Military Eligibility for the Supplemental Nutrition Assistance Program: Simulating the Exemption of the Basic Allowance for Housing from Gross Income.

BACKGROUND: Twenty-four percent of active-duty service member households experienced food insecurity in 2020; however, limited data have suggested that few participate in the Supplemental Nutrition Assistance Program (SNAP). A potential reason for low SNAP participation among active-duty military households is that the basic allowance for housing (BAH) is considered countable income for SNAP eligibility determination. OBJECTIVES: This study explores how many more service members' households, referred to as "SNAP units" (that is, a group of individuals who live together and regularly buy food and prepare meals together), would become eligible for SNAP benefits if the BAH is excluded from countable income in deciding eligibility. METHODS: This study used 2016-2020 American Community Survey 5-y estimates to construct a sample of active-duty military households combined with data on military pay and allowances to simulate changes to SNAP eligibility and poverty status with a BAH exemption as well as impacts on federal spending on SNAP. RESULTS: Eligibility for SNAP among military SNAP units increases from 0.4% to 1.5% (263% increase) if a service member's BAH was exempted from their gross income. The increase was driven by SNAP units whose highest-ranking service member was from the noncommissioned officer ranks without dependents. As more military SNAP units became eligible and chose to participate, annual SNAP disbursements (that is, amount of funds spent on SNAP) for the whole program increased by up to 1.3%, compared with FY16-20 SNAP disbursements. With an increase in SNAP participation, the poverty rate among military SNAP units decreases from 8.7% to 1.4% (83.9% decrease). CONCLUSIONS: Exempting service members' BAH from their gross income would likely increase SNAP eligibility and participation among military households and, in turn, reduce poverty.

Effectiveness of an Interactive, Highly Tailored "Video Doctor" Intervention to Suppress Viral Load and Retain Patients With HIV in Clinical Care: A Randomized Clinical Trial.

BACKGROUND: To determine whether Positive Health Check, a highly tailored video doctor intervention, can improve viral suppression and retention in care. SETTING: Four clinics that deliver HIV primary care. METHODS: A hybrid type 1 effectiveness-implementation randomized trial design was used to test study hypotheses. Participants (N = 799) who were not virally suppressed, were new to care, or had fallen out of care were randomly assigned to receive Positive Health Check or the standard of care alone. The primary endpoint was viral load suppression, and the secondary endpoint was retention in care, both assessed at 12 months, using an intention-to-treat approach. A priori subgroup analyses based on sex assigned at birth and race were examined as well. RESULTS: There were no statistically significant differences between Positive Health Check (N = 397) and standard of care (N = 402) for either endpoint. However, statistically significant group differences were identified from a priori subgroup analyses. Male participants receiving Positive Health Check were more likely to achieve suppression at 12 months than male participants receiving standard of care adjusted risk ratio [aRR] [95% confidence interval (CI)] = 1.14 (1.00 to 1.29), P = 0.046}. For retention in care, there was a statistically significant lower risk for a 6-month visit gap in the Positive Health Check arm for the youngest participants, 18-29 years old [aRR (95% CI) = 0.55 (0.33 to 0.92), P = 0.024] and the oldest participants, 60-81 years old [aRR (95% CI) = 0.49 (0.30 to 0.81), P = 0.006]. CONCLUSIONS: Positive Health Check may help male participants with HIV achieve viral suppression, and younger and older patients consistently attend HIV care. REGISTRY NAME: Positive Health Check Evaluation Trial. Trial ID: 1U18PS004967-01. URL: https://clinicaltrials.gov/ct2/show/NCT03292913.

Positive Health Check evaluation: A type 1 hybrid design randomized trial to decrease HIV viral loads in patients seen in HIV primary care.

For people with HIV, important transmission prevention strategies include early initiation and adherence to antiretroviral therapy and retention in clinical care with the goal of reducing viral loads as quickly as possible. Consequently, at this point in the HIV epidemic, innovative and effective strategies are urgently needed to engage and retain people in health care to support medication adherence. To address this gap, the Positive Health Check Evaluation Trial uses a type 1 hybrid randomized trial design to test whether the use of a highly tailored video doctor intervention will reduce HIV viral load and retain people with HIV in health care. Eligible and consenting patients from four HIV primary care clinical sites are randomly assigned to receive either the Positive Health Check intervention in addition to the standard of care or the standard of care only. The primary aim is to determine the effectiveness of the intervention. A second aim is to understand the implementation potential of the intervention in clinic workflows, and a third aim is to assess the costs of intervention implementation. The trial findings will have important real-world applicability for understanding how digital interventions that take the form of video doctors can be used to decrease viral load and to support retention in care among diverse patients attending HIV primary care clinics.

