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.

Do High School Students Participate in Second Chance Breakfast Programs?

BACKGROUND: Breakfast consumption often decreases as youth get older. The School Breakfast Program (SBP) provides an opportunity to intervene and increase breakfast consumption, especially among high school students. METHODS: Project breakFAST implemented an expanded breakfast service at 12 high schools. In this longitudinal evaluation, school administrators provided SBP participation and demographic data on all ninth and 10th graders for two full consecutive school years. Students screened for eating breakfast <3 times/week were randomly selected to participate in the cohort study. The cohort completed a survey on perceived barriers, benefits, and breakfast habits. RESULTS: At baseline, all 12 schools had only traditional before school cafeteria SBP service. Mean participation was 16.3% and ranged from 7.9 to 38.1%. After the intervention, there was an increase in participation to 25.7% (p = .004) ranging from 14.1 to 47.5%. There was no change in breakfast participation before school (13.3%, p = .06). Students who traveled to school by car, bike, or walking at baseline were 4.5% less likely to participate in second chance breakfast at follow-up than those who took the bus to school (p = .006). CONCLUSION: Second chance breakfast is an option for increasing high school breakfast participation, especially for those riding the bus.

Breakfast Is Brain Food? The Effect on Grade Point Average of a Rural Group Randomized Program to Promote School Breakfast.

BACKGROUND: Adolescents frequently miss breakfast which may impact cognitive, academic, and health outcomes. This analysis describes the effect of a trial to assess school level changes to increase breakfast consumption on grade point average (GPA). METHODS: Sixteen rural Minnesota high schools were randomized to a policy and environmental change intervention or delayed intervention (control) group. Baseline screening identified, randomly selected and enrolled 9th and 10th grade students who eat breakfast ≤3 times per school week for assessment. Mean unweighted GPA was provided by 13 schools for 636 students. Student-level and administrative data were used for sociodemographic and free or reduced-price meals (FRPM). Linear mixed models and latent class analysis (LCA) were used to assess change in GPA. RESULTS: Students were 54% female, 76% white, and 34% received FRPM. Unweighted cumulative GPA mean = 2.82 (0.78) at baseline. There was no significant intervention effect on GPA postintervention or 1-year follow-up. LCA revealed two classes: "higher" (N = 495) and "lower" (N = 141) resource. There was an intervention effect among low-resource students from baseline to 1-year post only among the control condition (delayed intervention). CONCLUSIONS: In combination with the full study results, increasing breakfast consumption may have an impact particularly for low resource students.

A behavioural economics approach to improving healthy food selection among food pantry clients.

OBJECTIVE: To test the effect of a behavioural economics intervention in two food pantries on the nutritional quality of foods available at the pantries and the foods selected by adults visiting food pantries. DESIGN: An intervention (SuperShelf) was implemented in two food pantries (Sites A and B), with two other pantries (Sites C and D) serving as a control for pantry outcomes. The intervention aimed to increase the amount and variety of healthy foods (supply), as well as the appeal of healthy foods (demand) using behavioural economics strategies. Assessments included baseline and 4-month follow-up client surveys, client cart inventories, pantry inventories and environmental assessments. A fidelity score (range 0-100) was assigned to each intervention pantry to measure the degree of implementation. A Healthy Eating Index-2010 (HEI-2010) score (range 0-100) was generated for each client cart and pantry. SETTING: Four Minnesota food pantries, USA.ParticipantsClients visiting intervention pantries before (n 71) and after (n 70) the intervention. RESULTS: Fidelity scores differed by intervention site (Site A=82, Site B=51). At Site A, in adjusted models, client cart HEI-2010 scores increased on average by 11·8 points (P<0·0001), whereas there was no change at Site B. HEI-2010 pantry environment scores increased in intervention pantries (Site A=8 points, Site B=19 points) and decreased slightly in control pantries (Site C=-4 points, Site D=-3 points). CONCLUSIONS: When implemented as intended, SuperShelf has the potential to improve the nutritional quality of foods available to and selected by pantry clients.

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.

State Agency Support of Weight-Related School Policy Implementation.

BACKGROUND: In this study, we describe state agency strategies to support weight-related policy implementation in schools, and examine the association among state support, obesity prevalence, and strength of state policies governing school nutrition and physical education. METHODS: The 2012 School Health Policies and Practices Study describes prevalence of implementation support state agencies provided to schools/districts. Implementation support items were analyzed by weight-related policy area (eg, advertising, wellness policy) and by type of support (eg, technical assistance). Results were summed to create a total weight-related policy support score. Linear regression was used to examine associations between policy support and state youth obesity prevalence (2011-2012 National Survey for Children's Health), overall and stratified by state policy strength (2012 Classification of Laws Associated with School Students). RESULTS: States provided support most commonly for school meals and wellness policies (89% and 81%, respectively) and least often for after-school PE (26%). Most states (80%) provided technical assistance. The total weight-related policy support score had a significant positive association with state-level youth overweight/obesity prevalence (p = .03). CONCLUSION: State agencies appear to be responding to their youth obesity prevalence with technical support. Schools and state agencies should work in collaboration to provide a healthy school environment for all students.

