Municipal officials' perspectives on policymaking for addressing obesity and health equity.

Background: Obesity evidence-based policies (EBPs) can make a lasting, positive impact on community health; however, policy development and enactment is complex and dependent on multiple forces. Aims and objectives: This study investigated key factors affecting municipal officials' policymaking for obesity and related health disparities. Methods: Semi-structured interviews were conducted with 20 local officials from a selection of municipalities with high obesity or related health disparities across the United States between December 2020 and April 2021. Findings: Policymakers follow a general decision-making process with limited distinction between health and other policy areas. Factors affecting policymaking included: being informed about other local, state, and federal policy, conducting their own research using trustworthy sources, and seeking constituent and stakeholder perspectives. Key facilitators included the need for timely, relevant local data, and seeing or hearing from those impacted. Key local policymaking barriers included constituent opposition, misinformation, controversial issues with contentious solutions, and limited understanding of the connection between issues and obesity/health. Policymakers had a range of understanding about causes of health disparities, including views of individual choices, environmental influences on behaviors, and structural factors impacting health. To address health disparities, municipal officials described: a variety of roles policymakers can take, limitations based on the scope of government, challenges with intergovernmental collaboration or across government levels, ability of policymakers and government employees to understand the problem, and the challenge of framing health disparities given the social-political context. Discussion and conclusion: Understanding factors affecting the uptake of EBPs can inform local-level interventions that encourage EBP adoption.

Applying RE-AIM to Evaluate the External Validity of Weight Gain Prevention Interventions in Young Adults: A Systematic Review.

OBJECTIVES: The purpose of this review was to use RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) to assess the extent to which weight gain prevention studies targeting young adults reported on elements of external validity. DESIGN: Systematic review. ELIGIBILITY CRITERIA: Articles of interest included a lifestyle/behavioral intervention targeting weight gain prevention. Eligibility criteria included the following: study design of randomized controlled trials, quasi-randomized control trials, or natural experiments; average participant age between 18 and 35 years; study duration of at least 12 months; and published in English between January 2008 and May 2018. Studies had to report weight or body mass index as a measured outcome and were excluded if they were paired with smoking cessation programs, were conducted in specific groups (ie, pregnant women, breast cancer survivors), or were follow-ups to weight loss studies. STUDY SELECTION: After removing duplicates, the search yielded 11426 articles. Titles and abstracts were screened by 1 reviewer; 144 articles were assessed in a full-text review by 2 reviewers. Discrepancies were resolved by consensus. Nine studies (13 articles) were included in the review. MAIN OUTCOMES MEASURES: Reported elements of the RE-AIM framework. RESULTS: A total of 9 studies met the selection criteria. All studies lacked full reporting on external validity elements. Of the total of 60 RE-AIM reporting criteria, 8 were reported by all 9 studies, 26 criteria were reported by fewer than 4 studies, and 22 criteria were not reported by any of the studies. DISCUSSION: There remains inadequate reporting of elements of external validity and generalizability in weight gain prevention studies. This is a significant scientific constraint that limits the information required to disseminate and implement prevention of weight gain interventions for population impact. Standardized reporting may be needed to ensure results that demonstrate not only internal validity but also external validity and generalizability are needed to promote public health impact.

Letting Go: Conceptualizing Intervention De-implementation in Public Health and Social Service Settings.

The discontinuation of interventions that should be stopped, or de-implementation, has emerged as a novel line of inquiry within dissemination and implementation science. As this area grows in human services research, like public health and social work, theory is needed to help guide scientific endeavors. Given the infancy of de-implementation, this conceptual narrative provides a definition and criteria for determining if an intervention should be de-implemented. We identify three criteria for identifying interventions appropriate for de-implementation: (a) interventions that are not effective or harmful, (b) interventions that are not the most effective or efficient to provide, and (c) interventions that are no longer necessary. Detailed, well-documented examples illustrate each of the criteria. We describe de-implementation frameworks, but also demonstrate how other existing implementation frameworks might be applied to de-implementation research as a supplement. Finally, we conclude with a discussion of de-implementation in the context of other stages of implementation, like sustainability and adoption; next steps for de-implementation research, especially identifying interventions appropriate for de-implementation in a systematic manner; and highlight special ethical considerations to advance the field of de-implementation research.

Comparison of Research Framing Preferences and Information Use of State Legislators and Advocates Involved in Cancer Control, United States, 2012-2013.

