Nature-based social interventions to address loneliness among vulnerable populations: a common study protocol for three related randomized controlled trials in Barcelona, Helsinki, and Prague within the RECETAS European project.

BACKGROUND: The negative effects of loneliness on population health and wellbeing requires interventions that transcend the medical system and leverage social, cultural, and public health system resources. Group-based social interventions are a potential method to alleviate loneliness. Moreover, nature, as part of our social and health infrastructure, may be an important part of the solutions that are needed to address loneliness. The RECETAS European project H2020 (Re-imagining Environments for Connection and Engagement: Testing Actions for Social Prescribing in Natural Spaces) is an international research project aiming to develop and test the effectiveness of nature-based social interventions to reduce loneliness and increase health-related quality of life. METHODS: This article describes the three related randomized controlled trials (RCTs) that will be implemented: the RECETAS-BCN Trial in Barcelona (Spain) is targeting people 18+ from low socio-economic urban areas; the RECETAS-PRG Trial in Prague (Czech Republic) is addressing community-dwelling older adults over 60 years of age, and the RECETAS-HLSNK trial is reaching older people in assisted living facilities. Each trial will recruit 316 adults suffering from loneliness at least sometimes and randomize them to nature-based social interventions called "Friends in Nature" or to the control group. "Friends in Nature" uses modifications of the "Circle of Friends" methodology based on group processes of peer support and empowerment but including activities in nature. Participants will be assessed at baseline, at post-intervention (3 months), and at 6- and 12-month follow-up after baseline. Primary outcomes are the health-related quality-of-life according to 15D measure and The De Jong Gierveld 11-item loneliness scale. Secondary outcomes are health and psychosocial variables tailored to the specific target population. Nature exposure will be collected throughout the intervention period. Process evaluation will explore context, implementation, and mechanism of impact. Additionally, health economic evaluations will be performed. DISCUSSION: The three RECETAS trials will explore the effectiveness of nature-based social interventions among lonely people from various ages, social, economic, and cultural backgrounds. RECETAS meets the growing need of solid evidence for programs addressing loneliness by harnessing the beneficial impact of nature on enhancing wellbeing and social connections. TRIAL REGISTRATION: Barcelona (Spain) trial: ClinicalTrials.gov, ID: NCT05488496. Registered 29 July 2022. Prague (Czech Republic) trial: ClinicalTrials.gov, ID: NCT05522140. Registered August 25, 2022. Helsinki (Finland) trial: ClinicalTrials.gov, ID: NCT05507684. Registered August 12, 2022.

Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health.

Nature-based solutions including urban forests and wetlands can help communities cope better with climate change and other environmental stressors by enhancing social-ecological resilience. Natural ecosystems, settings, elements and affordances can also help individuals become more personally resilient to a variety of stressors, although the mechanisms underpinning individual-level nature-based resilience, and their relations to social-ecological resilience, are not well articulated. We propose 'nature-based biopsychosocial resilience theory' (NBRT) to address these gaps. Our framework begins by suggesting that individual-level resilience can refer to both: a) a person's set of adaptive resources; and b) the processes by which these resources are deployed. Drawing on existing nature-health perspectives, we argue that nature contact can support individuals build and maintain biological, psychological, and social (i.e. biopsychosocial) resilience-related resources. Together with nature-based social-ecological resilience, these biopsychosocial resilience resources can: i) reduce the risk of various stressors (preventive resilience); ii) enhance adaptive reactions to stressful circumstances (response resilience), and/or iii) facilitate more rapid and/or complete recovery from stress (recovery resilience). Reference to these three resilience processes supports integration across more familiar pathways involving harm reduction, capacity building, and restoration. Evidence in support of the theory, potential interventions to promote nature-based biopsychosocial resilience, and issues that require further consideration are discussed.

Effects of a community gardening intervention on diet, physical activity, and anthropometry outcomes in the USA (CAPS): an observer-blind, randomised controlled trial.

