Strength and comprehensiveness of district school wellness policies predict policy implementation at the school level

Student perceptions of U.S. based school day physical activity best practices in relation to accelerometer-based sedentary behavior and activity

Objective

To examine associations between student perceptions of school physical activity best practices and accelerometer-based physical activity during school days.

Methods

The sample was 758 students in grades 3rd-4th or 6th-7th (female-58 %; 31 % Black/African American) from 33 schools across five school districts in a Mid-Atlantic state in the U.S. Students completed the Perceptions of the Environment at School survey to assess perceived implementation of 11 school physical activity best practices and wore an Actical ankle accelerometer for 7 days between 2017 and 2019. Accelerometer cutpoints were applied for percent time in sedentary, light, and moderate-vigorous physical activity (MVPA) during school hours. Adjusted mixed effects linear regression models were used to predict percent time in each physical activity category, with separate models for elementary and middle school.

Results

More best practices were perceived by elementary versus middle schoolers (sum score = 3.3 versus 1.5, p < .01). For every additional best practice perceived, elementary schoolers spent 0.64 % less time in sedentary behavior (B = -0.62; SE = 0.27, p = .02), equivalent to ∼12 fewer minutes/week in sedentary behaviors, and 0.58 % more time in light activity (B = 0.58; SE = 0.25, p = .02; ∼10 more minutes/week). No associations observed for middle schoolers or MVPA.

Conclusions

Few best practices were perceived as being implemented in school. Elementary schoolers who perceived more best practices spent more time in light activity and less in sedentary behavior, but this relationship was not found among middle schoolers. Future research should promote implementation of school physical activity best practices and examine the linkage between implementation, student perceptions, and behavior change.Trial Registration: Clinical Trials, NCT03432715; Registered on 02/2/2018.

Quality evaluation of nutrition policies in early childhood education and care services in Nerang, QLD

ISSUE ADDRESSED

Food environments in early childhood, such as early childhood education and care services, influence the development of dietary patterns and behaviours that traverse into adulthood, where they affect health and longevity. Nutrition policies are mandatory in early childhood education and care services in Australia and can positively or negatively shape the food environment. However, the quality of such nutrition policies is unknown. This study aimed to evaluate the comprehensiveness and strength of nutrition policies of early childhood education and care services among services participating in a university-community alliance in South East Queensland.

METHODS

Early childhood education and care services (n = 12) in Nerang, Queensland, Australia, participated in a cross-sectional study evaluating the comprehensiveness and strength of nutrition policies across four domains (Nutrition Education, Nutrition Standards, Promoting Healthy Eating and Communication and Evaluation) of the Wellness in Child Care Assessment Tool.

RESULTS

Nutrition policies evaluated in this study had median total comprehensiveness scores of 55 (out of 100) and median total strength scores of 19 (out of 100). 'Nutrition Education' had the highest median scores for comprehensiveness (67 out of 100) and strength (33 out of 100), while 'Nutrition Standards' had the lowest comprehensiveness score (41 out of 100), and 'Communication and Evaluation' had the lowest strength score (0 out of 100).

CONCLUSIONS

All services have a nutrition policy, but there are opportunities to enhance both the content and linguistic strength of statements within policies related to nutrition domains. SO WHAT?: There is a clear need to improve the comprehensiveness and strength of written statements in nutrition policies across all four domains, particularly 'Nutrition Standards' and 'Communication and Evaluation'.

State Legislation Related to School Nutrition: Predictors of Bill Passage From 2010-2019

OBJECTIVE

This study aimed to discover the prevalence of school nutrition state legislation and to identify the correlates of enactment.

DESIGN, SETTING, AND PARTICIPANTS

An online legislative database, Legiscan, was used to collect bills related to school nutrition from the US from 2010 to 2019. Bills were coded and compiled into a study database with state-level dietary variables (obesity prevalence, fruit, and vegetable intake, sugar-sweetened beverage consumption), community variables (percent White, poverty), and bill-characteristic variables (party affiliation in legislature, strength of language, party of governor, school gardens, vegetable intake, and other salient variables). Multivariable models were built to examine predictors of bill enactment.

RESULTS

Of the 462 bills introduced, 38.7% (n = 156) were enacted. In a multivariable model, the strength of bill language, political party affiliation, implementation of school gardens, and vegetable intake were the variables associated with bill passage. Bills with strong language were less likely to be enacted (P <0.001). Bills introduced by Democrats were more likely to be enacted (P = 0.01).

CONCLUSION AND IMPLICATION

This study showed a better understanding of legislative support for child nutrition via policy surveillance of bills and their correlates of enactment. This information can be used to prioritize advocacy efforts and identify ways research can better inform policy.

