Effects of a Behavioral Economics Intervention on Food Choice and Food Consumption in Middle-School and High-School Cafeterias.

INTRODUCTION: Changing food choice architecture in school cafeterias through behavioral economics may increase student selection and consumption of healthy foods. However, most research assesses the effects of short-term interventions. We evaluated a year-long choice architecture intervention implemented by school food service staff. METHODS: Food service staff from 6 secondary schools in one school district received training and support to implement behavioral economics strategies in their cafeterias to promote student selection of fruit, vegetables, and low-fat white milk. We compared student selection and consumption of these foods in the intervention schools to 5 comparison schools in the same district on the basis of visual assessment of plate waste. We applied a difference-in-differences approach to estimate intervention effect. RESULTS: Data for 902 students were assessed at baseline, and data for 1,407 were assessed at follow-up. In fully adjusted analyses for all students, there were significantly greater absolute increases in the proportions of intervention school students selecting any fruit, including (0.09) and excluding (0.16) juice, and students selected more fruit items including (0.21) and excluding (0.17) juice. The absolute increase in proportion of intervention students consuming fruit excluding juice (0.14) was significantly greater. However, in some analyses, fewer intervention students who selected fruits or vegetables ate them, or they ate fewer of them. There were no intervention effects for vegetables or low-fat white milk. CONCLUSION: Our results indicate that behavioral economics-based choice architecture can promote student selection of healthy foods, but they raise questions about whether it increases their consumption.

Examining the Washington State Breastfeeding-Friendly Policy Development Process Using the Advocacy Coalition Framework.

Objectives Breastfeeding promotion is increasingly recognized as a key public health strategy. Policies can promote breastfeeding by creating supportive environments and addressing challenges. In 2014, the Washington State legislature considered bills to create a voluntary recognition system for breastfeeding-friendly hospitals, clinics, worksites and childcare settings. These Breastfeeding-Friendly Washington (BFW) bills (SB 6298 and HB 2329) did not pass. Methods The purpose of this case study was to analyze the policy development process for the BFW bills using the Advocacy Coalition Framework. Data were collected through semi-structured interviews with key stakeholders in the state policy process, and document review. We used thematic analysis to identify deductive and inductive themes. Results Though all policy actors indicated general support for breastfeeding, two main coalitions (proponents and opponents) diverged in their support of the BFW bills as policy solutions to address barriers to breastfeeding. We conducted 29 interviews with mainly bill proponents, and 54 documents confirmed data about bill opponents. Proponents supported the bills given increasingly strong evidence of breastfeeding's benefits and that public policy could address environmental challenges to breastfeeding. Opponents saw the bills as government overreach into the private matter of choosing to breastfeed. Opposition to the bills came late in the session, and proponents felt opponents' messaging misconstrued the intent of the legislation. Conclusions for Practice Key learnings for developing breastfeeding-friendly state policies include analyzing differences between proponents' and opponents' beliefs, framing advocacy messages beyond individuals and health, expanding the coalition outside of traditional health entities, and anticipating the opposition.

Getting research to the policy table: a qualitative study with public health researchers on engaging with policy makers.

INTRODUCTION: Little attention has been given to how researchers can best provide evidence to policy makers so that it informs policy making. The objectives of this study were to increase understanding about the current state of public health nutrition and obesity researcher practices, beliefs, barriers, and facilitators to communicating and engaging with policy makers, and to identify best practices and suggest improvements. METHODS: Eighteen semistructured interviews were conducted from 2011 to 2013 with public health nutrition and obesity researchers who were highly involved in communicating research to policy makers. Interviews were transcribed verbatim, coded, and analyzed to identify common themes. RESULTS: Study participants described wide variation in practices for communicating and engaging with policy makers and had mixed beliefs about whether and when researchers should engage. Besides a lack of formal policy communication training, barriers noted were promotion and tenure processes and a professional culture that does not value communicating and engaging with policy makers. Study participants cited facilitators to engaging with policy makers as ranging from the individual level (eg, desire to make a difference, relationships with collaborators) to the institutional level (eg, training/mentorship support, institutional recognition). Other facilitators identified were research- and funding-driven. Promising strategies suggested to improve policy engagement were more formal training, better use of intermediaries, and learning how to cultivate relationships with policy makers. CONCLUSION: Study findings provide insights into the challenges that will need to be overcome and the strategies that might be tried to improve communication and engagement between public health researchers and policy makers.

