healthcare provider about what vaccines are recommended for you. Learn more at Lung.org/vaccines.
Educational Pathways of Delaware Dentists: An Investigative Review of Dental Educational Records Dating Over 85 Years
Matt McNeill, B.S.
Research Associate, Delaware Health Force, Delaware Academy of Medicine & Public Health
Timothy E. Gibbs, M.P.H.
Director and Primary Investigator, Delaware Health Force, Delaware Academy of Medicine & Public Health
Katherine Smith, M.D., M.P.H.
Executive Director, Delaware Academy of Medicine & Public Health
ABSTRACT
Objective: This report summarizes the findings from a comprehensive study conducted by The Delaware Academy of Medicine & Public Health’s Delaware Health Force program on the educational pathways of Delaware dentists from 1939-2024. Methods: Delaware undergraduate education, dental school attendance, residency hospital training, and stage transition records were stratified by gender and license activity status for practicing Delaware dentists, and trends based on Delaware proximity and regional movements were identified. Shifts in the Delaware dental pipeline were also identified. Results: The most common educational pathway for Delaware dentists was to complete their undergraduate education in Delaware, move to Pennsylvania for dental school, and then return to Delaware for residency and training. Most Delaware dentists remained in the Northeast for their entire training pathway. Conclusion: There is subtle regional diversity in the pathways of Delaware dentists, with an overwhelming leaning towards educational training at all levels in the Northeast and Mid-Atlantic regions of the country.
INTRODUCTION
Dentistry is a profession requiring extensive education and training. Understanding the educational pathways of practicing dentists provides insights into workforce development, regional educational influences, and potential areas for policy improvement. The Delaware Academy of Medicine & Public Health’s Delaware Health Force program conducted a study examining the educational backgrounds of all 1,259 dentists that have held a license in Delaware, since the introduction of electronic records. This report reviews their undergraduate education, dental school attendance, residency training, and transitions within their educational pathways.
METHODS
Study Population
The historical records of all dentists in Delaware were studied to determine the location of their undergraduate institution, dental school attended, and residency training location. Dentists were stratified by license status (active or inactive) and gender (male or female). Active licenses (N=1,259) include those dentists with an active Delaware dental license, a dentist academic license, or dental residency license. Inactive licenses include all other types of license statuses.
Education Pathway
All known information about undergraduate institutions, dental schools, and residency locations were compiled for the study population. Undergraduate records were found for 646 dentists (51.31%), dental school records for 1,037 dentists (82.37%), and residency records for 675 dentists (53.61%) out of the total 1,259 dentists studied.
Locations of all institutions were stratified into US Census Regions (table 1) and proximity to Delaware, based on state borders:
• Border States (states sharing a border with Delaware): Maryland, New Jersey, Pennsylvania
• States Bordering Border States: District of Colombia, New York, Ohio, Virginia, West Virginia
• Other States
• Other Countries
Table 1. US Census-Defined Regions
Northeast Connecticut, Delaware, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
South Alabama, Arkansas, District of Colombia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia
Midwest Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin
West Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming
Based on these data, trends on the movement of dentists from undergraduate institution to dental school, dental school to residency location, and residency location to Delaware were identified.
The final goal of this study was to examine the most influential dental schools and residency training locations over time. The results were stratified by the top five dental schools and residency
training locations, top five states for dental schools and residency training locations, and U.S. Census-defined regions for dental schools and residency training locations.
RESULTS
Undergraduate Education
The most common undergraduate school for Delaware dentists to attend was the University of Delaware (table 2). Pennsylvania (n=157) was the most common state in which Delaware dentists attended undergraduate studies, followed by Delaware (n=123), Maryland (n=56), New York (n=46), and Virginia (n=30).
Delaware dentists tended to complete their undergraduate studies in the northeast (n=371), followed by the south (n=164). Of the 646 dentists whose undergraduate institution was known, 123 attended school in Delaware, 231 attended school in one of Delaware’s bordering states, and 107 attended school in the states bordering Delaware’s border states. One hundred sixty (160) dentists came to Delaware after completing undergraduate education in another state, and 25 came from other countries (figure 1).
