Universal School Meals During the Pandemic: A Mixed Methods Analysis of Parent Perceptions from California and Maine.

BACKGROUND: In response to the COVID-19 pandemic, the United States Congress authorized the United States Department of Agriculture to waive a variety of school meal regulations and funded school meals daily for all students at no charge regardless of family income. Since federal Universal Free School Meals (UFSM) ended with the 2021-2022 school year, several states, including California and Maine, adopted state-level UFSM policies. OBJECTIVE: This study aimed to understand parent perceptions of school meals and the federal and new state UFSM policies in California and Maine, including potential challenges and benefits to students and households. DESIGN: A mixed methods study design was used. A quantitative cross-sectional survey was administered, and semi-structured interviews were conducted in English and Spanish during the 2021-2022 school year. PARTICIPANTS/SETTING: The quantitative survey was administered to parents of students in elementary, middle, and high schools in rural, suburban, and urban communities in California (n=1,110) and Maine (n=80). Qualitative interviews were then conducted with a subset of these parents in California (n=46) and Maine (n=20) using ZoomTM. Most survey participants (708 out of 1,190; 59.5%) and interviewees (40 out of 66; 60.6%) were parents of students who were eligible for free or reduced-price meals (FRPM). MAIN OUTCOME MEASURES: Parents' perceptions of UFSM, school meal quality, and experiences applying for FRPM were examined. ANALYSES PERFORMED: Tests of proportions were used to analyze survey data. Using grounded theory, interview transcripts were analyzed qualitatively by 2 trained research assistants, applying principles of content analysis to identify themes and domains. Inter-rater reliability was conducted. RESULTS: Parents perceived that school meals and UFSM saved families money and time, as parents had fewer meals to purchase and prepare for their children. Additionally, UFSM reduced parents' stress and reduced stigma for children and for parents, who described feelings of embarrassment when they previously filled out paperwork for FRPM. While parent perceptions of school meal quality and healthfulness were mixed, most parents reported feeling grateful for school meals. CONCLUSIONS: Parents had mixed opinions on the quality and healthfulness of school meals, but believed UFSM saved them money and time and reduced their stress. Parents also felt UFSM reduced stigma for families.

A Comprehensive Examination of the Contaminants in Drinking Water in Public Schools in California, 2017-2022.

OBJECTIVES: Reports of unsafe school drinking water in the United States highlight the importance of ensuring school water is safe for consumption. Our objectives were to describe (1) results from our recent school drinking water sampling of 5 common contaminants, (2) school-level factors associated with exceedances of various water quality standards, and (3) recommendations. METHODS: We collected and analyzed drinking water samples from at least 3 sources in 83 schools from a representative sample of California public schools from 2017 through 2022. We used multivariate logistic regression to examine school-level factors associated with lead in drinking water exceedances at the American Academy of Pediatrics (AAP) recommendation level (1 part per billion [ppb]) and state action-level exceedances of other contaminants (lead, copper, arsenic, nitrate, and hexavalent chromium). RESULTS: No schools had state action-level violations for arsenic or nitrate; however, 4% had ≥1 tap that exceeded either the proposed 10 ppb action level for hexavalent chromium or the 1300 ppb action level for copper. Of first-draw lead samples, 4% of schools had ≥1 tap that exceeded the California action level of 15 ppb, 18% exceeded the US Food and Drug Administration (FDA) bottled water standard of 5 ppb, and 75% exceeded the AAP 1 ppb recommendation. After turning on the tap and flushing water for 45 seconds, 2%, 10%, and 33% of schools exceeded the same standards, respectively. We found no significant differences in demographic characteristics between schools with and without FDA or AAP exceedances. CONCLUSIONS: Enforcing stricter lead action levels (<5 ppb) will markedly increase remediation costs. Continued sampling, testing, and remediation efforts are necessary to ensure drinking water meets safety standards in US schools.

Effectiveness of a School Drinking Water Promotion and Access Program for Overweight Prevention.

BACKGROUND AND OBJECTIVE: Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight. METHODS: Low-income, ethnically diverse elementary schools in California's Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019. RESULTS: Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence. CONCLUSIONS: Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students.

Incidence of Neonatal Hypothermia in the Newborn Nursery and Associated Factors.

