PSE Changes Research Articles

School-based nutrition education programs alone are not cost-effective for preventing childhood obesity: A microsimulation study

Although interventions to change nutrition policies, systems, and environments (PSE) for children are generally cost-effective for preventing childhood obesity, existing evidence suggests that nutrition education curricula, without accompanying PSE changes, are more commonly implemented. Estimate the societal costs and potential for cost-effectiveness of three nutrition education curricula frequently implemented in U.S. public schools for childhood obesity prevention. In 2021, we searched for nutrition education curricula in the SNAP-Ed Toolkit, a catalogue of interventions for obesity prevention coordinated by the federal government. Standard costing methodologies estimated the societal costs from 2023-2032 of nationwide implementation of each identified curriculum. Using the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model, which projects the costs, healthcare costs saved, and cases of obesity prevented for childhood obesity prevention interventions, we conducted threshold analyses for each curriculum, estimating the cost per quality-adjusted life year (QALY) for a range of hypothetical effects on child body mass index (BMI) to determine how large of an effect each curriculum would need to have to meet a cost-effectiveness threshold of $150,000 per QALY. Three nutrition education curricula without PSE were identified from SNAP-Ed; none had evidence of an impact on obesity risk. From 2023 to 2032, the estimated implementation costs of the curricula nationwide ranged from $1.80 billion (95% UI: $1.79-$1.82 billion) to $3.48 billion (95% UI: $3.44-$3.51 billion). Each curriculum would have to reduce average child BMI by 0.10 kg/m2 or more-an effect size that has not been reported by any of the three curricula, or by more comprehensive existing prevention programs-to be considered cost-effective at this threshold. SNAP-Ed-endorsed nutrition education curricula alone are unlikely to be cost-effective for preventing childhood obesity. Continued efforts to implement interventions with strong evidence for effectiveness, including PSE approaches, are needed.

External Factors Influencing the Implementation of Policy, System, and Environmental Change Strategies Within Cooperative Extension.

Introduction. Multilevel approaches are important to promote the adoption of healthier practices at the individual and community levels. Cooperative Extension pairs policy, systems, and environmental (PSE) change approaches with direct education programs focused on individual and community health. This study sought to understand Family and Consumer Sciences (FCS) Extension agents' perceptions of PSE change supports, benefits for their communities, and resources and partnerships important for implementation. Method. The Consolidated Framework for Implementation Research was used to develop a survey to assess outer setting domains related to PSE work. In addition to close-ended questions, the survey included several open-ended, qualitative questions exploring the benefits, resources, and relationships required to implement PSE changes. The surveys were collected online from FCS agents in two states. Descriptive statistics were calculated, open responses were coded, and key themes were established. Results. FCS agents (n=116) indicated high levels of agreement about having necessary support from state-level specialists (71%) and the overall Extension organization (64%). The largest gaps in support were reported as grant or external funding sources, time, and county programming funds. Half of the sample agreed that PSE training was adequate, but only 38.5% reported previously participating in PSE-specific training. Open-ended question responses revealed diverse relationships and numerous benefits of PSE work, including more sustainable health behavior changes and greater local Extension visibility. Discussion. Our findings corroborate previous work and identify potential gaps that future interventions can address to better support Extension and public health professionals when implementing PSE work at the community level.

Nurse-Involved Policy, Systems, and Environmental School-Based Interventions for Supporting Healthy Nutrition and Obesity Prevention Among Children and Adolescents: A Systematic Review.

Overweight and obesity are common in school-age children. Policy, system, and environmental (PSE) approaches-which entail making upstream changes to a school's context-can be leveraged to reduce childhood obesity. Nurses can advance PSE approaches in schools to promote healthy living habits. This review examines the effect of nurse-involved PSE interventions globally to promote healthy nutrition and reduce obesity in schools. We conducted a literature search using multiple databases from 2010 to 2023 for nurse-involved studies that implemented interventions focused on PSE change related to promoting healthy nutrition or reducing obesity in school settings. Twenty interventions globally were included in the systematic review synthesis. Improvements in anthropometrics, health and nutrition knowledge, attitudes, and beliefs were observed. PSE interventions can be leveraged to promote healthy nutrition and reduce obesity in school settings. Nurses in varying roles are uniquely qualified to advocate for and implement school-based interventions focused on PSE change.