Do differences in reported expenditures between household scanner data and expenditure surveys matter in health policy research?

Household scanner data are increasingly used to inform health policy such as sugar-sweetened beverage taxes. This article examines whether differences in the level of reported expenditures between IRI Consumer Network scanner panel and the Consumer Expenditure Survey (CES) lead to important differences in demand elasticities and policy simulation outcomes. Using each dataset, we estimated a structural consumer demand system with seven food groups and a numéraire good. To compare the two datasets on a level playing field, we went to great lengths to ensure that the explanatory variables in the two demand models were comparably constructed. Results indicate that scanner data households are not consistently more price responsive than the general population and underreported Consumer Network expenditures do not seem to result in systematic differences in price elasticities. The income elasticities are uniformly lower in Consumer Network than in CES for higher income households because of the positive association between income and the degree of underreporting. This, however, has limited effects on uncompensated price elasticities and policy simulations because food budget shares are small for higher income households. Overall, these findings support continued use of household scanner data in health policy research related to effects of price (dis)incentives.

Scanner Data-Based Panel Price Indexes.

We construct panel price indexes using retail scanner data that allow comparisons of consumption cost across space and time. Two types of panel indexes are examined: the rolling-window panel extensions of the multilateral Cave-Christensen-Diewert (CCD) index with the Törnqvist index as its elements, and of the multilateral Gini-Eltetö-Köves-Szulc (GEKS) index using the Fisher ideal index as its elements. The rolling window method maintains the nonrevisability of published index numbers while it allows index numbers for new periods and locations be calculated and the basket of items be updated. Meanwhile, the multilateral structure of price comparison eliminates significant downward drift in standard chained indexes. Using county-level bilateral and panel indexes based on retail beverage scanner data, we experimentally adjust for purchasing parity the portion of Supplemental Nutrition Assistance Program (SNAP) benefits that participants spend on beverages. Accounting for temporal and spatial cost differences causes over 2% of SNAP allotment spent on beverages be reallocated, or approximately a 5% change in allotment on average for a county. About 90% of the relocated SNAP fund is to adjust for spatial differences in food cost. We also compare SNAP allotments implied by the retail scanner data indexes with those implied by indexes based on the USDA Quarterly Food-at-Home Price Database (QFAHPD). The treatment of unit values and product quality may have contributed to the significant differences observed between the retail scanner data indexes and the QFAHPD indexes.

How Much Can Product Reformulation Improve Diet Quality in Households with Children and Adolescents?

Improvements in the healthfulness of packaged foods and beverages through reformulation could help reduce the prevalence of obesity among children and adolescents through improved diet quality. This study assessed changes in calories and four nutrients (saturated fat, total sugars, sodium, and dietary fiber) from 2012 through 2014 for packaged products frequently consumed by children and adolescents, simulated effects of potential improvements in 12 frequently consumed product categories based on actual purchasing patterns, and compared differences in prices of healthier versus less healthy products. Analysis of trends showed limited evidence that healthfulness of foods improved over the years examined. Simulation results showed minimal changes for calories and sodium, but daily intake of saturated fat could decrease by 4%, sugar consumption could decrease by 5%, and dietary fiber consumption could increase by 11% if products were reformulated to meet an existing healthfulness standard. Using a higher standard, caloric intake could decline by 4%, saturated fat by 6%, sugar by 9%, and sodium by 4%, and dietary fiber could increase by 14%. Healthier versions of most products ranged from an average of 3 to 12 cents more per serving, but not all healthier versions were more costly. Overall, reformulation is a potential avenue for improving diet quality in households with children and adolescents, but price could be a barrier to purchasing healthier products for some households.

Food Safety Practices in the U.S. Meat Slaughter and Processing Industry: Changes from 2005 to 2015.

Meat slaughter establishments use a multipronged approach to ensure beef and pork products are safe for human consumption. To determine the approaches most commonly used, we conducted a national survey of federally inspected meat slaughter and processing establishments (376 completed surveys, 66% response rate) in 2015. We compared the results with a survey that was conducted in 2005, albeit of potentially different establishments, by using a similar questionnaire and similar data collection methods, thus allowing for an evaluation of trends in food safety practices over time. The use of some food safety practices has increased over the 10-yr time period, whereas others remained the same or decreased. For example, the use of chemical sanitizers or hot water for food contact surfaces and tools increased from 51 to 93%. As another example, microbiological testing of raw meat after fabrication, in addition to that required by regulation, increased from 50 to 72%. However, the use of organic acid rinse on carcasses in the slaughter area remained the same, at 66% of establishments. Written policies and procedures to control the use of hazardous chemicals decreased from 75 to 65% of establishments. The survey findings can be used to characterize food safety practices and technologies in the meat slaughter and processing industry and identify areas for improvement.