Developing local board of health guidelines to promote healthy food access - King County, Washington, 2010-2012.

Policies that change environments are important tools for preventing chronic diseases, including obesity. Boards of health often have authority to adopt such policies, but few do so. This study assesses 1) how one local board of health developed a policy approach for healthy food access through vending machine guidelines (rather than regulations) and 2) the impact of the approach. Using a case study design guided by "three streams" policy theory and RE-AIM, we analyzed data from a focus group, interviews, and policy documents. The guidelines effectively supported institutional policy development in several settings. Recognition of the problem of chronic disease and the policy solution of vending machine guidelines created an opening for the board to influence nutrition environments. Institutions identified a need for support in adopting vending machine policies. Communities could benefit from the study board's approach to using nonregulatory evidence-based guidelines as a policy tool.

Nutrition-related policy and environmental strategies to prevent obesity in rural communities: a systematic review of the literature, 2002-2013.

INTRODUCTION: Residents of rural communities in the United States are at higher risk for obesity than their urban and suburban counterparts. Policy and environmental-change strategies supporting healthier dietary intake can prevent obesity and promote health equity. Evidence in support of these strategies is based largely on urban and suburban studies; little is known about use of these strategies in rural communities. The purpose of this review was to synthesize available evidence on the adaptation, implementation, and effectiveness of policy and environmental obesity-prevention strategies in rural settings. METHODS: The review was guided by a list of Centers for Disease Control and Prevention Recommended Community Strategies and Measurements to Prevent Obesity in the United States, commonly known as the "COCOMO" strategies. We searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Public Affairs Information Service, and Cochrane databases for articles published from 2002 through 2013 that reported findings from research on nutrition-related policy and environmental strategies in rural communities in the United States and Canada. Two researchers independently abstracted data from each article, and resolved discrepancies by consensus. RESULTS: Of the 663 articles retrieved, 33 met inclusion criteria. The interventions most commonly focused on increasing access to more nutritious foods and beverages or decreasing access to less nutritious options. Rural adaptations included accommodating distance to food sources, tailoring to local food cultures, and building community partnerships. CONCLUSIONS: Findings from this literature review provide guidance on adapting and implementing policy and environmental strategies in rural communities.

Developing an agenda for research about policies to improve access to healthy foods in rural communities: a concept mapping study.

BACKGROUND: Policies that improve access to healthy, affordable foods may improve population health and reduce health disparities. In the United States most food access policy research focuses on urban communities even though residents of rural communities face disproportionately higher risk for nutrition-related chronic diseases compared to residents of urban communities. The purpose of this study was to (1) identify the factors associated with access to healthy, affordable food in rural communities in the United States; and (2) prioritize a meaningful and feasible rural food policy research agenda. METHODS: This study was conducted by the Rural Food Access Workgroup (RFAWG), a workgroup facilitated by the Nutrition and Obesity Policy Research and Evaluation Network. A national sample of academic and non-academic researchers, public health and cooperative extension practitioners, and other experts who focus on rural food access and economic development was invited to complete a concept mapping process that included brainstorming the factors that are associated with rural food access, sorting and organizing the factors into similar domains, and rating the importance of policies and research to address these factors. As a last step, RFAWG members convened to interpret the data and establish research recommendations. RESULTS: Seventy-five participants in the brainstorming exercise represented the following sectors: non-extension research (n = 27), non-extension program administration (n = 18), "other" (n = 14), policy advocacy (n = 10), and cooperative extension service (n = 6). The brainstorming exercise generated 90 distinct statements about factors associated with rural food access in the United States; these were sorted into 5 clusters. Go Zones were established for the factors that were rated highly as both a priority policy target and a priority for research. The highest ranked policy and research priorities include strategies designed to build economic viability in rural communities, improve access to federal food and nutrition assistance programs, improve food retail systems, and increase the personal food production capacity of rural residents. Respondents also prioritized the development of valid and reliable research methodologies to measure variables associated with rural food access. CONCLUSIONS: This collaborative, trans-disciplinary, participatory process, created a map to guide and prioritize research about polices to improve healthy, affordable food access in rural communities.