A mixed-method evaluation of the New York State Healthy Pantry Initiative: application of the SNAP-Ed evaluation framework

ABSTRACT Food pantry nutrition environments are important settings for improving access to healthful foods among food-insecure populations. The Healthy Pantry Initiative (HPI) used policy, systems, and environmental (PSE) changes to improve the food pantry nutrition environment from October 2018 through September 2019. Program implementers assessed the need for PSE changes, developed action plans, and collected baseline, implementation, and follow-up data. Guided by the SNAP-Ed Evaluation framework, the collected data were used to capture information about HPI need, planning, adoption, implementation, and reach, from the perspective of frontline nutrition educators.

Policy, Systems, and Environmental Strategies to Support Healthy Eating Behaviors in Early Childhood: A Scoping Review of Existing Evaluation Tools

BackgroundPolicy, systems, and environmental (PSE) change strategies aimed at supporting healthy eating behaviors work to enhance optimal nutrition by making healthy foods more available and accessible in the community. PSE change strategies can complement and strengthen knowledge, skills, and behaviors obtained through individual-level nutrition education. ObjectiveThis scoping review aimed to identify existing literature evaluating early childhood (ie, children younger than age 5 years) PSE change strategies supporting healthy eating behaviors and to describe the evaluation tools used to assess the identified PSE change strategies. MethodsThree databases (PubMed, Cumulated Index in Nursing and Allied Health Literature, and Web of Science) were used to systematically search for articles published between 2013 and 2023 written in English and conducted in the United States that evaluated PSE change strategies supporting healthy eating behaviors in young children (ie, children younger than age 5 years). Two study members conducted the review, discussing and reconciling discrepancies until a consensus was reached for interobserver reliability. ResultsFindings from this review identified 48 studies evaluating early childhood PSE change strategies supporting healthy eating behaviors, with 36 studies using 25 PSE-focused evaluation tools to evaluate these strategies. Most tools (80%) assessed PSE change strategies supporting access and availability of healthy food and beverage options in early childhood education settings. Studies did not evaluate child-level outcomes (ie, attitudes, preferences, and behaviors) to showcase improvement of early childhood nutrition. Only 60% of the tools reported evidence of validity or reliability. ConclusionsMost of the studies identified in this scoping review were aimed to evaluate healthy eating PSE change strategies focused on improving access to and availability of healthy foods and beverages in early childhood education settings. Future research is needed to develop and validate PSE-focused evaluation tools assessing child-level healthy eating practices and behaviors.

Physical Activity Policy, Systems, and Environment Change Through Extension SNAP-Ed: A Multistate Perspective.

The Supplemental Nutrition Assistance Program-Education (SNAP-Ed) provides nutrition education and support for healthy living in SNAP-qualifying communities. SNAP-Ed supports policy, systems, and environmental (PSE) efforts to make the healthy choice an easier choice. SNAP-Ed implementers have widely adopted healthy eating PSE supports. However, physical activity (PA) PSE strategies are less common, with limited awareness between states of how other SNAP-Ed implementers approach PA-focused PSE work. Physical Activity Policy, Research, and Evaluation Network (PAPREN) Rural Active Living Workgroup project members sought to explore how Extension-based SNAP-Ed implements PA-focused PSE approaches. A sample of Extension-based SNAP-Ed program (n = 8) leaders were purposefully recruited from eligible universities in six of the seven SNAP-Ed regions. An interview guide to systematically collect information about current Extension SNAP-Ed implementation focused on PA PSE strategies was developed iteratively by the PAPREN Rural Active Living Workgroup Extension PA PSE project team. PA PSE Extension SNAP-Ed implementation efforts occurred at the state, county, and community levels and/or within local organizations. PA PSEs included school PA policy change, shared-use agreements, active transportation promotion, park development, walking challenges, and PA-promoting signage. All interviews highlighted the importance of partnerships at local, county, and state levels for PSE efforts. Extension-based SNAP-Ed shows potential to bring community partners together to plan and implement PA-focused PSE approaches. With a focus on SNAP-eligible people and substantial geographic reach, Extension SNAP-Ed is uniquely situated as a public health partner to broadly implement PA PSE changes.

