First Analysis of Nationwide Trends in the Use of the SNAP-Ed Evaluation Framework.

OBJECTIVE: To understand Supplemental Nutrition Assistance Program-Education (SNAP-Ed) Implementing Agencies'(SIAs) use of the SNAP-Ed Evaluation Framework (Framework), which is a tool that includes 51 indicators that SNAP-Ed programs can use to measure the success of their programs in the first 5 years after its release. METHODS: A repeated cross-sectional study design was utilized to administer electronic surveys to between 124 and 154 SIAs who received SNAP-Ed funding in fiscal years 2017, 2019, and 2021. Analyses included descriptive statistics and tests of proportions. RESULTS: Most SIAs indicated that they used the Framework to inform both data collection instruments and program planning decisions and the rates remained relatively constant over the 3 time points (> 80%). The most common specific use of the Framework across all 3 time points was to define, count, or measure the work accomplished, but this statistically decreased from 2017 (76%) to 2021 (57%) (z-score = 3.31; P < 0.001). CONCLUSIONS AND IMPLICATIONS: The results of this analysis confirmed that 5 years after its introduction, uptake and use of the Framework was high and that, as a whole, SIAs focused on priority indicators set by the US Department of Agriculture, with no notable increases in addressing and measuring longer-term, multisector, and population-wide outcomes. The systematic study of the Framework's usability over time has a broader application to other national health promotion initiatives with shared frameworks.

Application of an Implementation Framework Using Mixed Methods in Preschool Settings.

Research Findings. Application of mixed methods in a dissemination and implementation framework can give researchers a better understanding of the reach and delivery of early childhood obesity prevention programs in preschool settings, as well as potential facilitators and barriers related to implementation and sustainability. This study utilized a simultaneous, exploratory, mixed-methods design to investigate individual-, organizational-, and intervention-level factors that were related to the implementation and sustainability of policy, system, and environment (PSE) changes as part of a larger obesity prevention program in a randomly selected sample of preschool centers (n = 20). Individual-level factors, and specifically the attitudes and skills of preschool providers, were identified in both the qualitative and quantitative data as important factors related to the sustainability of PSE changes (r = .56, p < .01). Staff and leadership engagement and adaptability of the program were also identified as important factors related to the implementation and sustainability of PSE changes. Practice or Policy. These findings highlight the complexity of implementation success and suggest PSE obesity prevention interventions in preschool centers require the consideration of numerous, multilevel factors to ensure programming is impactful and sustained over time.

Implementation Factors and Teacher Experience of the Integrated Nutrition Education Program: A Mixed Methods Program Evaluation.

BACKGROUND: School-based programs are widely implemented to address childhood obesity. Despite the promise of these programs, evidence on their effectiveness is mixed. Adopting a dissemination and implementation (D&I) science focus utilizing mixed methods can provide a broader understanding and more robust details about these programs. The goal of this evaluation is to understand how implementation factors and teacher experience influence implementation success and outcomes of the Integrated Nutrition Education Program (INEP), an elementary school-based nutrition program, using a mixed-methods design. METHODS: Reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework guided the development of the evaluation and multiple methods were deployed. Hierarchical linear regression was used to assess the association between D&I construct variables within levels of influence and teacher perception of INEP impact from a quantitative end-of-year teacher survey. Follow-up qualitative interviews with teachers were analyzed using constant comparison analysis. RESULTS: Workload and burden emerged as significant factors related to implementation in the quantitative analysis. The follow-up qualitative data collection identified other factors teachers found important to the adoption, implementation, and maintenance of INEP. CONCLUSION: Results of this evaluation can be used to inform program improvement efforts for INEP and provide information on ways to promote reach, effectiveness, adoption, implementation, and maintenance of similar school-based health promotion programs.

Understanding the experience of the implementer: teachers' perspectives on implementing a classroom-based nutrition education program.

School-based programs are widely implemented to combat childhood obesity, but these programs have mixed results. Dissemination and implementation science approaches to evaluation using qualitative methods can provide more robust details about program functioning that may be able to help explain the variation in the impact of these programs. Fourteen in-depth interviews were conducted with classroom teachers implementing a school-based program, the Integrated Nutrition Education Program (INEP), to explore their experience. Factors related to organization, individual and intervention levels emerged as facilitators and barriers to program implementation. Key factors were school culture at the organization level, individual perception and belief in the intervention at the individual level and program content, perceived complexity and adaptability at the intervention level. Socioeconomic status of the community and family involvement were contextual factors identified across all levels. Findings from this qualitative evaluation can be used for the quality improvement of INEP, but beyond this these can also be informative for other school-based programs to promote adoption, implementation and maintenance.

