The Availability and Price of Healthy Food in Seattle by Neighborhood Sociodemographic Characteristics.

INTRODUCTION: Unequal access to healthy food in the local food retail environment contributes to diet quality disparities. We assessed whether in-store availability and prices of healthy foods differ by neighborhood-level income and racial and ethnic composition in a representative sample of food stores in Seattle, Washington. METHODS: We developed and validated an in-store survey tool and surveyed 134 stores. We measured availability and prices of 19 items. For each store, we calculated a healthy food availability score (range, 0-25), and mean prices within each category. Using census tract data, we identified the median household income and proportions of Black and Hispanic residents for each store's neighborhood and grouped them by tertiles of these neighborhood characteristics across Seattle census tracts. We used Wald tests to compare mean availability scores and prices between tertiles and applied postestimation weights to reflect store-type distributions within each tertile. RESULTS: Neighborhoods with lower income and a larger proportion of Black residents had lower healthy food availability scores compared with neighborhoods with higher income (8.06 [95% CI, 7.04-9.07] vs 12.40 [95% CI, 10.63-14.17], P < .001) and fewer Black residents (8.88 [95% CI, 7.79-9.98] vs 12.32 [95% CI, 10.51-14.14], P = .003). Availability did not differ by Hispanic population proportions. Mean prices of grains, eggs, and meat were lower in neighborhoods with larger proportions of Black residents. CONCLUSION: We found systematic differences in healthy food availability based on neighborhood-level income and racial composition. In-store assessments of the food retail environment can inform local, tailored strategies to improve healthy food access.

Sweetened beverage taxes: Economic benefits and costs according to household income.

Taxing sweetened beverages has emerged as an important and effective policy for addressing their overconsumption. However, taxes may place a greater economic burden on people with lower incomes. We assess the degree to which sweetened beverage taxes in three large US cities placed an inequitable burden on populations with lower incomes by assessing spending on beverage taxes by income after taxes have been implemented, as well as any net transfer of funds towards lower income populations once allocation of tax revenue is considered. We find that while lower income populations pay a higher percentage of their income in beverage taxes, there is no difference in absolute spending on beverage taxes per capita, and that there is a sizable net transfer of funds towards programs targeting lower income populations. Thus, when considering both population-level taxes paid and sufficiently targeted allocations of tax revenues, a sweetened beverage tax may have characteristics of an equitable public policy.

Countermarketing About Fruit Drinks, Alone or With Water Promotion: A 2019 Randomized Controlled Trial in Latinx Parents.

Objectives. To test whether fruit drink countermarketing messages alone or combined with water promotion messages reduce Latinx parents' purchases of fruit drinks for children aged 0 to 5 years. Methods. We performed a 3-arm randomized controlled online trial enrolling 1628 Latinx parents in the United States during October and November 2019. We assessed the effect of culturally tailored fruit drink countermarketing messages (fruit drink‒only group), countermarketing and water promotion messages combined (combination group), or car-seat safety messages (control) delivered via Facebook groups for 6 weeks on parental beverage choices from a simulated online store. Results. The proportion of parents choosing fruit drinks decreased by 13.7 percentage points in the fruit drink‒only group (95% confidence interval [CI] = -20.0, -7.4; P < .001) and by 19.2 percentage points in the combination group (95% CI = -25.0, -13.4; P < .001) relative to control. Water selection increased in both groups. Conclusions. Fruit drink countermarketing messages, alone or combined with water promotion messages, significantly decreased parental selection of fruit drinks and increased water selection for their children. Public Health Implications. Countermarketing social media messages may be an effective and low-cost intervention for reducing parents' fruit drink purchases for their children. (Am J Public Health. 2021;111(11):1997-2007. https://doi.org/10.2105/AJPH.2021.306488).

Perceptions of the possible health and economic impacts of Seattle's sugary beverage tax.

