Quality of Health Education Teacher Preparation Program Curricula Throughout the United States.

BACKGROUND: Undergraduate majors in education, specifically in school health education (HE), have declined considerably in the United States. Reductions in state and federal funding for K-12 public education and increased demands on educators to prioritize standardized academic outcomes versus focusing on the whole child encompass many factors leading to fewer qualified teachers and reduced quality of HE delivery within schools. METHODS: A content analysis of over 300 HE teacher preparation programs throughout the United States was conducted from 2019 to 2020 to assess available and required curriculum for pre-service HE teachers. Seven curriculum areas were reviewed: nutrition, physical activity (PA) and physical education (PE), HE, chronic disease management (CDM), social emotional learning and mental health (SEL/MH), drug abuse and tobacco prevention (DA/TP), and a methods course in teaching HE. RESULTS: Findings indicated program type influenced course offerings, with stand-alone HE and joint HE/PE programs providing the most comprehensive curriculum. Most programs required courses in general HE, PA and PE, and nutrition. Programs were deficient in offering courses in CDM, DA/TP, and SEL/MH. CONCLUSION: This article contains recommendations to improve the quality of HE delivery in public schools, for example by ensuring that school health educators are trained in providing skills-based HE to youth, which can assist in addressing child and youth health outcomes (eg, CDM, mental health) for the nation.

Community Solutions to Increase the Healthfulness of Grocery Stores: Perspectives of Immigrant Parents.

Grocery store environments are recognized as one of the most crucial community settings for developing and maintaining healthy nutritional behaviors in children. This is especially true for disadvantaged ethnic minority families, such as immigrants, who reside in the Detroit Metropolitan area and have historically experienced inequities that result in poor health outcomes. Rates of obesity and type II diabetes have affected Detroit 38% more than the rest of the state and nationwide. In 2019, almost 54% of children aged 0-17 in Metro Detroit lived in poverty, and 21.6% experienced food insecurity, compared with the state level of 14.2%. Moreover, nearly 50% of ethnic minority children in Metro Detroit consume sports drinks, and 70% consume soda or pop in an average week. The primary purpose of this study was to explore immigrant parents' perspectives on (1) how in-store Sugar-Sweetened Beverage (SSB) marketing impacts the purchasing behaviors of parents and the eating behaviors of toddlers, and the secondary objective was to (2) determine strategies to reduce SSB purchases and consumption within grocery environments from the viewpoints of immigrant parents. A qualitative multiple-case study design was used to achieve the aims of this study. Semi-structured individual interviews were completed with 18 immigrant parents of children aged 2 to 5 years old who were consumers in 30 independently owned full-service grocery stores within the immigrant enclaves of Detroit, Dearborn, Hamtramck, and Warren, Michigan. Three key thematic categories emerged from the parents' narratives. These themes were: (1) non-supportive grocery store environments; (2) acculturation to the American food environment; and (3) strategies to support reduced SSB consumption among young immigrant children. The findings of this study revealed widespread SSB marketing targeting toddlers within the participating independently owned grocery stores. Even if families with young children practiced healthy nutritional behaviors, the prices, placements, and promotion of SSBs were challenges to establishing and sustaining these healthy eating habits. The parents believed that planning and implementing retail-based strategies in collaboration with families and considering families' actual demands would assist in managing children's eating patterns and reducing early childhood obesity.

Enhanced Measurement of Sugar-Sweetened Beverage Marketing to Young Immigrant Children in Grocery Store Environments.

