Cooking, Healthy Eating, Fitness and Fun (CHEFFs): Qualitative Evaluation of a Nutrition Education Program for Children Living at Urban Family Homeless Shelters

摘要

Objectives. We assessed the feasibility of a 15-week nutrition education, physical activity, and media literacy program for children living in urban family homeless shelters. Methods. We developed a qualitative monitoring tool to evaluate program process and impact at 2 shelter sites in the Bronx, New York, from 2009 to 2012. Facilitators recorded indications of participants’ understanding of intended messages and demonstrations of changes in attitudes and behaviors. Comments, insights, and actions were recorded as they occurred. Facilitators also documented barriers to delivery of content and activities as intended. We used content analysis to examine data for patterns and identify themes. Results. A total of 162 children participated at the 2 shelter sites. Analysis of qualitative data yielded 3 themes: (1) children’s knowledge and understanding of content, (2) children’s shift in attitudes or intentions, and (3) interpretations through children’s life experience. Food insecurity as well as shelter food service and policies were important influences on children’s choices, hunger, and sense of well-being. Conclusions. Children’s experiences highlighted the need to advocate for shelter policies that adequately provide for children’s nutritional and physical activity requirements and foster academic development. Homelessness is a time of great insecurity and upheaval. Homeless children and families face major challenges, including poverty, food insecurity, unemployment, dislocation from schools and neighborhoods, difficulty accessing medical care, and disruptions of support networks when most needed. In New York City (NYC), the number of homeless families and children living in shelters is steadily increasing. 1 From July 2010 to June 2011 (latest available data), approximately 40?000 homeless children spent at least 1 night in the NYC shelter system, and the average stay during that period was 8.5 months. 2 As of June 2013, there were more than 10?000 families with children and more than 20?000 children living in family homeless shelters in NYC on a given day. 3 Urban family homeless shelters are often located in isolated, low-income neighborhoods that lack access to healthy foods and safe outdoor spaces for physical activity. 4–6 Shelters often have limited or no facilities for storing and preparing food, further constraining healthy eating. 7–10 A qualitative study conducted among sheltered homeless children in urban Minnesota found that shelter policies, food access in the surrounding community, and parental feeding strategies restricted children’s food choices, which resulted in increased hunger and poorer perceived health. 10 New York Children’s Health Project (NYCHP) provides comprehensive primary health care to homeless children and families via mobile and on-site clinics at family shelters, domestic violence shelters, and a shelter for homeless youths. Because food insecurity, lack of access to fresh foods, and limited cooking facilities make it difficult for homeless families to eat healthfully, NYCHP provides nutrition programs to help children and their families make healthier choices both while homeless and housed. Consistent with the “hunger-obesity paradox,” 11–13 the homeless population has a high prevalence of overweight and obesity. Of children aged 6 to 11 years seen at NYCHP in 2011, approximately 39% were overweight (19%) or obese (20%) and at higher risk for weight-related health problems compared with children of the same age group nationally (15% overweight, 18% obese). 14 Inadequate nutrition and obesity are known risk factors for health problems in the sheltered homeless population. 8,15–19 Studies of nutritional intake among homeless children have shown deficiencies in essential vitamins and minerals, as well as recommended servings of all food groups except fats. 17,20–22 However, a literature search found only 1 study of a nutrition education intervention conducted in a family homeless shelter setting. 23 In 2009, NYCHP launched a nutrition education and physical activity program, Cooking, Healthy Eating, Fitness and Fun (CHEFFs), for children living in 2 family homeless shelters. The CHEFFs curriculum focused on fundamental nutrition concepts and skills, incorporating physical activity into children’s daily routine, and media literacy to help children understand the influence of advertising on their choices. The purpose of this study was to assess the feasibility of conducting a nutrition program among sheltered homeless children, and evaluate the effect on children’s knowledge, attitudes, and intentions using assessment tools developed specifically for the context and challenges of the setting. To our knowledge, this is the first report of a nutrition education program for homeless children.