Refining and implementing the Food Assortment Scoring Tool (FAST) in food pantries.

OBJECTIVE: Hunger relief agencies have a limited capacity to monitor the nutritional quality of their food. Validated measures of food environments, such as the Healthy Eating Index-2010 (HEI-2010), are challenging to use due to their time intensity and requirement for precise nutrient information. A previous study used out-of-sample predictions to demonstrate that an alternative measure correlated well with the HEI-2010. The present study revised the Food Assortment Scoring Tool (FAST) to facilitate implementation and tested the tool's performance in a real-world food pantry setting. DESIGN: We developed a FAST measure with thirteen scored categories and thirty-one sub-categories. FAST scores were generated by sorting and weighing foods in categories, multiplying each category's weight share by a healthfulness parameter and summing the categories (range 0-100). FAST was implemented by recording all food products moved over five days. Researchers collected FAST and HEI-2010 scores for food availability and foods selected by clients, to calculate correlations. SETTING: Five food pantries in greater Minneapolis/St. Paul, Minnesota, USA. SUBJECTS: Food carts of sixty food pantry clients. RESULTS: The thirteen-category FAST correlated well with the HEI-2010 in prediction models (r = 0·68). FAST scores averaged 61·5 for food products moved, 63·8 for availability and 62·5 for client carts. As implemented in the real world, FAST demonstrated good correlation with the HEI-2010 (r = 0·66). CONCLUSIONS: The FAST is a flexible, valid tool to monitor the nutritional quality of food in pantries. Future studies are needed to test its use in monitoring improvements in food pantry nutritional quality over time.

The Mastery Matrix for Integration Praxis: The development of a rubric for integration practice in addressing weight-related public health problems.

In response to the limitations of siloed weight-related intervention approaches, scholars have called for greater integration that is intentional, strategic, and thoughtful between researchers, health care clinicians, community members, and policy makers as a way to more effectively address weight and weight-related (e.g., obesity, diabetes, cardiovascular disease, cancer) public health problems. The Mastery Matrix for Integration Praxis was developed by the Healthy Eating and Activity across the Lifespan (HEAL) team in 2017 to advance the science and praxis of integration across the domains of research, clinical practice, community, and policy to address weight-related public health problems. Integrator functions were identified and developmental stages were created to generate a rubric for measuring mastery of integration. Creating a means to systematically define and evaluate integration praxis and expertise will allow for more individuals and teams to master integration in order to work towards promoting a culture of health.

A Low-Cost, Grab-and-Go Breakfast Intervention for Rural High School Students: Changes in School Breakfast Program Participation Among At-Risk Students in Minnesota.

OBJECTIVE: Evaluate the impact of a grab-and-go component embedded within a larger intervention designed to promote School Breakfast Program (SBP) participation. DESIGN: Secondary data analysis. SETTING: Rural Minnesota high schools. PARTICIPANTS: Eight schools were enrolled in the grab-and-go only intervention component. An at-risk sample of students (n = 364) who reported eating breakfast ≤3 d/wk at baseline was enrolled at these schools. INTERVENTIONS: Grab-and-go style breakfast carts and policies were introduced to allow all students to eat outside the cafeteria. MAIN OUTCOME MEASURES: Administrative records were used to determine percent SBP participation (proportion of non-absent days on which fully reimbursable meals were received) for each student and school-level averages. ANALYSIS: Linear mixed models. RESULTS: School-level increases in SBP participation from baseline to the school year of intervention implementation were observed for schools enrolled in the grab-and-go only component (13.0% to 22.6%). Student-level increases in SBP participation were observed among the at-risk sample (7.6% to 21.9%) and among subgroups defined by free- or reduced-price meal eligibility and ethnic or racial background. Participation in SBP increased among students eligible for free or reduced-price meals from 13.9% to 30.7% and among ineligible students from 4.3% to 17.2%. CONCLUSIONS AND IMPLICATIONS: Increasing access to the SBP and social support for eating breakfast are effective promotion strategies.

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.

It Takes a Village: Promoting Parent and Family Education on Healthy Lifestyles for Minnesota Secondary Students.

BACKGROUND: This study examines school strategies to educate parents over time about physical activity and nutrition and how those strategies are related to adolescent health behaviors. METHODS: Data from the Minnesota School Health Profiles Lead Health Education Teacher survey (2008-2012) and the Minnesota Student Survey (MSS, 2013) included provisions for parent education about physical activity and nutrition and student physical activity and dietary intake behaviors. Analyses were performed using SAS, version 9.3. A generalized estimating equation (GEE) was used to examine changes over time in school policies. Adjusted linear regression models examined cross-sectional association between school policies (2012) and school-level mean student outcomes (2013). RESULTS: Parent education about physical activity and nutrition was constant over time, with the exception of a decrease in physical activity education in schools with low minority enrollment. There was a positive relationship between schools offering physical activity education for parents and the number of days a student meets physical activity and water consumption recommendations. There was no relationship between strategies for nutrition education and dietary intake. CONCLUSIONS: School providing strategies for parent engagement around student physical activity and nutrition may increase parent engagement overall and improve adolescent and school-related outcomes.