BACKGROUND: Unhealthy diet, physical inactivity, and social disconnection are important modifiable risk factors for non-communicable and other chronic diseases, which might be alleviated through nature-based community interventions. We tested whether a community gardening intervention could reduce these common health risks in an adult population that is diverse in terms of age, ethnicity, and socioeconomic status. METHODS: In this observer-blind, randomised, controlled trial, we recruited individuals who were on Denver Urban Garden waiting lists for community gardens in Denver and Aurora (CO, USA), aged 18 years or older, and had not gardened in the past 2 years. Participants were randomly assigned (1:1), using a randomised block design in block sizes of two, four, or six, to receive a community garden plot (intervention group) or remain on a waiting list and not garden (control group). Researchers were masked to group allocation. Primary outcomes were diet, physical activity, and anthropometry; secondary outcomes were perceived stress and anxiety. During spring (April to early June, before randomisation; timepoint 1 [T1]), autumn (late August to October; timepoint 2 [T2]), and winter (January to March, after the intervention; timepoint 3 [T3]), participants completed three diet recalls, 7-day accelerometry, surveys, and anthropometry. Analyses were done using the intention-to-treat principle (ie, including all participants randomly assigned to groups, and assessed as randomised). We used mixed models to test time-by-intervention hypotheses at an α level of 0·04, with T2 and T3 intervention effects at an α level of 0·005 (99·5% CI). Due to potential effects of the COVID-19 pandemic on outcomes, we excluded all participant data collected after Feb 1, 2020. This study is registered with ClinicalTrials.gov, NCT03089177, and data collection is now complete. FINDINGS: Between Jan 1, 2017, and June 15, 2019, 493 adults were screened and 291 completed baseline measures and were randomly assigned to the intervention (n=145) or control (n=146) groups. Mean age was 41·5 years (SD 13·5), 238 (82%) of 291 participants were female, 52 (18%) were male, 99 (34%) identified as Hispanic, and 191 (66%) identified as non-Hispanic. 237 (81%) completed measurements before the beginning of the COVID-19 pandemic. One (<1%) participant in the intervention group had an adverse allergic event in the garden. Significant time-by-intervention effects were observed for fibre intake (p=0·034), with mean between-group difference (intervention minus control) at T2 of 1·41 g per day (99·5% CI -2·09 to 4·92), and for moderate-to-vigorous physical activity (p=0·012), with mean between-group difference of 5·80 min per day (99·5% CI -4·44 to 16·05). We found no significant time-by-intervention interactions for combined fruit and vegetable intake, Healthy Eating Index (measured using Healthy Eating Index-2010), sedentary time, BMI, and waist circumference (all p>0·04). Difference score models showed greater reductions between T1 and T2 in perceived stress and anxiety among participants in the intervention group than among those in the control group. INTERPRETATION: Community gardening can provide a nature-based solution, accessible to a diverse population including new gardeners, to improve wellbeing and important behavioural risk factors for non-communicable and chronic diseases. FUNDING: American Cancer Society, University of Colorado Cancer Centre, University of Colorado Boulder, National Institutes of Health, US Department of Agriculture National Institute of Food and Agriculture, Michigan AgBioResearch Hatch projects.

Thinking Health-related Behaviors in a Climate Change Context: A Narrative Review.

BACKGROUND: Human activities have changed the environment so profoundly over the past two centuries that human-induced climate change is now posing serious health-related threats to current and future generations. Rapid action from all scientific fields, including behavioral medicine, is needed to contribute to both mitigation of, and adaption to, climate change. PURPOSE: This article aims to identify potential bi-directional associations between climate change impacts and health-related behaviors, as well as a set of key actions for the behavioral medicine community. METHODS: We synthesized the existing literature about (i) the impacts of rising temperatures, extreme weather events, air pollution, and rising sea level on individual behaviors (e.g., eating behaviors, physical activity, sleep, substance use, and preventive care) as well as the structural factors related to these behaviors (e.g., the food system); and (ii) the concurrent positive and negative roles that health-related behaviors can play in mitigation and adaptation to climate change. RESULTS: Based on this literature review, we propose a first conceptual model of climate change and health-related behavior feedback loops. Key actions are proposed, with particular consideration for health equity implications of future behavioral interventions. Actions to bridge the fields of behavioral medicine and climate sciences are also discussed. CONCLUSIONS: We contend that climate change is among the most urgent issues facing all scientists and should become a central priority for the behavioral medicine community.