Development of a School Health Policy Implementation Survey: A Delphi Study

Data on school health policy implementation are limited due to the absence of a validated measurement tool. The purpose of this study was to create and pilot a school health policy implementation survey. A modified, four-round Delphi process was used to achieve consensus on content and format of the survey. The final 76-item survey was piloted in 655 schools with a return rate of 57.1% (n  =  378). Seven schools participated in environmental audits. Based on the audits, survey responses represented an accurate description of school practices for 84.2% (n  =  64) of questions. The remaining 15.8% (n  =  12) of survey items were eliminated or revised. This measurement tool begins to fill the research gap between the evaluation of written school health policy and implementation. Further, this tool may be used by school nurses in alignment with the Framework for 21st Century School Nursing Practice.

Investigating implementation of school health policies through a health equity lens: A measures development study protocol

Background

School-based policies that ensure provision of nutrition, physical activity, and other health-promoting resources and opportunities are essential in mitigating health disparities among underserved populations. Measuring the implementation of such policies is imperative to bridge the gap between policy and practice. Unfortunately, limited practical, psychometrically strong measures of school policy implementation exist. Few available explicitly focus on the issues of equity and social justice as a key component of implementation, which may result in underassessment of the equity implications of policy implementation. The purpose of this study is to develop equity-focused measures in collaboration with practitioners, researchers, and other key implementation partners that will facilitate evaluation of policy implementation determinants (i.e., barriers and facilitators), processes, and outcomes.

Methods

We will actively seek engagement from practitioners, researchers, and advocacy partners (i.e., stakeholders) who have expertise in school health policy throughout each phase of this project. We propose a multi-phase, 1-year project comprising the following steps: (1) selection of relevant constructs from guiding frameworks related to health equity and implementation science; (2) initial measure development, including expert feedback on draft items; (3) pilot cognitive testing with representatives from key target populations (i.e., school administrators, teachers, food service staff, and students and parents/guardians); and (4) measure refinement based on testing and assessment of pragmatic properties. These steps will allow us to establish initial face and content validity of a set of instruments that can undergo psychometric testing in future studies to assess their reliability and validity.

Discussion

Completion of this project will result in several school policy implementation measurement tools which can be readily used by practitioners and researchers to evaluate policy implementation through a health equity lens. This will provide opportunities for better assessment and accountability of policies that aim to advance health equity among school-aged children and their families.

Trial registration

Open Science Framework Registration doi: 10.17605/OSF.IO/736ZU.

Coordinated Health in Texas Elementary Schools' Campus Improvement Plans: Analysis of Regional Differences and Trends between 2016 and 2020

Schools signal health priorities through policies. Using a repeated cross-sectional study design, we compare the presence and strength of policies related to four topics—physical activity, nutrition, mental health, and bullying—described in elementary school Campus Improvement Plans (CIPs; also called school improvement plans) within Texas, across four Texas Public Health Regions (PHRs), and between 2016 and 2020. CIPs were collected using a multi-stage probability-based survey approach, scored using an adapted WellSAT tool, and analyzed to determine associations between PHR or year and health topic. Across 170 CIPs, bullying was the most frequently addressed topic, followed by mental health, physical activity, and nutrition. On average, schools addressed 2.7 ± 1.3 topics within their CIP; 38.2% of schools addressed all four, 26.5% addressed three, 12.4% addressed two, 15.3% addressed one, and 7.6% addressed none. CIPs in the same district had high levels of clustering (ICCs = 0.28–0.55). The mostly rural Panhandle PHR included the fewest topics in their CIPs and used the weakest policy language. Between 2016 and 2020, there was a decrease in the proportion of CIPs that addressed nutrition; the strength of language for mental health and bullying also decreased. Regional and time trends reveal opportunities for more robust school health policy interventions.

The Role of Technical Assistance in School Wellness Policy Enhancement

BACKGROUND

School settings offer an opportunity to impact student health and wellness. Quality wellness policies are important in establishing strong wellness environments, but current resources to support policy development, maintenance, and dissemination are lacking. The Building Healthy Schools Program aimed to develop capacity of school districts to improve the strength and comprehensiveness of wellness policies and sustain these activities.

METHODS

Fifteen school districts in Pennsylvania participated in a program to facilitate the improvement of district wellness policies and practices. Program staff provided technical assistance to evaluate wellness policies before and after program implementation. Professional development and tailored training was provided for school personnel to create sustainability. Statistical analysis was performed to evaluate policy improvement.