INTRODUCTION: Evidence-based policy plays an important role in prevention of cancer and other chronic diseases. The needs of actors involved in policy decision-making should inform knowledge translation strategies. This study examines the differences between state legislators and advocates in how they seek and use information and what their preferences are for how research information is framed. METHODS: We conducted a cross-sectional comparison of survey responses by US advocates (n = 77) and state legislators (n = 265) working on issues related to cancer control. RESULTS: Advocates differed significantly from legislators on all demographic characteristics. Advocates reported seeking and using information more frequently than legislators, though legislators used legislative research bureaus more often (0.45 point difference, P = .004). Both legislators and advocates prioritized the presentation and timeliness of research information similarly but reported different preferences for source (information bias, information relevance, delivery of information by trusted person) of research information. Several differences between advocates and legislators were modified by participant age. CONCLUSION: Our study provides insights for development of knowledge translation strategies to enhance evidence-based policy making for cancer control that are tailored to state-level legislators and advocates. Additional research efforts should evaluate the effectiveness of such knowledge translation strategies, particularly among advocates.

CHILE: Outcomes of a group randomized controlled trial of an intervention to prevent obesity in preschool Hispanic and American Indian children.

OBJECTIVE: We examined the outcomes of the Child Health Initiative for Lifelong Eating and Exercise (CHILE) study, a group randomized controlled trial to design, implement, and test the efficacy of a trans-community intervention to prevent obesity in children enrolled in Head Start centers in rural American Indian and Hispanic communities in New Mexico. METHODS: CHILE was a 5-year evidence-based intervention that used a socioecological approach to improving dietary intake and increasing physical activity of 1898 children. The intervention included a classroom curriculum, teacher and food service training, family engagement, grocery store participation, and healthcare provider support. Height and weight measurements were obtained four times (fall of 2008, spring and fall of 2009, and spring of 2010), and body mass index (BMI) z-scores in the intervention and comparison groups were compared. RESULTS: At baseline, demographic characteristics in the comparison and intervention groups were similar, and 33% of all the children assessed were obese or overweight. At the end of the intervention, there was no significant difference between the two groups in BMI z-scores. CONCLUSIONS: Obesity prevention research among Hispanic and AI preschool children in rural communities is challenging and complex. Although the CHILE intervention was implemented successfully, changes in overweight and obesity may take longer than 2years to achieve.

Early nutrition transition in Haiti: linking food purchasing and availability to overweight status in school-aged children.

OBJECTIVE: The primary aim was to examine the association of socio-economic factors and diet with overweight (including obesity) among school-aged children in Haiti. The secondary aim was to describe food availability and the physical activity built environment in participating schools. DESIGN: This cross-sectional study examined baseline data from the intervention Mamba study assessing the effectiveness of a fortified peanut butter paste in school-aged children. Logistic regression modelling was used to test hypothesized factors in association with overweight status. SETTING: Six primary schools in Cap-Haitien, the second largest city in Haiti. SUBJECTS: Children (n 968) aged 3-13 years, in good health and enrolled in a participating school for the 2012/13 school year. RESULTS: Child age (adjusted OR (AOR); 95 % CI=0·25; 0·12, 0·56), child age squared (1·08; 1·03, 1·13), always purchasing food at school (3·52; 1·12, 11·08), mother's BMI (1·10; 1·04, 1·16) and household ownership of a bicycle (0·28; 0·11, 0·71) were significantly associated with overweight (likelihood ratio=36, P<0·0001). Consumption of fish was significantly lower in overweight children in the binary analysis (P=0·033) and improved the fit of the model. Schools had limited time and space for physical activity and foods sold by vendors were predominantly high in sugar or fat. CONCLUSIONS: To our knowledge the present study is the first to examine the covariates of childhood overweight or describe school food availability and physical activity built environments in Haiti. Further research is necessary to identify intervention targets and feasible, cost-effective approaches for prevention of obesity in Haiti children.

Effectively communicating with local policymakers: a randomized trial of policy brief dissemination to address obesity.

