How policy implementation shapes the impact of U.S. food assistance policies: the case study of the Child and Adult Care Food Program

Much of the chronic disease burden in the U.S. population can be traced to poor diet. There has been a sustained focus on influencing children's diets and encouraging healthier eating habits by changing policies for what foods and beverages can be served to children through large federally-funded nutrition assistance programs. Yet without attention to how nutrition policies are implemented, and the surrounding context for these policies, these policy changes may not have the intended results. In this perspective, we used Bullock et al.'s (2021) Process Model of Implementation from a Policy Perspective to analyze how the complexities of the implementation process of large-scale nutrition policies can dilute potential health outcomes. We examine the Child and Adult Care Food Program (CACFP), a federal program focused on supporting the provision of nutritious meals to over 4 million children attending childcare, as a case study. We examine how the larger societal contexts of food insecurity, attitudes towards the social safety net, and a fragmented childcare system interact with CACFP. We review the "policy package" of CACFP itself, in terms of its regulatory requirements, and the various federal, state, and local implementation agencies that shape CACFP's on-the-ground implementation. We then review the evidence for how each component of the CACFP policy implementation process impacts uptake, costs, feasibility, equity, and effectiveness at improving children's nutrition. Our case study demonstrates how public health researchers and practitioners must consider the complexities of policy implementation processes to ensure effective implementation of nutrition policies intended to improve population health.

The societal costs and health impacts on obesity of BMI report cards in US schools

OBJECTIVE

This study aimed to estimate the 10-year cost-effectiveness of school-based BMI report cards, a commonly implemented program for childhood obesity prevention in the US where student BMI is reported to parents/guardians by letter with nutrition and physical activity resources, for students in grades 3 to 7.

METHODS

A microsimulation model, using data inputs from evidence reviews on health impacts and costs, estimated: how many students would be reached if the 15 states currently measuring student BMI (but not reporting to parents/guardians) implemented BMI report cards from 2023 to 2032; how many cases of childhood obesity would be prevented; expected changes in childhood obesity prevalence; and costs to society.

RESULTS

BMI report cards were projected to reach 8.3 million children with overweight or obesity (95% uncertainty interval [UI]: 7.7-8.9 million) but were not projected to prevent any cases of childhood obesity or significantly decrease childhood obesity prevalence. Ten-year costs totaled $210 million (95% UI: $30.5-$408 million) or $3.33 per child per year with overweight or obesity (95% UI: $3.11-$3.68).

CONCLUSIONS

School-based BMI report cards are not cost-effective childhood obesity interventions. Deimplementation should be considered to free up resources for implementing effective programs.

De-implementing public health policies: a qualitative study of the process of implementing and then removing body mass index (BMI) report cards in Massachusetts public schools

BACKGROUND

This study explored reasons for the adoption of a policy to distribute report cards to parents about children's weight status ("BMI report cards") in Massachusetts (MA) public schools in 2009 and the contextual factors influencing the policy removal in 2013.

METHODS

We conducted semi-structured, qualitative interviews with 15 key decision-makers and practitioners involved with implementing and de-implementing the MA BMI report card policy. We analyzed interview data using a thematic analytic approach guided by the Consolidated Framework for Implementation Research (CFIR) 2.0.

RESULTS

Primary themes were that (1) factors other than scientific evidence mattered more for policy adoption, (2) societal pressure spurred policy adoption, (3) problems with the policy design contributed to inconsistent implementation and dissatisfaction, and (4) media coverage, societal pressure, and organizational politics and pressure largely prompted de-implementation.

CONCLUSIONS

Numerous factors contributed to the de-implementation of the policy. An orderly process for the de-implementation of a policy in public health practice that manages drivers of de-implementation may not yet exist. Public health research should further focus on how to de-implement policy interventions when evidence is lacking or there is potential for harm.

Food insecurity and the role of food assistance programs in supporting diet quality during the COVID-19 pandemic in Massachusetts

Background

Economic and supply chain shocks resulting from the COVID-19 pandemic in 2020 led to substantial increases in the numbers of individuals experiencing food-related hardship in the US, with programs aimed at addressing food insecurity like the Supplemental Nutrition Assistance Program (SNAP) and food pantries seeing significant upticks in utilization. While these programs have improved food access overall, the extent to which diet quality changed, and whether they helped mitigate diet quality disruptions, is not well understood.

