Inclusive and intersectoral: community health improvement planning opportunities to advance the social determinants of health and health equity.

BACKGROUND: Community health improvement plans (CHIPs) are strategic planning tools that help local communities identify and address their public health needs. Many local health departments have developed a CHIP, yet there is a lack of research on the extent to which these plans address root causes of health disparities such as the social determinants of health. This study aims to inventory the social determinants of health included in 13 CHIPs and examine facilitators and challenges faced by local health departments and partners when trying to include the social determinants of health. METHODS: We conducted a comparative plan evaluation by scoring 13 CHIPs on their inclusion of equity orientation, inclusive planning processes, and five social determinants of health: health care access and quality, the neighborhood and built environment, economic stability, social and community context, and education access and quality. To supplement the plan evaluation, we conducted 32 in-depth interviews with CHIP leaders and stakeholders to understand the factors contributing to the inclusion and exclusion of the social determinants of health in the planning process. RESULTS: CHIPs received an average score of 49/100 for the inclusion of the social determinants of health. Most plans addressed health care access and quality and the neighborhood and built environment, but they often did not address economic stability, the social and community context, and education access and quality. Regarding their overall equity orientation, CHIPs received an average score of 35/100, reflecting a relative lack of attention to equity and inclusive planning processes in the plans. Interviews revealed that challenges engaging partners, making clear connections between CHIPs and social determinants, and a lack of capacity or public and partner support often led to the exclusion of the social determinants of health. Recommendations to improve planning processes include improving data infrastructure, providing resources for dedicated planning staff and community engagement incentives, and centering equity throughout the planning process. CONCLUSIONS: Although local health departments can leverage CHIPs to improve population health and address health disparities, they face a range of challenges to including the social determinants of health in CHIPs. Additional resourcing and improved data are needed to facilitate broader inclusion of these determinants, and more work is needed to elevate equity throughout these planning processes.

Legislative Health Notes: Preliminary Learnings From Piloting a New Policy Analysis Tool.

CONTEXT: In 2018, the Health Impact Project (the Project) developed and tested a new health in all policies (HiAP) tool called "legislative health notes" to provide state and local legislators with peer-reviewed evidence, public health data, and local data that illustrate potential positive and negative health and equity effects of proposed bills. OBJECTIVES: The Project sought to refine the health note methodology while piloting the tool in the Colorado and Indiana General Assemblies, and with the Council of the District of Columbia, and worked with affiliates to introduce them in North Carolina, Ohio, and California. DESIGN AND PARTICIPANTS: External partners solicited feedback on health notes via semistructured interviews and surveys from legislators, legislative staff, and expert reviewers who were familiar with health notes in each of these jurisdictions. RESULTS: Respondents shared that health notes were nonpartisan, were easy for nonexperts to understand, and would be more effective if delivered earlier in the legislative process. CONCLUSION: In response to informant feedback, practitioners can explore adding high-level summaries, increasing focus on health equity implications and the potential to work with legislators during the policy formulation phase. Data from this pilot suggest that legislative health notes are a promising nonpartisan and standardized tool to better understand the health and equity implications of proposed legislation.

Rural Libraries as Resources and Partners for Outside Active Play Streets.

BACKGROUND: Urban and rural areas have different types of built environments and community infrastructure, which lead to different types of successful community-based physical activity initiatives. Temporary Play Streets are a supported way to increase physical activity and perceptions of the built environment as a space for active lifestyles. PURPOSE: Within the field of public health, public libraries constitute an underutilized community partner. To begin to understand the capacity of rural librarians to support rural Play Streets, a cross-sectional questionnaire was developed for distribution to rural librarians. METHODS: The sampling frame targeted members of the membership-based U.S. Association for Rural & Small Libraries (ARSL). Among respondents, 65% reported offering outdoor physical activity programs in the past, and 61% reported continuing to offer versions of this programming during the COVID-19 pandemic. Librarians work with a broad range of community partners on this programming, and already own much of the equipment necessary for a successful Play Streets initiative. CONCLUSIONS: The results of this study corroborate claims from previous research, which shows that in small and rural communities, public libraries have the capacity to play a role in promoting physical activity through involvement in community partnerships. Additional work is needed to understand, evaluate, and support this opportunity to weave rural librarians into community-based physical activity promotion efforts more fully.

Acquisition, mobility and food insecurity: integrated food systems opportunities across urbanicity levels highlighted by COVID-19.

