Recruitment of Low-wage Workers for a Time-Sensitive Natural Experiment to Evaluate a Minimum Wage Policy: Challenges and Lessons Learned.

Natural experiments are often used for answering research questions in which randomization is implausible. Effective recruitment strategies are well documented for observational cohort studies and clinical trials, unlike recruitment methods for time-sensitive natural experiments. In this time-sensitive study of the impact of a minimum wage policy, we aimed to recruit 900 low-wage workers in Minneapolis, Minnesota and Raleigh, North Carolina. We present our recruitment strategies, challenges, and successes for participant screening and enrollment of a difficult-to-reach population.

Integration as a Tool for Interprofessional Work: A Synthesis of the Literature Regarding How to Use Integrative Strategies to Address Complex Public Health Problems.

BACKGROUND AND PURPOSE: There has been limited success addressing complex public health problems using "siloed" approaches. A next important step in addressing persistent public health problems is adopting an "integrative" approach-intentional collaboration across the domains of research, clinical practice, community, and policy. This synthesis of the literature aggregates and synthesizes the diffuse and multi-disciplinary integration literature base to describe key concepts, aspects of praxis, and challenges and successes to help guide interprofessional practice. METHODS: A three-step approach was used: 1) a wide-ranging search for articles on integration theory/praxis; 2) a more focused search in the health literature bases; 3) a snowball strategy to identify additional studies. DISCUSSION/CONCLUSIONS: Identified themes included elements of successful integration; characteristics of an effective integrator; and dynamics between stakeholders in integration praxis. Results of this synthesis of the integration literature provide a deeper understanding of integration and points to clear and exciting next steps for integration praxis and inquiry.

An Economic Analysis of Updating and Expanding School Breakfast Program Offerings in High Schools.

BACKGROUND: School breakfast is an important nutritional component of a student's day. Many schools operate a school breakfast program, but high schools have low rates of participation. This study aimed to investigate the economic impact on school food service, of expanding the school breakfast program to increase participation in high schools. METHODS: Ten rural high schools participated in the economic analysis of expanding their school breakfast program. Schools provided data on costs of daily operation and start-up costs. Analyses calculated the daily breakeven point, revenue, cost, and days needed to recoup costs. RESULTS: Schools sold enough breakfast meals to break even on daily costs of operating an expanded program. Schools saw daily profits ranging from $196-$432 and recouped costs associated with expanding the breakfast program within 15-46 days. CONCLUSIONS: Expanding the school breakfast program can be economical for schools, while increasing student exposure to the health and academic benefits of school breakfast.

A Group Randomized Intervention Trial Increases Participation in the School Breakfast Program in 16 Rural High Schools in Minnesota.

BACKGROUND: Breakfast consumption is associated with better diet quality and healthier weights, yet many adolescents miss breakfast. Nationally, 17.1% of students participate in the School Breakfast Program (SBP). Only 10% of high school students participate. OBJECTIVE: Our aim was to evaluate an environmental intervention to increase SBP participation in high schools. DESIGN: A group randomized trial was carried out from 2012 to 2015. PARTICIPANTS/SETTING: Ninth- and 10th-grade students enrolled in 16 rural schools in Minnesota (median 387 students) were randomized to intervention or control condition. INTERVENTION: A school-based intervention that included two key components was implemented over a 12-month period. One component focused on increasing SBP participation by increasing student access to school breakfast through changes in school breakfast service practices (eg, serving breakfast from a grab-n-go cart in the atrium; expanding breakfast service times). The other component focused on promoting school breakfast through student-directed marketing campaigns. MAIN OUTCOME MEASURE: Change in school-level participation in the SBP was assessed between baseline (among ninth and tenth graders) and follow-up (among tenth and eleventh graders). School meal and attendance records were used to assess change in school-level participation rates in the SBP. STATISTICAL ANALYSES: The Wilcoxon test was used for analysis of difference in change in mean SBP participation rate by experimental group. RESULTS: The median change in SBP participation rate between baseline and follow-up was 3% (interquartile range=13.5%) among the eight schools in the intervention group and 0.5% (interquartile range=0.7%) among the eight schools in the control group. This difference in change between groups was statistically significant (Wilcoxon test, P=0.03). The intervention effect increased throughout the intervention period, with change in mean SBP participation rate by the end of the school year reaching 10.3% (95% CI 3.0 to 17.6). However, among the intervention schools, the change in mean SBP participation rates was highly variable (range=-0.8% to 24.8%). CONCLUSIONS: Interventions designed to improve access to the SBP by reducing environmental and social barriers have potential to increase participation among high school students.