RESULTS

Thirteen of the 15 participating districts completed a policy revision. Median strength (p = .001) and comprehensiveness (p = .002) scores improved from baseline to post-program and there were significant improvements in most assessment sub-sections. Some districts were hesitant to make strong language improvements due to their limited capacity (ie, staff) for implementation. Champions (n = 13; 87%) reported confidence to revise wellness policy language independently in the future.

CONCLUSIONS

Technical assistance provided to districts facilitated significant improvements to wellness policy language, especially in the implementation, evaluation, and communication; critical components for policy impact on school wellness environments. In addition, participant feedback suggested an ability to sustain activities in the future. Both external (ie, technical assistance) and internal resources are needed to facilitate school districts' ongoing wellness policy improvement and implementation, including improved model wellness policy language and enforcement within schools, respectively.

Competitive Food and Beverage Policies and Obesity among Middle School Students: Variability by Urbanicity in California

Introduction: This study examined the association between California school nutrition policies and population-level trends in childhood overweight/obesity by levels of urbanicity. Methods: We used interrupted time series with Fitnessgram data on overweight/obesity from the period 2002 to 2010 pertaining to African American, Latino, Asian, and White students in seventh grades who attended California public schools. We used multilevel logistic regression models to examine the impact of the introduction of successive California school nutrition policies on overweight/obesity prevalence, stratified by gender and adjusted for school district-, school-, and student-level characteristics. Results: At the start of the study period, rural areas and second cities (i.e., population centers with lower population densities than urban areas) had relatively low prevalence, but experienced sharp increases in 2002-2004, leading to higher prevalence of overweight/obesity than suburban areas. There was evidence of beneficial policy influences on overweight/obesity in most areas, except for girls in urban areas and boys in second cities. The evidence of beneficial changes was strongest among children attending schools located in rural areas, and boys in suburban and urban areas. These results persisted even after we accounted for differences in racial/ethnic compositions, socioeconomic characteristics of the schools and school neighborhoods, and school sizes, as well as child-level race/ethnicity, age, and student fitness levels. Conclusion: Despite evidence of beneficial policy impact, childhood obesity prevalence remains high, especially in urban areas in California. Additional policies and environmental interventions are recommended to address obesogenic risk factors unique to each area.

How to Make Physical Activity Promotion Work in Thai Schools: Perspectives of Multiple Stakeholders

BACKGROUND

This study aimed to determine current practice in physical activity (PA) promotion in Thai schools, explore barriers and facilitators to PA promotion within the school setting, and identify strategies to support schools' future practice.

METHODS

A qualitative study design was applied comprising document analysis, focus groups, in-depth interviews, and onsite observations. The focus groups and in-depth interviews were conducted with 144 informants, purposively recruited through 24 schools in 4 regions across Thailand. Inductive content analysis was used.

RESULTS

Most schools were promoting PA in the absence of written policies, and without an accurate understanding of PA. Nonalignment of school performance indicators and policies, concerns about children's academic performance, and lack of budget were raised as barriers to PA promotion, whereas strong partnerships with multiple local stakeholders facilitated school-based PA promotion. Mandated government PA policies and more information support were suggested as strategies to enhance schools' future practices.

CONCLUSIONS

For PA promotion to be successful in the school setting, significant challenges will need to be addressed. Results from this study help the government and concerned stakeholders to better understand the situation at the school level, and further strive for achieving the target PA levels specified in the National PA Plan.

Strength and Comprehensiveness of Drinking Water Language in California School District Wellness Policies

OBJECTIVE(S)

Assess the quality of water language in California school district wellness policies and examine how language quality relates to school drinking water access.

DESIGN

Cross-sectional study.

PARTICIPANTS

Random sample of 240 schools selected from all California public schools, stratified by geography and grades served.

VARIABLES MEASURED

Policies (2016-2018) were coded for quality (strength and comprehensiveness) using an adapted school wellness policy tool. School administrators completed phone interviews about drinking water access on their campus.

ANALYSIS

Descriptive statistics (eg, means, standard deviations) summarized school-level characteristics and main outcomes. Mixed-effects linear regression models were used to examine the relationship between the strength and comprehensiveness of water policy language and water access.

RESULTS

On a scale of 0-100, mean strength was 11.3 (SD, 5.7), and mean comprehensiveness was 28.8 (SD, 8.7). There was an inverse association between the quality of water language in policies and excellence in drinking water access in schools.

CONCLUSIONS AND IMPLICATIONS

The strength and comprehensiveness of water language in California school district wellness policies were low. Districts would benefit from improving the quality of water language in their wellness policies and examining challenges to implementing policies.