Rationale, Feasibility, and Acceptability of the Meeting in Nature Together (MINT) Program: A Novel Nature-Based Social Intervention for Loneliness Reduction with Teen Parents and Their Peers.

Recently, there has been an increase in feelings of loneliness and mental health conditions among adolescents. Within this population, parenting teens are at an increased risk for these conditions. Outdoor experiences are shown to be an antidote to loneliness and a way to promote social connectedness by amplifying the processes for supporting social relationships. In 2020-2021, we piloted the 8-week Meeting in Nature Together program (MINT) at a charter school for pregnant and parenting teenagers in Colorado, USA. MINT aimed to promote relatedness and nature connection for students ages 14 to 19. MINT included online and in-person group meetings with educational content, creative activities, discussion, park excursions, mindfulness activities, journaling, and nature photography. Here, we ask, can a school-level nature-based social intervention reduce loneliness among pregnant and parenting teens by promoting and sustaining social connections? How acceptable is MINT to participants? Methods included audiovisual recording transcriptions, surveys, and observation field notes. Results suggest that MINT fostered social connections through a tailored nature-based intervention delivered to a typically isolated community in culturally sensitive, developmentally appropriate ways. MINT proved feasible and effective as participants reported high levels of satisfaction and interest in continuing to engage in activities promoted in MINT.

Understanding Emerging Environmental Health Concerns and Environmental Public Health-Tracking Priorities Among State and Local Professionals in Colorado.

CONTEXT: Colorado is experiencing dramatic changes related to population growth, climate change, and expanded industrial activity. Local and state public health professionals are trying to address a growing array of unique public health issues with stagnant or limited resources. OBJECTIVES: To understand, through perspectives from local and state public health professionals, the alignment of contemporary environmental and community health issues with state and local capacity and state environmental public health-tracking priorities. DESIGN: During 2014-2015, we conducted semistructured interviews which informed the development of a statewide survey of Colorado's professionals from public health, emergency management, forestry, and transportation. SETTING: This work took place in Colorado. PARTICIPANTS: Fifteen professionals from public (n = 9), academic (n = 4), and private (n = 2) sectors were interviewed. Forty-seven professionals, representing 34 counties and 40 public agencies, completed the 25-minute online survey. MAIN OUTCOME MEASURES: Environmental and community health concerns; contributing factors to environmental concerns; strengths and limitations of capacity to respond to issues; and frequency of community engagement activities. RESULTS: Top environmental health concerns were indoor air pollution (eg, radon), outdoor air pollution, and waste management. Transportation, extreme weather (eg, wildfires), and oil and gas development were most frequently reported as major contributing factors to concerns. Obesity, physical inactivity, and mental illness were the top community health concerns. To remain prepared for emerging challenges, professionals cited a need for more spatiotemporal-refined data related to their top concerns in the environmental public health-tracking database, and support from local, state, and federal agencies, in addition to personnel and funding. To address concerns, participants reported frequently working with government officials, advisory committees, and media outlets. CONCLUSIONS: This project illuminates opportunities to strengthen connections between the state's environmental public health-tracking priorities and local-level capacity related to professionals' top concerns. It also suggests reinforcing and broadening partnerships to improve data infrastructure and inform environmental public health priorities.

Improving lifestyles sustainability through community gardening: results and lessons learnt from the JArDinS quasi-experimental study.