School Obesity Prevention Policies and Practices in Minnesota and Student Outcomes: A Longitudinal Cohort Study.

INTRODUCTION: The School Obesity-related Policy Evaluation (ScOPE) Study uses existing public surveillance data and applies a rigorous study design to evaluate effectiveness of school policies and practices impacting student behavioral and weight outcomes. METHODS: The ScOPE Study used a cohort of 50 combined junior-senior and high schools in Minnesota to evaluate the change in weight-related policy environments in 2006 and 2012 and test the effect of policy change on students attending those schools in 2007 and 2013. Exposure variables included school practices about foods and beverages available in school vending machines and school stores, physical education requirements, and intramural opportunities. Primary study outcomes were average school-level ninth grade student BMI percentile, obesity prevalence, daily servings of fruits/vegetables, and daily glasses of soda. RESULTS: Availability of fruits/vegetables in schools was associated with a significant increase in total daily intake among ninth grade students by 0.4 servings. Availability of soda in schools was associated with a significant increase in total daily intake among ninth grade boys by 0.5 servings. Less-healthy snack and drink availability in schools was associated with a small, significant increase (1%) in student BMI percentile at the school level. CONCLUSIONS: Use of a school-level longitudinal cohort study design over a 6-year period uniquely adds to the methodologic rigor of school policy and practice evaluation studies. The ScOPE Study provides marginal evidence that school policies and practices, especially those that restrict vending and school store offerings, may have small effects on weight status among ninth grade students.

Application of the Healthy Eating Index-2010 to the hunger relief system.

OBJECTIVE: To demonstrate the feasibility of applying the Healthy Eating Index-2010 (HEI-2010) to the hunger relief setting, specifically by assessing the nutritional quality of foods ordered by food shelves (front-line food provider) from food banks (warehouse of foods). DESIGN: This Healthy FOOD (Feedback On Ordering Decisions) observational study used electronic invoices detailing orders made by 269 food shelves in 2013 and analysed in 2015 from two large Minnesota, USA food banks to generate HEI-2010 scores. Initial development and processing procedures are described. RESULTS: The average total HEI-2010 score for the 269 food shelves was 62·7 out of 100 with a range from 28 to 82. Mean component scores for total protein foods, total vegetables, fatty acids, and seafood and plant proteins were the highest. Mean component score for whole grains was the lowest followed by dairy, total fruits, refined grains and sodium. Food shelves located in micropolitan areas and the largest food shelves had the highest HEI-2010 scores. Town/rural and smaller food shelves had the lowest scores. Monthly and seasonal differences in scores were detected. Limitations to this approach are identified. CONCLUSIONS: Calculating HEI-2010 for food shelves using electronic invoice data is novel and feasible, albeit with limitations. HEI-2010 scores for 2013 identify room for improvement in nearly all food shelves, especially the smallest agencies. The utility of providing HEI-2010 scores to decision makers in the hunger relief setting is an issue requiring urgent study.

School district wellness policy quality and weight-related outcomes among high school students in Minnesota.

Weight-related outcomes were examined among high school students in Minnesota public school districts according to the quality of district wellness policies. Wellness policy strength and comprehensiveness were scored using the Wellness School Assessment Tool (WellSAT) for 325 Minnesota public school districts in 2013. The associations between WellSAT scores and district-level means of high school student responses to a statewide survey of health behaviors were examined in this ecologic study. WellSAT Total Strength and Total Comprehensiveness scores were positively associated with both student mean Body Mass Index (BMI) percentile (Strength: P = 0.018, Comprehensiveness: P = 0.031) and mean percent overweight or obese (Strength: P = 0.008, Comprehensiveness: P = 0.026), but only in districts with > 50% of students eligible for Free or Reduced-Price Lunches (FRPLs), or 'high FRPL districts'. WellSAT Physical Education and Physical Activity subscale scores were also positively associated with the mean days per week students engaged in physical activity for ≥ 60 min in high FRPL districts (Strength: P = 0.008, Comprehensiveness: P = 0.003) and in low FRPL districts (< 35% eligible) for Strength score: (P = 0.027). In medium FRPL districts (35-50% eligible), Nutrition Education and Wellness Promotion Strength and Comprehensiveness subscale scores were positively associated with, respectively, daily servings of vegetables (P = 0.037) and fruit (P = 0.027); and WellSAT Total scores were positively associated with daily vegetable servings (Strength: P = 0.037, Comprehensiveness: P = 0.012). Administrators of economically disadvantaged school districts with a higher percentage of overweight students may be recognizing the need for stronger wellness policies and the specific importance of implementing policies pertaining to physical activity as a means to improve student health.