Perceived impact and feasibility of strategies to improve access to healthy foods in Washington State, USA.

OBJECTIVE: The present study measured the perceived impact and political and implementation feasibility of state-level policy strategies related to increasing access to healthy foods and limiting unhealthy foods. DESIGN: Potential state-level policy strategies to improve access to healthy foods were identified through a review of evidence-based literature and policy recommendations. Respondents rated the perceived impact and political and implementation feasibility of each policy on a five-point scale using online surveys. SETTING: Washington State policy process. SUBJECTS: Forty-nine content experts (national researchers and subject experts), forty policy experts (state elected officials or their staff, gubernatorial or legislative policy analysts) and forty-five other stakeholders (state-level advocates, programme administrators, food producers). RESULTS: In aggregate, respondents rated policy impact and implementation feasibility higher than political feasibility. Policy experts rated policy strategies as less politically feasible compared with content experts (P < 0·02) or other stakeholders (P < 0·001). Eight policy strategies were rated above the median for impact and political and implementation feasibility. These included policies related to nutrition standards in schools and child-care facilities, food distribution systems, urban planning projects, water availability, joint use agreements and breast-feeding supports. CONCLUSIONS: Although they may be perceived as potentially impactful, some policies will be more difficult to enact than others. Information about the potential feasibility of policies to improve access to healthy foods can be used to focus limited policy process resources on strategies with the highest potential for enactment, implementation and impact.

Work-Related Factors Associated With Health and Well-Being of Early Care and Education Workers.

OBJECTIVE: We assessed and examined relationships between the health and working conditions of early care and education workers. METHODS: We surveyed early care and education workers ( n = 2242) about their socioeconomic characteristics; work organization; psychosocial, physical, and ergonomic exposures; coping behaviors; and health. RESULTS: Nearly half of respondents reported chronic health conditions. Most worked full time, half earned less than $30,000 a year, and many reported unpaid hours or inability to take breaks. One-quarter reported economic strain. Numerous exposures were prevalent. Workers' general health was poorer than normed averages, although their physical functioning was slightly better. Sixteen percent of workers reported work-related injuries, and 43% reported depressive symptoms. Factors associated with health included socioeconomic characteristics, having a chronic condition, job type, access to benefits, eight psychosocial stressors, four physical exposures, sleep, and alcohol consumption. CONCLUSIONS: Findings support the need for attention to this workforce's health.

Early Care and Education Workers' Experience and Stress during the COVID-19 Pandemic.

Early care and education (ECE) workers experience many job-related stressors. During the COVID-19 pandemic, ECE programs either closed or remained open while workers faced additional demands. We deployed a survey of the center-based ECE workforce in Washington State (United States) one year into the COVID-19 pandemic to assess impacts and workers' perceived stress levels. We describe the prevalence of reported impacts, including workplace closures; job changes; COVID-19 transmission; risk factors for severe COVID-19; the use of social distancing practices; satisfaction with workplace responses; perceptions of worker roles, respect, and influence; and food and financial insecurity. Themes from open-ended responses illustrate how workers' jobs changed and the stressors that workers experienced as a result. Fifty-seven percent of ECE workers reported moderate or high levels of stress. In a regression model assessing unique contributions to stress, work changes that negatively impacted home life contributed most to stress. Feeling respected for one's work and feeling positive about one's role as an "essential worker" contributed to lower levels of stress. Experiencing financial insecurity, caring for school-aged children or children of multiple ages, being younger, and being born in the United States also contributed to higher stress. Findings can inform policies designed to support the workforce.