Objective

To evaluate food insecurity, food pantry and/or SNAP participation associations with both diet quality as well as perceived disruptions in diet during the COVID-19 pandemic among Massachusetts adults with lower incomes.

Methods

We analyzed complete-case data from 1,256 individuals with complete data from a cross-sectional online survey of adults (ages 18 years and above) living in Massachusetts who responded to "The MA Statewide Food Access Survey" between October 2020 through January 2021. Study recruitment and survey administration were performed by The Greater Boston Food Bank. We excluded respondents who reported participation in assistance programs but were ineligible (n = 168), those who provided straightlined responses to the food frequency questionnaire component of the survey (n = 34), those with incomes above 300% of the federal poverty level (n = 1,427), those who completed the survey in 2021 (n = 8), and those who reported improved food insecurity (n = 55). Current dietary intake was assessed via food frequency questionnaire. Using Bayesian regression models, we examined associations between pandemic food insecurity, perceived disruption in diet, diet quality, and intakes of individual foods among those who completed a survey in 2020. We assessed interactions by pantry and SNAP participation to determine whether participation moderated these relationships.

Results

Individuals experiencing food insecurity reported greater disruption in diet during the pandemic and reduced consumption of healthy/unhealthy foods. Pantry participation attenuated significant associations between food insecurity and lower consumption of unhealthy (b = -1.13 [95% CI -1.97 to -0.31]) and healthy foods (b = -1.07 [-1.82 to -0.34]) to null (unhealthy foods: -0.70 [-2.24 to 0.84]; healthy foods: 0.30 [-1.17 to 1.74]), whereas SNAP participation attenuated associations for healthy foods alone (from -1.07 [-1.82 to -0.34] to -0.75 [-1.83 to 0.32]). Results were robust to choice of prior as well as to alternative modeling specifications.

Conclusion

Among adults with lower incomes, those experiencing food insecurity consumed less food, regardless of healthfulness, compared to individuals not experiencing food insecurity. Participation in safety-net programs, including SNAP and pantry participation, buffered this phenomenon. Continued support of SNAP and the food bank network and a focus on access to affordable healthy foods may simultaneously alleviate hunger while improving nutrition security.

Lead Concentrations in US School Drinking Water: Testing Programs, Prevalence, and Policy Opportunities, 2016‒2018

Objectives. To detail baseline drinking water sample lead concentrations and features of US state-level programs and policies to test school drinking water for lead in 7 states' operating programs between 2016 and 2018. Methods. We coded program and policy documents using structured content analysis protocols and analyzed state-provided data on lead concentration in drinking water samples collected in public schools during initial testing phases. Results. We analyzed data from 5688 public schools, representing 35% of eligible schools in 7 states. The number of samples per school varied. The proportion of schools identifying any sample lead concentration exceeding 5 parts per billion varied (13%-81%). Four states exceeded 20%. Other program features varied among states. Instances of lead above the state action level were identified in all states. Conclusions. In 2018, many US public school students attended schools in states without drinking water lead-testing programs. Testing all drinking water sources may be recommended. Public Health Implications. Initiating uniform school drinking water lead testing programs and surveillance over time could be used to reduce risk of lead exposure in drinking water. (Am J Public Health. 2022;112(S7):S679-S689. https://doi.org/10.2105/AJPH.2022.306961).

Moving from Policy to Practice for Early Childhood Obesity Prevention: A Nationwide Evaluation of State Implementation Strategies in Childcare

Policies requiring childcare settings to promote healthy eating, physical activity, and limited screentime have the potential to improve young children's health. However, policies may have limited impact without effective implementation strategies to promote policy adoption. In this mixed-methods study, we evaluated the type, quality, and dose of implementation strategies for state-level childcare licensing regulations focused on healthy eating, physical activity, or screentime using: (1) a survey of state licensing staff and technical assistance providers (n = 89) in 32 states; (2) a structured review of each state's childcare licensing and training websites for childcare providers; and (3) in-depth, semi-structured interviews with 31 childcare licensing administrators and technical assistance providers across 17 states. Implementation strategies for supporting childcare providers in adopting healthy eating, physical activity, and screentime regulations vary substantially by state, in quantity and structure. Childcare programs' financial challenges, staff turnover, and lack of adequate facilities were identified as key barriers to adoption. Access to federal food programs was seen as critical to implementing nutrition regulations. Implementation resources such as training and informational materials were rarely available in multiple languages or targeted to providers serving low-income or racially/ethnically diverse families. There is a substantial need for implementation supports for ensuring policies are successfully and equitably implemented in childcare.