Barriers to Policy, Systems, and Environment Work: Using Community Engagement as a Tool in SNAP-Ed’s Multi-Level Comprehensive Programming

Implementing policy, system, and environmental (PSE) changes has several well-known challenges that have been documented in Supplemental Nutrition Assistance Program Education’s (SNAP-Ed) comprehensive approach to obesity prevention and reduction. The purpose of the current study was to explore the use of community engagement (CE) as a strategy to address the common challenges experienced in implementing a multi-component community-based program. Phone interviews (N = 7) were conducted with SNAP-Ed educators in Utah using semi-structured interviews. Emergent themes were identified as transcripts were coded independently by two researchers until a high level of agreement was achieved. Four themes emerged from the interviews: barriers to PSE progress, educator CE, the perceived value of using a CE approach to PSE work, and future supports that could increase educators’ ability to use CE when doing PSE work. While effective at eliciting long-term improvements among priority populations, there are several well-documented challenges associated with developing, implementing, and sustaining PSE projects. CE, defined as the process of involving members of a community in the planning, design, implementation, and improvement of a community-based initiative, may be an effective strategy to overcome many of these challenges and lead to long-term PSE changes and improved health outcomes.

Healthy eating and active living policy, systems, and environmental changes in rural Louisiana: a contextual inquiry to inform implementation strategies

BackgroundHealthy eating and active living policy, systems, and environmental (PSE) changes are implemented across the United States through Cooperative Extension. However, translating multisector PSE changes to practice in community settings is challenging and there is a lack of knowledge about barriers and facilitators to PSE changes among state Extension systems using standardized frameworks. Therefore, a research-to-practice partnership effort aimed to identify Louisiana Cooperative Extension Service Family and Consumer Science (LFCS) practitioners’ barriers and facilitators to implementing PSE changes in rural Louisiana communities.MethodsA qualitative approach using the 2022 Consolidated Framework for Implementation Research (2022 CFIR) was used. Focus group discussions were conducted at five LFCS regional trainings between February and May 2022. All LFCS practitioners with any level of experience implementing healthy eating and active living PSE changes were eligible to participate, with emphasis on understanding efforts within more rural communities. Focus group discussions were audio-recorded and transcribed verbatim. Researchers analyzed qualitative data using the constant comparison method and 2022 CFIR domains and constructs including Inner Setting (LFCS organization), Outer Setting (rural Louisiana communities), Innovation (PSE changes), and Individuals (PSE change implementation actors/partners).ResultsAcross the five regions, LFCS practitioners (n = 40) described more barriers (n = 210) than facilitators (n = 100); findings were often coded with multiple 2022 CFIR domains. Reported Inner Setting barriers were lack of formal or informal information sharing and lack of access to knowledge and information. Outer Setting barriers included sustaining and initiating community partnerships and local environmental or political conditions. Individual barriers included a lack of time and expertise, and Innovation barriers included the complex nature of rural PSE changes. Facilitators were mentioned at multiple levels and included community partner buy-in and practitioners’ motivation to implement PSE changes.ConclusionsImplementation strategies are needed to build on organizational strengths and to overcome multi-level barriers to PSE change implementation among LFCS practitioners. The results from the in-depth contextual inquiry used could serve as a guide for future pragmatic assessment efforts among other state Extension systems or as a model for identifying barriers and facilitators and associated implementation strategies among other public health systems in the U.S. and abroad.

Protocol: identifying policy, system, and environment change interventions to enhance availability of blood for transfusion in Kenya, a mixed-methods study

BackgroundSafe blood is essential for the care of patients with life-threatening anemia and hemorrhage. Low blood donation rates, inefficient testing procedures, and other supply chain disruptions in blood administration affect patients in low-resource settings across Sub-Saharan countries, including Kenya. Most efforts to improve access to transfusion have been unidimensional, usually focusing on only point along the blood system continuum, and have excluded community stakeholders from early stages of intervention development. Context-appropriate interventions to improve the availability of safe blood at the point of use in low-resource settings are of paramount importance. Thus, this protocol proposes a multifaceted approach to characterize the Kenyan blood supply chain through quantitative and qualitative analyses as well as an industrial engineering approach.MethodsThis study will use a mixed-methods approach in addition to engineering process mapping, modeling and simulation of blood availability in Kenya. It will be guided by a multidimensional three-by-three-by-three matrix: three socioeconomic settings, three components of the blood system continuum, and three levels of urgency of blood transfusion. Qualitative data collection includes one-on-one interviews and focus group discussions with stakeholders across the continuum to characterize ground-level deficits and potential policy, systems, and environment (PSE) interventions. Prospectively-collected quantitative data will be used to estimate blood collection and transfusion of blood. We will create a process map of the blood system continuum to model the response to PSE changes proposed by stakeholders. Lastly, we will identify those PSE changes that may have the greatest impact on blood transfusion availability, accounting for differences across socioeconomic settings and levels of urgency.DiscussionIdentifying and prioritizing community-driven interventions to improve blood supply in low-resource settings are of utmost importance. Varied constraints in blood collection, processing, delivery, and use make each socioeconomic setting unique. Using a multifaceted approach to understand the Kenyan blood supply and model the response to stakeholder-proposed PSE changes may lead to identification of contextually appropriate intervention targets to meet the transfusion needs of the population.