Food Safety Practices in the Egg Products Industry.

We conducted a national census survey of egg product plants (n = 57) to obtain information on the technological and food safety practices of the egg products industry and to assess changes in these practices from 2004 to 2014. The questionnaire asked about operational and sanitation practices, microbiological testing practices, food safety training for employees, other food safety issues, and plant characteristics. The findings suggest that improvements were made in the industry's use of food safety technologies and practices between 2004 and 2014. The percentage of plants using advanced pasteurization technology and an integrated, computerized processing system increased by almost 30 percentage points. Over 90% of plants voluntarily use a written hazard analysis and critical control point (HACCP) plan to address food safety for at least one production step. Further, 90% of plants have management employees who are trained in a written HACCP plan. Most plants (93%) conduct voluntary microbiological testing. The percentage of plants conducting this testing on egg products before pasteurization has increased by almost 30 percentage points since 2004. The survey findings identify strengths and weaknesses in egg product plants' food safety practices and can be used to guide regulatory policymaking and to conduct required regulatory impact analysis of potential regulations.

Improving the implementation of diabetes self-management: findings from the Alliance to Reduce Disparities in Diabetes.

To enhance the health and well-being of patients managing type 2 diabetes, the five grantees comprising the Alliance to Reduce Disparities in Diabetes implemented evidence-based approaches to patient self-management education as part of their programs. This article describes strategies implemented by the grantees that may help explain program success, defined as improvement in clinical values and patient-reported outcomes. A process evaluation of grantee programs included interviews and document review at the beginning, midpoint, and end of the Alliance initiative. A total of 97 interviews were conducted over time with 65 program representatives. The Alliance programs served 2,328 people from diverse racial and ethnic backgrounds and provided 36,826 diabetes self-management sessions across the intervention sites. Framework analysis of the interviews identified four key themes that emerged across time and program sites that may help account for program success: empowerment, increasing access and support, addressing local needs and barriers, and care coordination. The overall evaluation findings may help other diabetes self-management programs seeking to translate and implement evidence-based approaches to reduce disparities and enhance patient well-being.

Cross-site evaluation of the Alliance to Reduce Disparities in Diabetes: clinical and patient-reported outcomes.

Alliance programs implemented multilevel, multicomponent programs inspired by the chronic care model and aimed at reducing health and health care disparities for program participants. A unique characteristic of the Alliance programs is that they did not use a fixed implementation strategy common to programs using the chronic care model but instead focused on strategies that met local community needs. Using data provided by the five programs involved in the Alliance, this evaluation shows that of the 1,827 participants for which baseline and follow-up data were available, the program participants experienced significant decreases in hemoglobin A1c and blood pressure compared with a comparison group. A significant time by study group interaction was observed for hemoglobin A1c as well. Over time, more program participants met quality indicators for hemoglobin A1c and blood pressure. Those participants who attended self-management classes and experienced more resources and support for self-management attained more benefit. In addition, program participants experienced more diabetes competence, increased quality of life, and improvements in diabetes self-care behaviors. The cost-effectiveness of programs ranged from $23,161 to $61,011 per quality-adjusted life year. In sum, the Alliance programs reduced disparities and health care disparities for program participants.

Predicting the Effects of Sugar-Sweetened Beverage Taxes on Food and Beverage Demand in a Large Demand System.

A censored Exact Affine Stone Index incomplete demand system is estimated for 23 packaged foods and beverages and a numéraire good. Instrumental variables are used to control for endogenous prices. A half-cent per ounce increase in sugar-sweetened beverage prices is predicted to reduce total calories from the 23 foods and beverages but increase sodium and fat intakes as a result of product substitution. The predicted decline in calories is larger for low-income households than for high-income households, although welfare loss is also higher for low-income households. Neglecting price endogeneity or estimating a conditional demand model significantly overestimates the calorie reduction.

Analysis of the Costs and Economic Feasibility of Requiring Postharvest Processing for Raw Oysters.

Because of concerns about Vibrio vulnificus, the U.S. Food and Drug Administration is considering requirements for postharvest processing (PHP) of oysters harvested from the Gulf of Mexico during warm-weather months and intended for raw consumption. As described in the paper, feasible PHP methods for warm-weather-harvested oysters include cool pasteurization, high hydrostatic pressure, and low-dose gamma-irradiation. We estimate that the costs of applying PHP are approximately 5 to 6 cents per half-shell oyster intended for raw consumption. However, most oyster processors have insufficient volumes to cost-effectively install PHP equipment. To assist these smaller operations, central PHP facilities operated by a 3rd party would be needed. A geographic information system analysis that minimized volume-weighted travel distances from each Gulf oyster operation identified 6 optimal PHP facility locations in the Gulf region. Even with the establishment of central PHP facilities, some oyster operations will become unprofitable and be at risk for closure.