The marketing of Sugar-Sweetened Beverages (SSBs) within grocers is an obesogenic factor that negatively impacts children's nutritional behavior, specifically for people from racial and ethnic minority groups, such as immigrants. We aimed to develop and employ a methodology that more precisely assesses the availability, price, and promotion of SSBs to young immigrant children within independently owned grocery stores. A case comparison design was used to explore the differences in the grocery store landscape of SSB marketing by conducting an enhanced Nutrition Environment Measures Survey-SSB (NEMS-SSB) within 30 grocery stores in the Hispanic and Latino enclaves in Southwest Detroit, in the Arab and Chaldean enclaves in North-central Detroit, and in Warren, Hamtramck, and Dearborn, in comparison with 48 grocers in Metro Detroit. Unsweetened, plant-based, and organic toddler and infant beverages, as well as questions about marketing, were added to the original NEMS to capture the promotion tactics used in marketing SSBs. NEMS-SSB scores revealed that, in the immigrant enclaves, there was a significantly higher availability of SSBs in grocery stores (-2.38), and they had lower prices than those in the comparison group (-0.052). Unsweetened, plant-based, and organic beverages were unavailable in 97% of all participating grocery stores across both groups. Signage featuring cartoon characters was the most frequent in-store SSB marketing tactic across both groups. Widespread SSB marketing toward toddlers within the grocery stores in immigrant enclaves could be linked with the higher early childhood obesity prevalence among the immigrant population. Our findings can assist local and national organizations in developing and implementing healthy eating interventions. This study must be repeated in other immigrant enclaves across states to provide comparable results.

Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework to Advance the Science and Practice of Healthy Food Retail.

Although healthy food retail strategies are widely used, there appears to be a limited understanding of the processes and determinants for successful adoption, implementation, and sustainment. To fill this gap, we recommend the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to be used to advance the science and practice of healthy food retail. In this perspective, we: (1) introduce EPIS and describe why it was chosen as a recommended implementation science framework for healthy food retail, (2) highlight healthy food retail evidence supporting EPIS, and (3) discuss research and practice needs moving forward.

Refining the Nutrition Environment Measures Survey (NEMS) for Healthy Community Stores: Adaptations to Capture Alternative Food Retailers and Align with Dietary Guidelines.

Inadequate consumption of healthy food is an ongoing public health issue in the United States. Food availability measures of supply versus consumption of healthy foods are disconnected in many studies. There is a need for an objective assessment of the food environment in order to assess how the food supply aligns with the Healthy Eating Index (HEI). Data were collected as part of the Healthy Community Stores Case Study Project, including a refined Nutrition Environment Measures Survey for Healthy Community Stores (NEMS-HCS) and an updated Healthy Food Availability Index that aligns with the Healthy Eating Index (HFAHEI). This paper will focus on the NEMS-HCS development process, findings, and HFAHEI application. All food items were more likely to be found at grocery stores rather than corner stores. Food pricing was often above the Consumer Price Index averages for six food items. The NEMS-HCS assessment better aligned with the HEI because it included a wider variety of meats, frozen fruits and vegetables, and an increased selection of whole grains. HFAHEI scoring was inclusive of non-traditional and alternative community stores with a health focus, making it suitable for use at the local level, especially in neighborhoods where supermarkets and large chain stores are less common.

Balancing Mission and Margins: What Makes Healthy Community Food Stores Successful.

Mission-driven, independently-owned community food stores have been identified as a potential solution to improve access to healthy foods, yet to date there is limited information on what factors contribute to these stores' success and failure. Using a multiple case study approach, this study examined what makes a healthy community food store successful and identified strategies for success in seven community stores in urban areas across the United States. We used Stake's multiple case study analysis approach to identify the following key aims that contributed to community store success across all cases: (1) making healthy food available, (2) offering healthy foods at affordable prices, and (3) reaching community members with limited economic resources. However, stores differed in terms of their intention, action, and achievement of these aims. Key strategies identified that enabled success included: (1) having a store champion, (2) using nontraditional business strategies, (3) obtaining innovative external funding, (4) using a dynamic sourcing model, (5) implementing healthy food marketing, and (6) engaging the community. Stores did not need to implement all strategies to be successful, however certain strategies, such as having a store champion, emerged as critical for all stores. Retailers, researchers, philanthropy, and policymakers can utilize this definition of success and the identified strategies to improve healthy food access in their communities.

A Commentary on the Healthy Community Stores Case Study Project: Implications for Retailers, Policy, and Future Research.