Outcomes of a Multi-Component School-Based Nutrition Program.

BACKGROUND: This paper presents the effectiveness of a multi-component elementary school-based nutrition education program, the Integrated Nutrition Education Program (INEP), which has been in existence for over 25 years. INEP includes components to address multiple layers of influence: hands-on nutrition education lessons in the classroom (student-level), parent education, and outreach (home-level), and facilitation of a planning process to implement policy, system, and environmental (PSE) school changes (school-level). METHODS: Three evaluation tools assessed the effectiveness of the program: (1) classroom plate waste measurement in intervention (N = 149 students) and demographically-matched comparison schools (N = 131 students), (2) pre/post classroom surveys completed by students who participated in INEP (N = 204), and (3) PSE change data from participating schools (N = 47 schools). RESULTS: Students who participated in the nutrition education program were more likely to consume vegetable-based recipes and vegetables included in classroom nutrition lessons compared to students in comparison classrooms (Chinese vegetable salad: p < .001; couscous salad: p < .001; snap peas: p = .001). Classroom survey analyses showed improvements in student self-efficacy (p < .001), preference for vegetables (p = .005), and knowledge (p < .001). In addition, through a wellness planning process, schools implemented an average of 3.7 PSE changes per school. CONCLUSIONS: Results demonstrate a multi-component school-based nutrition education program improves student nutrition-related outcomes.

Development of a Dissemination and Implementation Framework for an Early Childhood Obesity Prevention Program.

Dissemination and implementation (D&I) science addresses the disconnect between evidence-based research and practical application in community settings. Early childhood education settings are ideal for the application of D&I research because of their widespread use for implementing health promotion interventions. A D&I framework was applied to the Culture of Wellness in Preschools program, a comprehensive early childhood obesity prevention program. The development and application of the Culture of Wellness in Preschools D&I framework can lead to a more comprehensive approach to program evaluation and quality improvement and can contribute more broadly to the body of evidence of nutrition-related health promotion programs.

An exploration of constructs related to dissemination and implementation of an early childhood systems-level intervention.

Obesity and overweight in early childhood have detrimental impacts on children's health and development. Changing policy, system and environmental features focused on physical activity and healthy eating behaviors as part of health promotion interventions can play a key role in prevention strategies in early childhood education settings. These types of changes can have broad reach and are often sustained over time, which allows for impact on children who enter the early childhood education setting year after year. However, there is currently a gap between the generation of evidence for health promotion programs and their application into practice. This study used qualitative methods to evaluate intervention-, organizational- and individual-level factors within a dissemination and implementation framework that may be related to the implementation of a health-promoting intervention in early childhood education settings. Intervention-level factors, including feasibility and adaptability, organizational-level factors, including staff and leadership engagement, and individual-level factors, including attitudes, skills and knowledge, were identified as constructs that impacted the successful implementation of the intervention. These findings provide insight into core dissemination and implementation constructs that should be targeted by obesity prevention interventions in early childhood education settings to ensure maximum impact on sustainable behavior change.

Brain Characteristics Noted Prior to and Following Cranial Orthotic Treatment.

OBJECTIVE: This case report aims to assess a potential association between cranial asymmetry, brain deformation, and associated developmental delay. STUDY DESIGN: Two infants born at ≥37 weeks pursuing cranial orthotic treatment for severe Deformational Plagiocephaly (DP) (cranial vault asymmetry index >8.75%) underwent developmental assessment using Mullen Scales of Early Learning (MSEL) and non-sedated brain structural and diffusion magnetic resonance imaging (MRI) prior to and following cranial orthotic treatment. RESULTS: In both infants with DP, tractography results revealed alterations in the white matter pathways of the brain. Both infants also had low to low/normal visual receptivity and fine motor skills. After cranial orthotic treatment, cranial asymmetry improved but did not completely resolve, tractography demonstrated a change toward normalized white matter pathways, and visual receptivity and fine motor skills improved. CONCLUSIONS: These preliminary findings suggest a potential link between DP, altered brain structures, and developmental assessment. Further investigation with a larger sample is warranted.

Self-Reported and Diagnosed Depression in Rural Colorado: Findings from the San Luis Valley Community Health Survey.