OBJECTIVE: To investigate acquisition and mobility experiences of food-insecure individuals across urbanicity levels (i.e., urban, suburban, rural) in the early months of the COVID-19 pandemic. DESIGN: Cross-sectional study using a nationally representative online panel to measure where food-insecure individuals acquired food, food acquisition barriers and mobility to food sources, which were evaluated across urbanicity levels using chi-squared tests and 95 % CI. SETTING: USA. PARTICIPANTS: 2011 adults (18 years or older). RESULTS: Food insecurity impacted 62·3 % of adults in urban areas, 40·5 % in rural areas and 36·7 % in suburban areas (P < 0·001). Food acquisition barriers that were significantly more prevalent among food-insecure adults in urban areas were a change in employment status (34·2 %; 95 % CI 27·2 %, 41·1 %; P < 0·0001) and limited availability of food in retailers (38·8 %; 95 % CI 31·7 %, 45·9 %; P < 0·001). In rural areas, food-insecure adults primarily acquired food for the household from supercentres (61·5 %; 95 % CI 50·4 %, 72·5 %; P < 0·05), while locally sourced foods were less common among food-insecure adults in rural areas (6·9 %; 95 % CI 0·01 %, 13·0 %) compared to urban areas (19·8 %; 95 % CI 14·3 %, 25·4 %; P < 0·01). Transportation as a barrier did not vary significantly by urbanicity, but food-insecure adults across urbanicity levels reported utilising a range of transportation modes to acquire food. CONCLUSIONS: A planning approach that links urban and rural areas could address food insecurity by enhancing the integration of food production, transportation and food distribution, building towards a more resilient and equitable food system for all Americans.

Implementing Play Streets in Low-Income Rural Communities in the United States.

Play streets involve the temporary closure of streets that for a specified time create a safe place for active play. Play streets have been implemented primarily in cities; it is unknown if they could be adapted and implemented in rural areas. To learn about implementation, core components of play streets and inform adaptation, we conducted systematic peer-reviewed and grey literature searches and interviews with a purposive sample of key informants. Data were analyzed by theme and used to inform implementation of play streets by four community organizations in low-income rural areas of Maryland, North Carolina, Oklahoma, and Texas from June to September 2017. Core elements of play streets in urban areas were present in rural settings-the content (e.g., activities offered), delivery of the intervention in partnership with community members and local organizations, and reoccurrence of play streets at a single location. There were three key adaptations relating to delivery and context to consider uniquely when implementing play streets in rural areas (1) using locations other than streets, (2) varying locations to account for geographic dispersion, and (3) maximizing participation and resources by coupling play streets with community events. Play streets can be successfully implemented in rural settings with these modifications, which support feasibility, reach, and access. Play streets in rural areas should include activities for active play that are age-appropriate and fun, without necessarily tailoring content for rural areas.

Real-Time Video Scan Method for Community Partner Use to Inform Play Streets Implementation.

System for Observing Play and Recreation in Communities (SOPARC) can provide accurate assessment of physical activity; however, the skills, time, and human resources necessary to collect/interpret SOPARC data can be challenging for community organizations. This article describes a more accessible adaptation of SOPARC using video recordings for community organizations to obtain physical activity feedback at Play Streets. Narrated panoramic video scans occurred every 30 minutes at each Play Street using an iPad. Videographers narrated: (1) sex, (2) age group (child, teen, adult, senior), and (3) activity level (sedentary, walking, vigorous) for everyone recorded. SOPARC video scans, in-person iSOPARC observations, and interviews were conducted with Play Streets implementors to determine validity and feasibility. Validity was examined using Lin's concordance correlation coefficient (CCC). In-person and video scans showed near perfect agreement for sedentary individuals (CCC = .95) and substantial agreement for active individuals (CCC = .72). Overall, community partners felt that they "could see how [the scans] could be useful" and "help[ed] see a bit more clearly what's happening." The method described here is a more accessible systematic observation approach to measure physical activity for communities implementing Play Streets. Further, this method can be used without research training while still providing valuable activity feedback.

Impact of The Community Eligibility Provision of the Healthy, Hunger-Free Kids Act on Student Nutrition, Behavior, and Academic Outcomes: 2011-2019.