Analysis of the relationship between economic measures and Salmonella testing results in young chicken slaughter establishments.

Food processing establishments incur costs to install, maintain, and operate equipment and implement specific food safety practices. During times of economic recession, establishments might reduce their food safety efforts to conserve resources and reduce costs of operation. This study was conducted to determine whether financial performance measures are systematically associated with Salmonella test results. The association between Salmonella test results from 182 federally inspected young chicken slaughter establishments from 2007 to 2009 and financial performance was examined while controlling for other establishment characteristics. Results indicated that the smallest establishments, which slaughtered fewer than 0.2 million chickens per year, had three times as many positive test results as did the largest establishments, which slaughtered more than 86.0 million chickens per year (P < 0.01). Establishments that slaughtered more than 0.2 million but fewer than 18.5 million chickens had 1.5 times as many positive test results (P = 0.02). Two statistically significant financial performance measures were identified, but the effects were limited. Establishments in bankruptcy had 1.4 times as many positive test results as did those not in bankruptcy (P = 0.02); however, only five establishments were in bankruptcy. Establishments with better payment performance generally had better Salmonella test results, but the effect was significant only in the winter season.

Certified kitchen managers: do they improve restaurant inspection outcomes?

Restaurants are associated with a significant number of foodborne illness outbreaks in the United States. Certification of kitchen managers through an accredited training and testing program may help improve food safety practices and thus prevent foodborne illness. In this study, relationships between the results of routine restaurant inspections and the presence of a certified kitchen manager (CKM) were examined. We analyzed data for 4461 restaurants in Iowa that were inspected during 2005 and 2006 (8338 total inspections). Using logistic regression analysis, we modeled the outcome variable (0 = no critical violations [CVs]; 1 = one or more CVs) as a function of presence or absence of a CKM and other explanatory variables. We estimated separate models for seven inspection categories. Restaurants with a CKM present during inspection were less likely to have a CV for personnel (P < 0.01), food source or handling (P < 0.01), facility or equipment requirements (P < 0.05), ware-washing (P < 0.10), and other operations (P < 0.10). However, restaurants with a CKM present during inspection were equally likely to have a CV for temperature or time control and plumbing, water, or sewage as were restaurants without a CKM present. Analyses by type of violation within the temperature and time control category revealed that restaurants with a CKM present during inspection were less likely to have a CV for hot holding (P < 0.05), but the presence of a CKM did not affect other types of temperature and time control violations. Our analyses suggest that the presence of a CKM is protective for most types of CVs, and we identify areas for improving training of CKMs.

Analysis of Salmonella control performance in U.S. young chicken slaughter and pork slaughter establishments.

In the 1996 U.S. Food Safety and Inspection Service's (FSIS) "Pathogen Reduction; Hazard Analysis and Critical Control Point (PR/HACCP) Systems, Final Rule," Salmonella was selected for microbiological testing and monitoring. Using data from an FSIS-sponsored survey of meat and poultry slaughter establishments, inspection results, and other establishment characteristics, potential variables affecting pathogen control, as measured by Salmonella test results, were investigated. The analysis data sets included 153 federally inspected young chicken slaughter establishments, of which 111 exceeded half the Salmonella performance standard at least once from 2003 through 2005, and 121 federally inspected pork slaughter establishments, of which 28 exceeded half the Salmonella performance standard. Logistic regression results for young chicken slaughter establishments indicate they were more likely to exceed half the standard if they had higher inspection noncompliance rates (P = 0.10) and older production space (P = 0.10), and were less likely to exceed it if they used a higher percentage of raw poultry inputs purchased from outside sources (P = 0.10). Results for pork slaughter establishments indicate they were more likely to exceed half the standard if they had a higher rate of voluntary microbiological testing (P = 0.08), and were less likely to exceed it if they were larger (P = 0.08) and used a higher percentage of raw pork inputs purchased from outside sources (P = 0.02). In general, indicators of plant characteristics, food safety practices, and management philosophy are associated with different levels of pathogen control performance that vary by species slaughtered.

Food Safety Knowledge and Practices among Older Adults: Identifying Causes and Solutions for Risky Behaviors.