Importance: Thermoregulation is a key component of well-newborn care. There is limited epidemiologic data on hypothermia in late preterm and term infants admitted to the nursery. Expanding on these data is essential for advancing evidence-based care in a population that represents more than 3.5 million births per year in the US. Objective: To examine the incidence and factors associated with hypothermia in otherwise healthy infants admitted to the newborn nursery following delivery. Design, Setting, and Participants: A retrospective cohort study using electronic health record data from May 1, 2015, to August 31, 2021, was conducted at a newborn nursery at a university-affiliated children's hospital. Participants included 23 549 infants admitted to the newborn nursery, from which 321 060 axillary and rectal temperature values were analyzed. Exposures: Infant and maternal clinical and demographic factors. Main Outcomes and Measures: Neonatal hypothermia was defined according to the World Health Organization threshold of temperature less than 36.5 °C. Hypothermia was further classified by severity (mild: single episode, temperature 36.0-36.4 °C; moderate/severe: persistent or recurrent hypothermia and/or temperature <36.0 °C) and timing (early: all hypothermic episodes occurred within the first 24 hours after birth; late: any episode extended beyond the first 24 hours). Results: Of 23 549 included infants (male, 12 220 [51.9%]), 5.6% were late preterm (35-36 weeks' gestation) and 4.3% were low birth weight (≤2500 g). The incidence of mild hypothermia was 17.1% and the incidence of moderate/severe hypothermia was 4.6%. Late hypothermia occurred in 1.8% of infants. Lower birth weight and gestational age and Black and Asian maternal race and ethnicity had the highest adjusted odds across all classifications of hypothermia. The adjusted odds ratios of moderate/severe hypothermia were 5.97 (95% CI 4.45-8.00) in infants with a birth weight less than or equal to 2500 vs 3001 to 3500 g, 3.17 (95% CI 2.24-4.49) in 35 week' vs 39 weeks' gestation, and 2.65 (95% CI 1.78-3.96) in infants born to Black mothers and 1.94 (95% CI 1.61-2.34) in infants born to Asian mothers vs non-Hispanic White mothers. Conclusions and Relevance: In this cohort study of infants in the inpatient nursery, hypothermia was common, and the incidence varied by hypothermia definition applied. Infants of lower gestational age and birth weight and those born to Black and Asian mothers carried the highest odds of hypothermia. These findings suggest that identifying biological, structural, and social determinants of hypothermia is essential for advancing evidence-based equitable thermoregulatory care.

Drink Tap: A Multisector Program to Promote Water Access and Intake in San Francisco Parks.

Taxes on sugar-sweetened beverages (SSBs), or drinks with added sugars, show promise in decreasing purchases and consumption of SSBs. Some have called for coupling such taxes with improvements in access to safe drinking water as a strategy for reducing inequities in SSB intake, yet no studies have examined such an approach. Drink Tap is a San Francisco-based program in which public tap water stations were installed in parks and public spaces (winter 2017) and promotional efforts (fall and winter 2018) encouraged water intake. At the same time, San Francisco and surrounding communities were also implementing SSB taxes. We conducted a quasi-experimental study to examine whether water access and promotion combined with SSB taxes affected beverage intake habits more than SSB taxes alone. We conducted 1-hour observations (N = 960) at 10 intervention parks (Drink Tap plus SSB taxes) and 20 comparison parks (SSB taxes only) in San Francisco Bay Area cities before (July-September 2016) and after (June-August 2019) implementation of Drink Tap. We found significant adjusted percentage increases in drinking water among visitors to intervention parks, compared with comparison parks: water from park water sources (+80%, P < .001) and water from reusable bottles (+40%, P = .02). We found no significant reductions in visitors observed drinking bottled water, juices, or SSBs. The Drink Tap intervention led to increases in water intake from park sources and reusable bottles across parks that surpassed increases achieved through SSB taxes alone. Jurisdictions should consider coupling tap water access and promotion with policies for reducing intake of SSBs.

Parent Perception of School Meals in the San Joaquin Valley during COVID-19: A Photovoice Project.