In the United States, low-income, underserved rural and urban settings experience poor access to healthy, affordable food. Introducing new food outlets in these locations has shown mixed results for improving healthy food consumption. The Healthy Community Stores Case Study Project (HCSCSP) explored an alternative strategy: supporting mission-driven, locally owned, healthy community food stores to improve healthy food access. The HCSCSP used a multiple case study approach, and conducted a cross-case analysis of seven urban healthy food stores across the United States. The main purpose of this commentary paper is to summarize the main practice strategies for stores as well as future directions for researchers and policy-makers based on results from the prior cross-case analyses. We organize these strategies using key concepts from the Retail Food Environment and Customer Interaction Model. Several key strategies for store success are presented including the use of non-traditional business models, focus on specific retail actors such as store champions and multiple vendor relationships, and a stores' role in the broader community context, as well as the striking challenges faced across store locations. Further exploration of these store strategies and how they are implemented is needed, and may inform policies that can support these types of healthy retail sites and sustain their efforts in improving healthy food access in their communities.

Forms of Community Engagement in Neighborhood Food Retail: Healthy Community Stores Case Study Project.

Community engagement is well established as a key to improving public health. Prior food environment research has largely studied community engagement as an intervention component, leaving much unknown about how food retailers may already engage in this work. The purpose of this study was to explore the community engagement activities employed by neighborhood food retailers located in lower-income communities with explicit health missions to understand the ways stores involve and work with their communities. A multiple case study methodology was utilized among seven retailers in urban U.S. settings, which collected multiple sources of data at each retailer, including in-depth interviews, store manager sales reports, store observations using the Nutrition Environment Measures Survey for Stores, public documents, and websites. Across-case analysis was performed following Stake's multiple case study approach. Results indicated that retailers employed a wide variety of forms of community engagement within their communities, including Outreach, Building Relationships through Customer Relations, Giving Back, Partnering with Community Coalitions, and Promoting Community Representation and Inclusiveness. Strategies that built relationships through customer relations were most common across stores; whereas few stores demonstrated community inclusiveness where members participated in store decision making. Findings provide a more comprehensive view of the ways local food retailers aim to develop and sustain authentic community relationships. Additional research is needed to evaluate the impact of community engagement activities on improving community health.

The Association Between Home or Community Garden Access and Adolescent Health.

Little is known about the influence of home or community garden (HCG) access on adolescent health. The objective of this study was to determine the association between adolescent self-rated health, nutrition knowledge, attitudes, and intake with HCG access. Urban high school students (n = 401) completed a questionnaire prior to a nutrition education intervention. Point biserial correlations and one-way analyses of variance evaluated garden access and health variables. Garden access differed by race ( P < .001), and students with HCG access consumed more vegetables than students who did not ( P = .003) and rated themselves as healthier ( P = .034). Findings suggest that garden access is associated with higher adolescent vegetable consumption and higher self-rated health. Future research should investigate adolescent levels of engagement in HCGs.

Assessing the Influence of Food Insecurity and Retail Environments as a Proxy for Structural Racism on the COVID-19 Pandemic in an Urban Setting.

A collaborative partnership launched the Great Grocer Project (GGP) in March 2021 in Detroit, Michigan where health inequities, including deaths due to COVID-19, have historically been politically determined and informed by socially entrenched norms. Institutional and structural racism has contributed to a lack of diversity in store ownership among Detroit grocers and limited access to high-quality, affordable healthy foods as well as disparate food insecurity among Detroit residents. The GGP seeks to promote Detroit's healthy grocers to improve community health and economic vitality through research, programs, and policies that have the potential to advance health equity. A cross-sectional design was used to explore relationships between scores from the Nutrition Environment Measures Surveys-Stores (NEMS-S) in 62 stores and city-level data of COVID-19 cases and deaths as well as calls to 211 for food assistance. Regression and predictive analyses were conducted at the ZIP code level throughout the city to determine a relationship between the community food environment and food insecurity on COVID-19 cases and deaths. COVID-19 cases and deaths contributed to greater food insecurity. The use of ZIP code data and the small sample size were limitations within this study. Causation could not be determined in this study; therefore, further analyses should explore the potential effects of individual grocery stores on COVID-related outcomes since a cluster of high-scoring NEMS-S stores and calls to 211 for food security resources inferred a potential protective factor. Poor nutrition has been shown to be associated with increased hospitalizations and deaths due to COVID-19. It is important to understand if a limited food environment can also have a negative effect on COVID-19 rates and deaths. Lessons learned from Detroit could have implications for other communities in using food environment improvements to prevent an uptick in food insecurity and deaths due to COVID-19 and other coronaviruses.

Increasing Healthy Food Access for Low-Income Communities: Protocol of the Healthy Community Stores Case Study Project.