The Community Eligibility Provision (CEP) allows high-poverty schools participating in US Department of Agriculture meal programs to offer universal free breakfast and lunch. Authorized as part of the Healthy, Hunger-Free Kids Act of 2010, CEP became available to eligible schools nationwide in 2014.Emerging evidence suggests that schools that provide universal free meals experience positive impacts on student nutrition, behavior, and academic performance. In particular, schools benefit from increased meal participation rates. There is mixed evidence of impacts on test scores and attendance, and limited but promising results showing improvements in weight outcomes, on-time grade promotion rates, disciplinary referrals, and food security.In this article, we summarize the growing evidence base and suggest policy approaches to increase the use of CEP by eligible schools.

The relationship between joining a US free trade agreement and processed food sales, 2002-2016: a comparative interrupted time-series analysis.

OBJECTIVE: To examine changes in sales of highly processed foods, including infant formulas, in countries joining free trade agreements (FTAs) with the US. DESIGN: Annual country-level data for food and beverage sales come from Euromonitor International. Analyses are conducted in a comparative interrupted time-series (CITS) framework using multivariate random-effects linear models, adjusted for key confounders: gross domestic product (GDP) per capita, percent of the population living in urban areas and female labor force participation rate. Memberships in other FTAs and investment treaties are also explored as possible confounders. SETTING: Changes are assessed between 2002 and 2016. PARTICIPANTS: Ten countries joining US FTAs are compared with eleven countries without US FTAs in force; countries are matched on national income level, world region and World Trade Organization membership. RESULTS: After countries join a US FTA, sales are estimated to increase by: 0·89 (95 % CI 0·16, 1·6; P = 0·016) kg per capita per annum for ultra-processed products, 0·81 (95 % CI 0·47, 1·1; P < 0·001) kg per capita per annum for processed culinary ingredients and 0·17 (95 % CI 0·052, 0·29; P = 0·005) kg per capita under age 5 per annum for baby food. No significant change is estimated for minimally processed foods. In statistical models, large unexplained variations in country-specific trends suggest additional unmeasured country-level factors also impact sales trends following entry into US FTAs. CONCLUSIONS: These findings strongly support the conclusion that joining US FTAs can contribute to detrimental changes in national dietary consumption that increase population risk of non-communicable diseases.

Factors that Influenced Adoption of a School-Based Trauma-Informed Universal Mental Health Intervention.

We know little about why school administrators choose to adopt preventive mental health interventions within the context of school-based prevention trials. This study used a qualitative multiple-case study design to identify factors that influenced the adoption of a trauma-informed universal intervention by urban public school administrators during an efficacy trial. Semi-structured interviews were conducted with 15 school administrators who adopted a trauma-informed mindfulness intervention called RAP (Relax, be Aware, and do a Personal Rating) Club as part of their participation in a school-based trial with eighth graders. Findings indicated that administrators adopted RAP Club to provide support for students affected by trauma and prevent students from engaging in unhealthy coping behaviors. Examples of contextual factors that contributed to adoption included a lack of trauma-informed mental health programs within schools, inadequate district funding for preventive school mental health services, and the perceived benefits of engaging in a university-community partnership. The study's findings suggest strategies to increase school program adoption in the context of research and, more broadly, for implementation science.

Creating and Disseminating a Resource for State Policy Makers About Injury and Violence Prevention: A Case Example of Translating Research to Policy.

The gap between evidence and policy is a challenge that can be bridged through strategic outreach and translation efforts. We developed and disseminated the Resource for State Policy Makers (the Resource) to lessen the information gap between state policy makers and injury prevention researchers in Maryland. Our goal was to produce and disseminate a resource for policy makers that could be replicated by public health professionals in other states and regions. The Maryland Department of Health assumed production of the Resource in 2017, with assistance from our team. Several states and regions have replicated the Resource for their own jurisdictions. This experience provides an informative case example of one approach to increasing the role of evidence in policy making.

Building evidence to reduce inequities in youth physical activity and obesity: Introduction to the Physical Activity Research Center (PARC) Special Section.

This guest editorial introduces the rationale and goals of the Physical Activity Research Center. It provides an overview of the five papers in this Special Section plus six commissioned studies intended to inform advocacy efforts.

Come together, play, be active: Physical activity engagement of school-age children at Play Streets in four diverse rural communities in the U.S.