BACKGROUND: Despite an increasing number of studies highlighting the health benefits of community gardening, the literature is limited by cross-sectional designs. The "JArDinS" quasi-experimental study aimed to assess the impact of community garden participation on the adoption of more sustainable lifestyles among French adults. METHODS: Individuals entering a community garden in Montpellier (France) in 2018 (n = 66) were compared with pairwise matched individuals with no experience in community gardening (n = 66). Nutritional quality, environmental impact and cost of monthly household food supplies, level of physical activity measured by accelerometers, as well as mental and social well-being, sensitivity to food waste, and connection with nature were evaluated at baseline (t0) and 12 months later (t1) to explore sustainability of lifestyles in social/health, environmental and economic dimensions. Linear mixed models were used to determine the independent effect of community gardening on investigated lifestyles components. In-depth interviews were conducted at t1 with 15 gardeners to better understand changes that may have occurred in gardeners' lives during the first year of gardening. RESULTS: At t0, gardeners had lower education level, lower BMI and their household reported lower percentage of meals consumed outside of the home compared to non-gardeners (p <  0.05). Participating in the community garden had no significant impact, in spite of sufficient statistical power, on fruit and vegetables supplies (main outcome), nor on physical activity parameters, nor on others of the social/health, environmental and economic lifestyles components investigated. Qualitative interviews suggested the existence of pre-established health and environmental consciousness in some gardeners and revealed several barriers to the participation such as lack of time, lack of gardening knowledge, physical difficulty of gardening, health problems and conflicts with other gardeners. CONCLUSIONS: The health benefits of community gardening previously reported by cross-sectional studies might be confounded by selection bias. The JArDinS study highlights the need to identify solutions to overcome barriers related to community garden participation when designing relevant public health interventions for the promotion of sustainable lifestyles. TRIAL REGISTRATION: The study was registered at clinicaltrials.gov as NCT03694782 . Date of registration: 3rd October 2018, retrospectively registered.

Feasibility of collection and analysis of microbiome data in a longitudinal randomized trial of community gardening.

Aim: We explored the feasibility of collecting and analyzing human microbiome data in a longitudinal randomized controlled trial of community gardening. Methods & materials: Participants were randomly assigned to gardening (N = 8) or control (N = 8). Participants provided stool, mouth, hand and forehead microbiome samples at six timepoints. Analyses combined mixed models with Qiita output. Results: Participant satisfaction was high, with 75% of participants completing evaluations. While no microbial effects were statistically significant due to small sample size, the analysis pipeline utility was tested. Conclusion: Longitudinal collection and analysis of microbiome data in a community gardening randomized controlled trial is feasible. The analysis pipeline will be useful in larger studies for assessment of the pathway between microbiota, gardening and health outcomes.

A Study of Perceived Nature, Shade and Trees and Self-Reported Physical Activity in Denver.

(1) Background: Current evidence on the association between greenery and physical activity (PA) remains inconsistent. Most studies on this association use objective measures of greenness, which do not reveal people's perceptions of greenness in neighborhoods, or the role of quality components of greenness, such as shade, trees, and the presence of nature on this association. (2) Methods: Drawing on data from the Neighborhood Environment and Health Survey-a cross-sectional population-based survey of Denver residents in 2007-we examined which measures of greenness (perceived and objective) correlated with the self-reported PA. We also assessed how components of perceived greenness, shade, trees and the presence of nature, correlated with PA. (3) Results: Perceived greenness, reflecting perception of trees, shade and the presence of nature, was positively associated with reported moderate-vigorous PA. Conclusion: Findings provide evidence that quality aspects of greenness affect people's perception of the neighborhood in a way that relates to PA. The individual contributions of shade, trees, and the presence of nature in this association should be analyzed in future studies. Understanding the link between shade and trees and PA has implications for how to plan for walkability and sun safety at the neighborhood scale.

Perceptions of the Built Environment and Support for Policies That Promote Physical Activity.