School Administrators' Experiences in a 6-Month Health and Wellness Community of Practice

BACKGROUND

A statewide 6-month school administrator health and wellness program encouraged participants to use a fitness tracker to self-monitor their physical activity and sleep patterns. The purpose of this study was to examine participants' experience in a school administrator health and wellness program and their perceptions of the impact on health-related behaviors, including activity/movement, nutrition, and sleep.

METHODS

Each of the 45 participants completed a semi-structured interview at three points in the program. Questions were designed to discern school administrators' perceptions of their ideal health and wellness balance at home and work.

RESULTS

School administrators reported new insights into their own well-being, benefits of social supports in their personal wellness journey, an expanded understanding of their ideal health and wellness balance at home and work, and a stronger sense of serving as a role model who needs to take care of him/herself.

CONCLUSIONS

Although the program was helpful in establishing an ideal health and wellness balance at home and work for some school administrators, future programs should better emphasize nutrition and scaffold opportunities to maintain new habits following program completion.

Understanding the need for a whole-of-society approach in school nutrition policy implementation: a qualitative analysis

BACKGROUND

Only three of twenty Caribbean Community (CARCICOM) countries have mandatory school nutrition policies despite one third of the region's children being overweight or obese. In Barbados, there are nutrition guidelines which lack the legal mandate of a formal policy. We aim to assess the comprehensiveness of current national nutrition guidelines and to understand the factors operating in the inner and outer school setting that may influence the implementation of a mandatory school nutrition policy from the perspectives of school administrators.

METHODS

A documentary analysis of existing nutritional guidelines was conducted along with qualitative semi-structured interviews in primary (elementary) and secondary (high) schools in Barbados. We purposively sampled six primary and four secondary school administrators (principals, deputy principals or senior teachers) to explore their knowledge and views on the National School Nutrition Guidelines. The deterministic implementation paradigm, Consolidated Framework for Implementation (CFIR), was used to explore the complexities within the inner and outer settings of schools. Documentary analysis used a theory-based framework informed by the Wellness School Assessment Tool-school policy analysis questionnaire. Interview transcripts were team coded using thematic analysis with constant comparison facilitated by NVIVO software version12.

RESULTS

School administrators were unaware of the existing National School Nutrition Guidelines which documentary analysis found to be restrictive and weak for implementation. Administrators envisioned a government-led (outer setting), whole of society approach as the most effective strategy for the development and implementation of a proposed mandatory school nutrition policy. School administrators identified lack of financial and human resources as barriers to nutrition policy implementation. Formal and informal food vendors are institutionalized in schools and are influential determinants of the school food environment. Schools have individually reached into the outer setting to work with civil society organizations and private individuals to provide financial support and nutrition expertise to their institutions. Mass media campaigns in the outer setting may influence child and parental food choices.

CONCLUSION

School administrators describe that government-led, CSO supported policy development using a whole-of-society approach has implications for improving nutrition policy implementation. Our findings demonstrate the use of a deterministic implementation framework in the pre-implementation phase of school nutrition policy development.

Use of School Wellness Policy Templates in One Texas Public Health Region: A Mixed-Methods Analysis

BACKGROUND

Federal law requires most school districts to develop school wellness policies (SWPs), which state agencies assist in by providing templates. Templates provide standard language, which districts may edit for numerous reasons. We aimed to identify the frequency/consistency of template usage and identify the types of edits districts make when using SWP templates.

METHODS

We identified SWPs (N = 117) and templates (N = 2) from districts in 1 Texas public health region. We developed template specific coding guides, which allowed us to examine the frequency SWPs used template text within multiple areas (eg, nutrition goals, reporting). We also collected/categorized SWP edits from the template text and conducted a thematic analysis of locally developed SWPs and SWP templates.

RESULTS

Of 117 SWPs, 81.2% used a 2020 template, 13.7% used a 2005 template, and 5.1% created their own SWP. Across template-based SWPs, 44 content edits (0.4 per policy) occurred in 9 categories. Thematic analysis revealed: (1) locally developed SWPs created an informed mission statement linked to their goals; (2) Locally developed SWPs provided details that the current template includes in wellness plans.

CONCLUSIONS

Most districts used exact template language when writing their SWP. Adding spaces where districts can specify details could improve SWP content.

A systematic review of school health policy measurement tools: implementation determinants and outcomes

BACKGROUND

Governments in some countries or states/provinces mandate school-based policies intended to improve the health and well-being of primary and secondary students and in some cases the health of school staff. Examples include mandating a minimum time spent per week in programmed physical activity, mandating provision of healthy foods and limiting fat content of school meals, and banning tobacco products or use on school campuses. Although school health researchers have studied whether schools, districts, or states/provinces are meeting requirements, it is unclear to what extent implementation processes and determinants are assessed. The purposes of the present systematic review of quantitative measures of school policy implementation were to (1) identify quantitative school health policy measurement tools developed to measure implementation at the school, district, or state/provincial levels; (2) describe the policy implementation outcomes and determinants assessed and identify the trends in measurement; and (3) assess pragmatic and psychometric properties of identified implementation measures to understand their quality and suitability for broader application.