Insights from Washington State's COVID-19 Response: A Mixed-Methods Evaluation of WIC Remote Services and Expanded Food Options Using the RE-AIM Framework.

BACKGROUND: In response to the COVID-19 pandemic, Washington State's Supplemental Nutrition Program for Women, Infants, and Children (WA WIC) adopted federal waivers to transition to remote service delivery for certification and education appointments. WA WIC also expanded the approved food list without using federal waivers, adding more than 600 new items to offset challenges participants experienced accessing foods in stores. OBJECTIVE: This study aimed to assess the reach and effectiveness of the programmatic changes instituted by WA WIC during the COVID-19 pandemic; the processes, facilitators, and challenges involved in their implementation; and considerations for their continuation in the future. DESIGN: A mixed-methods design, guided by the RE-AIM framework, including virtual, semi-structured focus groups and interviews with WA WIC staff and participants, and quantitative programmatic data from WIC agencies across the state. PARTICIPANTS/SETTING: This study included data from 52 state and local WIC staff and 40 WIC participants across the state of Washington and from various WA WIC programmatic records (2017-2021). The research team collected data and conducted analyses between January 2021 and August 2021. ANALYSIS: An inductive thematic analysis approach with Dedoose software was used to code qualitative data, generate themes, and interpret qualitative data. Descriptive statistics were calculated for quantitative programmatic data, including total participant count, percent increase and decrease in participation, percent of food benefits redeemed monthly, and appointment completion rates. RESULTS: All WA WIC participants (n = 125,279 in May 2020) experienced the programmatic changes. Participation increased by 2% from March to December 2020 after WA WIC adopted programmatic changes in response to the COVID-19 pandemic. Certification and nutrition education completion rates increased by 5% and 18% in a comparison of June 2019 with June 2020. Food benefit redemption also increased immediately after the food list was expanded in April 2020. Staff and participants were highly satisfied with remote service delivery, predominantly via the phone, and participants appreciated the expanded food options. Staff and participants want a remote service option to continue and suggested various changes to improve service quality. CONCLUSIONS: Participation in WIC and appointment completion rates increased after WA WIC implemented service changes in response to the COVID-19 pandemic. Staff and participants were highly satisfied with remote services, and both desire a continued hybrid model of remote and in-person WIC appointments. Some of the suggested changes to WIC, especially the continuation of remote services, would require federal policy change, and others could be implemented under existing federal regulations.

Healthy Food Environments in Food Pantries: Lessons Learned from a Sodium Reduction Intervention.

In the United States, food pantries increasingly serve as regular food sources for low income households experiencing high rates of chronic disease, including hypertension. Sodium consumption is a modifiable risk factor for hypertension, so pantry customers would benefit from access to low-sodium foods. Pantry customers often experience difficulty acquiring healthy foods, however; little is known about pantry foods' sodium content specifically. This study assesses the sodium content of pantry foods and lessons learned from an adaptable intervention to support pantries in adopting policies and environmental changes to make healthy, lower-sodium foods appealing and accessible. We conducted sodium assessments of food at 13 food pantries, tracked implementation of intervention strategies, and interviewed 10 pantry directors. More than half of food items in 11 categories met sodium standards for foods to be chosen "often". Pantry directors reported valuing the intervention approach and implemented six of nine behavioral economics strategies, especially those targeting the visibility and convenience of foods, along with layout changes and expanded customer choice. One pantry adopted an agency-specific nutrition policy and 12 adopted a coalition-level policy. Results can inform intervention efforts to make available healthy options appealing and easy to select while also improving the customer experience in food pantries.

Making seafood accessible to low-income and nutritionally vulnerable populations on the U.S. West Coast.