BACKGROUND: Taxes on sugary beverages are an emerging strategy to improve health by reducing consumption and raising revenues to support community wellbeing. However, taxes may have unintended consequences, and perceptions of these consequences may affect attitudes towards this policy. METHODS: In June 2017, the Seattle City Council passed an ordinance imposing a tax on sugary beverages, effective January 1, 2018. Between October and December 2017, we recruited 851 adults in Seattle to complete a survey (telephone or online) about support for the tax and their perceptions of tax-related health and economic impacts. We first analyzed data for the full sample. We then tested for differences in participants' responses by household income level (< 260% Federal Poverty Level [FPL], ≥ 260% FPL) and across race/ethnicities using chi-square tests. Analyses used population weights and adjusted for multiple comparisons, using the Holm-Bonferroni Sequential Correction (p < 0.01). RESULTS: A majority of participants supported the sugary beverage tax (59%; 95% Confidence Interval [CI]: 55, 63%) and believed that the tax would improve public health (56%; CI: 52, 60%). Most participants believed that the tax would not negatively affect small businesses (52%; CI: 48, 56%) nor result in job loss (66%; CI: 62, 70%). Most participants also perceived that the tax would not negatively impact their own finances (79%; CI: 75, 82%). However, fewer lower-income (48%; CI: 42, 53%), versus higher-income participants (61%; CI: 55, 66%), perceived that the tax would improve public health, would not result in job loss (lower-income: 58%; CI: 53, 64%; higher-income: 71%; CI: 66, 75%) and would not negatively affect their own finances (lower-income: 68%; CI: 62, 73%; higher-income: 85%; CI: 81, 88%). Compared to non-Hispanic Whites, (82%; CI: 79, 86%), a smaller proportion of non-Hispanic Blacks (63%; 95% CI: 48, 75%), and Hispanics (67%; 95% CI: 51, 79%), perceived that the tax would have negative consequences for their own family finances. CONCLUSIONS: A majority of respondents supported the sugary beverage tax in Seattle. Lower-income participants were more concerned about potential financial consequences. Further evaluation of the extent to which unintended consequences occur is needed.

Casino Ownership and Health-Related Community Resources Among Native American Tribes in California.

INTRODUCTION: Casinos are significantly associated with improved health among some Native Americans living on tribal lands. An increase in health-related community resources related to tribal ownership of casinos may be one mechanism through which the health of Native Americans is improved. However, no studies have quantitatively assessed whether casinos are associated with having more community resources. METHODS: To investigate the association between casino ownership and health-related community resources among Native Americans, we surveyed 81 of California's 110 federally recognized tribes about casino ownership and health-related community resources during 2015 and 2016. We created a total health-related community resources score (maximum of 50 points) by grouping resources into 5 subdomains (community infrastructure, health care and education, social determinants, recreational infrastructure, and recreation programs), which we scored for a maximum of 10 points each and then summed. Casino ownership was our independent variable. We used adjusted linear regression models to test the association between casino ownership and health-related community resources. RESULTS: Half (49%) of the tribes surveyed owned a casino. Compared with tribes without casinos, tribes with casinos had higher total health-related community resource scores (ß = 5.09; 90% confidence interval [CI], 1.17-9.01). Casino-owning tribes had more resources related to community infrastructure (ß = 1.81; 90% CI, 0.81-2.80), social determinants of health (ß = 1.45; 90% CI, 0.24-2.67) and recreational infrastructure (ß = 1.08; 90% CI, 0.24-1.92) compared with tribes without casinos. CONCLUSIONS: Casino ownership is significantly associated with health-related community resources. Future research should assess whether community resources mediate the relationship between economic resources and health among Native Americans.

Creating Environments to Support Breastfeeding: The Challenges and Facilitators of Policy Development in Hospitals, Clinics, Early Care and Education, and Worksites.

Objectives Supportive organizational breastfeeding policies can establish enabling environments for breastfeeding. In this qualitative study we identify facilitators and barriers to the development, adoption, and implementation of supportive breastfeeding policies and practices in four influential sectors for breastfeeding women: hospitals, clinics, early care and education settings, and worksites. Methods We interviewed 125 individuals representing 110 organizations in Washington State about their breastfeeding policy development and implementation process between August 2014 and February 2015. Greenhalgh's diffusion of innovations framework guided the interviews and qualitative analysis. Results Breastfeeding policy facilitators across the sectors include national and state laws and regulations, performance tracking requirements, and an increasingly supportive sociopolitical climate; barriers include limited resources and appreciation about the need for breastfeeding policies, and certain organizational characteristics such as workforce age. Despite broad support for breastfeeding, organizations differed on perceptions about the usefulness of written breastfeeding policies. Personal breastfeeding experiences of policy makers and staff affect organizational breastfeeding policies and practices. Conclusions for Practice Supportive organizational systems and environments are built through effective policy development processes; public health can support breastfeeding policy development and assure a coordinated continuum of care by leveraging federal health care policy requirements, building networks to support training and collaboration, and disseminating strategies that reflect the personal nature of breastfeeding.