Improving healthy food access in low-income communities continues to be a public health challenge. One strategy for improving healthy food access has been to introduce community food stores, with the mission of increasing healthy food access; however, no study has explored the experiences of different initiatives and models in opening and sustaining healthy food stores. This study used a case study approach to understand the experiences of healthy food stores in low-income communities. The purpose of this paper is to describe the methodology used and protocol followed. A case study approach was used to describe seven healthy food stores across urban settings in the U.S. Each site individually coded their cases, and meetings were held to discuss emerging and cross-cutting themes. A cross-case analysis approach was used to produce a series of papers detailing the results of each theme. Most case studies were on for-profit, full-service grocery stores, with store sizes ranging from 900 to 65,000 square feet. Healthy Food Availability scores across sites ranged from 11.6 (low) to 26.5 (high). The papers resulting from this study will detail the key findings of the case studies and will focus on the challenges, strategies, and experiences of retail food stores attempting to improve healthy food access for disadvantaged communities. The work presented in this special issue will help to advance research in the area of community food stores, and the recommendations can be used by aspiring, new, and current community food store owners.

Food insecurity in Detroit: exploring the relationship between patient-reported food insecurity and proximity to healthful grocery stores.

OBJECTIVE: The objective of the current study was to determine if patients of a large health care system in Detroit who self-identify as food insecure live further away from healthy grocery stores compared with food secure patients. Second, we explored whether food insecurity and distance to healthy grocery stores are related to ecological measures of vehicle availability in the area of residence. DESIGN: A secondary data analysis that uses baseline data from a pilot intervention/feasibility study. SETTING: Detroit, Michigan, USA. PARTICIPANTS: Patients of Henry Ford Health System were screened for food insecurity to determine eligibility for a pilot intervention/feasibility study (i.e. Henry's Groceries for Health), conducted through a collaboration with Gleaners Community Foodbank of Southeastern Michigan. Only patients residing in Detroit city limits (including Highland Park and Hamtramck) were included in the secondary analysis. Of the 1,100 patients included in the analysis, 336 (31 %) were food insecure. RESULTS: After accounting for socio-demographic factors associated with food insecurity, we did not find evidence that food insecure patients lived further away from healthier grocery stores, nor was this modified by ecological measures of vehicle access. However, some neighbourhoods were identified as having a significantly higher risk of food insecurity. CONCLUSIONS: Food insecure patients in Detroit are perhaps limited by social and political determinants and not their immediate neighbourhood geography or physical access to healthy grocery stores. Future research should explore the complexity in linkages between household socio-economic factors, socio-cultural dynamics and the neighbourhood food environment.

Development of a School Health Policy Implementation Survey: A Delphi Study.

Data on school health policy implementation are limited due to the absence of a validated measurement tool. The purpose of this study was to create and pilot a school health policy implementation survey. A modified, four-round Delphi process was used to achieve consensus on content and format of the survey. The final 76-item survey was piloted in 655 schools with a return rate of 57.1% (n = 378). Seven schools participated in environmental audits. Based on the audits, survey responses represented an accurate description of school practices for 84.2% (n = 64) of questions. The remaining 15.8% (n = 12) of survey items were eliminated or revised. This measurement tool begins to fill the research gap between the evaluation of written school health policy and implementation. Further, this tool may be used by school nurses in alignment with the Framework for 21st Century School Nursing Practice.

Nutrition Supports Deconstructed and Disrupted: An Evaluation of a Multilevel School-Based Intervention during the Time of COVID.

The Best Food Forward (BFF) project aims to provide multiple nutrition supports and interventions to improve family food security (FS) and health outcomes associated with FS within two metropolitan school districts. A quasi-experimental time-series design guided a multilevel evaluation for BFF through surveys, biometric screenings, focus groups, and observations among a random sample of caregiver-child dyads. FS, utilization of school meal programs, and nutrition behaviors were observed and analyzed at three time points: preintervention, postintervention pre-COVID-19, and postintervention post-COVID-19. Participants included 122 parents and 162 youth. Families reported (1) an income less than $35,000 annually (48.8%) and (2) a COVID-19-related job loss (36.9%). Parents used Supplemental Nutrition Assistance Programs or Women, Infants, Children benefits prior to (51.1%) and following COVID-19 (50.0%). No significant differences in FS were found. RM-ANOVA indicated an increase in breakfast consumption at home and a decrease in use of the school breakfast program (F(1.78, 74) = 19.64, p < 0.001, partial η2 = 0.21) and school lunch program (F(1.51, 74) = 23.30, p < 0.001, partial η2 = 0.24). Rates of FS and eating behaviors did not change significantly over time. Correlations of program usage and eating behaviors demonstrate the importance of promoting participation in school meal programs. BFF may have prevented significant decreases in FS during COVID-19.