Across the U.S., Play Streets - temporary street closures creating safe places for play for a few hours- are being implemented in urban areas during summer. Play Streets have never been implemented or evaluated in rural communities but have the potential to address challenges residents face accessing safe physical activity opportunities in these areas. Community organizations in four diverse low-income rural communities (selected to represent African American, American Indian, Latino, or White, non-Hispanic populations) received mini-grants in 2017 to implement four, three-hour Play Streets during the summer focusing on school-aged children in elementary-to-middle school. Physical activity was measured using Digi-walker (Yamax-SW200) pedometers and the System for Observing Play and Recreation in Communities (SOPARC/iSOPARC). Sixteen Play Streets were implemented in rural Maryland, North Carolina, Oklahoma, and Texas communities during June-September 2017. A total of 370 children (mean age = 8.81 years [SD = 2.75]; 55.0% female) wore pedometers across all 16 Play Streets (µâ€¯= 23.13 [SD = 8.59] children/Play Street). School-aged children with complete data (n = 353) wore pedometers for an average of 92.97 min (SD = 60.12) and accrued a mean of 42.08 steps/min (SD = 17.27), with no significant differences between boys (µâ€¯= 43.82, SD = 15.76) and girls (µâ€¯= 40.66, SD = 18.34). iSOPARC observations revealed no significant differences in child activity by sex; however, male teens were more active than female teens. Most adults were sedentary during Play Streets according to pedometer and iSOPARC data. Children in diverse rural communities are physically active at Play Streets. Play Streets are a promising intervention for promoting active play among children that lack safe opportunities to be active.

The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.

OBJECTIVE: To evaluate the secondary impact of a multilevel, child-focused, obesity intervention on food-related behaviours (acquisition, preparation, fruit and vegetable (FV) consumption) on youths' primary caregivers. DESIGN: B'More Healthy Communities for Kids (BHCK) group-randomized controlled trial promoted access to healthy foods and food-related behaviours through wholesaler and small store strategies, peer mentor-led nutrition education aimed at youths, and social media and text messaging targeting their adult caregivers. Measures included caregivers' (n 516) self-reported household food acquisition frequency for FV, snacks and grocery items over 30 d, and usual FV consumption in a sub-sample of 226 caregivers via the NCI FV Screener. Hierarchical models assessed average treatment effects (ATE). Treatment-on-the-treated-effect (TTE) analyses evaluated correlation between behavioural change and exposure to BHCK. Exposure scores at post-assessment were based on self-reported viewing of BHCK materials and participating in activities. SETTING: Thirty Baltimore City low-income neighbourhoods, USA.ParticipantsAdult caregivers of youths aged 9-15 years. RESULTS: Of caregivers, 90·89 % were female; mean age 39·31 (sd 9·31) years. Baseline mean (sd) intake (servings/d) was 1·30 (1·69) fruits and 1·35 (1·05) vegetables. In ATE, no significant intervention effect was found on caregivers' food-related behaviours. In TTE, each point increase in BHCK exposure score (range: 0-6·9) increased caregivers' daily fruit consumption by 0·2 servings (0·24 (se 0·11); 95 % CI 0·04, 0·47). Caregivers reporting greater social media exposure tripled their daily fruit intake (3·16 (se 0·92); 95 % CI 1·33, 4·99) and increased their frequency of unhealthy food purchasing v. baseline. CONCLUSIONS: Child-focused community-based nutrition interventions may also benefit family members' fruit intake. Child-focused interventions should involve adult caregivers and intervention effects on family members should be assessed. Future multilevel studies should consider using social media to improve reach and engage caregiver participants.

Considering health and health disparities during state policy formulation: examining Washington state Health Impact Reviews.

BACKGROUND: As part of efforts to expand Health in All Policies (HiAP) in Washington State in the U.S., the Washington State Board of Health (BOH) received statutory authority in 2006 to conduct Health Impact Reviews (HIRs). HIRs analyze the potential impacts of proposed legislation and budget decisions on health and health disparities. Public health professionals who are aware of HIRs are interested in adopting a similar process in their states; however, there is limited information about HIRs, how they are perceived, and how they could advance HiAP. METHODS: This research involved a descriptive analysis of a sample of HIRs and semi-structured interviews with a purposive sample of 17 key informants. For the descriptive analysis, all HIRs requested or completed between January 1, 2007 and April 1, 2016 that had a request form submitted by a legislator or the governor that was available in the BOH's online database were reviewed. Information was collected on several variables including the bill number and title, sponsor and political affiliation, and the sector to which the bill or budgetary proposal pertained. A purposeful sample of legislators, staff, advocates, and lobbyists who were involved with HIRs during the study period were invited to participate in semi-structured interviews. Topic coding was used to identify key themes from the qualitative data. RESULTS: During the study period, 20 legislators requested 36 HIRs; 32 HIRs were completed. HIRs were requested for several bill topics, including education (11/36) and labor and employment (9/36). Legislators who requested HIRs felt they provided valuable data on health and health disparities for proposed bills. Individuals who were less supportive of HIRs perceived them as an advocacy or political tool. The main barrier to widespread use of HIRs in Washington was a lack of awareness among legislators. CONCLUSIONS: HIRs are one strategy to advance HiAP for state policy decisions. HIRs are a potentially effective tool for highlighting how legislative proposals and budgets positively and negatively impact health and health disparities. Future efforts should promote awareness and highlight shared benefits of HIRs among legislators and their staff, as well as their scientific integrity, methodological rigor, and objectivity.