Process evaluation of a regional public health model to reduce chronic disease through policy and systems changes, Washington State, 2010-2014.

INTRODUCTION: Although the regionalization of public health systems has been well documented in the case of emergency preparedness, there is little literature on the application of regional approaches to other aspects of public health. From 2011 through 2014 the Washington State Department of Health implemented a Community Transformation Grant to support community-level policy and systems changes to decrease chronic disease risk factors and increase access to clinical preventive services. The Department of Health implemented the grant through a regional model, grouping 32 of the state's 35 local health jurisdictions into 5 regions. Our process evaluation identifies the challenges and facilitators to Community Transformation Grant planning and implementation. METHODS: We conducted 34 key informant interviews with people directly involved in the implementation of the Community Transformation Grant. We interviewed state and local partners, including representatives from each region, the Department of Health, external consultants, and regional partners. We collected data from October 2013 through July 2014. RESULTS: Challenges for planning, building, and implementing a regional model for chronic disease prevention included stakeholder buy-in, regional geography, and communication; facilitators included shared regional history and infrastructure, strong leadership, collaborative relationships, shared vision and goals, sufficient funding, and direct technical assistance and training. CONCLUSION: Lessons learned in Washington State provide a foundation for other states interested in using a regional approach to reduce chronic disease risk. Policy and systems changes require adequate time, funding, and staffing. States and funders should work closely with local leaders to address these challenges and facilitators.

Universal Free School Meals Policy and Childhood Obesity.

BACKGROUND AND OBJECTIVES: The Community Eligibility Provision (CEP), a universal free school meals policy, increases school meal participation by allowing schools in low-income areas to provide free breakfast and lunch to all students; however, its impact on obesity remains uncertain. The objective of this study is to estimate the association of CEP with child obesity. METHODS: School obesity prevalence was calculated using BMI measurements collected annually between 2013 and 2019 from students in California public schools in grades 5, 7, and 9. To estimate the association of CEP with obesity, we used a difference-in-differences approach for staggered policy adoption with an outcome regression model conditional on covariates, weighted by student population size. RESULTS: The analysis included 3531 CEP-eligible schools using school-level obesity prevalence calculated from 3 546 803 BMI measurements. At baseline, on average, 72% of students identified as Hispanic, 11% identified as white, 7% identified as Black, and 80% were eligible for free or reduced-price meals. Baseline obesity prevalence was 25%. Schools that participated in CEP were associated with a 0.60-percentage-point net decrease in obesity prevalence after policy adoption (95% confidence interval: -1.07 to -0.14 percentage points, P = .01) compared with eligible, nonparticipating schools, corresponding with a 2.4% relative reduction, given baseline prevalence. Meals served increased during this period in CEP-participating schools only. CONCLUSIONS: In a balanced sample of California schools, CEP participation was associated with a modest net decrease in obesity prevalence compared with eligible, nonparticipating schools. These findings add to the growing literature revealing potential benefits of universal free school meals for children's well-being.

Sweetened Beverage Tax Implementation and Change in Body Mass Index Among Children in Seattle.