BACKGROUND: To assess how perceptions of the community built environment influence support for community policies that promote physical activity (PA). METHODS: A national cross-sectional survey assessed perceptions of the local built environment and support of community policies, including school and workplace policies, promoting PA. A random digit-dialed telephone survey was conducted in US counties selected on Behavioral Risk Factor Surveillance System data for high or low prevalence of obesity and inactivity. A total of 1208 subjects were interviewed, 642 from high-prevalence counties and 566 from low-prevalence counties. Analyses were stratified by county prevalence of obesity and inactivity (high or low). Linear models adjusted for covariates were constructed to assess the influence of built environment perceptions on policy support. RESULTS: Perception of more destinations near the residence was associated with increased support for community policies that promote PA, including tax increases in low-prevalence (obesity and inactivity) counties (P < .01). Positive perception of the workplace environment was associated (P < .001) with increased support for workplace policies among those in high-, but not low-, prevalence counties. CONCLUSIONS: Support for community policies promoting PA varies by perception of the built environment, which has implications for policy change.

Dog ownership, the natural outdoor environment and health: a cross-sectional study.

OBJECTIVES: Dog owners walking their dog in natural outdoor environments (NOE) may benefit from the physical activity facilitated by dog walking and from time spent in nature. However, it is unclear whether dog owners receive additional health benefits associated with having access to NOE above the physical activity benefit of walking with their dog. We investigated associations between dog ownership, walking, time spent in NOE and health and whether these associations differed among those with good and poor access to NOE and those living in green and less green areas. DESIGN: Cross-sectional study. SETTING: The Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe project. PARTICIPANTS: n=3586 adults from Barcelona (Spain), Doetinchem (the Netherlands), Kaunas (Lithuania) and Stoke-on-Trent (UK). DATA COLLECTION AND ANALYSIS: We calculated access to NOE with land maps and residential surrounding greenness with satellite data. Leisure time walking, time spent in NOE and general and mental health status were measured using validated questionnaires. Associations were estimated using multilevel analysis with a random intercept defined at the neighbourhood level. RESULTS: Dog ownership was associated with higher rates of leisure time walking and time spending in NOE (OR 2.17, 95% CI 1.86 to 2.54 and 2.37, 95% CI 2.02 to 2.79, respectively). These associations were stronger in those living within 300 m of a NOE and in greener areas. No consistent associations were found between dog ownership and perceived general or mental health status. CONCLUSIONS: Compared with non-dog owners, dog owners walked more and spent more time in NOE, especially those living within 300 m of a NOE and in greener areas. The health implications of these relationships should be further investigated. In a largely physically inactive society, dog walking in NOE may be a simple way of promoting physical activity and health.

Gardening and age-related weight gain: Results from a cross-sectional survey of Denver residents.

This study examined whether gardening modifies the association between age and body mass index (BMI). We used data from the Neighborhood Environments and Health Survey, which was conducted in Denver (N = 469) between 2006 and 2007. We fit two general linear mixed models. The base model had BMI in kg/m2 as the outcome, and age, an indicator variable for non-gardening status and the age-by-non-gardening status interaction as predictors. The adjusted model included as covariates the potential confounders of education, ethnicity and self-reported health. We assessed self-selection bias and confounding. BMI was 27.18 kg/m2 for non-gardeners, 25.62 kg/m2 for home gardeners, and 24.17 kg/m2 for community gardeners. In the base model, a statistically significant association was observed between age and BMI for non-gardeners but not for the combined community and home gardening group (F = 9.27, ndf = 1, ddf = 441, p = 0.0025). In the adjusted model, the association between age and BMI in non-gardeners was not statistically significant (F = 1.72, ndf = 1, ddf = 431, p = 0.1908). Gardeners differed on social and demographic factors when compared to non-gardeners. The results from the base model are consistent with the hypothesis that gardening might offset age-related weight gain. However, the cross-sectional design does not permit differentiation of true causal effects from the possible effects of bias and confounding. As a follow-up study, to remove bias and confounding, we are conducting a randomized clinical trial of community gardening in Denver.

Amplifying Health Through Community Gardens: A Framework for Advancing Multicomponent, Behaviorally Based Neighborhood Interventions.