The LSU AgCenter Healthy Communities Initiative: Community-Participatory Policy, Systems, and Environmental Change

The LSU AgCenter Healthy Communities Initiative: Community-Participatory Policy, Systems, and Environmental Change

Using CDC's Worksite Health ScoreCard to Evaluate Nutrition and Physical Activity Interventions in Priority Communities in New York State, 2015-2020.

The aim of our study was to evaluate a statewide obesity prevention program, designed to improve two social determinants of health (access to healthy foods and opportunities for physical activity) by changing worksite policies, systems, and environments. We used data on social determinants of health to identify priority communities and funded 25 contractors to recruit and engage worksites in those communities. We employed a pre/post quasi-experimental design and used the Centers for Disease Control and Prevention's Worksite Health ScoreCard to assess implementation of nutrition and physical activity strategies. Contractors collaborated with partners to conduct pre- and postassessments at 313 worksites. Worksites were successful at implementing all except one strategy; implementation doubled for eight strategies and tripled for three. We used weighted scores to incorporate strength of the evidence-base and level of impact into our analysis; increases in strategy implementation were statistically significant in worksites that provided places to purchase food and beverages and in those that did not. Our study revealed several important recommendations for practice. Use available data to prioritize communities experiencing health disparities and identify PSE change strategies to increase access to nutritious foods and physical activity opportunities. Engage with reputable community-based partners from different sectors when designing and implementing programs. Use standardized tools, such as the Worksite Health ScoreCard, to evaluate public health initiatives.

Activating Worksites to Implement Policy, Systems, and Environmental Changes: Outcomes and Overcoming Challenges.

Although workplaces are prime settings for health promotion, little is known about the implementation of policy, systems, and environmental (PSE) changes focused on chronic disease. PSEs have broader reach and are more sustainable than individual level strategies. non-experimental, one group design with no control.Setting: West Virginia, a state with significant chronic disease-related health disparities. Convenience sample of 27 workplaces, representing 6 industry types. $1000 in micro funding awarded to workplaces to participate in Centers for Disease Control and Prevention (CDC) Work@Health®/ScoreCard, and implement PSEs. ScoreCard baseline results; post project survey results. Descriptive analysis of ScoreCard; survey responses coded into PSE and I (individual level strategies) categories; frequencies were calculated. 63% of the workplaces were very small (1-100 employees). Chronic disease-related organizational practices (ScoreCard) were minimal: nutrition (5/24), physical activity (7/22), diabetes (5/15), cholesterol (4/13), and high blood pressure (6/16). Workplaces reported a total of 95 PSEs: P-8, S-55, and E-32. Policy change was the least frequently attempted and reported PSE strategy. More research with a stronger study design is needed to determine if (1) baseline organizational practices (Scorecard scores) improve, (2) PSEs (especially P) can be implemented without micro funding/TA, (3) workplace-type is related to use of the funds/TA, and (4) enacting PSE changes leads to healthier employees.

