This study builds on prior literature examining food insecurity during the ongoing COVID-19 pandemic by exploring the role of federal nutrition assistance programs within the context of Vermont, a predominantly rural state characterized by a relatively robust policy and social response to the pandemic (71). Rural populations experience higher rates of food insecurity and are more likely participate in nutrition assistance programs as compared to their urban counterparts (4, 72). Vermont readily accepted and implemented numerous federal waivers made available in association with the Families First Coronavirus Response Act to increase the flexibility of programs in response to COVID-19, from provision of P-EBT to suspension of certain face-to-face interview requirements to the temporary restructuring of school meal delivery (73). The state also boasted among the lowest COVID-19 caseloads at the time of survey administration (71). We found that, despite shortcomings, participants generally perceived federal nutrition assistance programs as helpful or easy to use. We documented notable levels of food insecurity, suboptimal fruit and vegetable intake, and perceived stress among participants and non-participants alike. Understanding food and nutrition security and perceived stress outcomes under these conditions can provide insights regarding how nutrition assistance programs can provide for the most vulnerable even in such challenging times.
Our findings regarding nutrition assistance program perception correspond closely to prior studies on several counts. In line with calls for increased total SNAP benefit allotment in other studies (44, 74), we find that 47% of participants felt that benefits were not adequate to meet their household’s needs. Likewise, restricted product options available through WIC are a continuing topic of debate (51), which is reflected in our results, although our respondents were not prompted make a value judgment on these limitations. Our results also suggest that online utilization options for SNAP and WIC participants could improve accessibility and efficacy of these programs, which echoes perceptions of convenience and time savings associated with online options in earlier studies (48, 53, 75, 76). However, in considering expanding online options for these programs, it is important to revisit reported concerns, including associated transaction costs and limited control over selection and quality (75, 77, 78). Logistical challenges associated with school meal delivery in other studies, such as scheduling conflicts with school breakfasts (56, 63), are more difficult to evaluate against our results, given the altered format of meal delivery during the pandemic. However, new and additional logistical challenges, including accessibility of school meals related to site location, timing, and lack of delivery options continue to pose challenges for a substantial number of participants. However, at-home options for school meals may overcome other perceived challenges, such as infringement on family mealtimes (63)
Despite a perception of utility among participants, we found that – aligning with prior literature (4, 42) – federal nutrition assistance program participation was significantly associated with food insecurity for both low-income and not low-income respondents, even when we explore this using matching techniques to compare similar households. We also found a reduced probability of meeting fruit intake recommendations for low-income program participants, and a reduced probability of meeting vegetable intake recommendations for low-income SNAP/WIC participants. There is a substantial body of literature supporting the efficacy of federal nutrition assistance programs in alleviating food insecurity and, to some degree, improving diet quality (7, 8, 79). Our findings should be considered within the unique context of the time and place at which our data were collected, and of course, as subject to limitations in the analytical models employed.
It has been documented that the pandemic exacerbated food insecurity (80) and changed eating patterns. While some studies have found evidence of increased fruit and vegetable intake during the pandemic (81), these impacts were not universal. In a survey of Michigan adults, Litton and Beavers (82) found that food insecure respondents not only consumed fewer fruits and vegetables than their food secure counterparts but were more likely to report decreasing fruit and vegetable consumption in the early months of the pandemic, for reasons including quality, availability, price, desire to reduce store trips, and fears of contamination. While fresh fruit and vegetable prices increased relatively little in comparison with meat, fish and dairy products during the early months of the pandemic (83), challenges in access related to fears of contamination and exposure and increased concerns over spoilage as a consequence of reduced grocery trips (82) should not be discounted. Limitations to online ordering options for SNAP and WIC participants are of particular relevance. While Vermont farmers markets were broadly able to remain open during much of the pandemic, even brief closures posed substantial issues for farmers and patrons alike, and reduced vendor space and preordering requirements upon reopening may have impacted Vermonters who regularly relied on such avenues (84). Likewise, research suggests that baseline rates of perceived stress increased in response to the pandemic among populations including college students and frontline workers, among others (85–87).