Provider Adherence to Nutrition and Physical Activity Best Practices Within Early Care and Education Settings in Minnesota, Helping to Reduce Early Childhood Health Disparities.

Licensed child care providers, and the early care and education settings in which they operate, are uniquely situated to influence children's healthy eating and physical activity through practices, attitudes, and supportive physical and social environments. However, preliminary research indicates that child-, family-, and provider-level characteristics affect adherence to best practices across early care and education settings. The current article used survey data ( n = 618) to characterize differences in child care providers' adherence to nutrition, physical activity, and mealtime best practices, based on child-, family- and provider-level characteristics, and to describe secular trends in adherence to nutrition and physical activity best practices between 2010 and 2016. Results indicate that differences exist across certain characteristics, including child race/ethnicity, family's use of child care assistance, language spoken at home, and provider educational attainment; however, it is notable that in most cases providers serving children of minority race and children in low-income families have a higher rate of compliance with the nutrition and physical activity best practices studied. Additionally, the comparison of adherence to best practices from 2010 to 2016 suggests that, while there was an increase in mean adherence from 2010 to 2016, overall trends in adherence across child-, family- and provider-level characteristics have been consistent across time. Public health professionals should continue to advocate for opportunities for providers to learn how to best incorporate best practices within their setting (e.g., education and training opportunities) as well as for the development and adoption of systems-level changes (e.g., expansion of food assistance programs) to reduce barriers to adherence to best practices.

Change in the implementation of healthy nutrition and physical activity best practices in Minnesota early care settings: A longitudinal cohort study (2010-2016).

The goal of the 'Healthy Start, Healthy State' study was to describe changes in the implementation of healthy nutrition and physical activity (PA) best practices in early child care and education (ECE) settings from 2010 to 2016. A cohort of 215 Minnesota licensed center- and family/home-based providers completed a survey describing 15 nutrition and 8 PA best practices that they "already do" in 2010 and again in 2016 were analyzed in 2016. There was a significant net implementation rate increase for 15 best practices (10 nutrition, 5 PA) in centers and 12 best practices (8 nutrition, 4 PA) in family/home-based programs. The 2010 nutrition and PA scores were negatively associated with mean change in 2016 indicating the decreased potential for improvement among sites with more best practices already implemented in 2010. Adjusted for 2010 nutrition score and other factors, centers implemented, on average, 1.45 more nutrition best practices from 2010 to 2016 than family/home based programs, and CACFP participating programs implemented, on average, 1.7 more nutrition best practices from 2010 to 2016 than non-CACFP participants. Urbanicity, provider education, and provider years of experience were not significantly associated with 2010-2016 change in nutrition score. The mean PA score change had a small but significant increase for each additional year of provider ECE experience after adjusting for the 2010 score. State-level surveillance of implemented best practices in ECE settings is useful. Findings identify opportunities for stakeholders to respond with targeted technical support and training and to consider potential future policy levers.

Altering the School Breakfast Environment Reduces Barriers to School Breakfast Participation Among Diverse Rural Youth.

BACKGROUND: The purpose is to determine if altering school breakfast policies and the school breakfast environment will positively impact adolescent beliefs of the barriers and benefits of eating breakfast. METHODS: There were 904 adolescents from 16 rural high schools, Minnesota, in the BreakFAST Study who reported eating breakfast fewer than 4 times per week at baseline. Schools were randomized to intervention (N = 8 schools) or delayed intervention (N = 8) condition. The intervention lasted 1 school year. Students completed an online survey of beliefs of barriers and benefits to eating breakfast at baseline and follow-up. Summative scales were created. Bivariate and multivariate linear regression, accounting for clustering by school, was performed using SAS. Sex interaction was tested. Models tested the effect of the intervention on change in summative scales from baseline to follow -up. RESULTS: Participants were 54% female, 69.1% white, 36.6% eligible for free or reduced-price meals (FRM) and 13.1% of families received public assistance. The change in reported barriers was significantly different in intervention versus control schools (Net difference = 1.0, p = .03). There was no intervention effect of perceived benefits. CONCLUSIONS: A school-based policy and environmental change intervention can successfully reduce perceived barriers to eating school breakfast.