Dental School Attendance
Following undergraduate education, dental school attendance is a critical component of professional training. A majority of Delaware dentists attended Temple University for dental school (n=288), followed by the University of Maryland’s (n=165) and Pennsylvania’s Schools of Dentistry (n=135, see figure 2).
Of the 1,037 dentists with recorded dental schools, 665 attended dental school in one of Delaware’s border states. The state with the most Delaware dentists attending dental school within its borders
was Pennsylvania (n=466), followed by Maryland (n=165) and New York (n=66). A majority of dentists stayed in the northeast for dental school (n=613), although many also attended school in the south (n=305).
We also explored what the most common states to attend dental school were for individuals who graduated from an undergraduate school in Delaware. Of the 113 undergraduates from Delaware, 86.7% attended dental school in either Pennsylvania (n=76) or Maryland (n=22). Delaware universities graduating dental students included Delaware State University (4), University of Delaware (119), and Wesley College (1).
Residency Hospital Training
A majority of Delaware dentists completed their residency training at Christiana Care Health System (n=283, see figure 3). A smaller number completed their training in Pennsylvania, New York, and Maryland. Regionally, we again see a majority of Delaware dentists completing residency in the northeast, followed by the south
Figure 1. Undergraduate School States by Gender and License Status (n=646)
Table 2. Top 10 Undergraduate Universities for Delaware Dentists, by Gender & Current License Status (n=252)
2. Top 10 Dental Schools of Delaware Dentists, by Gender and License Status (n=768)
Figure
Figure 3. Top 10 Residency Hospitals for Delaware Dentists, by Gender & License Status (n=401)
Transitions Within Educational Pathways
Retention during transitions between undergraduate institution, dental school, and dental residency training were also studied. Because Delaware does not have a state dental school, all Delaware residents interested in attending dental school must leave the state to do so. Delaware dentists who began their undergraduate education in Pennsylvania tended to stay in Pennsylvania, but over 60% of Delaware dentists chose to attend dental school in a different state than the one in which they completed their undergraduate education (figure 4)
Transitions between U.S. Census-defined regions were also explored for this transition, to determine whether overall region played as great or similar an influence in transitional pathways as states. While the majority of students did change from one state to another, over 64% of students did not change from one region to another, indicating that staying within one’s region is more important than staying in specifically the same state between undergraduate and dental schools (figure 5).
Similarly, over 75% of dentists chose a different state for their residency training than the state in which they attended dental school (figure 6). The most frequent transition pathway was for dentists graduating in Pennsylvania to come to Delaware for their residency training. This may indicate that individuals who started their educational career in a Delaware undergraduate school may be more inclined to return to Delaware for residency training than another state, if they plan on staying in Delaware to practice.
Transitions between U.S. Census-defined regions were also explored for the transition between dental school and residency training (figure 7). Similar to the transition between undergraduate and dental schools, while the majority of dentists changed states between dental school and residency training, the majority also stayed within the same region between dental school and residency training. This may suggest that staying within one’s region is more important than staying within a specific state during a transitional period.
A deeper analysis was conducted on these transitional pathways to determine the most common undergraduate to dental school to residency training pathways both at the state level and at the regional level. These pathways were further stratified by gender and license activity status.
At the state level, Delaware dentists studied in Delaware for at least one of the three levels of education through their educational careers, in four out of five of the most common educational pathways (figure 8). The most common transitional pathway was to start in Delaware for undergraduate education, move to Pennsylvania for dental school, and return to Delaware for residency training. All female dentists that have taken this pathway are still actively practicing in Delaware.
At the regional level, the majority of dentists stayed in the Northeast region for their entire educational career, and all five of the most common educational pathways for dentists in Delaware included only transitions between the Northeast and South regions, with the fifth most common pathway completing all educational levels in the South (figure 9). This indicates that the Midwest and West regions do not contribute significantly to the educational pathways of Delaware dentists.