METHODS

Peer-reviewed journal articles published 1995-2020 were included if they (1) had multiple-item quantitative measures of school policy implementation and (2) addressed overall wellness, tobacco, physical activity, nutrition, obesity prevention, or mental health/bullying/social-emotional learning. The final sample comprised 86 measurement tools from 67 peer-review articles. We extracted study characteristics, such as psychometric and pragmatic measure properties, from included articles based on three frameworks: (1) Implementation Outcomes Framework, (2) Consolidated Framework for Implementation Research, and (3) Policy Implementation Determinants Framework.

RESULTS

Most implementation tools were developed to measure overall wellness policies which combined multiple policy topics (n = 35, 40%) and were in survey form (n = 75, 87%). Fidelity was the most frequently prevalent implementation outcome (n = 70, 81%), followed by adoption (n = 32, 81%). The implementation determinants most assessed were readiness for implementation, including resources (n = 43, 50%), leadership (n = 42, 49%), and policy communication (n = 41, 48%). Overall, measures were low-cost and had easy readability. However, lengthy tools and lack of reported validity/reliability data indicate low transferability.

CONCLUSIONS

Implementation science can contribute to more complete and rigorous assessment of school health policy implementation processes, which can improve implementation strategies and ultimately the intended health benefits. Several high-quality measures of implementation determinants and implementation outcomes can be applied to school health policy implementation assessment. Dissemination and implementation science researchers can also benefit from measurement experiences of school health researchers.

Putting Policy Into Practice: School-Level Compliance With and Implementation of State Concussion Laws

CONTEXT

Each year, approximately 2 million US children 18 years or younger sustain a concussion, a type of mild traumatic brain injury (TBI). Concussions can have detrimental effects on physical, cognitive, emotional, or sleep health.

POLICY

Between 2009 and 2014, all 50 US states and Washington, District of Columbia, enacted state concussion laws aimed to increase awareness about concussion and reduce the prevalence and severity of this injury. Most state laws include the following core tenets: (1) immediate removal from play after an actual or suspected concussion; (2) medical clearance before an athlete can return to play (RTP); and (3) concussion education for athletes, parents, and coaches.

IMPLEMENTATION

State concussion laws allow for substantial interpretation at the school level, resulting in considerable variation in the content of school written concussion policies and the level of implementation of state law requirements at the school level.

EVALUATION

We assessed the degree of high school written concussion policy compliance with the respective state law and examined the relationship between concussion policy compliance and school-level implementation of concussion laws. Seventy-one school officials completed a semistructured telephone interview and submitted their school's written concussion policy. Of the 71 policies analyzed, most complied with the removal-from-play, RTP, and concussion education tenets (90.1%, 97.2%, and 76.1%, respectively). The majority of participants reported that their school implemented the removal-from-play (91.5%), RTP (93.0%), and concussion education (80.6%) tenets well or very well. No significant relationships were found between researcher-rated school policy compliance and school-reported implementation of state law requirements at the school level.

DISCUSSION

Our findings suggest that most participating schools complied with their state concussion law and implemented law requirements well or very well. Future studies should identify facilitators and barriers to the implementation of state concussion laws at the school level.

State Wellness Policy Requirement Laws Matter for District Wellness Policy Comprehensiveness and Wellness Policy Implementation in the United States

Beginning with the school year 2006-2007, U.S. school districts participating in the federal Child Nutrition Programs were required to adopt and implement a local wellness policy (LWP) that included goals and/or standards for nutrition education, school meals, other foods sold or served in schools, and physical activity. A primary challenge with LWPs has been inconsistent implementation. This study examined whether state wellness policy requirement laws and district LWP comprehensiveness influence district level implementation, using law/policy data from the National Wellness Policy Study and school food authority (SFA)-reported district LWP implementation from the School Nutrition and Meal Cost Study. Generalized linear and structural equation models were used, controlling for SFA and district characteristics. SFAs in states with wellness policy requirement laws (vs. those in states without) reported implementing significantly more practices (59.56% vs. 44.57%, p < 0.01). State wellness policy requirement laws were associated with district LWP comprehensiveness (coeff.: 0.463; 95% CI: 0.123, 0.803) and district-level implementation (coeff.: 1.392; 95% CI: 0.299, 2.485). District LWP comprehensiveness was associated with district implementation (coeff.: 0.562; 95% CI: 0.072, 1.053), but did not mediate the state law-district implementation relationship. This study highlights the important role that state laws and district LWPs can play in facilitating wellness policy implementation.