Corner Store Owners as Health Promotion Agents in Low-Income Communities.

Reports of small business owner motivations for participation in health promotion interventions are rarely reported in the literature, particularly in relation to healthy eating interventions. This study explicates and defines the development of healthy corner stores as community-based enterprises (CBEs) within eight low-income, suburban communities. CBEs are defined as community-oriented small businesses with a common goal to improve population health. The corner stores assessed in this study were participants in Healthy HotSpot (HH), a corner store initiative of the Cook County Department of Public Health. To determine store alignment with the CBE construct, a case study design was used for qualitative inquiry. Participant narratives from store owners (n = 21), community-based organizations (CBOs; n = 8) and consumer focus groups (n = 51) were analyzed using an iterative process to determine how store owners aligned with the CBE construct, and how this influenced continuation of health promotion activities. Several key factors influenced the strength of store owners' alignment with the CBE construct. They included the following: (a) shared ethno-cultural identities and residential area as consumers; (b) positive, trustworthy relationships with consumers; (c) store owners valuing and prioritizing community health, often over profits; and (d) collaboration with a highly engaged CBO in the HH project. Results can assist in theory development and intervention design in working with corner store owners, and other small business owners, as health promotion agents to improve and sustain health outcomes and help ensure the economic vitality of low-income communities.

Policy, systems, and environmentally oriented school-based obesity prevention: opportunities and challenges.

Public health is increasingly emphasizing policy, systems, and environmental (PSE) change as a key strategy for population-level health promotion and disease prevention. When applied to childhood obesity, this strategy typically involves school systems, since children spend large portions of their days in school and are heavily influenced by this environment. While most school systems have implemented nutrition education and physical activity programs for some time, their understanding and use of PSE approaches to obesity prevention is accelerating based on several large federally funded initiatives. As part of one initiative's evaluation, key informant interviews reveal the specific obesity prevention PSE strategies schools are attempting and the corresponding barriers and facilitators to their implementation. These evaluation findings raise several fundamental issues regarding school-based obesity prevention, including the potential role of school personnel, the influence of grant funding on school health initiatives, and the fit between public health and educational priorities.

Partnering with community institutions to increase access to healthful foods across municipalities.

BACKGROUND: Low-income and minority communities have higher rates of nutrition-related chronic diseases than do high-income and nonminority communities and often have reduced availability to healthful foods. Corner store initiatives have been proposed as a strategy to improve access to healthful foods in these communities, yet few studies evaluating these initiatives have been published. COMMUNITY CONTEXT: Suburban Cook County, Illinois, encompasses 125 municipalities with a population of more than 2 million. From 2000 through 2009, the percentage of low-income suburban Cook County residents increased 41%; African-American populations increased 20%, and Hispanic populations increased 44%. A 2012 report found that access to stores selling healthful foods was low in several areas of the county. METHODS: Beginning in March 2011, the Cook County Department of Public Health recruited community institutions (ie, local governments, nonprofit organizations, faith-based institutions) who recruited corner stores to participate in the initiative. Corner stores were asked to add new, healthful foods (May-June 2011) to become eligible to receive new equipment, marketing materials, and enhanced community outreach (July 2011-February 2012). OUTCOMES: Nine community institutions participated. Of the 53 corner stores approached, 25 (47%) participated in the trial phase, which included offering 6 healthful foods in their stores. Of those, 21 (84%) completed the conversion phase, which included expansion of healthful foods through additional equipment and marketing and promotional activities. INTERPRETATION: Community institutions can play a key role in identifying and engaging corner stores across jurisdictions that are willing and able to implement a retail environment initiative to improve access to healthful foods in their communities.