Figure 4. Proportion of Dentists Remaining in the Same State for Undergraduate and Dental School
Figure 5. Proportion of Dental Students Remaining in the Same Region as Their Undergraduate School
Figure 6. Proportion of Delaware Dental Residents Remaining in the Same Region as their Dental School
7. Dental Graduates with Regional Transition Between Dental School and Residency Hospital
Figure
Figure 8. Educational Pathways for Delaware Dentists, by Gender and License Status
Figure 9. Educational Region Pathways for Delaware Dentists, by Gender and License Status
Changes in Dental Education Over Time
Records for dental school graduation dates were obtained as far back as 1939. Three of the top five contributors over the last 85 years have been dental schools in Pennsylvania, with the number one contributor Temple Dental School being the strongest contributor through most of the latter half of the twentieth century, well into the twenty first century with a slight drop off in 2017 (figure 10)
The number one (Pennsylvania) and two (Maryland) states where Delaware dentists graduated from dental school are both Delaware border states. Despite New Jersey’s proximity to Delaware, it does not make the top five most common states for dental school attendance, superseded not only by New York and Washington D.C., but also by Massachusetts.
DISCUSSION
For most of Delaware’s history, the Northeast has been the most common region for dentists from Delaware to complete their dental education, with occasional spikes in dentists completing their education in the South due to the influence primarily of Maryland and Washington D.C.
The Northeast is by far the most common region for dentists in Delaware to complete their residency training. This is likely due not only to the influence of Pennsylvania, but also the added
influence of New York, specifically New York City, where the majority of residents from New York complete their training, and which has a high density of training hospitals due to a high population density. The South is the next most common region for dentists to complete residency training, likely due to the influence of Maryland and Washington D.C.
Records for residency training completion were obtained as far back as 1954. While the number one residency training location has been Christiana Care Health System since 1961, it is also the only residency training location in Delaware with any level of significant contribution to training Delaware dentists. Due primarily to the popularity of Christiana Care’s residency programs, Delaware is the number one state where dentists complete their residency before practicing in Delaware. All three of Delaware’s immediate border states are also among the most common states for Delaware dentists to complete residency training, which indicates that proximity to Delaware during residency may be a strong deciding factor in choosing to practice in Delaware.
Dentist Recruitment Action Plan
Recruiting dentists in Delaware hinges on understanding where graduates train and how that training translates into talent pipelines. In a state with a mix of urban centers, suburban communities, and rural pockets, knowing the
Figure 10. Changes in Delaware Dentist Dental School Education Sites Over Time
undergraduate origins, dental schools, and residency backgrounds of candidates will help to map recruiting channels, build lasting relationships, and design pathways that attract the right practitioners to practices and organizations. Because Delaware lacks a dental school within its borders, most local dentists will likely continue to come from programs in the Mid-Atlantic and Northeast and will likely remain close to their training communities after graduation. This amplifies the value of regional partnerships and a deliberate, Delawarefocused recruitment strategy that will leverage these crossborder connections and create a clear pipeline to practicing within the state.
Dental and Pre-Dental Pipelines
• Establishing relationships with nearby dental schools and residency programs in the Mid-Atlantic (Pennsylvania, New Jersey, Maryland, and New York);
• Establish relationships with pre-dental programs and campus career centers at universities in the surrounding region;
• Emphasizing externships, shadowing opportunities, and joint continuing education events that reveal practice culture and clinical strengths; and
• Offer Delaware-centric experiences to familiarize students with Delaware’s patient mix, payer landscape, and opportunities for mentorship.
Residency Pipelines
• Prioritize relationships with program directors and faculty in the Mid-Atlantic corridor;
• Establish a Delaware-focused residency-to-privatepractice pathway that includes mentorship, case collaboration, a defined ownership or partnership track, and financial incentives that acknowledge regional living costs and the local market;
• Create pathways for specialty programs (Orthodontics, Endodontics, Oral and Maxillofacial Surgery, Pediatric Dentistry, etc.) that reflect the needs of those specialties.
Implementation of this Action Plan in Delaware should be methodical and measurable. Residencies and institutions should build a candidate database that ties individuals to their training institution, graduation year, and preferred geographic regions, then segment outreach by target Delaware counties (New Castle, Kent, and Sussex) and by specialty needs. Outreach should be multi-channel and relationship-driven with personalized outreach to program directors and alumni coordinators, attendance at regional residency conferences, and active participation in school fairs and career events. Programs should offer meaningful experiences—externships in a Delaware practice, collaborative case reviews, and joint continuing education sessions—to demonstrate clinical quality and a welcoming practice culture. Incentives should include competitive compensation packages aligned with Delaware market data, along with loan-repayment support where feasible, professional development allowances, flexible scheduling, and a transparent path to ownership or leadership roles that aligns with candidates’ long-term goals.