Importance: Sweetened beverage taxes have been associated with reduced purchasing of taxed beverages. However, few studies have assessed the association between sweetened beverage taxes and health outcomes. Objective: To evaluate the association between the Seattle sweetened beverage tax and change in body mass index (BMI) among children. Design, Setting, and Participants: In this longitudinal cohort study, anthropometric data were obtained from electronic medical records of 2 health care systems (Kaiser Permanente Washington [KP] and Seattle Children's Hospital Odessa Brown Children's Clinic [OBCC]). Children were included in the study if they were aged 2 to 18 years (between January 1, 2014, and December 31, 2019); had at least 1 weight measurement every year between 2015 and 2019; lived in Seattle or in urban areas of 3 surrounding counties (King, Pierce, and Snohomish); had not moved between taxed (Seattle) and nontaxed areas; received primary health care from KP or OBCC; did not have a recent history of cancer, bariatric surgery, or pregnancy; and had biologically plausible height and BMI (calculated as weight in kilograms divided by height in meters squared). Data analysis was conducted between August 5, 2022, and March 4, 2024. Exposure: Seattle sweetened beverage tax (1.75 cents per ounce on sweetened beverages), implemented on January 1, 2018. Main Outcomes and Measures: The primary outcome was BMIp95 (BMI expressed as a percentage of the 95th percentile; a newly recommended metric for assessing BMI change) of the reference population for age and sex, using the Centers for Disease Control and Prevention growth charts. In the primary (synthetic difference-in-differences [SDID]) model used, a comparison sample was created by reweighting the comparison sample to optimize on matching to pretax trends in outcome among 6313 children in Seattle. Secondary models were within-person change models using 1 pretax measurement and 1 posttax measurement in 22 779 children and fine stratification weights to balance baseline individual and neighborhood-level confounders. Results: The primary SDID analysis included 6313 children (3041 female [48%] and 3272 male [52%]). More than a third of children (2383 [38%]) were aged 2 to 5 years); their mean (SE) age was 7.7 (0.6) years. With regard to race and ethnicity, 789 children (13%) were Asian, 631 (10%) were Black, 649 (10%) were Hispanic, and 3158 (50%) were White. The primary model results suggested that the Seattle tax was associated with a larger decrease in BMIp95 for children living in Seattle compared with those living in the comparison area (SDID: -0.90 percentage points [95% CI, -1.20 to -0.60]; P < .001). Results from secondary models were similar. Conclusions and Relevance: The findings of this cohort study suggest that the Seattle sweetened beverage tax was associated with a modest decrease in BMIp95 among children living in Seattle compared with children living in nearby nontaxed areas who were receiving care within the same health care systems. Taken together with existing studies in the US, these results suggest that sweetened beverage taxes may be an effective policy for improving children's BMI. Future research should test this association using longitudinal data in other US cities with sweetened beverage taxes.

Seattle's sweetened beverage tax implementation and changes in interior marketing displays.

Policymakers aim sugar-sweetened beverage (SSB) taxes at decreasing SSB consumption; however, little is known about their impact on beverage marketing in the retail environment. We assessed changes in interior marketing displays within large food stores before and after the implementation of Seattle's SSB tax. We used Poisson difference-in-difference (DID) models to estimate whether presence and variety of interior beverage marketing displays in Seattle changed from before to after the tax compared to displays in non-taxed comparison area stores, overall, and by beverage type. We found no significant changes in overall SSB or non-SSB interior marketing displays in Seattle versus the comparison area. There was less of an increase in displays for diet soda (DID 0.79, 90% CI 0.65, 0.97), and more of an increase in displays for diet energy drinks (DID 1.78, 90% CI 1.03, 3.09) in Seattle versus comparison area. There was mixed evidence that stores changed interior marketing displays in response to the SSB tax.

Evaluation of Seattle's sweetened beverage tax on tax support and perceived economic and health impacts.

It is important to understand whether the publics' attitudes towards sugary beverage taxes (SBT) change after tax implementation to ensure the long-term success of tax policies. Seattle's SBT went into effect on January 1, 2018. We administered a mixed-mode survey to adults in Seattle and comparison areas, pre- and 2-years post-tax, to evaluate the impact of the SBT on 1) tax support and 2) perceived tax impacts (N = 2,933). Using a difference-in-differences approach, we employed adjusted income-stratified modified Poisson models to test the impacts of the tax on net changes in attitudes in Seattle versus the comparison areas, pre- to post-tax. Among lower-income individuals in Seattle, support for the tax increased by 14% (PRDD: 1.14; 95% CI: 1.08, 1.21) and there was a 20% net-increase in the perception that the SBT would positively affect the economy (PRDD: 1.20; 95% CI: 1.05, 1.39), compared to changes in the comparison areas. Among higher-income individuals in Seattle, support for the tax was not different (PRDD: 0.93; 95% CI: 0.70, 1.22) pre- to post-tax, but there was a net-increase in the perception that the tax would have negative effects on small businesses (PRDD: 1.44; 95% CI: 1.03, 2.00) and family finances (PRDD: 1.86; 95% CI: 1.09, 3.19). After living with the tax for 2-years, support for the tax increased among lower-income individuals in Seattle. Tax support was high and unchanged among higher-income individuals, but overall attitudes became more negative. Policy makers should consider investing in ongoing campaigns that explain the benefits of SSB taxes and revenues.

