School Meals for All: A Qualitative Study Exploring Lessons in Successful Advocacy and Policymaking in Maine and California.

BACKGROUND: The COVID-19 pandemic focused national attention on food insecurity, equity, and the role of school meal programs in supporting children, families, and communities. In doing so, the pandemic created a rare policy window - an opportunity to advance a longstanding public health goal of guaranteed access to free school meals for all students. In July 2021, California and Maine became the first states to authorize school meal for all legislation (also known as universal free meals). OBJECTIVE: The aim of this study was to explore perspectives of policymakers, state agency officials, and advocates on the conditions and mechanisms that facilitated passage of school meal for all legislation in California and Maine. DESIGN: A qualitative case study was conducted. PARTICIPANTS: Between December 2021 and June 2022, semi-structured interviews were conducted with 30 policymakers, state agency officials, and advocates. ANALYSIS: Performed: Interviews were analyzed using principles of content analysis. Key themes are organized using Kingdon's multiple streams framework for public policy. RESULTS: Eleven key themes were identified. Lessons are drawn from the policy and advocacy strategies used to advance laws in California and Maine. For instance, paving the way with incremental policy change, tailoring messaging to diverse audiences, and organizing at the grassroots and grasstops levels were critical to success of advocacy efforts. CONCLUSIONS: Promising practices can guide efforts to expand access to school meals and advance other child nutrition policies in other states and nationally. Moving forward, lessons learned from implementation of universal free school meal legislation in California, Maine, and other early adopters should be documented and shared.

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.

Parent perceptions of school meals and how perceptions differ by race and ethnicity.

Parental perceptions of school meals can affect student participation and overall support for school meal policies. Little is known about parental school meal perceptions under universal free school meals (UFSM) policies. We assessed California parents' perceptions of school meals during the COVID-19 emergency response with federally funded UFSM and whether perceptions differed by race/ethnicity. Among 1110 California parents of K-12 students, most reported school meals benefit their families, saving them money (81.6%), time (79.2%), and stress (75.0%). Few reported that their child would be embarrassed to eat school meals (11.7%), but more parents of White students than Hispanic students reported this. Many parents reported that their child likes to eat lunch to be with friends (64.7%); about half felt their child has enough time to eat (54.2%). Fewer parents perceived school lunches to be of good quality (36.9%), tasty (39.6%), or healthy (44.0%). Parents of Hispanic and Asian students had less favorable perceptions of school meal quality, taste, and healthfulness than parents of White students. Parents report that school meals benefit their families, but policy efforts are needed to ensure schools have the resources needed to address cultural appropriateness. Schools should address parental perceptions of meals to optimize participation, nutrition security, and health.

Parent Perceptions of School Meals Influence Student Participation in School Meal Programs.

OBJECTIVE: To evaluate if parent perceptions of school meals influence student participation. DESIGN: In May 2022, an online survey was used to evaluate parents' perceptions of school meals and their children's participation. PARTICIPANTS: A total of 1,110 California parents of kindergarten through 12th-grade students. MAIN OUTCOME MEASURES: Student participation in school lunch and breakfast. ANALYSIS: Principal component analysis and Poisson regression models. RESULTS: Three groups of parental perceptions were identified: (1) positive perceptions (eg, liking school meals and thinking that they are tasty and healthy), (2) perceived benefits to families (eg, school meals save families money, time, and stress), and (3) negative (eg, concerns about the amount of sugar in school meals and stigma). More positive parental perceptions about school meals and their benefits to families were associated with greater student meal participation. In contrast, more negative parental perceptions were associated with reduced student participation in school meals (P < 0.05). CONCLUSION AND IMPLICATIONS: Parent perceptions of school meals may affect student participation in school meal programs. Working to ensure parents are familiar with the healthfulness and quality of school meals and the efforts schools are making to provide high-quality, appealing meals may be critical for increasing school meal participation rates.

Efficacy and safety of a synbiotic infant formula for the prevention of respiratory and gastrointestinal infections: a randomized controlled trial.