School Breakfast Program Participation and Rural Adolescents' Purchasing Behaviors in Food Stores and Restaurants.

BACKGROUND: Little is known about adolescents' food purchasing behaviors in rural areas. This study examined whether purchasing food at stores/restaurants around schools was related to adolescents' participation in school breakfast programs and overall diet in rural Minnesota. METHODS: Breakfast-skippers enrolled in a group-randomized intervention in 2014 to 2015 (N = 404 from 8 schools) completed 24-hour dietary recalls and pre/post surveys assessing food establishment purchase frequency. Healthy Eating Index Scores (HEI-2010) were calculated for each student. Student-level school breakfast participation (SBP) was obtained from school food service records. Mixed-effects regression models estimated: (1) whether SBP was associated with store/restaurant use at baseline, (2) whether an increase in SBP was associated with a decrease in store/restaurant use, and (3) whether stores/restaurant use was associated with HEI-2010 scores at baseline. RESULTS: Students with increased SBP were more likely to decrease fast-food restaurant purchases on the way home from school (OR 1.017, 95% CI 1.005, 1.029), but were less likely to decrease purchases at food stores for breakfast (OR 0.979, 95% CI 0.959, 0.999). Food establishment use was associated with lower HEI-2010 dairy component scores (p = .017). CONCLUSIONS: Increasing participation in school breakfast may result in modest changes in purchases at food establishments.

Healthy Eating and Activity Across the Lifespan (HEAL): A call to action to integrate research, clinical practice, policy, and community resources to address weight-related health disparities.

Despite intense nationwide efforts to improve healthy eating and physical activity across the lifespan, progress has plateaued. Moreover, health inequities remain. Frameworks that integrate research, clinical practice, policy, and community resources to address weight-related behaviors are needed. Implementation and evaluation of integration efforts also remain a challenge. The purpose of this paper is to: (1) Describe the planning and development process of an integrator entity, HEAL (Healthy Eating and Activity across the Lifespan); (2) present outcomes of the HEAL development process including the HEAL vision, mission, and values statements; (3) define the planned integrator functions of HEAL; and (4) describe the ongoing evaluation of the integration process. HEAL team members used a theoretically-driven, evidence-based, systemic, twelve-month planning process to guide the development of HEAL and to lay the foundation for short- and long-term integration initiatives. Key development activities included a review of the literature and case studies, identifying guiding principles and infrastructure needs, conducting stakeholder/key informant interviews, and continuous capacity building among team members. Outcomes/deliverables of the first year of HEAL included a mission, vision, and values statements; definitions of integration and integrator functions and roles; a set of long-range plans; and an integration evaluation plan. Application of the HEAL integration model is currently underway through community solicited initiatives. Overall, HEAL aims to lead real world integrative work that coalesce across research, clinical practice, and policy with community resources to inspire a culture of health equity aimed at improving healthy eating and physical activity across the lifespan.

Increasing Social Support for Breakfast: Project BreakFAST.

High school students in the United States are known to be frequent skippers of breakfast. Social support is one key element needed to encourage adolescents to consume school breakfast. This article presents an analysis of the influence of a school policy and environment change intervention on the social support of adolescents to eat breakfast. METHOD: The intervention included school policy changes in 16 schools randomized to intervention and delayed-intervention conditions, in order to allow quick and easy access to breakfast as well as to allow breakfast consumption in classrooms and hallways; a School Breakfast Program marketing campaign to address normative and attitudinal beliefs; and increasing social support and role modeling to encourage breakfast eating. The participants in the study completed an online survey at baseline and again postintervention. RESULTS: The final analysis included only students who completed the relevant survey (n = 904) items on both the baseline and follow-up surveys. The students in the intervention group showed a higher level of social support post intervention than the control group with a significant adjusted p of .02. Most of the overall social support change was explained by a change in the "other kids at my school" and "other school staff" categories. CONCLUSIONS: The BreakFAST study shows the benefits of school staff and kids other than friends supporting a behavior change to include breakfast consumption in adolescents.