Introduction: Evidence-based policies are a powerful tool for impacting health and addressing obesity. Effectively communicating evidence to policymakers is critical to ensure evidence is incorporated into policies. While all public health is local, limited knowledge exists regarding effective approaches for improving local policymakers' uptake of evidence-based policies. Methods: Local policymakers were randomized to view one of four versions of a policy brief (usual care, narrative, risk-framing, and narrative/risk-framing combination). They then answered a brief survey including questions about their impressions of the brief, their likelihood of using it, and how they determine legislative priorities. Results: Responses from 331 participants indicated that a majority rated local data (92%), constituent needs/opinions (92%), and cost-effectiveness data (89%) as important or very important in determining what issues they work on. The majority of respondents agreed or strongly agreed that briefs were understandable (87%), believable (77%), and held their attention (74%) with no brief version rated significantly higher than the others. Across the four types of briefs, 42% indicated they were likely to use the brief. Logistic regression models showed that those indicating that local data were important in determining what they work on were over seven times more likely to use the policy brief than those indicating that local data were less important in determining what they work on (aOR = 7.39, 95% CI = 1.86,52.57). Discussion: Among local policymakers in this study there was no dominant format or type of policy brief; all brief types were rated similarly highly. This highlights the importance of carefully crafting clear, succinct, credible, and understandable policy briefs, using different formats depending on communication objectives. Participants indicated a strong preference for receiving materials incorporating local data. To ensure maximum effect, every effort should be made to include data relevant to a policymaker's local area in policy communications.

A scoping review of frameworks in empirical studies and a review of dissemination frameworks.

BACKGROUND: The field of dissemination and implementation (D&I) research has grown immensely in recent years. However, the field of dissemination research has not coalesced to the same degree as the field of implementation research. To advance the field of dissemination research, this review aimed to (1) identify the extent to which dissemination frameworks are used in dissemination empirical studies, (2) examine how scholars define dissemination, and (3) identify key constructs from dissemination frameworks. METHODS: To achieve aims 1 and 2, we conducted a scoping review of dissemination studies published in D&I science journals. The search strategy included manuscripts published from 1985 to 2020. Articles were included if they were empirical quantitative or mixed methods studies about the dissemination of information to a professional audience. Studies were excluded if they were systematic reviews, commentaries or conceptual papers, scale-up or scale-out studies, qualitative or case studies, or descriptions of programs. To achieve aim 1, we compiled the frameworks identified in the empirical studies. To achieve aim 2, we compiled the definitions from dissemination from frameworks identified in aim 1 and from dissemination frameworks identified in a 2021 review (Tabak RG, Am J Prev Med 43:337-350, 2012). To achieve aim 3, we compile the constructs and their definitions from the frameworks. FINDINGS: Out of 6017 studies, 89 studies were included for full-text extraction. Of these, 45 (51%) used a framework to guide the study. Across the 45 studies, 34 distinct frameworks were identified, out of which 13 (38%) defined dissemination. There is a lack of consensus on the definition of dissemination. Altogether, we identified 48 constructs, divided into 4 categories: process, determinants, strategies, and outcomes. Constructs in the frameworks are not well defined. IMPLICATION FOR D&I RESEARCH: This study provides a critical step in the dissemination research literature by offering suggestions on how to define dissemination research and by cataloging and defining dissemination constructs. Strengthening these definitions and distinctions between D&I research could enhance scientific reproducibility and advance the field of dissemination research.

A scoping review of de-implementation frameworks and models.

BACKGROUND: Reduction or elimination of inappropriate, ineffective, or potentially harmful healthcare services and public health programs can help to ensure limited resources are used effectively. Frameworks and models (FM) are valuable tools in conceptualizing and guiding the study of de-implementation. This scoping review sought to identify and characterize FM that can be used to study de-implementation as a phenomenon and identify gaps in the literature to inform future model development and application for research. METHODS: We searched nine databases and eleven journals from a broad array of disciplines (e.g., healthcare, public health, public policy) for de-implementation studies published between 1990 and June 2020. Two raters independently screened titles and abstracts, and then a pair of raters screened all full text records. We extracted information related to setting, discipline, study design, methodology, and FM characteristics from included studies. RESULTS: The final search yielded 1860 records, from which we screened 126 full text records. We extracted data from 27 articles containing 27 unique FM. Most FM (n = 21) were applicable to two or more levels of the Socio-Ecological Framework, and most commonly assessed constructs were at the organization level (n = 18). Most FM (n = 18) depicted a linear relationship between constructs, few depicted a more complex structure, such as a nested or cyclical relationship. Thirteen studies applied FM in empirical investigations of de-implementation, while 14 articles were commentary or review papers that included FM. CONCLUSION: De-implementation is a process studied in a broad array of disciplines, yet implementation science has thus far been limited in the integration of learnings from other fields. This review offers an overview of visual representations of FM that implementation researchers and practitioners can use to inform their work. Additional work is needed to test and refine existing FM and to determine the extent to which FM developed in one setting or for a particular topic can be applied to other contexts. Given the extensive availability of FM in implementation science, we suggest researchers build from existing FM rather than recreating novel FM. REGISTRATION: Not registered.