BACKGROUND: Early life nutrition is crucial for the development of the gut microbiota that, in turn, plays an essential role in the maturation of the immune system and the prevention of infections. OBJECTIVES: The aim of this study was to investigate whether feeding synbiotic infants and follow-on formulas during the first year of life reduces the incidence rate (IR) of infectious diarrhea compared with standard formulas. Secondary endpoints included the IR of other infectious diseases as well as fecal milieu parameters. METHODS: In this double-blind, controlled trial, 460 healthy, 1-mo-old infants were randomly assigned to receive a synbiotic [galacto-oligosaccharides (GOS)/Limosilactobacillus fermentum CECT 5716] (IF, n = 230) or a control formula (CF, n = 230) until 12 mo of age. A reference group of breastfed infants (HM, n = 80) was included. Data on infections were recorded throughout the study period and stool samples were collected at 4 and 12 mo of age. RESULTS: IR of infectious diarrhea during the first year of life was 0.60 (CF), 0.56 (IF), and 0.29 (HM), with no statistically significant difference between groups. The IR of lower respiratory tract infections, 1 of the secondary endpoints, however, was lower in IF than in CF [0.79 compared with 1.01, IR ratio = 0.77 (0.60-1.00)]. Additionally, fecal pH was significantly lower at 4 mo (P < 0.0001), whereas secretory IgA was significantly higher at 12 mo of age (P = 0.015) in IF compared with CF. CONCLUSIONS: Although no difference is observed in the incidence of diarrhea, consumption of a synbiotic formula containing L. fermentum CECT5716 and GOS in infancy may reduce the incidence of lower respiratory tract infections and affect the immune system and fecal milieu. Additional research is warranted to further investigate the potential interaction of the gut-lung axis. This trial was registered at clinicaltrials.gov as NCT02221687.

Teacher and Caregiver Perspectives on Water Is K'é: An Early Child Education Program to Promote Healthy Beverages among Navajo Children.

The Water is K'é program was developed to increase water consumption and decrease consumption of sugar-sweetened beverages for young children and caregivers. The pilot program was successfully delivered by three Family and Child Education (FACE) programs on the Navajo Nation using a culturally centered curriculum between 2020 to 2022. The purpose of this research was to understand teacher and caregiver perspectives of program feasibility, acceptability, impact, and other factors influencing beverage behaviors due to the pilot program. Nine caregivers and teachers were interviewed between June 2022 and December 2022, and a study team of four, including three who self-identified as Navajo, analyzed the data using inductive thematic analysis and consensus building to agree on codes. Five themes emerged, including feasibility, acceptability, impact, suggestions for future use of the program, and external factors that influenced water consumption. The analysis showed stakeholders' strong approval for continuing the program based on impact and acceptability, and identified factors that promote the program and barriers that can be addressed to make the program sustainable. Overall, the Water is K'é program and staff overcame many challenges during the COVID-19 pandemic to support healthy behavior change that had a rippled influence among children, caregivers, teachers, and many others.

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.

Infant blood concentrations of folate markers and catabolites are modified by 5,10-methylenetetrahydrofolate reductase C677T genotype and dietary folate source.

BACKGROUND: Folate intake and polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene may affect folate metabolism in infants. OBJECTIVES: We investigated the association between infant's MTHFR C677T genotype, the dietary folate source, and concentrations of folate markers in the blood. METHODS: We studied 110 breastfed infants (reference) and 182 infants who were randomly assigned to receive infant formulas enriched with either 78 µg folic acid or 81 µg (6S)-5-methyltetrahydrofolate (5-MTHF) per 100 g milk powder for 12 wk. The blood samples were available at the ages of <1 mo (baseline) and 16 wk. MTHFR genotype and concentrations of folate markers and catabolites [i.e., para-aminobenzoylglutamate (pABG)] were analyzed. RESULTS: At baseline, carriers of the TT genotype (vs. CC) had lower mean (SD) concentrations (all in nmol/L) of red blood cell (RBC) folate [1194 (507) vs. 1440 (521), P = 0.033) and plasma pABG [5.7 (4.9) vs. 12.5 (8.1), P < 0.001] but higher plasma 5-MTHF [33.9 (16.8) vs. 24.0 (12.6), P < 0.001]. Irrespective of the genotype, infant formula with 5-MTHF (vs. folic acid) caused a significant increase in RBC folate concentration [1278 (466) vs. 947 (552), P < 0.001]. In breastfed infants, plasma concentrations of 5-MTHF and pABG increased significantly by 7.7 (20.5) and 6.4 (10.5), respectively, from baseline to 16 wk. Infant formula that complies with the present EU legislation for folate intake increased RBC folate and plasma pABG concentrations at 16 wk (P < 0.001) than formula-fed infants. At 16 wk, plasma pABG concentrations remained ∼50% lower in carriers of the TT (vs. the CC) genotype among all feeding groups. CONCLUSIONS: Folate intake from infant formula according to the present EU legislation increased RBC folate and plasma pABG concentrations in infants to a greater extent than breastfeeding, particularly in carriers of the TT genotype. However, this intake did not completely abolish the between-genotype differences in pABG. Whether these differences have any clinical relevance, however, remains unclear. This trial was registered at clinicaltrials.gov as NCT02437721.