Messaging and branding should emphasize how a Delaware practice supports clinicians who trained elsewhere but are drawn to the state’s quality of life, community impact, and growing patient base, and should highlight success stories of dentists who trained out of state and chose Delaware for residency, practice, or ownership opportunities.
Study Limitations
The study acknowledges limitations related to data completeness. Undergraduate records were found for 646 dentists (51.31%), dental school records for 1,037 dentists (82.37%), and residency records for 675 dentists (53.61%) out of the total 1,259 dentists studied. This data was further analyzed to determine which records obtained belonged to actively practicing dentists or dentists who no longer practice in Delaware. This information is provided to better contextualize the data, and these gaps may affect the generalizability of some conclusions.
CONCLUSION
The Delaware Academy of Medicine & Public Health’s investigation offers valuable insights into the educational pathways of Delaware dentists over 85 years. The data reveal subtle regional diversity in the pathways of Delaware dentists, with an overwhelming leaning towards educational training at all levels in the Northeast and Mid-Atlantic regions of the country, from New York to Washington D.C. This study highlights critical transitions in the educational pipeline for dentists in Delaware and touches on evolving trends in the pipeline over time. Despite some data limitations, this comprehensive analysis provides a foundation for future workforce planning and educational policy development in dentistry for the state of Delaware.
Mr. McNeill may be contacted at mmcneill@delamed.org
ACKNOWLEDGEMENT
The authors would like to recognize Junkui Cui, Ph.D. and Jose Hernandez-Yepez, B.S., for their contributions to this report.
A USDA, federally-funded program to provide reimbursement for meals served in childcare centers, adult day care centers, and family or group day care homes.
A team of highly trained registered dietitians who provide direct nutrition counseling and support to patients who want to lose weight, improve cardiovascular health, or feel better. Counseling is available for those who have special nutritional or sport-related needs, and works with the High School Wellness Centers in Delaware to promote the benefits of good nutrition to teens in Delaware.
Delaware 211
https://delaware211.org
Statewide helpline (call 2-1-1 or text zip code to 898-211) connecting residents to food assistance, housing, healthcare, and social services.
Delaware Academy of Nutrition and Dietetics
https://eatrightdelaware.org/resources/
A professional organization in Delaware comprised of registered dietitians, nutritionists, and dietetic technicians who reside and/or work in Delaware. The Delaware chapter of the Academy of Nutrition & Dietetics is made up by approximately 200 members, and provides education programs for members and advocates for nutrition-related legislative issues impacting the public.
Delaware Council on Farm and Food Policy
https://farmandfood.delaware.gov
Advises the governor on food policy and food security matters in Delaware, and coordinates statewide food system collaboration.
Delaware Farmers Markets
https://agriculture.delaware.gov/communications-marketing/farmers-markets-guide/ Comprehensive directory of Delaware farmers markets with locations, hours, and information on SNAP/EBT acceptance.
Delaware Food is Medicine Committee
A state committee established in 2025 to integrate nutrition into healthcare and improve health outcomes through food-based interventions. First State Food System Program
https://business.delaware.gov/delaware-grocery-initiatives-first-state-food-system-grant-program/ Supports Delaware farmers, grocers, and food supply chain entities to expand access to healthy foods in food deserts.
Food Bank of Delaware
https://fbd.org/
Distributes food statewide from local food closets, mobile pantries, and schools. Provides job training, nutrition education, financial coaching, SNAP outreach, and legislative advocacy.
Provides medically tailored groceries and nutrition education to Medicaid patients with chronic conditions.
Healthy Kids, Healthy Future (Nemours)
https://healthykidshealthyfuture.org/
A national effort to empower early care and education providers to make positive health changes in their child care programs. HKHF continues the work of “Let’s Move! Child Care.”
Lutheran Community Services Delaware – Food is Medicine
https://lcsde.org/food-is-medicine
Co-founder of Delaware Food Farmacy, delivers medically tailored groceries and operates food pantry programs across the state.