School-based nutrition programs are crucial to reducing food insecurity. The COVID-19 pandemic adversely impacted students' school meal participation. This study seeks to understand parent views of school meals during COVID-19 to inform efforts to improve participation in school meal programs. Photovoice methodology was used to explore parental perception of school meals in San Joaquin Valley, California, a region of predominately Latino farmworker communities. Parents in seven school districts photographed school meals for a one-week period during the pandemic and then participated in focus group discussions and small group interviews. Focus group discussions and small group interviews were transcribed, and data were analyzed using a team-based, theme-analysis approach. Three primary domains emerged: benefits of school meal distribution, meal quality and appeal, and perceived healthfulness. Parents perceived school meals as beneficial to addressing food insecurity. However, they noted that meals were unappealing, high in added sugar, and unhealthy, which led to discarded meals and decreased participation in the school meal program. The transition to grab-and-go style meals was an effective strategy for providing food to families during pandemic school closures, and school meals remain an important resource for families experiencing food insecurity. However, negative parental perceptions of the appeal and nutritional content of school meals may have decreased school meal participation and increased food waste that could persist beyond the pandemic.

A Cross-sectional Study Characterizing Pediatric Temperature Percentiles in Children at Well-Child Visits.

BACKGROUND: Temperature measurement plays a central role in determining pediatric patients' disease risk and management. However, current pediatric temperature thresholds may be outdated and not applicable to children. OBJECTIVE: To characterize pediatric temperature norms and variation by patient characteristics, time of measurement, and thermometer route. METHODS: In this cross-sectional study, we analyzed 134,641 well-child visits occurring between 2014-2019 at primary care clinics that routinely measured temperature. We performed bivariate and multivariable quantile regressions with clustered standard errors to determine temperature percentiles and variation by age, sex, time of measurement, and thermometer route. We performed sensitivity analyses: 1) using a cohort that excluded visits with infectious diagnoses that could explain temperature aberrations and 2) including clinic as a fixed effect. RESULTS: The median rectal temperature for visits of infants ≤12 months old was 37.2˚C, which was 0.4˚C higher than the median axillary temperature. The median axillary temperature for children 1-18 years old was 36.7˚C, which was 0.1˚C lower than the median values of all other routes. The 99th percentile for rectal temperatures in infants was 37.8˚C and the 99.9th percentile for axillary temperatures in children was 38.5˚C. Adjusted analyses did not demonstrate clinically significant variation in temperature by sex, age, or time of measurement. CONCLUSIONS: These updated temperature norms can serve as reference values in clinical practice and should be considered in the context of thermometer route used and the clinical condition being evaluated. Variations in temperature values by sex, age, and time of measurement were not clinically significant.

Water Security Experiences and Water Intake Among Elementary Students at Low-Income Schools: A Cross-Sectional Study.

OBJECTIVE: To examine students' experiences of water security at school and how experiences relate to intake of water from different sources of water at school. DESIGN/METHODS: In this cross-sectional study, 651 students in grades 3 to 5 in 12 low-income public elementary schools in the San Francisco area completed surveys about their daily intake of water from different sources of water at school, experiences of water security including safety, cleanliness, and taste of water at school, and their demographics. Multivariable linear regressions examined associations between students' water security experiences at school and reported intake from different sources of water at school. RESULTS: Approximately half of students were Latino (56.1%) and had overweight/obesity (50.4%). Most (74.5%) had some negative water security experience at school. Students drank from the school fountain or water bottle filling station a mean of 1.2 times/day (standard deviation [SD] = 1.4), sinks 0.2 times/day (SD = 0.7), tap water dispensers 0.2 times/day (SD = 0.6), and bottled water 0.5 times/day (SD = 1.0). In multivariable linear regression, students with more negative experiences of school water security drank less frequently from fountains (-0.5 times/day, P value < .001), but more frequently from tap water dispensers (0.1 times/day, P value = .040) and sinks (0.1 times/day, P value = .043), compared to students with no negative perceptions. CONCLUSIONS: On average, students had negative school water security experiences, which decreased their consumption of water from tap water sources. However, relationships between negative water security experiences and reported water intake appeared to be mitigated by water source. Schools should consider installing more appealing water sources to promote water intake.

Mitigating childhood food insecurity during COVID-19: a qualitative study of how school districts in California's San Joaquin Valley responded to growing needs.