Obesity prevention in early care and education: a comparison of licensing regulations across Canadian provinces and territories

BACKGROUND

Early care and education (ECE) settings represent an important point of intervention for childhood obesity prevention efforts. The objective of this paper was to compare ECE licensing regulations for each Canadian province/territory to evidence-based, obesity prevention standards.

METHODS

Two authors reviewed existing ECE regulations for each province/territory and examined whether the regulatory text supported standards for nutrition (n = 11), physical activity (n = 5) and screen time (n = 4). Provinces/territories were evaluated on the strength of regulatory language for each standard (i.e. fully, partially, or not addressed) and a total comprehensiveness score (maximum score of 20). ECE centres and homes were examined separately.

RESULTS

The majority of provinces/territories required providers to follow Canada's Food Guide, but few had regulations for specific foods or beverages. Most provinces/territories included standards related to written menus and drinking water, but the strength of these standards was weak. Many provinces/territories required physical activity and outdoor opportunities to be provided daily, but few included a time requirement. Only two provinces included any screen time standards. Total comprehensiveness scores averaged 5.7 for centres and 5.4 for homes.

CONCLUSIONS

Canadian provinces/territories have insufficient obesity prevention regulations in ECE settings, highlighting a potential point of intervention to prevent obesity.

Alignment Of US School Lunches With The EAT-Lancet Healthy Reference Diet's Standards For Planetary Health

By feeding more than thirty million schoolchildren daily, the National School Lunch Program's food offerings substantially influence a contributing factor to climate change: US food production methods. Modifying school lunch nutrition standards could be a policy strategy to reduce climate change while promoting human health. To estimate how school lunches could be adjusted to encourage both outcomes, we compared the composition of school lunches with the EAT-Lancet Commission's healthy reference diet science-based benchmarks for reducing food system impacts on climate change. Analyzing more than 5,000 lunches served in the US during school year 2014-15, we found that they exceeded EAT-Lancet targets for dairy, fruit, refined grains, red meat, and starchy vegetables while containing insufficient whole grains, legumes, vegetables, and nuts. In addition, estimated food costs were higher for school lunches than for lunches meeting EAT-Lancet targets. Our findings suggest that redesigning school lunches could provide high-quality nutrition while benefiting the environment and reducing food costs.

Implementing the New Child and Adult Care Food Program's Nutrition Standards in Boston

In 2017, the US Department of Agriculture’s Child and Adult Care Food Program’s (CACFP’s) nutrition standards were updated to improve nutrition and meal quality while remaining feasible for child care providers to implement. We conducted a pre–post study of 13 family child care home (FCCH) providers in Boston, Massachusetts, to compare reported opportunities for training and technical assistance and knowledge of new nutrition standards before the effective date of the updates (October 1, 2017) and 1 year later. The McNemar test was used to test for differences in provider responses. Few FCCH providers received training or technical assistance or had knowledge of most new standards at baseline or at follow-up; however, provider-reported knowledge of the whole-grain standard improved over time (from 6 providers to 12 providers) (P = .03). One year post implementation, FCCH providers still needed additional training, technical assistance, or other support to meet the new nutrition standards for meals served to children.

Acquisition of Bottled Water Among US Households

Objectives

While drinking plain water instead of sugar-sweetened beverages (SSB) may improve diet and prevent diseases, bottled water is more costly than tap water and typically does not contain fluoride for oral health benefits. We explored bottled water acquisition among US households and its relationship with SSB acquisition.

Methods

We used data from the USDA Food Acquisition and Purchasing Survey, which collected 7 days of data on all foods purchased or obtained for free in a nationally representative sample of 4826 households during 2012. Data were collected using food record books and bar code scanners. We assessed the prevalence of acquiring bottled water to bring home and for immediate consumption away from home, volume of water acquired, money spent on water, and the association of water acquisition with SSB acquisition. Differences in prevalence according to race/ethnicity, Census region, education level, rural status, and income/SNAP status were assessed using Chi-square tests. Adjusted linear models were used to assess the association of acquiring water for home or away from home with per-capita household total SSB calories acquired.