Costs, Reach, and Benefits of COVID-19 Pandemic Electronic Benefit Transfer and Grab-and-Go School Meals for Ensuring Youths' Access to Food During School Closures.

Importance: School meals are associated with improved nutrition and health for millions of US children, but school closures due to the COVID-19 pandemic disrupted children's access to school meals. Two policy approaches, the Pandemic Electronic Benefit Transfer (P-EBT) program, which provided the cash value of missed meals directly to families on debit-like cards to use for making food purchases, and the grab-and-go meals program, which offered prepared meals from school kitchens at community distribution points, were activated to replace missed meals for children from low-income families; however, the extent to which these programs reached those who needed them and the programs' costs were unknown. Objective: To assess the proportion of eligible youths who were reached by P-EBT and grab-and-go meals, the amount of meals or benefits received, and the cost to implement each program. Design, Setting, and Participants: This cross-sectional study was conducted from March to June 2020. The study population was all US youths younger than 19 years, including US youths aged 6 to 18 years who were eligible to receive free or reduced-price meals (primary analysis sample). Exposures: Receipt of P-EBT or grab-and-go school meals. Main Outcomes and Measures: The main outcomes were the percentage of youths reached by P-EBT and grab-and-go school meals, mean benefit received per recipient, and mean cost, including implementation costs and time costs to families per meal distributed. Results: Among 30 million youths eligible for free or reduced-price meals, grab-and-go meals reached an estimated 8.0 million (27%) and P-EBT reached 26.9 million (89%). The grab-and-go school meals program distributed 429 million meals per month in spring 2020, and the P-EBT program distributed $3.2 billion in monthly cash benefits, equivalent to 1.1 billion meals. Among those receiving benefits, the mean monthly benefit was larger for grab-and-go school meals ($148; range across states, $44-$176) compared with P-EBT ($110; range across states, $55-$114). Costs per meal delivered were lower for P-EBT ($6.46; range across states, $6.41-$6.79) compared with grab-and-go school meals ($8.07; range across states, $2.97-$15.27). The P-EBT program had lower public sector implementation costs but higher uncompensated time costs to families (eg, preparation time for meals) compared with grab-and-go school meals. Conclusions and Relevance: In this economic evaluation, both the P-EBT and grab-and-go school meal programs supported youths' access to food in complementary ways when US schools were closed during the COVID-19 pandemic from March to June 2020.

A Qualitative Study of Living in a Healthy Food Priority Area in One Seattle, WA, Neighborhood.

Policy makers in several major cities have used quantitative data about local food environments to identify neighborhoods with inadequate access to healthy food. We conducted qualitative interviews with residents of a healthy food priority area to assess whether residents' perceptions of food access were consistent with previous quantitative findings, and to better understand lived experience of food access. We found that proximity to stores, transportation mode, and cost shaped decisions about food shopping. The local food bank played an important role in improving food access. Participants had varied suggestions for ways to improve the neighborhood, both related and unrelated to the food environment.

Qualitative Study on Participant Perceptions of a Supermarket Fruit and Vegetable Incentive Program.

BACKGROUND: Complete Eats Rx is a fruit and vegetable prescription program designed to incentivize fruit and vegetable consumption among Supplemental Nutrition Assistance Program (SNAP) participants via $10 incentives distributed either weekly or per encounter to purchase fruits and vegetables at a mid-price supermarket chain in Washington State. OBJECTIVE: To better understand SNAP participants' experience, and to determine perceived impacts and consequences of the program. DESIGN: Qualitative analysis of nine photovoice sessions. Participants chose the topics for discussion. Sessions were audiorecorded and transcribed. Thematic content analysis was performed to identify key emergent themes using Atlas.ti. SETTING: Spokane, Seattle, and Yakima, Washington. PARTICIPANTS: Twenty-six individuals who received a fruit and vegetable prescription within the past 6 months, 23 of whom attended all three photovoice sessions offered at their site. Participants were recruited from three participating health care or public health organizations in Spokane, Seattle, and Yakima, Washington. ANALYSIS: Transcriptions were coded using inductive methods. Coded statements were organized into major themes. Coding structures and analysis were strengthened by iterative interactions between researchers. RESULTS: Participants reported Complete Eats Rx was an important resource for families and improved food security, diet quality, and the ability to purchase healthy foods, including a greater variety of fruits and vegetables. Primary barriers to food security and fruit and vegetable consumption included limited geographic accessibility and the high cost of fruits and vegetables, exacerbated by other financial constraints such as rising housing costs. Participants reported supermarket checkout difficulty because of embarrassment, stigmatization, and inability to redeem incentives. The most frequently mentioned barrier to perceived program acceptability was having only one supermarket chain as the acceptor of the incentive. CONCLUSION: Partnering with supermarkets to accept fruit and vegetable incentives is a unique strategy to increase produce purchasing that can be adopted by other localities. Focus on geographic accessibility, appropriate price points, and positive shopping experiences via expansion to local grocers, improvements in staff interactions, and a transition to an electronic system may improve incentive redemption and usability.