The article presents a framework for understanding the relationship between community garden participation, and the myriad ways gardens and participation lead to emotional, social, and health impacts. Existing empirical research relating community gardens to health behaviors, such as physical activity and diet, and longer-term chronic disease-related outcomes is summarized. The research areas discussed include the effects of community garden participation on individual, social, emotional, and environmental processes; health behaviors including diet and physical activity; and health outcomes such as self-rated health, obesity, and mental health. Other mechanisms through which community gardens may affect population health are described. Applying a multitheoretical lens to explore associations between community garden participation and health enables us to delineate key aspects of gardening that elicit positive health behaviors and multifactorial health assets that could be applied to designing other types of health interventions.

How to Identify Success Among Networks That Promote Active Living.

OBJECTIVES: We evaluated organization- and network-level factors that influence organizations' perceived success. This is important for managing interorganizational networks, which can mobilize communities to address complex health issues such as physical activity, and for achieving change. METHODS: In 2011, we used structured interview and network survey data from 22 states in the United States to estimate multilevel random-intercept models to understand organization- and network-level factors that explain perceived network success. RESULTS: A total of 53 of 59 "whole networks" met the criteria for inclusion in the analysis (89.8%). Coordinators identified 559 organizations, with 3 to 12 organizations from each network taking the online survey (response rate = 69.7%; range = 33%-100%). Occupying a leadership position (P < .01), the amount of time with the network (P < .05), and support from community leaders (P < .05) emerged as correlates of perceived success. CONCLUSIONS: Organizations' perceptions of success can influence decisions about continuing involvement and investment in networks designed to promote environment and policy change for active living. Understanding these factors can help leaders manage complex networks that involve diverse memberships, varied interests, and competing community-level priorities.

Municipal Officials' Participation in Built Environment Policy Development in the United States.

PURPOSE: This study examined municipal officials' participation in built environment policy initiatives focused on land use design, transportation, and parks and recreation. DESIGN: Web-based cross-sectional survey. SETTING: Eighty-three municipalities with 50,000 or more residents in eight states. SUBJECTS: Four hundred fifty-three elected and appointed municipal officials. MEASURES: Outcomes included self-reported participation in land use design, transportation, and parks and recreation policy to increase physical activity. Independent variables included respondent position; perceptions of importance, barriers, and beliefs regarding physical activity and community design and layout; and physical activity partnership participation. ANALYSIS: Multivariable logistic regression models. RESULTS: Compared to other positions, public health officials had lower participation in land use design (78.3% vs. 29.0%), transportation (78.1% vs. 42.1%), and parks and recreation (67.1% vs. 26.3%) policy. Perceived limited staff was negatively associated with participation in each policy initiative. Perceptions of the extent to which physical activity was considered in community design and physical activity partnership participation were positively associated with participation in each. Perceived lack of collaboration was associated with less land use design and transportation policy participation, and awareness that community design affects physical activity was associated with more participation. Perceived lack of political will was associated with less parks and recreation policy participation. CONCLUSION: Public health officials are underrepresented in built environment policy initiatives. Improving collaborations may improve municipal officials' policy participation.

Support for physical activity policies and perceptions of work and neighborhood environments: variance by BMI and activity status at the county and individual levels.

PURPOSE: To examine support for local policies encouraging physical activity and perceived neighborhood environment characteristics by physical activity and weight status of respondents across U.S. counties. DESIGN: We used a random-digit-dial, computer-assisted telephone interview (CATI) to conduct a cross-sectional telephone questionnaire in selected U.S. counties in 2011. SETTING: Counties with high prevalences of obesity and sedentary behavior (HH; n = 884) and counties with low prevalences of obesity and sedentary behavior (LL; n = 171) were selected nationally. SUBJECTS: Adult respondents from HH (n = 642) and LL (n = 566) counties. MEASURES: Questions were asked of respondents, pertaining to support for physical activity policies in various settings, neighborhood features, time spent in physical activity and sedentary behaviors, self-reported weight and height, and personal demographic information. ANALYSIS: Means and frequencies were calculated; bivariable and multivariable linear and logistic regression models, developed. Models were adjusted for individual characteristics and county HH/LL status. RESULTS: Respondents in LL counties perceived their neighborhood and work environments to be more supportive of healthy behaviors and were more supportive of local physical activity policies than respondents in HH counties (p < .001 for all). Positive neighborhood environment perceptions were related to reduced body mass index, increased physical activity, and decreased sedentary behavior. CONCLUSION: Policy support and neighborhood environments are associated with behaviors. Results can inform targeting policy agendas to facilitate the improvement of environments (community, work, and school) to be more supportive of physical activity.