Can Monitoring Make It Happen? An Assessment of How Reporting, Monitoring, and Evaluation Can Support Local Wellness Policy Implementation in US Schools

US school districts participating in federal child nutrition programs are required to develop a local wellness policy (LWP). Each district is allowed flexibility in policy development, including the approaches used for policy reporting, monitoring, and evaluation (RME). The aim of this convergent mixed-methods study was to quantitatively examine RME provisions in policies among a nationally representative sample of districts in the 2014-2015 school year in order to examine whether policies were associated with RME practices in those districts, and to qualitatively examine perceived challenges to RME practices. Data were compiled through the School Nutrition and Meal Cost Study and the National Wellness Policy Study. In multivariable regression models accounting for demographics, survey respondents were significantly more likely to report that their district had informed the public about LWP content and implementation, if there was a relevant policy provision in place. Having a strong policy (as compared to no policy) requiring evaluation was associated with reports that the district had indeed evaluated implementation. Having definitive/required provisions in policies was significantly associated with actual use of RME practices. RME activities are an important part of policy implementation, and these results show that policy provisions addressing RME activities must be written with strong language to require compliance. In interviews with 39 superintendents, many reported that RME activities are challenging, including difficulty determining how to monitor and show impact of their district's wellness initiatives. Furthermore, the qualitative results highlighted the need for vetted tools that are freely available, widely used, and feasible for districts to use in assessing their progress toward meeting the goals in their LWPs.

A Canadian-wide perspective on the essential conditions for taking a comprehensive school health approach

Background

The primary purpose of this research was to explore Comprehensive School Health (CSH) stakeholders’ perceptions of the essential conditions for taking a CSH approach in other contexts across Canada. The secondary purpose was to examine the need for and development of an evaluative tool or resource to assess the implementation of the essential conditions.

Methods

Data were generated through individual semi-structured interviews (n = 38) and small group interviews (n = 3) with 45 participants across Canada involved in implementing policies or programs which take a CSH approach. Interviews were subjected to content analysis.

Results

There was positive support for the essential conditions and results indicated the essential conditions are relevant across Canada. Findings revealed the necessity for a new essential condition that reflected support and leadership from the school district and/or provincial/territorial governing bodies. Modifications to the description of each of the essential conditions were also suggested to provide clarity. Results also indicated that an evaluative tool that was concise, meaningful, and provided immediate feedback would be useful to school communities to establish readiness, assess, and improve ongoing implementation of CSH approaches.

Conclusions

This research contributes to the evidence-base of CSH by providing school communities across Canada with a set of refined and understandable essential conditions that support successful implementation. Further, the development of an evaluation tool will support school health champions, researchers, and policymakers in the optimization and implementation of policies or programs which take a CSH approach, ultimately supporting healthier school communities across the country.

State Laws Matter When It Comes to District Policymaking Relative to the Whole School, Whole Community, Whole Child Framework

BACKGROUND

The Whole School, Whole Community, Whole Child (WSCC) framework supports the "whole child" across 10 domains. This study assessed state law and district policy WSCC coverage.

METHODS

Primary legal research was used to compile relevant district policies and state laws for a stratified random sample of 368 public school districts across 20 states for school year 2017-18. Policies/laws were evaluated on 79 items across the WSCC domains (range: 3-14 items/domain). Multivariable regressions examined the relationship between state laws and district policies, controlling for district characteristics, and weighted to account for the sample design and non-response.

RESULTS

On average, district policies and state laws addressed 53% and 60% of the 79 items, respectively. State law predicted district policy WSCC attention across items (coeff. = 0.26, 95% CI = 0.14, 0.38) and 4 domains: physical activity (coeff. = 0.57, 95% CI = 0.29, 0.86); health services (coeff. = 0.50, 95% CI = 0.39, 0.62); social and emotional climate (coeff. = 0.34, 95% CI = 0.23, 0.45); and family engagement (coeff. = 0.41, 95% CI = 0.28, 0.54). State law was associated with lower district-level coverage in 3 domains (health education; counseling, psychological, and social services; and community involvement).

CONCLUSIONS

Although WSCC implementation is locally-driven, states have an active role to play in setting a policy "floor" for guiding district WSCC attention.