OBJECTIVES: To explore best practices and challenges in providing school meals during COVID-19 in a low-income, predominantly Latino, urban-rural region. DESIGN: Semi-structured interviews with school district stakeholders and focus groups with parents were conducted to explore school meal provision during COVID-19 from June to August 2020. Data were coded and themes were identified to guide analysis. Community organisations were involved in all aspects of study design, recruitment, data collection and analysis. SETTING: Six school districts in California's San Joaquin Valley. PARTICIPANTS: School district stakeholders (n 11) included food service directors, school superintendents and community partners (e.g. funders, food cooperative). Focus groups (n 6) were comprised of parents (n 29) of children participating in school meal programmes. RESULTS: COVID-19-related challenges for districts included developing safe meal distribution systems, boosting low participation, covering COVID-19-related costs and staying informed of policy changes. Barriers for families included transportation difficulties, safety concerns and a lack of fresh foods. Innovative strategies to address obstacles included pandemic-electronic benefits transfer (EBT), bus-stop delivery, community pick-up locations, batched meals and leveraging partner resources. CONCLUSIONS: A focus on fresher, more appealing meals and greater communication between school officials and parents could boost participation. Districts that leveraged external partnerships were better equipped to provide meals during pandemic conditions. In addition, policies increasing access to fresh foods and capitalising on United States Department of Agriculture waivers could boost school meal participation. Finally, partnering with community organisations and acting upon parent feedback could improve school meal systems, and in combination with pandemic-EBT, address childhood food insecurity.

Implementation of Universal School Meals during COVID-19 and beyond: Challenges and Benefits for School Meals Programs in Maine.

School meals play a major role in supporting children's diets and food security, and policies for universal school meals (USM) have the potential to contribute to positive child health outcomes. During the COVID-19 pandemic, schools provided free school meals to all students in the United States, but this national USM policy ended in school year (SY) 2022-2023; however, a few states have adopted policies to continue USM statewide for SY 2022-2023. Research examining the challenges and strategies for successful continuation of USM is essential, along with studying pandemic-related challenges that are likely to persist in schools. Therefore, we conducted a study in Maine (with a USM policy) to evaluate the impact of COVID-19 and the concurrent implementation of USM, as well as examine differences in implementation by school characteristics, throughout the state. A total of n = 43 school food authorities (SFAs) throughout Maine completed surveys. SFAs reported multiple benefits of USM including increased school meal participation; reductions in the perceived stigma for students from lower-income households and their families; and no longer experiencing unpaid meal charges and debt. SFAs also experienced challenges due to the COVID-19 pandemic, particularly regarding costs. When considering future challenges, most respondents were concerned with obtaining income information from families, product and ingredient availability, and the costs/financial sustainability of the school meal programs. Overall, USM may have multiple important benefits for students and schools, and other states should consider implementation of a USM policy.

Storybooks About Healthy Beverage Consumption: Effects in an Online Randomized Experiment With Parents.

INTRODUCTION: Parents spend substantial time reading to their children, making storybooks a promising but understudied avenue for motivating parents to serve their children healthier beverages. This study examines parents' reactions to messages promoting healthy beverage consumption embedded in a children's storybook. METHODS: In 2020, a total of 2,164 demographically diverse parents of children aged 6 months to 5 years participated in an online survey. Participants were randomized to view control messages (school readiness) or 1 of 3 beverage message topics (sugary drink discouragement, water encouragement, or combined discouragement and encouragement) presented as pages from the storybook Potter the Otter. Survey items assessed parents' reactions to the messages and their perceptions, beliefs, and intentions regarding sugary drinks and water. Data were analyzed in 2021. RESULTS: Compared with control messages, exposure to the beverage messages led to higher discouragement from serving children sugary drinks and higher encouragement to serve children more water (p<0.001). The beverage messages also elicited more thinking about beverages' health impacts and led to stronger perceptions that sugary drinks are unhealthy (p<0.001). Moreover, the beverage messages led to higher intentions to limit serving children sugary drinks and higher intentions to serve children more water (p≤0.02). Parents' reactions to the beverage messages did not differ by most demographic characteristics. Few differences in outcomes were observed among the 3 beverage message topics. CONCLUSIONS: Embedding beverage messages in storybooks is a promising, scalable strategy for motivating parents from diverse backgrounds to serve children more water and fewer sugary drinks.

Examining recent trends in the racial disparity gap in tap water consumption: NHANES 2011-2018.