A systematic review of system dynamics and agent-based obesity models: Evaluating obesity as part of the global syndemic.

The problem of obesity has recently been reframed as part of the global syndemic-the co-occurring, interacting pandemics of obesity, undernutrition, and climate change that are driven by common underlying societal drivers. System science modeling approaches may help clarify how these shared drivers operate and the best ways to address them. The objective of this paper was to determine to what extent existing agent-based and system dynamics computational models of obesity provide insights into the shared drivers of the global syndemic. Peer-reviewed studies published until July 2018 were identified from Scopus, Web of Science, and PubMed databases. Thirty-eight studies representing 30 computational models were included. They show a growing use of system dynamics and agent-based modeling in the past decade. They most often examined mechanisms and interventions in the areas of social network-based influences on obesity, physiology and disease state mechanics, and the role of food and physical activity environments. Usefulness for identifying common drivers of the global syndemic was mixed; most models represented Western settings and focused on obesity determinants close to the person (eg, social circles, school settings, and neighborhood environments), with a relative paucity in models at mesolevel and macrolevel and in developing country contexts.

Weight gain prevention content delivered to mothers: Lessons from an intervention embedded in a community organization.

BACKGROUND: Transparent reporting of the intervention content study participants receive is particularly important for dissemination and implementation of evidence-based interventions to address obesity. This study explores intervention delivery and perceptions of content when an intervention is embedded within an organization's usual practice and associations with weight outcomes. METHODS: This is a secondary analysis from the Healthy Eating and Active Living Taught at Home (HEALTH) randomized trial. HEALTH is a weight gain prevention intervention embedded within a national home visiting programme (Parents as Teachers, PAT). To be consistent with PAT practice, HEALTH has a suggested but also flexible home visit structure. Therefore, the number and frequency of home visits are determined by the family's needs and preferences based on the parent educator's professional judgement. The proportion of participants who received each curriculum core lesson was explored among the 105 families randomized to the HEALTH intervention group, as were mean parent educator perception ratings of the visits (5-point Likert-type scale). A chi-square test was used to examine the association between utilization (ie, low: 1-6, middle: 7-12, or high: 13-18 visits) category and weight maintenance. RESULTS: Mothers received on average 13.3 (standard deviation 6.2) core visits. Mean parent educator perception of the mothers' response (out of 5) ranged from 3.99 to 4.27; educators' perception of their own experience with the lesson ranged from 4.13 to 4.34. Among mothers who maintained their weight, 13% were low, 22% were middle, and 65% were high utilizers, while among mothers who gained weight, 3%, 31%, and 67% were low, middle, and high utilizers, respectively; this difference was not statistically significant. CONCLUSIONS: This study identified wide variation in the visits families received from the curriculum but minimal variation in visit perceptions. Future studies could explore whether there are optimal patterns for visit content, associated with successful outcomes.

The Impact of a Healthy Weight Intervention Embedded in a Home-Visiting Program on Children's Weight and Mothers' Feeding Practices.

OBJECTIVE: To examine whether a healthy weight intervention embedded in the Parents as Teachers (PAT) home visiting program, which was previously found to improve mothers' body mass index (BMI) and obesity-related behaviors, changed the BMI of preschool children or maternal feeding practices. METHODS: This stratified randomized trial included preschool-aged children at risk for overweight whose mothers were overweight or had obesity (n = 179). The Healthy Eating and Active Living Taught at Home (HEALTH) intervention was based on the Diabetes Prevention Program. Differences were examined using repeated-measures mixed-ANOVA models. RESULTS: Compared with PAT usual care, the HEALTH intervention had no effect on children's BMI or maternal feeding practices. However, combined analyses showed that children's BMI percentile decreased (P  = .007), BMI z-scores were maintained (P  = .19), and 3 of 8 feeding practices improved over time (P < .05). CONCLUSIONS AND IMPLICATIONS: Additional research is needed to assess the effectiveness of PAT to prevent preschool-age obesity using rigorous designs (eg, group-randomized trials) and to identify its active components. HEALTH is ready to be scaled up to prevent maternal weight gain through embedding within the national PAT program.