Systematic review of how Play Streets impact opportunities for active play, physical activity, neighborhoods, and communities.

BACKGROUND: Active play and physical activity are important for preventing childhood obesity, building healthy bones and muscles, reducing anxiety and stress, and increasing self-esteem. Unfortunately, safe and accessible play places are often lacking in under-resourced communities. Play Streets (temporary closure of streets) are an understudied intervention that provide safe places for children, adolescents, and their families to actively play. This systematic review examines how Play Streets impact opportunities for children and adolescents to engage in safe active play and physical activity, and for communities and neighborhoods. Methods for evaluating Play Streets were also examined. METHODS: A systematic literature review was conducted in Academic Search Complete, CINHAL, PsycINFO, PubMED, Web of Science, and Google Scholar. Peer-reviewed intervention studies published worldwide were included if they were published in English, through December 2017 and documented free-to-access Play Streets or other temporary spaces that incorporated a designated area for children and/or adolescents to engage in active play. Systematic data extraction documented sample, implementation, and measurement characteristics and outcomes. RESULTS: Of 180 reviewed abstracts, 6 studies met inclusion criteria. Studies were conducted in five different countries (n = 2 in U.S.), using mostly cross-sectional study designs (n = 4). Physical activity outcomes were measured in half of the studies; one used observational and self-report measures, and two used device-based and self-report measures. In general, Play Streets provided safe places for child play, increased sense of community, and when measured, data suggest increased physical activity overall and during Play Streets. CONCLUSIONS: Play Streets can create safe places for children to actively play, with promise of increasing physical activity and strengthening community. Given the popularity of Play Streets and the potential impact for active play, physical activity, and community level benefits, more rigorous evaluations and systematic reporting of Play Streets' evaluations are needed.

Knowledge and Beliefs About Pedestrian Safety in an Urban Community: Implications for Promoting Safe Walking.

As more people walk for transport and exercise, it is possible to avoid a concomitant increase in the number of pedestrian injuries. Understanding how the public views pedestrian safety can help inform the development of prevention strategies that support national efforts to promote walking and walkable communities. As part of the formative research for a community pedestrian safety health promotion campaign, we administered an online questionnaire to employees and students at a large urban medical campus, along with residents in the neighboring communities, to determine their knowledge, attitudes, and behavior regarding pedestrian safety; awareness of relevant traffic safety laws; and effective strategies that could improve pedestrian safety. Pearson Chi square Test of Independence was used to investigate differences between individuals who mainly traveled as drivers versus those who mainly traveled as pedestrians. Statistical significance was established at p < .05. A total of 3808 adults completed the online survey. More drivers than pedestrians reported that pedestrian safety was an important problem (73 and 64%, respectively; p < .001). A large proportion of respondents incorrectly reported the existing state laws addressing right of way, fines, and enforcement, with significant differences between drivers and pedestrians (p < .001). Significantly more pedestrians than drivers supported changing traffic signals to increase crossing time (p = .001), while more drivers than pedestrians supported creating structures to prevent midblock crossing (p = .003). Effective interventions to improve pedestrian safety need to tailor messages for both drivers and pedestrians, increase awareness of the laws, and implement comprehensive strategies.

Analyzing the impacts of global trade and investment on non-communicable diseases and risk factors: a critical review of methodological approaches used in quantitative analyses.