OBJECTIVE: As tap water distrust has grown in the USA with greater levels among Black and Hispanic households, we aimed to examine recent trends in not drinking tap water including the period covering the US Flint Water Crisis and racial/ethnic disparities in these trends. DESIGN: Cross-sectional analysis. We used log-binomial regressions and marginal predicted probabilities to examine US nationally representative trends in tap and bottled water consumption overall and by race/ethnicity. SETTING: The National Health and Nutrition Examination Survey data, 2011-2018. PARTICIPANTS: Nationally representative sample of 9439 children aged 2-19 years and 17 268 adults. RESULTS: Among US children and adults, respectively, in 2017-2018 there was a 63 % (adjusted prevalence ratio (PR): 1·63, 95 % CI (1·25, 2·12), P < 0·001)) and 40 % (PR: 1·40, 95 % CI (1·16, 1·69), P = 0·001)) higher prevalence of not drinking tap water compared to 2013-2014 (pre-Flint Water Crisis). For Black children and adults, the probability of not drinking tap water increased significantly from 18·1 % (95 % CI (13·4, 22·8)) and 24·6 % (95 % CI (20·7, 28·4)) in 2013-2014 to 29·3 % (95 % CI (23·5, 35·1)) and 34·5 % (95 % CI (29·4, 39·6)) in 2017-2018. Among Hispanic children and adults, not drinking tap water increased significantly from 24·5 % (95 % CI (19·4, 29·6)) and 27·1 % (95 % CI (23·0, 31·2)) in 2013-2014 to 39·7 % (95 % CI (32·7, 46·8)) and 38·1 % (95 % CI (33·0, 43·1)) in 2017-2018. No significant increases were observed among Asian or White persons between 2013-2014 and 2017-2018. Similar trends were found in bottled water consumption. CONCLUSIONS: This study found persistent disparities in the tap water consumption gap from 2011 to 2018. Black and Hispanics' probability of not drinking tap water increased following the Flint Water Crisis.

Frequency and Consequences of Routine Temperature Measurement at Well-Child Visits.

OBJECTIVES: To determine the (1) frequency and visit characteristics of routine temperature measurement and (2) rates of interventions by temperature measurement practice and the probability of incidental fever detection. METHODS: In this retrospective cohort study, we analyzed well-child visits between 2014-2019. We performed multivariable regression to characterize visits associated with routine temperature measurement and conducted generalized estimating equations regression to determine adjusted rates of interventions (antibiotic prescription, and diagnostic testing) and vaccine deferral by temperature measurement and fever status, clustered by clinic and patient. Through dual independent chart review, fever (≥100.4°F) was categorized as probable, possible, or unlikely to be incidentally detected. RESULTS: Temperature measurement occurred at 155 527 of 274 351 (58.9%) well-child visits. Of 24 clinics, 16 measured temperature at >90% of visits ("routine measurement clinics") and 8 at <20% of visits ("occasional measurement clinics"). After adjusting for age, ethnicity, race, and insurance, antibiotic prescription was more common (adjusted odds ratio: 1.21; 95% CI 1.13-1.29), whereas diagnostic testing was less common (adjusted odds ratio: 0.76; 95% CI 0.71-0.82) at routine measurement clinics. Fever was detected at 270 of 155 527 (0.2%) routine measurement clinic visits, 47 (17.4%) of which were classified as probable incidental fever. Antibiotic prescription and diagnostic testing were more common at visits with probable incidental fever than without fever (7.4% vs 1.7%; 14.8% vs 1.2%; P < .001), and vaccines were deferred at 50% such visits. CONCLUSIONS: Temperature measurement occurs at more than one-half of well-child visits and is a clinic-driven practice. Given the impact on subsequent interventions and vaccine deferral, the harm-benefit profile of this practice warrants consideration.

Strength and Comprehensiveness of Drinking Water Language in California School District Wellness Policies.

OBJECTIVE(S): Assess the quality of water language in California school district wellness policies and examine how language quality relates to school drinking water access. DESIGN: Cross-sectional study. PARTICIPANTS: Random sample of 240 schools selected from all California public schools, stratified by geography and grades served. VARIABLES MEASURED: Policies (2016-2018) were coded for quality (strength and comprehensiveness) using an adapted school wellness policy tool. School administrators completed phone interviews about drinking water access on their campus. ANALYSIS: Descriptive statistics (eg, means, standard deviations) summarized school-level characteristics and main outcomes. Mixed-effects linear regression models were used to examine the relationship between the strength and comprehensiveness of water policy language and water access. RESULTS: On a scale of 0-100, mean strength was 11.3 (SD, 5.7), and mean comprehensiveness was 28.8 (SD, 8.7). There was an inverse association between the quality of water language in policies and excellence in drinking water access in schools. CONCLUSIONS AND IMPLICATIONS: The strength and comprehensiveness of water language in California school district wellness policies were low. Districts would benefit from improving the quality of water language in their wellness policies and examining challenges to implementing policies.