P137 Southeast Regional FFY2020 SNAP-Ed Policy, Systems and Environmental Change Evaluation

<h3>Objective</h3> The study objective was to evaluate the policy, systems, and environmental (PSE) changes implemented by Southeast Region (SER) SNAP-Ed programs during the COVID-19 pandemic in 2020. <h3>Use of Theory or Research</h3> This study was guided by the SNAP-Ed Evaluation Framework and Interpretive Guide. <h3>Target Audience</h3> PSE interventions were targeted toward sites that serve SNAP-Ed eligible populations that are at or below 185% of the federal poverty level. <h3>Program Description</h3> The SNAP-Ed program was implemented across eight states, including 25 implementing agencies. States focused on expansion of PSE interventions in 2020, to include long-term implementation strategies, which incorporates a multicomponent such as evidence-based education, marketing, community involvement, and/or staff training in addition to the PSE change. During the pandemic, many agencies focused on strengthening nutrition security. <h3>Evaluation Methods</h3> States reported PSE changes, multicomponent strategies, sites, promotional efforts, COVID program adaptations, and estimated reach. Data were reported via the Program Evaluation and Reporting System or through an Excel template. All data were cleaned and descriptive statistics for all PSEs were analyzed using R statistical software. <h3>Results</h3> Implementing agencies reported a total of 1,359 PSE changes across 7 states with a combined reach of 1,161,289. Common PSEs included novel food distribution systems, expanding access to fresh produce and edible gardens. A total of 666 sites (91%) reported a multicomponent intervention with their PSE nutrition change. <h3>Conclusions</h3> The study found that SNAP-Ed agencies were able to quickly and successfully pivot their programs to meet the needs of their communities during the pandemic reaching 1.1 million people with over 1,300 SNAP-Ed PSE changes compared to 830,049 in 2017. A shift in PSE implementation was seen. For example, more PSE changes occurred in food assistance sites, which included drive-through pantries. Also, there were increases in home and community garden projects to support families facing nutrition insecurity. Results indicate that most sites in SER are implementing multi-component interventions, that if continued, will lead to sustained, effective change over time. <h3>Funding</h3> Supplemental Nutrition Assistance Program - Education

P008 ArFoods in the Garden: A SNAP-Ed Educational/PSE Strategy

<h3>Objective</h3> To implement a nutrition, gardening-based pilot project in SNAP-Ed eligible schools that incorporates direct education, indirect education, and PSE <h3>Use of Theory or Research</h3> Studies show garden-based nutrition education combined with healthy food marketing has potential to improve children's diet quality and is associated with more positive food choices. <h3>Target Audience</h3> K-5th grade students, teachers in 4 SNAP-Ed eligible schools. <h3>Program Description</h3> University of Arkansas Division of Agriculture Cooperative Extension Service SNAP-Ed Program developed Arkansas Foods (ArFoods) to highlight locally grown foods. ArFoods consists of nutrition education posters, newsletters, and taste-testing activities that can be used alone or in conjunction with evidence-based curriculum. During Farm to School month 2021, ArFoods was used in school gardens. "ArFoods in the Garden" pilot project consisted of 34 individual events in 4 schools reaching 713 youth. Nutrition education posters featuring spinach were printed on corrugated plastic and used as crop markers. MyPlate resources were used, along with taste tests and physical activity breaks. Posters were displayed in cafeterias, and parent newsletters were sent home with students. <h3>Evaluation Methods</h3> Post-teacher survey used to assess value and effectiveness of pilot project, changes in eating habits of students and teachers, and PSE changes adopted. Students surveyed about whether they would try spinach again. <h3>Results</h3> All teachers (n = 6) reported the program was very valuable to their students; their students seemed more willing to try new foods. Among student respondents (n = 288), 80.9% indicated they would try spinach again. Among teachers, five (83%) reported because of program they were motivated to try new foods, eat healthier, and/or be more physically active; four (67%) reported making changes in classrooms. <h3>Conclusions</h3> This pilot project was an example of how multiple delivery methods (direct education, indirect education, policy, systems, and environmental) can be incorporated into SNAP-Ed approaches. The project was successful in increasing students' and teachers' willingness to try new healthy foods and/or be more physically active. <h3>Funding</h3> Supplemental Nutrition Assistance Program - Education

Factors Influencing Capacity and Readiness to Implement Healthy Eating Interventions in Food Pantries Through SNAP-Ed Programming