Adults aged 60 years and older are more likely than younger adults to experience complications, hospitalization, and death because of food-borne infections. Recognizing this risk, we conducted a nationally representative survey (n = 1,140) to characterize older adults' food safety knowledge, attitudes, and practices as well as the demographic characteristics of older adults with risky food handling practices. The survey was conducted using a Web-enabled panel. We found that although older adults consider themselves to be knowledgeable about food safety, many are not following recommended food safety practices. Areas for improvement include the following: reheating deli meats to steaming hot, not eating store-bought deli salads, cooking eggs properly, monitoring refrigerator temperature using a thermometer, using a food thermometer to check doneness of meat/poultry/egg dishes, and storing leftovers properly. The survey results also suggest that food safety education targeting older adults is needed and that such initiatives should emphasize practices to prevent listeriosis, a potentially fatal illness among older adults. Our findings suggest that, in particular, men, individuals with higher incomes, and college-educated individuals would benefit from food safety education.

Consumer home refrigeration practices: results of a web-based survey.

To reduce bacterial growth and to ensure the quality and safety of food products, the U.S. Department of Agriculture and the U.S. Food and Drug Administration advise consumers to clean their refrigerators regularly, use a refrigerator thermometer, and keep refrigerator temperatures at 40 degrees F (4.4 degrees C) or below. We conducted a nationally representative Web-enabled survey (n = 2,060) to collect data on refrigerator thermometer ownership, home refrigerator temperatures, and the frequency of home refrigerator cleaning. We stratified the sample to provide results for pregnant women, older adults (60 years or older), and the remaining population. About half of all respondents had cleaned their refrigerators at least 1 month before the survey. Only 11% of all respondents had a thermometer in their refrigerator before the survey. Older adults (77.5%) were more likely than the remaining population (70.4%) to have their refrigerators at the recommended temperature (P < 0.01). Older adults who were not married and who lived alone were less likely to have refrigerator thermometers and to have their refrigerators at a recommended temperature (P < 0.05). For all respondents, those who had previously owned a refrigerator thermometer were more likely to have their refrigerators at the recommended temperature than were respondents who did not previously own a thermometer (P < 0.01). Food safety educators can use the survey findings and results of previous research to target educational materials and help consumers, especially those at risk for listeriosis, to safely store refrigerated foods at home.

Consumer knowledge and use of open dates: results of a WEB-based survey.

Consumers are relying increasingly on ready-to-eat (RTE) foods because they are convenient, quick, and easy. Open dates let consumers know by which date to purchase or use RTE foods for best quality. To further characterize consumer knowledge and use of open dates for specific refrigerated RTE foods (smoked seafood, cooked crustaceans, bagged salads, prewashed cut produce, soft cheeses, frankfurters, deli meats, fermented sausages, and deli salads), we conducted a nationally representative web-enabled survey (n=2060). Before purchasing RTE foods, 48 to 68% of respondents check open dates all or most of the time. Before preparing RTE foods, 43 to 64% of respondents check open dates all or most of the time. Nearly two-thirds of respondents reported that their senses were the most important factors in deciding whether to eat a refrigerated food, which is an unsafe practice. About one-third of respondents reported that an open date is the most important factor in deciding whether to eat a refrigerated food. Many respondents, however, do not understand the meanings of the different types of dates. Only 18% correctly defined the use-by date. The findings suggest consumers could benefit from education regarding open dates and recommended storage times for RTE foods.

Consumer knowledge, storage, and handling practices regarding Listeria in frankfurters and deli meats: results of a Web-based survey.

Proper storage and handling of refrigerated ready-to-eat foods can help reduce the risk of listeriosis. A national Web-based survey was conducted to measure consumer awareness and knowledge of Listeria and to estimate the prevalence of the U.S. Department of Agriculture-recommended consumer storage and handling practices for frankfurters and deli meats. The demographic characteristics of consumers who are unaware of Listeria and who do not follow the recommended storage guidelines were also assessed. In addition, predictive models were developed to determine which consumers engage in risky storage practices. Less than half of the consumers surveyed were aware of Listeria, and most of those aware were unable to identify associated food vehicles. Awareness was lower among adults 60 years of age and older, an at-risk population for listeriosis, and individuals with relatively less education and lower incomes. Most households safely stored and prepared frankfurters. Most households stored unopened packages of vacuum-packed deli meats in the refrigerator within the U.S. Department of Agriculture-recommended storage guidelines (< or =14 days); however, many stored opened packages of vacuum-packed deli meats and freshly sliced deli meats for longer than the recommended time (< or =5 days). Men, more-educated individuals, and individuals living in metropolitan areas were more likely to engage in risky storage practices. This study identified the need to develop targeted educational initiatives on listeriosis prevention.