Impact of a Healthy Weight Intervention Embedded Within a National Home Visiting Program on the Home Food Environment.

Purpose: To determine whether a lifestyle intervention embedded within Parents as Teachers (PAT), a national child development and parenting home visiting program, helped families make food-related home environment changes. Design: Secondary data analysis of a stratified randomized pragmatic trial. (Trial Registration: This study is registered at www.clinicaltrials.gov NCT01567033). Setting: Participant homes in St. Louis, Missouri. Subjects: Women (n = 179 with pre-post data, of 230 with baseline) participating in standard PAT, with overweight or obesity, and at least one preschool child with BMI percentile ≥60%. Intervention: PAT + Healthy Eating and Active Living Taught at Home (HEALTH), embedded elements of the Diabetes Prevention Program within the standard PAT curriculum. PAT + HEALTH addressed specific behaviors that impact caloric intake (e.g., sugar-sweetened beverages), focusing on behavioral and environmental strategies. Consistent with PAT practice, the frequency, number, and focus (i.e., time spent on intervention components) of home visits were determined by the family's needs; dose structure was flexible [on average intervention: 23 (SD = 9), usual care: 13 (SD = 6) visits]. Measures: Food availability/accessibility and distractions in the home were assessed with items drawn largely from the HomeSTEAD Survey. Analysis: Generalized estimating equations (GEEs) were used to test equality of changes between baseline and 24 months in the intervention and usual care groups. Results: The only significant difference in the pattern of change between usual care and intervention was soda availability/accessibility (p = 0.013). Conclusion: This embedded intervention successfully reduced availability/accessibility of sugar-sweetened beverages in the home. However, given the limited impact on other food-related home environment factors, future interventions could seek to more effectively intervene on all aspects of the home environment.

Toolkits for dissemination and implementation research: Preliminary development.

The Dissemination and Implementation Research Core, a research methods core from the Clinical and Translation Science Award at Washington University in St. Louis Institute of Clinical and Translational Sciences, developed toolkits about dissemination and implementation (D&I) concepts (e.g., D&I outcomes, strategies). This paper reports on the development of the toolkits. These toolkits respond to 3 identified needs for capacity building in D&I research: resources for investigators new to the D&I field, consolidation of tools, and limitations in local contexts.

The Impact of the CHILE Intervention on the Food Served in Head Start Centers in Rural New Mexico.

BACKGROUND: The Child Health Initiative for Lifelong Eating and Exercise is a multicomponent obesity-prevention intervention, which was evaluated among Head Start (HS) centers in American Indian and predominantly Hispanic communities in rural New Mexico. This study examines the intervention's foodservice outcomes: fruits, vegetables, whole grains, discretionary fats, added sugars, and fat from milk served in meals and snacks. METHODS: Sixteen HS centers were randomized to intervention/comparison groups, following stratification by ethnicity and preintervention median body mass index of enrolled children. The foodservice component included quarterly trainings for foodservice staff about food purchasing and preparation. Foods served were evaluated before and after the 2-year intervention, in the fall 2008 and spring 2010. RESULTS: The intervention significantly decreased fat provided through milk and had no significant effect on fruit, vegetables and whole-grain servings, discretionary fats, and added sugar served in HS meals and snacks. When effect modification by site ethnicity was examined, the effect on fat provided through milk was only found in American Indian sites. CONCLUSIONS: Foodservice interventions can reduce the amount of fat provided through milk served in HS. More research is needed regarding the implementation of foodservice interventions to improve the composition of foods served in early education settings.

Effect of WIC Food Package Changes on Dietary Intake of Preschool Children in New Mexico.

OBJECTIVES: This study examined WIC policy change effects on dietary intake of preschool children from WIC-participating households in rural New Mexico communities. METHODS: Dietary intake of children enrolled in Head Start in 8 communities was compared before and after 2009 WIC food package changes. RESULTS: Following the policy change, participants reported significantly increased consumption of lower-fat milk, reduced consumption of saturated fat (grams), and decreased consumption of vegetables without potatoes. No significant differences in fruit, fruit juice, vegetables including potatoes, whole-grains and saturated fat (percent-energy) consumption were observed. CONCLUSIONS: WIC policy changes have the potential to improve children's saturated fat intake. More research with robust designs is necessary to examine long-term effects of WIC policy changes.