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.

Early life gut microbiota profiles linked to synbiotic formula effects: a randomized clinical trial in European infants.

BACKGROUND: Microbial colonization of the gastrointestinal tract after birth is an essential event that influences infant health with life-long consequences. Therefore, it is important to investigate strategies to positively modulate colonization in early life. OBJECTIVES: This randomized, controlled intervention study included 540 infants to investigate the effects of a synbiotic intervention formula (IF) containing Limosilactobacillus fermentum CECT5716 and galacto-oligosaccharides on the fecal microbiome. METHODS: The fecal microbiota from infants was analyzed by 16S rRNA amplicon sequencing at 4, 12, and 24 months of age. Metabolites (e.g., short-chain fatty acids) and other milieu parameters (e.g., pH, humidity, and IgA) were also measured in stool samples. RESULTS: Microbiota profiles changed with age, with major differences in diversity and composition. Significant effects of the synbiotic IF compared with control formula (CF) were visible at month 4, including higher occurrence of Bifidobacterium spp. and Lactobacillaceae and lower occurrence of Blautia spp., as well as Ruminoccocus gnavus and relatives. This was accompanied by lower fecal pH and concentrations of butyrate. After de novo clustering at 4 months of age, overall phylogenetic profiles of the infants receiving IF were closer to reference profiles of those fed with human milk than infants fed CF. The changes owing to IF were associated with fecal microbiota states characterized by lower occurrence of Bacteroides compared with higher levels of Firmicutes (valid name Bacillota), Proteobacteria (valid name Pseudomonadota), and Bifidobacterium at 4 months of age. These microbiota states were linked to higher prevalence of infants born by Cesarean section. CONCLUSIONS: The synbiotic intervention influenced fecal microbiota and milieu parameters at an early age depending on the overall microbiota profiles of the infants, sharing a few similarities with breastfed infants. This trial was registered at clinicaltrials.gov as NCT02221687.

Perceptions of Water Safety and Tap Water Taste and Their Associations With Beverage Intake Among U.S. Adults.

OBJECTIVES: Examine differences in perceptions of tap water (TW) and bottled water (BW) safety and TW taste and their associations with plain water (PW) and sugar-sweetened beverage (SSB) intake. DESIGN: Quantitative, cross-sectional study. SETTING: United States. SUBJECTS: 4,041 U.S. adults (≥18 years) in the 2018 SummerStyles survey data. MEASURES: Outcomes were intake of TW, BW, PW (tap and bottled water), and SSB. Exposures were perceptions of TW and BW safety and TW taste (disagree, neutral, or agree). Covariates included sociodemographics. ANALYSIS: We used chi-square analysis to examine sociodemographic differences in perceptions and multivariable logistic regressions to estimate adjusted odds ratios (AOR) for consuming TW ≤ 1 cup/day, BW > 1 cup/day, PW ≤ 3 cups/day, and SSB ≥ 1 time/day by water perceptions. RESULTS: One in 7 (15.1%) of adults did not think their home TW was safe to drink, 39.0% thought BW was safer than TW, and 25.9% did not think their local TW tasted good. Adults who did not think local TW was safe to drink had higher odds of drinking TW ≤ 1 cup/day (AOR = 3.12) and BW >1 cup/day (AOR = 2.69). Adults who thought BW was safer than TW had higher odds of drinking TW ≤1 cup/day (AOR = 2.38), BW > 1 cup/day (AOR = 5.80), and SSB ≥ 1 time/day (AOR = 1.39). Adults who did not think TW tasted good had higher odds of drinking TW ≤ 1 cup/day (AOR = 4.39) and BW > 1 cup/day (AOR = 2.91). CONCLUSIONS: Negative perceptions of TW safety and taste and a belief BW is safer than TW were common and associated with low TW intake. Perceiving BW is safer than TW increased the likelihood of daily SSB intake. These findings can guide programs and services to support water quality to improve perceptions of TW safety and taste, which might increase TW intake and decrease SSB 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.