Local Wellness Policy 5 years later: is it making a difference for students in low-income, rural Colorado elementary schools?

INTRODUCTION: The federally mandated Local Wellness Policy (LWP) was intended to promote student health in schools. This study assesses the 5-year effects of the LWP on the health practices of rural elementary schools in Colorado. METHODS: One year before and 5 years after the LWP mandate, a survey was administered to a random sample of principals, physical education (PE) teachers, and food-service managers in 45 rural, low-income elementary schools in Colorado. Response rates were 71% in 2005 and 89% in 2011. RESULTS: Minutes for PE and recess did not increase, nor did offerings of fresh fruits and vegetables. More schools adopted policies prohibiting teachers from taking recess away as punishment (9.7% in 2005 vs 38.5% in 2011, P = .02) or for making up missed instructional time, class work, or tests in other subjects (3.2% in 2005 vs 28.2% in 2011, P = .03). More schools scheduled recess before lunch (22.6% in 2005 vs 46.2% in 2011, P = .04) and developed policies for vending machines (42.9% in 2005 vs 85.7% in 2011, P = .01) and parties (21.4% in 2005 vs 57.9% in 2011, P = .004). CONCLUSION: Changes in school practices are modest, and arguably the important school practices such as increased PE and recess time and increased offerings of fruits and vegetables in the lunch line have not changed in the 5 years since the mandate went into effect. Further investigation is needed to identify the knowledge, skills, and attitudes as well as financial and physical resources required for school administrators to make changes in school practices.

In-depth interviews with state public health practitioners on the United States National Physical Activity Plan.

BACKGROUND: The United States National Physical Activity Plan (NPAP; 2010), the country's first national plan for physical activity, provides strategies to increase population-level physical activity to complement the 2008 physical activity guidelines. This study examined state public health practitioner awareness, dissemination, use, challenges, and recommendations for the NPAP. METHODS: In 2011-2012, we interviewed 27 state practitioners from 25 states. Interviews were recorded and transcribed verbatim. Transcripts were coded using a standard protocol, verified and reconciled by an independent coder, and input into qualitative software to facilitate development of common themes. RESULTS: NPAP awareness was high among state practitioners; dissemination to local constituents varied. Development of state-level strategies and goals was the most frequently reported use of the NPAP. Some respondents noted the usefulness of the NPAP for coalitions and local practitioners. Challenges to the plan included implementation cost, complexity, and consistency with other policies. The most frequent recommendation made was to directly link examples of implementation activities to the plan. CONCLUSIONS: These results provide early evidence of NPAP dissemination and use, along with challenges encountered and suggestions for future iterations. Public health is one of eight sectors in the NPAP. Further efforts are needed to understand uptake and use by other sectors, as well as to monitor long-term relevance, progress, and collaboration across sectors.

Policy, systems, and environmental approaches for obesity prevention: a framework to inform local and state action.

The public health literature has not fully explored the complexities of the policy process as they relate to public health practice and obesity prevention. We conducted a review of the literature across the policy science and public health fields, distilled key theories of policy making, and developed a framework to inform policy, systems, and environmental change efforts on obesity prevention. Beginning with a conceptual description, we focus on understanding three domains of the policy process: the problem domain, the policy domain, and the political domain. We identify key activities in the policy process including the following: (a) assessing the social and political environment; (b) engaging, educating and collaborating with key individuals and groups; (c) identifying and framing the problem; (d) utilizing available evidence; (e) identifying policy solutions; and (f) building public support and political will. The article provides policy change resources and case studies to guide and support local and state efforts around obesity prevention.