Results

A quarter (24.6%) of households acquired any bottled water during the study week with 16.2% acquiring water for home and 11.1% away from home. Prevalence of acquiring any bottled water differed by region and race/ethnicity and was highest among households in the South and West (each 26.8%) and among Hispanic households (35.2%). Among those that acquired each type, households spent $4.13 acquiring 14.1 liters of water for home, while households spent $1.65 acquiring 2.0 liters for away from home. In regression models, households that acquired bottled water for home had greater per capita SSB calorie acquisition than households that did not (adjusted mean: 1203 vs. 734 kcal/week; P = 0.0005); acquiring water for away from home was not associated with greater per capita SSB calorie acquisition (adjusted means: 931 vs. 1005 kcal; P = 0.34).

Conclusions

One quarter of US households acquire bottled water though acquisition differs according to demographic factors. Although plain water can reduce caloric intake when substituted for SSB, findings suggest that households that acquire bottled water for home also acquire more SSB calories than households that do not.

Funding Sources

Solely for authors time from their institutions.

A systematic review of strategies to increase drinking-water access and consumption among 0- to 5-year-olds

The objective of this study is to identify promising strategies for improving drinking-water access and consumption among children aged 0 to 5 years. MEDLINE/PubMed, Embase, ERIC, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched in this review. Studies included peer-reviewed, full-text studies from high-income countries, published in English between January 1, 2000, and January 12, 2018, that evaluated interventions to increase water access or consumption in children aged 0 to 5 years. Twenty-five studies met inclusion criteria; 19 used an effective intervention strategy to increase water access or water consumption. Three studies addressed both water access and consumption. Frequently used strategies included policy and practice changes, increasing water access and convenience, and education, training, or social support for caregivers. Studies were of fair methodological quality (average score: 18.8 of 26) for randomized studies and of moderate quality (5.1 of 9) for non-randomized studies. To date, few high-quality studies with objectively measured outcomes have clearly demonstrated strategies that may influence water intake and consumption among young children aged 0 to 5 years.

Advancing Public Health Policy in Louisiana Through Evidence-Based Strategies: Successes and Opportunities

In 2013, a team of public health professionals at Tulane University launched a project to explore strategies for shaping a healthier Louisiana. The team investigated methods for improving diet and physical activity behaviors in early childhood, school, and community settings that could be translated into specific policies. Through key informant interviews and scans of academic journals and reports issued by public health agencies, the team generated a set of actionable steps that could increase healthful behaviors. Previous efforts to address similar topics in Louisiana and other states, and their reception from policy makers, were also considered during analysis. Subsequently, a state legislator used the team's work to introduce public health legislation in 2014. The legislation led to a number of incremental changes in state policy and resolutions for additional policy-relevant studies. This case study summarizes the promising physical activity and nutrition strategies that were considered by the Tulane team, how the team's work product was integrated into state legislation, the outcomes of the legislation, and a set of recommendations for how Louisiana can expand on this work. This article demonstrates how the work of public health professionals can have a positive influence on the policy-making process through research and education.

A systematic review of universal campaigns targeting child physical abuse prevention

The purpose of this review was to better understand the impact of universal campaign interventions with a media component aimed at preventing child physical abuse (CPA). The review included 17 studies featuring 15 campaigns conducted from 1989 to 2011 in five countries. Seven studies used experimental designs, but most were quasi-experimental. CPA incidence was assessed in only three studies and decreased significantly in two. Studies also found significant reductions in relevant outcomes such as dysfunctional parenting, child problem behaviors and parental anger as well as increases in parental self-efficacy and knowledge of concepts and actions relevant to preventing child abuse. The following risk factors were most frequently targeted in campaigns: lack of knowledge regarding positive parenting techniques, parental impulsivity, the stigma of asking for help, inadequate social support and inappropriate expectations for a child's developmental stage. The evidence base for universal campaigns designed to prevent CPA remains inconclusive due to the limited availability of rigorous evaluations; however, Triple-P is a notable exception. Given the potential for such interventions to shift population norms relevant to CPA and reduce rates of CPA, there is a need to further develop and rigorously evaluate such campaigns.