Food Insecurity and Rural Adolescent Personal Health, Home, and Academic Environments.

BACKGROUND: Food-insecure (FIS) adolescents struggle in school and with health and mental health more often than food-secure (FS) adolescents. Rural communities experience important disparities in health, but little is known about rural FIS adolescents. This study aims to describe select characteristics of rural adolescents by food-security status. METHODS: Baseline analysis using data from a randomized trial to increase school breakfast participation (SBP) in rural Minnesota high schools. Students completed a survey regarding food security, characteristics, and home and school environments. Schools provided academic data and staff measured height and weight. Food security was dichotomized as FS vs FIS. Bivariate analysis, multivariate linear/logistic regression, and testing for interaction of food security and sex were performed. RESULTS: Food-insecure adolescents reported poorer health, less exercise, had lower grades, and higher SBP (p < .01). Food-insecure adolescents reported marginally fewer barriers (p = .06) and more benefits of breakfast (p = .05). All associations except reported benefits remained significant after adjustment. Interactions were identified with girls' grade point average and with boys' caloric and added sugar intake. CONCLUSIONS: Negative associations among food insecurity and positive youth development are identified in our sample. Policy and environmental strategies should address the complexities of these associations, including exploration of the role of school meals.

Eating breakfast together as a family: mealtime experiences and associations with dietary intake among adolescents in rural Minnesota, USA.

OBJECTIVE: Although existing evidence links breakfast frequency to better dietary quality, little is known specifically in regard to the benefits associated with eating breakfast together with one's family. The present study describes the prevalence and experience of having family meals at breakfast among rural families and examines associations between meal frequency and adolescent diet quality. DESIGN: Data were drawn from Project BreakFAST, a group-randomized trial aimed at increasing school breakfast participation in rural Minnesota high schools, USA. Linear mixed models were used to examine associations between student reports of family breakfast frequency and Healthy Eating Index 2010 (HEI-2010) scores while accounting for clustering within schools, demographics and household food security. SETTING: Adolescent students from sixteen schools completed online surveys, height and weight measurements, and dietary recalls at baseline in 2012-2014. SUBJECTS: The sample included 827 adolescents (55·1 % girls) in grades 9-10 who reported eating breakfast on at most three days per school week. RESULTS: On average, adolescents reported eating breakfast with their family 1·3 (sd 1·9) times in the past week. Family breakfast meals occurred most frequently in the homes of adolescents who reported a race other than white (P=0·002) or Hispanic ethnicity (P=0·02). Family breakfast frequency was directly associated with adolescent involvement in preparing breakfast meals (P<0·001) and positive attitudes (P≤0·01) about mealtime importance, interactions and structure. Family breakfast frequency was unrelated to most diet quality markers. CONCLUSIONS: Family meals may be one important context of opportunity for promoting healthy food patterns at breakfast. Additional research is needed to better inform and evaluate strategies.

Barriers, Benefits, and Behaviors Related to Breakfast Consumption Among Rural Adolescents.

BACKGROUND: We sought to determine if perceived barriers, benefits, and modifiable behaviors support or interfere with breakfast consumption in a racially and economically diverse rural high school population. METHODS: The participants were 832 Minnesota adolescents from 16 rural high schools. We used baseline data from a group randomized trial aimed at increasing school breakfast participation through policy and environmental-level school changes. Students completed an online survey asking about demographics, breakfast eating behaviors, and the barriers and benefits of eating as it relates to school performance. Bivariate and multivariate logistic regression, accounting for clustering by school, was performed using SAS. Each scale was modeled independently. RESULTS: Participants were 9th and 10th grade students, 36% free/reduced-price lunch (FRL), 30% non-White, and 55% female. Breakfast skippers compared to nonbreakfast skippers reported fewer school related benefits and beliefs and more barriers to eating breakfast (p < .01). Adjusted models revealed students reported more positive beliefs (OR = 0.78, 95% CI = 0.73-0.83), more benefits (OR = 0.95, 95% CI = 0.93-0.97) and fewer barriers (OR = 0.85, 95% CI = 0.82-0.87) and were less likely to skip breakfast. CONCLUSIONS: Future intervention research should focus on alleviating barriers and enhancing education around the school related benefits of eating breakfast.