Child and Adult Care Food Program Participation Benefits, Barriers and Facilitators for Independent Child Care Centers in California.

The Child and Adult Care Food Program (CACFP) provides reimbursements for nutritious foods for children with low-income at participating child care sites in the United States. The CACFP is associated with improved child diet quality, health outcomes, and food security. However CACFP participation rates are declining. Independent child care centers make up a substantial portion of CACFP sites, yet little is known about their barriers to participation. Researcher-led focus groups and interviews were conducted in 2021-2022 with 16 CACFP-participating independent centers and 5 CACFP sponsors across California CACFP administrative regions to identify participation benefits, barriers, and facilitators. Transcripts were coded for themes using the grounded theory method. CACFP benefits include reimbursement for food, supporting communities with low incomes, and healthy food guidelines. Barriers include paperwork, administrative reviews, communication, inadequate reimbursement, staffing, nutrition standards, training needs, eligibility determination, technological challenges, and COVID-19-related staffing and supply-chain issues. Facilitators included improved communication, additional and improved training, nutrition standards and administrative review support, online forms, reduced and streamlined paperwork. Sponsored centers cited fewer barriers than un-sponsored centers, suggesting sponsors facilitate independent centers' CACFP participation. CACFP participation barriers should be reduced to better support centers and improve nutrition and food security for families with low-income.

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.

Lead Concentrations in US School Drinking Water: Testing Programs, Prevalence, and Policy Opportunities, 2016‒2018.

Objectives. To detail baseline drinking water sample lead concentrations and features of US state-level programs and policies to test school drinking water for lead in 7 states' operating programs between 2016 and 2018. Methods. We coded program and policy documents using structured content analysis protocols and analyzed state-provided data on lead concentration in drinking water samples collected in public schools during initial testing phases. Results. We analyzed data from 5688 public schools, representing 35% of eligible schools in 7 states. The number of samples per school varied. The proportion of schools identifying any sample lead concentration exceeding 5 parts per billion varied (13%-81%). Four states exceeded 20%. Other program features varied among states. Instances of lead above the state action level were identified in all states. Conclusions. In 2018, many US public school students attended schools in states without drinking water lead-testing programs. Testing all drinking water sources may be recommended. Public Health Implications. Initiating uniform school drinking water lead testing programs and surveillance over time could be used to reduce risk of lead exposure in drinking water. (Am J Public Health. 2022;112(S7):S679-S689. https://doi.org/10.2105/AJPH.2022.306961).

Providing School Meals to All Students Free of Charge during the COVID-19 Pandemic and Beyond: Challenges and Benefits Reported by School Foodservice Professionals in California.

Universal school meals (USM) have the potential to increase access to healthy food for millions of U.S. students. This study evaluated school food authorities' (SFA) perspectives of federal USM in response to COVID-19 (school year (SY) 2021−22) and California's upcoming USM policy in the SY 2022−23. In February 2022, all SFAs in California (n = 1116) were invited to complete an online survey. Descriptive statistics and logistic regression examining differences by school demographic characteristics were used. Five hundred and eighty-one SFAs completed the survey; 63% of them first implemented USM during the COVID-19 pandemic. Reported benefits included increased student meal participation (79.2%) and reduced stigma (39.7%). Top challenges included staffing (76.9%) and meal packaging/solid waste (67.4%). Nearly all SFAs reported pandemic-related challenges procuring the necessary types (88.9%) and amounts of foods (85.9%), and non-food supplies/equipment (82.6%). Over 40% reported that federal reimbursements were insufficient to cover costs. SFAs with <40% FRPM-eligible students and/or higher student enrollment reported more current challenges and future concerns than those with ≥40% FRPMs and lower student enrollment. The top resources requested to implement CA's USM included additional facilities/equipment (83.8%), communications/marketing (76.1%), increasing meal participation (71.5%), and financial management (61.5%). Most California SFAs reported that implementing federal USM had the intended effect of feeding more children. This study's findings may be useful to the several other U.S. states implementing universal school meals in the SY 2022−23, and to other states or countries considering adopting a USM policy in the future.