Is the public sweet on sugary beverages? Social desirability bias and sweetened beverage taxes.

Social desirability bias has been documented in self-reported diet as well as in voting behavior, but not in regards to sweetened beverage consumption or sweetened beverage taxes. We find evidence that respondents in a mixed-mode opinion survey exhibit social desirability bias in both reported sweetened beverage consumption and beliefs about the health and economic benefits of sweetened beverage taxes. We do so in a study of 1704 adults residing in Seattle, Minneapolis, and the D.C. metro area. Phone respondents in our survey under-report sweetened beverage consumption by 0.63 beverages per week relative to web respondents (average web respondent consumption is 3.55 beverages per week). They also over-report their beliefs about the positive health and economic impacts of sweetened beverage taxes by 0.54 points in an 18-point index (average web respondent index score is 2.79). These differences are measured after we control for selection into survey mode by using matching methods, and we interpret them as occurring due to social desirability bias. In contrast to these findings, there is no modal difference in respondents' stated approval of sweetened beverage taxes, and so we conclude that this question is not subject to social desirability bias.

Development and Validation of a Photo-Evidence Tool to Examine Characteristics of Effective Drinking Water Access in Schools.

BACKGROUND: Federal law requires water access in schools where meals are served. Schools report high rates of water accessibility in cafeterias, but observations indicate lower adherence. Although observation is costly, it permits a more detailed assessment of a water source to determine whether it provides effective access that encourages water consumption and thus, healthy hydration for students. METHODS: To offer a less costly alternative to observations, researchers developed and validated a photo-evidence tool to examine characteristics of effective school drinking water access. Two observers recorded characteristics of 200 water sources in 30 schools, including type, wear, cleanliness, and water flow, and examined obstructions and beverage promotion near sources, as well as, drinking vessel availability. Observers photographed sources which were coded by a separate research team. Agreement between observation audits and photograph coding was assessed through percent agreement, and kappa statistics and correlation coefficients. RESULTS: Kappas indicated substantial (K > 0.60) or near perfect agreement (K > 0.80) for all characteristics of effective drinking water access with exception of wear. There was moderate agreement (r = 0.66) for water source cleanliness. CONCLUSIONS: Development and validation of a photo-evidence tool to examine characteristics of effective drinking water access in schools.

Impact of a sweetened beverage tax on beverage prices in Seattle, WA.

Seattle's Sweetened Beverage Tax is an excise tax of 1.75 cents per ounce on sugar-sweetened beverages and is one of the highest beverage taxes in the U.S. This study examined the impact of Seattle's tax on the prices of beverages. We conducted audits of 407 retail food stores and eating places (quick service restaurants and coffee shops) before and 6 months after the tax was implemented in Seattle and in a comparison area. Ordinary least squares difference-in-differences models with store fixed effects were used to estimate the effect of the tax on prices, stratified by beverage type and store type. In secondary analyses, we assessed the effect of the tax on the price of non-taxed beverages and foods. Results from the adjusted difference-in-differences models indicated the tax was associated with an average increase of 1.58 cents per ounce among Seattle retailers, representing 90 % of the price of the tax. By store type, price increases were highest in smaller grocery stores and drug stores. By beverage type, price increases were highest for energy beverages and soda and lowest for bottled coffee and juice drinks. Prices of some non-taxed beverages also increased while the prices of select healthy foods generally did not. The sweetened beverage tax in Seattle is higher than beverage taxes in most other cities, and nearly the full cost of the tax is being passed through to consumers for many beverage types and stores types.