ObjectivesFood pantries provide free food to households, including those receiving Supplemental Nutrition Assistance Program (SNAP), thereby buffering food insecurity in communities. The SNAP-Ed program identified food pantries as a targeted setting for policy, system, and environmental (PSE) changes to promote healthy eating. This study sought to identify factors influencing capacity and readiness to implement healthy eating PSE interventions in food pantries. MethodsWe conducted qualitative interviews with 26 residents and 12 SNAP-Ed staff from rural and urban counties in Ohio to identify themes and indicators related to community readiness and organizational and practitioner capacity to implement healthy eating PSEs in food pantries. Themes and related indicators were generated based on inductive and deductive coding of interview transcripts. Eleven food pantry and nutrition experts prioritized and weighted themes and indicators during a virtual consensus conference. ResultsFive themes emerged, and expert-derived weights (scaled low, 0 to high, 1) reflect the perceived importance of each to implementation of healthy eating PSE interventions in food pantries; (1) food pantry capacity and logistics [0.253], (2) networks & relationships [0.228], (3) community nutrition practitioner capacity [0.212], (4) food pantry user characteristics [0.156], and (5) stigma and stereotypes [0.1.52]. Overall, 17 indicators were identified across these themes. ConclusionsFood pantries are unique settings for implementing healthy eating PSE interventions, thus successful and sustained PSE change will require a tailored approach that considers food pantries capacity, needs and opportunities within the community, and capacity of community nutrition practitioners, including SNAP-Ed. The themes and indicators identified through this study will be incorporated into an online assessment tool to support tailored approaches that meet communities where they are. Funding SourcesFinancial support for this work was provided by the U.S. Department of Agriculture, Food and Nutrition Service, Supplemental Nutrition Assistance Program – Education (SNAP-Ed).

Exploring Extension Agent Capacity and Readiness to Adopt Policy, Systems and Environmental Change Approaches.

IntroductionEnhanced Extension outreach strategies combine traditional direct education programs with public health approaches like policy, systems, and environmental (PSE) change. However, the Cooperative Extension system and county-based Family and Consumer Sciences (FCS) Extension agents have historically prioritized direct education programming and diffusion of enhanced outreach strategies has varied. Extension personnel may lack capacity and readiness for successful PSE change implementation. This study explored perceived acceptability, capacity, and readiness for PSE change work among FCS Extension agents in two states.MethodA survey was developed framed by selected domains from the Consolidated Framework for Implementation Research: Intervention Characteristics, Inner Setting, Characteristics of Individuals, and Process. All questions utilized a 5-point Likert scale, except for an item examining respondents' stage of change regarding PSE change strategies. Descriptive statistics and response frequencies for all variables were calculated.ResultsSurvey responses (n = 116) indicated PSE change work was perceived as valuable. Potential barriers included perceived complexity, organizational readiness issues (e.g., reporting and evaluation structures; performance incentives), and worries about stakeholder responses in shifting away from direct education. Responses indicated self-efficacy for skills important in implementing PSE change. Most respondents (53%) indicated being at the pre-contemplation or contemplation stage of change in pursuing PSE change work.DiscussionCombining PSE change strategies and direct education programming allows Extension to do what it does best – provide effective programs to improve and sustain health and wellbeing of individuals and families. Findings are informative for others aiming to build capacity within community educators, Extension and public health professionals to implement PSE change.

Journey to Promoting Structural Change for Chronic Disease Prevention: Examining the Processes for Developing Policy, Systems, and Environmental Supports in Native American Nations

ABSTRACTBackgroundObesity and chronic disease rates continue to be disproportionally high among Native Americans (NAs) compared with the US general population. Policy, systems, and environmental (PSE) changes can address the root causes of these health inequalities by supporting access to healthy food and physical activity resources.ObjectiveWe aim to describe the actors and processes involved in developing PSE changes supporting obesity prevention in NA Nations.MethodsAs part of the Obesity Prevention Research and Evaluation of InterVention Effectiveness in NaTive North Americans 2 (OPREVENT2) trial (ClinicalTrials.gov registration: NCT02803853), we collected 46 in-depth interviews, 1 modified Talking Circle, 2 workshops, and 14 observations in 3 NA communities in the Midwest and Southwest regions of the United States. Participants included Tribal government representatives/staff, health staff/board members, store managers/staff, and school administrators/staff. We used a Grounded Theory analysis protocol to develop themes and conceptual framework based on our data.ResultsHealth staff members were influential in identifying and developing PSE changes when there was a strong relationship between the Tribal Council and health department leaders. We found that Tribal Council members looked to health staff for their expertise and were involved in the approval and endorsement of PSE changes. Tribal grant writers worked across departments to leverage existing initiatives, funding, and approvals to achieve PSE changes. Participants emphasized that community engagement was a necessary input for developing PSE changes, suggesting an important role for grassroots collaboration with community members and staff. Relevant contextual factors impacting the PSE change development included historical trauma, perspectives of policy, and “tribal politics”.ConclusionsThis article is the first to produce a conceptual framework using 3 different NA communities, which is an important gap to be addressed if structural changes are to be explored and enacted to promote NA health. The journey to change for these NA Nations provides insights for promoting future PSE change among NA Nations and communities.