Every School Healthy: An Urban School Case Study

BACKGROUND

In this case study, multiple participants in a large urban school district used the Whole School, Whole Community, Whole Child (WSCC) model to guide development of a district wellness policy. The model's health education component is highlighted, focusing on concerns for special needs students and ones speaking English as a New Language (ENL).

METHODS

Organizational structure was developed around the WSCC model and district wellness policy implementation through coordination, collaboration, and communication (3Cs) of programs, policies, and processes/practices (3Ps).

RESULTS

The WSCC approach guided the creation of a district wellness policy that influenced programming for students with special needs and required Youth Risk Behavior Survey (YRBS) data collection. Using YRBS and School Health Index (SHI) data in planning sexual health education illustrated improvements over time. Formation of the School Health and Wellness Collaborative under WSCC improved family engagement in sexual health education programs and practices. Relationships were established with community partners to impact student's sexual risk behaviors. Finally, the district co-created and implemented an evidenced-based sexual health curriculum, modifying it for special education and ENL students.

CONCLUSIONS

The WSCC approach is system changing. It takes time to develop the relationships vital to improve the 3Cs and 3Ps. Success is enhanced with a district wellness coordinator, the right people at the table, valid health data, and administrative and board support.

Local Data for Action: Statewide Dissemination of School Wellness Policy Evaluations in Wisconsin

School settings can influence child health, including physical activity and diet, through the promotion of high-quality wellness policies. Many studies have analyzed the quality of school wellness policies, but evidence is lacking regarding the dissemination of the policy evaluation results to school districts. This study describes the process the Wisconsin Health Atlas followed to disseminate tailored school wellness policy data reports and interactive dashboards to school districts throughout the state and the results of the statewide dissemination efforts. Prioritizing the translation of research to practice, the process included collaborating with key stakeholders and partners to provide formative feedback on the dissemination activities. The electronic and hard copy reports were disseminated to 232 districts through email and U.S. mail. Each district received a tailored report featuring an executive summary, local data for action, personalized policy recommendations, best practices, and a unique code to enter into interactive data dashboards to explore additional local, regional, and state-level data. In the utilization follow-up survey (20.3% response rate), respondents indicated that the report will help their district to improve the quality of their school wellness policy. Additionally, respondents who had used the report specified they used the data to identify areas for policy improvement and to support their triennial assessment, suggesting that districts value the technical support. To support school districts in improving the quality of school wellness policies, we recommend researchers prioritize collaborative dissemination efforts and provide actionable policy data when conducting school wellness policy evaluations.

Wisconsin School Wellness Policies after Federal Legislation Change: Understanding Key Mechanisms of Policy Improvement

BACKGROUND

The Final Rule of the Healthy Hunger Free Kids Act, published in 2016, required school districts participating in the federal Child Nutrition Programs to update their local wellness policies to reflect the more stringent requirements effective June 30, 2017.

OBJECTIVE

Our aim was to investigate whether Wisconsin school wellness policies (SWPs) were updated after the Final Rule, measure policy quality change, and describe mechanisms of successful policy change.

DESIGN

From 2016 through 2018, an explanatory sequential mixed-methods study examined change in SWP quality before and after the Final Rule was published. SWPs were collected in 2 waves reflecting policies written before and updated after the July 21, 2016 publication of the Final Rule. Semi-structured key-informant interviews were conducted with districts that demonstrated significant policy improvement.

PARTICIPANTS/SETTING

Quantitative analysis examined 442 Wisconsin school districts' SWPs. Semi-structured interviews were conducted with 14 school districts that demonstrated significant change between waves.

MAIN OUTCOME MEASURES

WellSAT 2.0 strength and comprehensiveness scores measured SWP quality among districts that updated their policies. Themes from interviews were identified using framework analysis.

STATISTICAL ANALYSIS PERFORMED

First, we calculated the proportion of Wisconsin school districts participating in federal Child Nutrition Programs for which SWPs were obtained at both waves of policy collection (n = 192 districts, 43.4%). Among districts that updated SWPs in wave II, repeated-measure analysis of variance tests described policy quality and policy quality change, respectively.

RESULTS

Among the 192 districts that updated their SWPs, policy quality increased overall and for 5 of 6 domains. Nutrition education scores did not show significant change. Interviewees commonly cited wellness leadership, support and resources, and buy-in and culture change as key components of policy improvement.

CONCLUSIONS

Fewer than half of Wisconsin school districts updated their policies in the 10 months after the Final Rule was published. SWP from these districts showed policy quality improvement in most areas. Interviews with successful districts indicate the common need for empowered leaders and supportive environments to facilitate culture change around student wellness.

The Association Between School Health Promotion Programs and School Wellness Policies

OBJECTIVE

Determine school wellness policy quality and evaluate the association between health promotion programs on school wellness policy quality.