Pandemic-specific challenges to food access may be particularly potent in a relatively rural context. Rural populations experience food insecurity at elevated rates, which may be exacerbated by structural barriers affecting access, such as large distances to supermarkets (88, 89). It is possible that, under these conditions, online delivery or curbside pickup options were more challenging or prohibitively expensive for some rural residents. Additionally, social support systems and community networks may play a unique role in the mitigation of food insecurity in rural settings (90), and constraints associated with new social distancing regulation compliance may have impacted such avenues. Additionally, although roughly one-third of our sample is classified as rural using the Rural Urban Commuting Area 4 category (RUCA) designation, the population density is low across the state, with only approximately 45,000 people, or about 10% of the state’s population residing in its largest city (91). In combination, exacerbated experiences of food and nutrition insecurity in concert with new structural barriers to nutrition assistance program utilization may have limited the capacity of programs to operate optimally or fully compensate for negative shifts in these outcomes for Vermont’s rural population. These limitations leave room for new and expanded strategies to improve access to healthy foods among program participants.
Although few studies have focused specifically on perceived stress during the pandemic, food insecurity is positively associated with various indicators of poor mental health (31, 32, 92). Some research indicates that this relationship may be attenuated by participation in SNAP and WIC (35, 36), but – in line with our findings – other studies have not identified a moderating effect (37). Interestingly, we do find that perceived stress was significantly lower among low-income respondents with a household member enrolled in a school food program. Few studies have explicitly evaluated the relationship between school meal participation and perceived stress of household members. Our results merit further investigation – Could school meal delivery or pickup have reduced the necessity of public ventures and associated risk of exposure for some families? Could school meal delivery and pick up options during the pandemic have influenced the frequency of family meals or reduced the burden of meal planning? While Nagata et al. (33) did not examine school meal participation during the pandemic, they do report a mediating effect of free groceries and meals on the association between food insecurity and poor mental health. Similarly, in a qualitative analysis, commercial family meal kit use has been associated with perceived benefits including reduced mental load for family meal providers (93). Additionally, evidence suggests that frequent family meals may be associated with lower rates of depressive symptoms and stress among parents (94). While these results cannot be directly applied to the role of school meals during the pandemic, further research could illuminate the pathways through which pandemic school meal formats might have impacted perceived stress in the household. It is also relevant to consider that the reduced burden of applying for school meal programs was removed due to the universal delivery approach taken during the time period under study.
As with any study, our survey and methods are subject to reasonable limitations. Although our sample size is relatively modest, it has a margin of error of 4% and was intentionally designed to reflect Vermont’s population on key demographic factors including income, race and ethnicity. Due to the limited sample of WIC participants, this population is only analyzed in conjunction with SNAP or both SNAP and school food participants, limiting the capacity of this study to distinguish between the impacts of these distinct programs. By design, our survey captures a breadth of data related to food insecurity during the COVID-19 pandemic but covering a substantial range of material naturally limits the depth of data that can practically be captured in any one area. Additionally, given the evolving nature of the pandemic context, subjects of importance to individual experiences of food and nutrition security continue to shift and emerge over time. For example, the administration of school meal programs was evolving at the time of data collection, making it challenging to clearly assess which specific program components and iterations participants responded to. Additionally, the limited number of open-ended responses collected suggests that the full breadth of participant experiences may not have been captured, although the supplementary qualitative data nonetheless adds depth.
Nearest neighbors matching analysis seeks to address weaknesses associated with selection bias in non-experimental study designs, but in the absence of perfect knowledge, such tools cannot perform perfectly. Although our survey captured many demographic variables known to be associated with food and nutrition security, perceived stress and federal nutrition assistance program participation, these are complex constructs influenced by a myriad of interrelated factors. It is likely that additional confounding variables exist that we were unable to fully evaluate. For example, our matching analysis was not able to account for differences in social support, which has been shown to influence food insecurity and perceived stress. Additionally, we were unable to control for the role that disability, physical health and comprehensive mental or emotional health may have on these outcomes, although such factors are known to interact with the experience of food insecurity (92, 95). Furthermore, our survey design could not meaningfully capture the specific food environments of participants, which can significantly impact food and nutrition security (88). Integrating these variables into future analyses might better isolate the impacts of federal nutrition assistance programs on food and nutrition security and perceived stress.
Of note, our matching analysis used binary outcomes to maximize power, except for perceived stress. However, by examining outcomes as binary, our models do not account for changes in the intensity of an outcome. While federal nutrition assistance program participation did not reduce food insecurity in our analysis, it is possible that participants may have experienced a reduction in the degree of food insecurity experienced, which would not be reflected in our models.