Temperature Measurement at Well-Child Visits in the United States.

OBJECTIVE: To determine the frequency and predictors of temperature measurement at well-child visits in the US and report rates of interventions associated with visits at which temperature is measured and fever is detected. STUDY DESIGN: In this cross-sectional study, we analyzed 22 518 sampled well-child visits from the National Ambulatory Medical Care Survey between 2003 and 2015. We estimated the frequency of temperature measurement and performed multivariable regression to identify patient, provider/clinic, and seasonal factors associated with the practice. We described rates of interventions (complete blood count, radiograph, urinalysis, antibiotic prescription, and emergency department/hospital referral) by measurement and fever (temperature ≥100.4 °F, ≥38.0 °C) status. RESULTS: Temperature was measured in 48.5% (95% CI 45.6-51.4) of well-child visits. Measurement was more common during visits by nonpediatric providers (aOR 2.0, 95% CI 1.6-2.5; reference: pediatricians), in Hispanic (aOR 1.9, 95% CI 1.6-2.3) and Black (aOR 1.5, 95% CI 1.2-1.9; reference: non-Hispanic White) patients, and in patients with government (aOR 2.0, 95% CI 1.7-2.4; reference: private) insurance. Interventions were more commonly pursued when temperature was measured (aOR 1.3, 95% CI 1.1-1.6) and fever was detected (aOR 3.8, 95% CI 1.5-9.4). CONCLUSIONS: Temperature was measured in nearly one-half of all well-child visits. Interventions were more common when temperature was measured and fever was detected. The value of routine temperature measurement during well-child visits warrants further evaluation.

A cluster-randomized controlled trial of an elementary school drinking water access and promotion intervention: Rationale, study design, and protocol.

INTRODUCTION: Promoting water consumption among children in schools is a promising intervention to reduce sugar-sweetened beverage (SSB) intake and achieve healthful weight. To date, no studies in the United States have examined how a school-based water access and promotion intervention affects students' beverage and food intake both in and out of school and weight gain over time. The Water First trial is intended to evaluate these interventions. METHODS: Informed by the PRECEDE-PROCEED model and Social Cognitive Theory, the Water First intervention includes: 1) installation of lead-free water stations in cafeterias, physical activity spaces, and high-traffic common areas in lower-income public elementary schools, 2) provision of cups/reusable water bottles for students, and 3) a 6-month healthy beverage education campaign. A five year-long cluster randomized controlled trial of 26 low-income public elementary schools in the San Francisco Bay Area is examining how Water First impacts students' consumption of water, caloric intake from foods and beverages, and BMI z-score and overweight/obesity prevalence, from baseline to 7 months and 15 months after the start of the study. Intervention impact on outcomes will be examined using a difference-in-differences approach with mixed-effects regression accounting for the clustering of students in schools and classrooms. DISCUSSION: This paper describes the rationale, study design, and protocol for the Water First study. If the intervention is effective, findings will inform best practices for implementing school water policies, as well as the development of more expansive policies and programs to promote and improve access to drinking water in schools.

Drinking Water in the United States: Implications of Water Safety, Access, and Consumption.

Recent water quality crises in the United States, and recognition of the health importance of drinking water in lieu of sugar-sweetened beverages, have raised interest in water safety, access, and consumption. This review uses a socioecological lens to examine these topics across the life course. We review water intakes in the United States relative to requirements, including variation by age and race/ethnicity. We describe US regulations that seek to ensure that drinking water is safe to consume for most Americans and discuss strategies to reduce drinking water exposure to lead, a high-profile regulated drinking water contaminant. We discuss programs, policies, and environmental interventions that foster effective drinking water access, a concept that encompasses key elements needed to improve water intake. We conclude with recommendations for research, policies, regulations, and practices needed to ensure optimal water intake by all in the United States and elsewhere.