BACKGROUND: A key mechanism through which globalization has impacted health is the liberalization of trade and investment, yet relatively few studies to date have used quantitative methods to investigate the impacts of global trade and investment policies on non-communicable diseases and risk factors. Recent reviews of this literature have found heterogeneity in results and a range of quality across studies, which may be in part attributable to a lack of conceptual clarity and methodological inconsistencies. METHODS: This study is a critical review of methodological approaches used in the quantitative literature on global trade and investment and diet, tobacco, alcohol, and related health outcomes, with the objective of developing recommendations and providing resources to guide future robust, policy relevant research. A review of reviews, expert review, and reference tracing were employed to identify relevant studies, which were evaluated using a novel quality assessment tool designed for this research. RESULTS: Eight review articles and 34 quantitative studies were identified for inclusion. Important ways to improve this literature were identified and discussed: clearly defining exposures of interest and not conflating trade and investment; exploring mechanisms of broader relationships; increasing the use of individual-level data; ensuring consensus and consistency in key confounding variables; utilizing more sector-specific versus economy-wide trade and investment indicators; testing and adequately adjusting for autocorrelation and endogeneity when using longitudinal data; and presenting results from alternative statistical models and sensitivity analyses. To guide the development of future analyses, recommendations for international data sources for selected trade and investment indicators, as well as key gaps in the literature, are presented. CONCLUSION: More methodologically rigorous and consistent approaches in future quantitative studies on the impacts of global trade and investment policies on non-communicable diseases and risk factors can help to resolve inconsistencies of existing research and generate useful information to guide policy decisions.

A qualitative study of facilitators and barriers to implementing worksite policies that support physical activity.

BACKGROUND: Physical inactivity is associated with several chronic diseases that are costly to society, employers, and individuals. Workplaces are a common location for physical activity (PA) initiatives because of the amount of time individuals who are employed full time spend at work. This research examined a statewide worksite wellness program, the Healthiest Maryland Businesses (HMB) program, to fill an important gap regarding the facilitators for and barriers to implementing workplace policies that support PA. METHODS: Individual telephone interviews were conducted in December 2015 with six HMB Coordinators and their supervisor, and from August through October 2016 with a purposeful sample of 15 businesses of various sizes from across Maryland, to learn about the role of leadership, and successes and challenges of implementing PA programs and policies. The sample of businesses was intentionally selected to capture perspectives from a range of businesses. Interviews were recorded and professionally transcribed. Descriptive coding was used to identify dominant themes that addressed the study aims and research questions. RESULTS: PA was not described as a priority for several large and small businesses. To garner more support for PA, interviewees emphasized associating PA initiatives with measures the businesses care about, such as health care costs from claims data. Small businesses also described having a need for PA programming yet reported having significant resource constraints. There was a strong interest in developing guidance for implementing PA break policies, which was mentioned as a critical support for workplace PA promotion. More commitment and investment of resources from leadership, and an engaged wellness committee with company representation at all levels and roles, were identified as vital for impactful programs. CONCLUSIONS: Most businesses are implementing PA programs with limited policy supports, which was mentioned as a barrier. Successful implementation of workplace wellness programs broadly, and PA initiatives specifically, are achievable through leadership buy-in, employee input, and policy supports, along with highlighting the economic benefits for businesses.

Using the CDC's Worksite Health ScoreCard as a Framework to Examine Worksite Health Promotion and Physical Activity.

INTRODUCTION: Worksite health promotion programs are emerging as an effective approach for addressing the adult obesity epidemic and improving the overall health of employees. METHODS: We conducted a scoping review to identify articles that described a physical activity component (eg, promoted increased physical or reduced sitting time) of a worksite health promotion intervention. Our search specified full-length articles published in English from January 2000 through July 2015. We used the Centers for Disease Control and Prevention's Worksite Health ScoreCard, a validated tool, as a framework to summarize information on organizational supports strategies (18 questions) and physical activity strategies (9 questions) implemented by worksite health promotion programs. We also determined whether or not the included studies reported significant (P < .05) improvements in physical activity. RESULTS: We identified 18 worksite health promotion programs; 11 produced significant improvements in physical activity. Incentives, health risk assessments, health promotion committees, leadership support, marketing, and subsidies or discounts for use of exercise facilities were the most effective organizational supports strategies cited, and physical activity seminars, classes, and workshops were the most effective physical activity strategies cited. CONCLUSION: The use of the Health ScoreCard allowed for a practical interpretation of our findings, which can inform next steps for the field. Future research should explore the relationships between components of worksite health promotion programs and their outcomes to further develop best practices that can improve worker health and promote physical activity.