Physical Activity, Nutrition, and Obesity Prevention Section
https://dhss.delaware.gov/dph/dpc/panonutrition/
A division of the Delaware Division of Public Health focusing on healthy eating and physical activity.
Provides healthy and nutritious meals to children in Delaware, and includes five programs: the National School Lunch Program, the School Breakfast Program, the Special Milk Program, the Afterschool Snack Program, and the Fresh Fruit and Vegetable Program.
DELAWARE RESOURCES
SNAP Program, Delaware
https://dhss.delaware.gov/dss/foodstamps/
State Supplemental Nutrition Assistance Program. The website includes program information, application, and EBT card management. Summer Food Service Program
A USDA, federally-funded program to ensure low-income children continue to receive nutritious meals when school is not in session. University of Delaware
Cooperative Extension – Nutrition
https://www.udel.edu/academics/colleges/canr/cooperative-extension/nutrition-wellness/nutrition/ Has programs assisting in managing diabetes, cooking for heart health, and understanding the basics of creating a nutritious plate. Programs cover budgeting, food safety, and consuming foods that are good for physical and mental well-being. The Extension also works with partners across the state to provide access to locally grown foods, healthier food options, and affordable options.
A resource for evidence-based nutrition services in Delaware. Trains students to become future nutrition professionals, provides medical nutrition therapy counseling for individuals and group nutrition education classes.
WIC Resources
https://delaware.wicresources.org/
Find information on the Woman, Infants, and Children nutrition program, including education, locations, and resources.
NATIONAL RESOURCES
American College of Culinary Medicine
https://culinarymedicine.org/
Resources for health care providers or food service professionals interested in culinary medicine certification, collections of relevant research, and great resource for recipes.
A national network of 200+ food banks, including the Food Bank of Delaware, working to end hunger through food distribution and advocacy. Food is Medicine National Network
https://tuftsfoodismedicine.org
Collaboration led by Tufts and Kaiser Permanente with major health organizations to develop and share best practices in food is medicine.
Federal nutrition program contact information and resources specific to Delaware, including SNAP retailers and regional office
USDA My Plate
https://www.myplate.gov/
Great resources and recipes, including a helpful app for meal planning.
USDA SNAP Store Locator
https://www.fns.usda.gov/snap/retailer-locator
Search tool to find authorized SNAP retailers and farmers markets accepting benefits.
Providers are on the front lines of behavioral health care: WHO: Pediatricians, family physicians, nurse practitioners, physician assistants, and OB-GYNs serving patients 21 and under.
CHALLENGE: Many providers feel unequipped to diagnose, treat, or manage behavioral health conditions.
DCPAP equips providers with expert guidance, training, and resources to navigate behavioral health challenges with confidence:
• Immediate access to a child and adolescent psychiatrist during office hours: Tuesdays and Thursdays, 12–2 p.m.
• Consultations within 24 hours for screening, diagnosis, and treatment.
• Ongoing training and education through live and recorded webinars, clinical guidelines, and more.
• Referral assistance to connect patients with specialized care.
Timely behavioral health support is critical:
· DCPAP’s provider-to-provider collaboration model connects you with child and adolescent psychiatrists for expert guidance.
· With timely support, you can confidently address behavioral health concerns, improving patient outcomes.
• ADHD, anxiety, depression, and other mental health concerns
• Medication management and treatment considerations
• Disruptive behavioral problems
COMMON TOPICS FOR DCPAP CONSULTATIONS: FOR PATIENTS 21 AND UNDER.
Public Health Delaware
About the Journal
updated November, 2025
Established in 2015, the Delaware Journal of Public Health is a peer-reviewed electronic publication created by the Delaware Academy of Medicine and Public Health. e publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, and peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, all relating to the public health sector in Delaware. Each issue is largely devoted to an overarching theme or current issue in public health.
DJPH content is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute to an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know.
If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact us at managingeditor@djph.org .
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11-4 DJPH Nutrition and Malnutrition as a Determinant of Health ONLINE_FINAL (1) by Delaware Academy of Medicine and the Delaware Public Health Association - Issuu