Along the U.S. West Coast, sustainable management has rebuilt fish stocks, providing an opportunity to supply nutrient-rich food to adjacent coastal communities where food insecurity and diet-based diseases are common. However, the market has not successfully supplied locally sourced seafood to nutritionally vulnerable people. Rather, a few organizations make this connection on a limited scale. We used a "positive deviant" approach to learn how these organizations' efforts developed, how they overcame challenges, and what conditions enabled their interventions. We found that organizations in these positive deviant cases provided fish from a wide variety of species and sources, and distributed them through different channels to a diversity of end consumers. A key factor facilitating success was the ability to negotiate a price point that was both profitable and reasonable for organizations supplying nutritionally vulnerable or low-income consumers. Further-more, securing access to grants overcame initial costs of establishing new supply channels. All cases highlighted the importance of individual champions who encouraged development and cultural connections between the initiative and the nearby community. Organizations overcame key challenges by establishing regulations governing these new channels and either using partnerships or vertically integrating to reduce costs associated with processing and transport. Oftentimes training and education were also critical to instruct workers on how to process unfamiliar fish and to increase consumer awareness of local fish and how to prepare them. These lessons illuminate pathways to improve the contribution of local seafood to the healthy food system.

An Assessment of Perceived Barriers to Farmers' Market Access.

OBJECTIVE: To explore whether Supplemental Nutrition Assistance Program-Education (SNAP-Ed) stakeholders (individuals involved in work to increase access to farmers' markets [FMs] for low-income populations) perceive the same barriers to shopping at FMs as those reported by SNAP participants in Washington State. DESIGN: Descriptive study; data included a stratified clustered random sample of SNAP participants and stakeholder interviews. SETTING: Washington State. PARTICIPANTS: A total of 400 SNAP participants and 51 SNAP-Ed stakeholders. MAIN OUTCOME MEASURES: The SNAP participants' reported barriers to accessing FMs and the SNAP-Ed stakeholders' perceptions of FM access barriers. ANALYSIS: Thematic content analysis, descriptive statistics, 2-sample tests of proportion, and Pearson chi-square tests (P < .025). RESULTS: A majority of SNAP participants reported they did not shop at an FM because it is inconvenient (n = 193; 51%) and not financially viable (n = 84; 22%). Moreover, 9% of SNAP participants (n = 34) stated that they experienced no barriers. The SNAP-Ed stakeholders placed increased emphasis on transportation and cost barriers compared with the SNAP participants. CONCLUSIONS AND IMPLICATIONS: Comprehensive, multilevel strategies that reflect the perspectives of SNAP participants could increase SNAP use at FMs. Opening FMs in diverse locations at variable operating times may address convenience barriers while engaging the targeted populations' communities to promote FMs, and FM incentive programs may address financial and awareness barriers.

Low-income workers' perceptions of wages, food acquisition, and well-being.

Although studies have demonstrated an association between increased economic resources and improvements in food security and health, there is a paucity of qualitative research regarding the relationships between household resources, food security, and health. Policy changes related to increasing low wages are potential opportunities to understand changes to material resources. The aims of this analysis were to describe how low-wage workers perceive household resources in relation to food acquisition and to explore how workers in low-wage jobs connect food and diet to perceptions of health and well-being. We analyzed 190 transcripts from 55 workers in low-wage jobs who were living in households with children who were part of the Seattle Minimum Wage Study (up to three in-depth qualitative interviews and one phone survey per participant, conducted between 2015 and 2017). We coded and analyzed interviews using Campbell's food acquisition framework and best practices for qualitative research. Participants relied on a combination of wages, government assistance, and private assistance from community or family resources to maintain an adequate food supply. Strategies tended to focus more on maintaining food quality than food quantity. Restricted resources also limited food-related leisure activities, which many participants considered important to quality of life. Although many low-wage workers would like to use additional income to purchase higher quality foods or increase food-related leisure activities, they often perceive trade-offs that limit income-based adjustments to food-spending patterns. Future studies should be specifically designed to examine food choices in response to changes in income.