A Qualitative Examination of California WIC Participants' and Local Agency Directors' Experiences during the Coronavirus Disease 2019 Pandemic.

BACKGROUND: The US Department of Agriculture granted waivers to allow flexibility in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) operations during the coronavirus disease 2019 (COVID-19) pandemic; however, research examining the associations between waiver introduction and changes in perceptions, practices, and challenges of WIC participants' and agency directors' experiences is limited. OBJECTIVE: The objective of this study was to assess California WIC participants' and agency directors' perceptions and practices of remote WIC services during the COVID-19 pandemic. A secondary aim was to understand other COVID-19 challenges related to maintaining access to healthy foods by WIC participants. DESIGN: A qualitative study that included semistructured interviews was conducted between June 2020 and March 2021. PARTICIPANTS AND SETTING: One hundred eighty-two WIC participants with a child aged 0 to 5 years from three regions of California (Southern, Central, and Northern) and 22 local WIC agency directors across the state were interviewed. MAIN OUTCOME MEASURES: WIC participants' and agency directors' perceptions, practices, and other challenges during COVID-19. STATISTICAL ANALYSES PERFORMED: Interviews were recorded, transcribed, and analyzed using a grounded theory approach. RESULTS: Participants shared that they valued the information received from WIC and were very satisfied with remote WIC services. Participants reported that enrolling in WIC remotely was easier than coming in person. All waivers and changes to WIC operations, namely the physical presence, remote benefit issuance, and separation of duties waivers, and remote work and remote delivery of nutrition education, were largely viewed by WIC agency directors as options that should be continued postpandemic. Further, a majority (63%) of households reported experiencing food insecurity, and half of respondents received food from a food bank or pantry during the pandemic. CONCLUSIONS: Findings suggest WIC will attract and retain the most families by offering a hybrid model of services, incorporating both onsite services and remote options to work more efficiently and effectively.

Factors Related to Water Filter Use for Drinking Tap Water at Home and Its Association With Consuming Plain Water and Sugar-Sweetened Beverages Among U.S. Adults.

OBJECTIVE: To examine factors associated with water filter use (WFU) for drinking tap water at home and its association with consuming plain water and sugar-sweetened beverages (SSBs). DESIGN: Quantitative, cross-sectional study. SETTING: The 2018 SummerStyles survey data. SUBJECTS: U.S. adults (≥18 years; N=4042). MEASURES: Outcomes were intake of plain water (tap/bottled water) and SSBs. Exposure was WFU (yes, no, not drinking tap water at home). Covariates included sociodemographics, weight status, Census regions, and home ownership status. ANALYSIS: We used multivariable logistic regressions to estimate adjusted odds ratios (AOR) and 95% confidence interval (CI) for consuming tap water, bottled water, or total plain water >3 cups/day (vs. ≤3 cups) and SSBs ≥1 time/day (vs. <1 time) by WFU. RESULTS: Overall, 36% of adults reported using a filter for drinking tap water at home; 14% did not drink tap water at home. Hispanics had significantly higher odds of using a water filter (AOR=1.50, 95% CI=1.14-1.98) vs non-Hispanic White. Factors significantly associated with lower odds of WFU were lower education (AOR=.69, 95% CI=.55-.86 for ≤high school; AOR=.78, 95% CI=.64-.95 for some college, vs college graduate), not being married (AOR=.81, 95% CI=.66-.98, vs married/domestic partnership), and lower household income (AOR=.68, 95% CI=.68-.90 for <$35,000, vs ≥$100,000). Using a water filter was associated with higher odds of drinking >3 cups/day of tap water (AOR=1.33, 95% CI=1.13-1.56) and lower odds of SSBs ≥1 time/day (AOR=.76, 95% CI=.62-.92). Not drinking tap water at home was associated with higher odds of drinking >3 cups/day bottled water (AOR=3.46, 95% CI=2.70-4.44). CONCLUSIONS: WFU was associated with higher tap water intake and lower SSB intake among U.S. adults. WFU was higher among Hispanics, but lower among those with lower education and income and not married adults. Although WFU was associated with healthful beverage habits, additional considerations for WFU may include source water quality, oral health, cost, and proper use.

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.

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.