PURPOSE: To gain a better understanding of depression in a rural community, survey results were used to compare differences in self-reported depressive symptoms and medical professional diagnosed depression among demographic groups. METHODS: A chi-square test of independence was performed to examine relationships among the depression-related variables. Logistic regression analyses were also performed to ascertain the effects of demographic characteristics and social support on depression. FINDINGS: A statistically significant association was found between the two depression-related variables (X2=145.17, P <.001). Income was significantly associated with both depression-related variables. Hispanic ethnicity, higher income, and some high school education were associated with decreased odds of self-reported medically diagnosed depression. Those reporting no or some social support had increased odds of both depression-related variables compared with those who reported always having social support. CONCLUSIONS: These findings provide a better understanding of depression in a rural community and may inform future public health interventions.

Systematic Changes to Help Parentsof Medically Complex Infants Manage Medical Expenses.

BACKGROUND: Financial obligations serve as an added source of stress and burden for parents of medically complex infants that have extended hospitalizations in the neonatal intensive care unit. Financial resources and support personnel are available to assist parents, but systems must be in place to help access these services. When neonatal intensive care unit nurses work collaboratively with financial support personnel, they improve families' access to financial resources. PURPOSE: The purpose of this quality improvement initiative was to increase and facilitate timely parent referrals to health benefits coordinators (HBCs). METHODS/SEARCH STRATEGY: Utilizing the Plan-Do-Study Act framework, the hospital's current system for HBC referrals was revised utilizing 3 Plan-Do-Study Act cycles. FINDINGS/RESULTS: A substantial increase in the percentage of HBC referrals, from preimplementation of less than 5% to a sustained average of 90% was observed. IMPLICATIONS FOR PRACTICE: A simple, sustainable screening process was successfully created to identify families with primary health insurance who qualified for coordination of benefits. This resulted in a significant increase in the number of HBC referrals. Minimal time is now required for the multidisciplinary team to ensure that parents, eligible for referral, are identified as soon as possible. Early identification and timely referral to the HBC may lessen the financial burden for families caring for children with medically complex long-term care needs by securing secondary insurance and other resources. IMPLICATIONS FOR RESEARCH: Research focused on the financial impact of the HBC role is needed.

Predictors of Persistent Infant Car Seat Challenge Failure.

BACKGROUND: Premature and other at-risk infants can experience cardiorespiratory problems when positioned in their car seats. The American Academy of Pediatrics recommends that all premature and at-risk infants undergo a period of observation in their car seat to monitor for apnea, bradycardia, and oxygen desaturation before hospital discharge. This Infant Car Seat Challenge (ICSC) is used to determine readiness for infant travel in a car seat. Infants failing the ICSC are discharged home in car beds and referred for a follow-up screen in the outpatient clinic. PURPOSE: The purpose of this study was to identify predictors for infants failing the follow-up ICSC after hospital discharge. METHODS/SEARCH STRATEGY: A retrospective, cross-sectional study design was used to examine charts of 436 infants referred from across New England, to Boston Children's Hospital's, Center for Healthy Infant Lung Development clinic between August 2008 and May 2015 for a follow-up ICSC. FINDINGS/RESULTS: Infants who failed the follow-up ICSC had statistically significant lower weights (0.27 ± 0.14 kg, difference ± standard error, P = .03) and younger postmenstrual ages (0.9 ± 0.4 weeks, P = .03). History of a cardiac condition (odds ratio, 3.6; 95% confidence interval, 1.5-8.5; P = .005) and respiratory illness (odds ratio, 2.1; confidence interval, 1.1 to 4.2; P = .03) were significant predictors of ICSC failure. IMPLICATIONS FOR PRACTICE: A follow-up ICSC is recommended for the safe transition of infants from a car bed to a car seat. IMPLICATIONS FOR RESEARCH: Further research is needed to investigate the causes of ICSC failure among high-risk infant populations.

What Makes Patient Navigation Most Effective: Defining Useful Tasks and Networks.

Given the momentum in adopting patient navigation into cancer care, there is a need to understand the contribution of specific navigator activities to improved clinical outcomes. A mixed-methods study combined direct observations of patient navigators within the Patient Navigation Research Program and outcome data from the trial. We correlated the frequency of navigator tasks with the outcome of rate of diagnostic resolution within 365 days among patients who received the intervention relative to controls. A focused content analysis examined those tasks with the strongest correlations between navigator tasks and patient outcomes. Navigating directly with specific patients (r = 0.679), working with clinical providers to facilitate patient care (r = 0.643), and performing tasks not directly related to their diagnostic evaluation for patients were positively associated with more timely diagnosis (r = 0.714). Using medical records for non-navigation tasks had a negative association (r = -0.643). Content analysis revealed service provision directed at specific patients improved care while systems-focused activities did not.