An Evaluation of Washington State SNAP-Ed Farmers' Market Initiatives and SNAP Participant Behaviors.

OBJECTIVE: To describe Supplemental Nutrition Assistance Program-Education (SNAP-Ed)-supported farmers' market (FM) access activities in Washington State communities and identify associations between participation in these activities and SNAP participants' FM shopping and fruit and vegetable consumption. DESIGN: Descriptive study; data included stakeholder interviews and surveys with FM managers and a stratified clustered random sample of SNAP participants. SETTING: Washington State. PARTICIPANTS: A total of 51 SNAP-Ed stakeholders, 400 SNAP participants, and 94 FM managers participated. MAIN OUTCOME MEASURE(S): Partnership measures and SNAP-Ed FM access activities; SNAP participants' participation in FM access activities, FM shopping frequency, and fruit and vegetable consumption. ANALYSIS: Thematic content analysis, descriptive statistics, and 0-inflated Poisson and ordinary least-squares regression models. RESULTS: A total of 343 FM access activities and strong multi-sector partnerships were identified. Fifty percent of SNAP participants shopped at an FM in the past year, and 30% at least monthly. The SNAP participants participating in FM access activities shopped at FMs more frequently (P=.005). The SNAP participants shopping at FMs ate fruit and vegetables more frequently than did non-FM shoppers (P<.001). CONCLUSIONS AND IMPLICATIONS: Through nutrition education and systems and environmental changes, Washington SNAP-Ed developed effective programming and multi-sector partnerships. These efforts are associated with SNAP participants' FM shopping and fruit and vegetable consumption.

Exploring the Use of Seattle's Farmers' Market Incentive Program ("Fresh Bucks") by Household Food Security Levels.

The objective of this study was to explore Seattle's farmers' market incentive program, known as Fresh Bucks, and associated shopping behaviors based on participants' food security status. Researchers surveyed a convenience sample of Fresh Bucks users and classified subjects as high/marginal, low, or very low food security. Investigators analyzed for differences in demographics and farmers' market shopping behaviors by food security levels. Study findings suggest that once present at the farmers' market, Fresh Bucks users across all food security levels experience the market and the Fresh Bucks program in similar ways. These relationships should be explored in a larger and more diverse population.

Validity and Interrater Reliability of the Visual Quarter-Waste Method for Assessing Food Waste in Middle School and High School Cafeteria Settings.

BACKGROUND: Measuring food waste (ie, plate waste) in school cafeterias is an important tool to evaluate the effectiveness of school nutrition policies and interventions aimed at increasing consumption of healthier meals. Visual assessment methods are frequently applied in plate waste studies because they are more convenient than weighing. The visual quarter-waste method has become a common tool in studies of school meal waste and consumption, but previous studies of its validity and reliability have used correlation coefficients, which measure association but not necessarily agreement. OBJECTIVE: The aims of this study were to determine, using a statistic measuring interrater agreement, whether the visual quarter-waste method is valid and reliable for assessing food waste in a school cafeteria setting when compared with the gold standard of weighed plate waste. METHODS: To evaluate validity, researchers used the visual quarter-waste method and weighed food waste from 748 trays at four middle schools and five high schools in one school district in Washington State during May 2014. To assess interrater reliability, researcher pairs independently assessed 59 of the same trays using the visual quarter-waste method. Both validity and reliability were assessed using a weighted κ coefficient. RESULTS: For validity, as compared with the measured weight, 45% of foods assessed using the visual quarter-waste method were in almost perfect agreement, 42% of foods were in substantial agreement, 10% were in moderate agreement, and 3% were in slight agreement. For interrater reliability between pairs of visual assessors, 46% of foods were in perfect agreement, 31% were in almost perfect agreement, 15% were in substantial agreement, and 8% were in moderate agreement. CONCLUSIONS: These results suggest that the visual quarter-waste method is a valid and reliable tool for measuring plate waste in school cafeteria settings.