Training High School Student "Citizen Scientists" to Document School Water Access: A Feasibility Study.

BACKGROUND: Youth water consumption is inadequate. Increasing adolescent water consumption could support decreased dental caries and body mass index (BMI). Most schools are required to provide free, potable water. However, there is evidence that schools' self-reported compliance data overestimate access to water in schools. We tested the feasibility of using student citizen scientists to collect high quality observational data about water sources in schools. METHODS: We trained 12 teams of high school students to use a validated photo-evidence protocol to photograph and submit data on water sources in elementary and secondary schools. We surveyed students and advisors to assess student learning, advisor burden, and project feasibility. RESULTS: Students submitted data for 325 water sources across 40 racially and economically diverse schools. We were able to use 99% of the student-submitted photographs to measure water source wear, cleanliness, accessibility, and flow. The majority of students (72%, N = 70) spent under 2 hours photographing each school. The majority of students and advisors felt the project was valuable and feasible. CONCLUSIONS: High school students can use a photographic method to collect data for analysis, and understand access to water in schools. This is a feasible, scalable, cost-effective method to gather valid water source data.

An Assessment of Perceived Barriers to Farmers' Market Access.

OBJECTIVE: To explore whether Supplemental Nutrition Assistance Program-Education (SNAP-Ed) stakeholders (individuals involved in work to increase access to farmers' markets [FMs] for low-income populations) perceive the same barriers to shopping at FMs as those reported by SNAP participants in Washington State. DESIGN: Descriptive study; data included a stratified clustered random sample of SNAP participants and stakeholder interviews. SETTING: Washington State. PARTICIPANTS: A total of 400 SNAP participants and 51 SNAP-Ed stakeholders. MAIN OUTCOME MEASURES: The SNAP participants' reported barriers to accessing FMs and the SNAP-Ed stakeholders' perceptions of FM access barriers. ANALYSIS: Thematic content analysis, descriptive statistics, 2-sample tests of proportion, and Pearson chi-square tests (P < .025). RESULTS: A majority of SNAP participants reported they did not shop at an FM because it is inconvenient (n = 193; 51%) and not financially viable (n = 84; 22%). Moreover, 9% of SNAP participants (n = 34) stated that they experienced no barriers. The SNAP-Ed stakeholders placed increased emphasis on transportation and cost barriers compared with the SNAP participants. CONCLUSIONS AND IMPLICATIONS: Comprehensive, multilevel strategies that reflect the perspectives of SNAP participants could increase SNAP use at FMs. Opening FMs in diverse locations at variable operating times may address convenience barriers while engaging the targeted populations' communities to promote FMs, and FM incentive programs may address financial and awareness barriers.

An Evaluation of Washington State SNAP-Ed Farmers' Market Initiatives and SNAP Participant Behaviors.

OBJECTIVE: To describe Supplemental Nutrition Assistance Program-Education (SNAP-Ed)-supported farmers' market (FM) access activities in Washington State communities and identify associations between participation in these activities and SNAP participants' FM shopping and fruit and vegetable consumption. DESIGN: Descriptive study; data included stakeholder interviews and surveys with FM managers and a stratified clustered random sample of SNAP participants. SETTING: Washington State. PARTICIPANTS: A total of 51 SNAP-Ed stakeholders, 400 SNAP participants, and 94 FM managers participated. MAIN OUTCOME MEASURE(S): Partnership measures and SNAP-Ed FM access activities; SNAP participants' participation in FM access activities, FM shopping frequency, and fruit and vegetable consumption. ANALYSIS: Thematic content analysis, descriptive statistics, and 0-inflated Poisson and ordinary least-squares regression models. RESULTS: A total of 343 FM access activities and strong multi-sector partnerships were identified. Fifty percent of SNAP participants shopped at an FM in the past year, and 30% at least monthly. The SNAP participants participating in FM access activities shopped at FMs more frequently (P=.005). The SNAP participants shopping at FMs ate fruit and vegetables more frequently than did non-FM shoppers (P<.001). CONCLUSIONS AND IMPLICATIONS: Through nutrition education and systems and environmental changes, Washington SNAP-Ed developed effective programming and multi-sector partnerships. These efforts are associated with SNAP participants' FM shopping and fruit and vegetable consumption.