Evaluation Results From the Healthy Work Collaborative: A Cross-Sectoral Capacity Building Partnership to Address Precarious Employment.

The COVID-19 pandemic has illuminated the profound health and safety risks of precariously employed workers, many of whom are disproportionately Latinx and Black. Precarious employment (PE) is a social determinant of health (SDOH) characterized by low wages, hazardous conditions, unstable work schedules, no termination protection, and few benefits. Even before COVID-19, calls for more effective health promotion efforts to address SDOH like PE existed. The University of Illinois at Chicago Center for Healthy Work, Healthy Communities Through Healthy Work developed the Healthy Work Collaborative (HWC) as an evidence-informed capacity building policy, systems, and environmental change (PSE) initiative. The HWC aimed to facilitate cross-sectoral partnerships between health and labor sector partners. The labor sector provided technical assistance (TA) to participants to improve their ability to address PE through PSE. This article reports findings from a mixed-methods evaluation using the Kirkpatrick training model including participants' reactions, learning, behavior, and outcomes. A pre-post survey was administered to participants (N = 21) and analyzed descriptively; 3-month post HWC interviews were conducted (N = 13) and thematically analyzed. Findings included positive results at all Kirkpatrick levels. Participants' reported that the HWC curriculum and delivery was valuable and well received; they demonstrated gains toward addressing PE through PSE knowledge and skills and increased or strengthened health/labor partnerships. In addition, HWC influenced participants' application of HWC concepts, and in a few cases, participants' made changes in policies and plans in their organizational settings. The HWC may serve as a model to address other SDOH through cross-sectoral PSE change.

Outcomes of a Multi-Component School-Based Nutrition Program.

This paper presents the effectiveness of a multi-component elementary school-based nutrition education program, the Integrated Nutrition Education Program (INEP), which has been in existence for over 25 years. INEP includes components to address multiple layers of influence: hands-on nutrition education lessons in the classroom (student-level), parent education, and outreach (home-level), and facilitation of a planning process to implement policy, system, and environmental (PSE) school changes (school-level). Three evaluation tools assessed the effectiveness of the program: (1) classroom plate waste measurement in intervention (N=149 students) and demographically-matched comparison schools (N=131 students), (2) pre/post classroom surveys completed by students who participated in INEP (N=204), and (3) PSE change data from participating schools (N=47 schools). Students who participated in the nutrition education program were more likely to consume vegetable-based recipes and vegetables included in classroom nutrition lessons compared to students in comparison classrooms (Chinese vegetable salad: p < .001; couscous salad: p < .001; snap peas: p = .001). Classroom survey analyses showed improvements in student self-efficacy (p < .001), preference for vegetables (p=.005), and knowledge (p < .001). In addition, through a wellness planning process, schools implemented an average of 3.7 PSE changes per school. Results demonstrate a multi-component school-based nutrition education program improves student nutrition-related outcomes.

Application of an Implementation Framework Using Mixed Methods in Preschool Settings.

Research Findings. Application of mixed methods in a dissemination and implementation framework can give researchers a better understanding of the reach and delivery of early childhood obesity prevention programs in preschool settings, as well as potential facilitators and barriers related to implementation and sustainability. This study utilized a simultaneous, exploratory, mixed-methods design to investigate individual-, organizational-, and intervention-level factors that were related to the implementation and sustainability of policy, system, and environment (PSE) changes as part of a larger obesity prevention program in a randomly selected sample of preschool centers (n = 20). Individual-level factors, and specifically the attitudes and skills of preschool providers, were identified in both the qualitative and quantitative data as important factors related to the sustainability of PSE changes (r = .56, p < .01). Staff and leadership engagement and adaptability of the program were also identified as important factors related to the implementation and sustainability of PSE changes. Practice or Policy. These findings highlight the complexity of implementation success and suggest PSE obesity prevention interventions in preschool centers require the consideration of numerous, multilevel factors to ensure programming is impactful and sustained over time.