METHODS

A descriptive cross-sectional study of 344 school districts in Oklahoma, a south-central region of the US. Secondary data including school districts' participation in health promotion programs for school years 2015 and 2016 and school wellness policy scores were used for this study. Descriptive statistics and Cohen d were used in the analysis.

RESULTS

School wellness policies had a mean comprehensiveness score of 43.7% and a mean strength score of 21.8%. The presence of ≥3 health promotion programs had a small effect (Cohen d range = 0.20 to 0.48) on school wellness policy scores.

CONCLUSIONS AND IMPLICATIONS

School wellness policies have room for improvement in both comprehensiveness and strength. Engagement in ≥3 health promotion programs may contribute to improved policy quality.

Disparities in the Healthfulness of School Food Environments and the Nutritional Quality of School Lunches

The Healthy, Hunger-Free Kids Act (HHFKA), a public law in the United States passed in 2010, sought to improve the healthfulness of the school food environment by requiring updated nutrition standards for school meals and competitive foods. Studies conducted since the passage of the HHFKA indicate improvements in the food environment overall, but few studies have examined whether these improvements varied by the socioeconomic and racial/ethnic composition of students in schools. To better understand the extent of disparities in the school food environment after HHFKA, this paper examined differences in the healthfulness of school food environments and the nutritional quality of school lunches by the school poverty level and racial/ethnic composition of students using data from the School Nutrition and Meal Cost Study. Results from chi-square analyses showed lower proportions of high poverty, majority black, and majority Hispanic schools had access to competitive foods, while higher proportions of these schools had a school wellness policy in addition to a district wellness policy. The overall nutritional quality of school lunches, as measured by total Healthy Eating Index (HEI)-2010 scores, did not vary significantly across school types, although some HEI component scores did. From these findings, we concluded that there were disparities in the school food environment based on the socioeconomic and racial/ethnic composition of students in schools, but no significant disparities in the overall nutritional quality of school lunches were found.

A Systems Approach Helps Explain Significant Improvements in Local Wellness Policies Among SNAP-Ed-Supported School Districts

OBJECTIVE

To assess changes in written local wellness policies (LWPs) across time within Supplemental Nutrition Assistance Program Education (SNAP-Ed)-participating districts.

DESIGN

Sequential, explanatory mixed methods.

SETTING

From October 1, 2015 to September 30, 2016, SNAP-Ed agencies submitted LWPs from partner school districts in Arizona. They received back scores and customized recommendations. To assess changes, LWPs were rescored between October 1, 2017 and September 30, 2018.

PARTICIPANTS

Sixteen local SNAP-Ed agencies worked with 57 districts.

INTERVENTIONS

Districts' LWP revisions supported by SNAP-Ed agencies during the 2-year pre-post period.

MAIN OUTCOME MEASURES

Policy comprehensiveness and strength from 0 (worst) to 100 (best), measured by the Wellness School Assessment Tool.

ANALYSIS

Paired t test to compare pre-post scores. Content analysis of State Educational Agency administrative reviews and thematic analysis of SNAP-Ed narrative reports to explore causation.

RESULTS

Total scores increased (comprehensiveness: +12.4, P < .001, 95% confidence interval, 8.1-16.7; strength: +13.5, P < .001, 95% CI, 9.3-17.7). Improvements were also found for comprehensiveness by section, except Nutrition Education, and for strength across all sections. Qualitative findings suggest that SNAP-Ed interventions combined with state and federal influence contributed to the improvements.

CONCLUSIONS AND IMPLICATIONS

Local wellness policies in SNAP-Ed-supported districts improved over time. State and federal LWP guidelines can work synergistically with SNAP-Ed interventions to influence improvements.

Going Beyond the State Law: Investigating High School Sport-Related Concussion Protocols

CONTEXT

State laws provide general guidelines for sport-related concussion (SRC) management, but do not comprehensively address the multiple layers of management for this complex injury. While high schools are encouraged to develop a SRC protocol that includes both state law tenets and additional management practices, the execution of this warrants examination.

OBJECTIVE

To investigate state law compliance and practice components included in high school SRC protocols, and determine whether the degree of sports medicine coverage influenced protocol quality.

DESIGN

Qualitative document analysis.

SETTING

High school athletics.

PARTICIPANTS

In total, 184 Pennsylvania high schools [24.3% of schools statewide; full-time athletic trainer=149, part-time athletic trainer=13, missing=21] voluntarily provided copies of their protocol from the 2018-2019 academic year.

MAIN OUTCOME MEASURES

Four athletic trainers conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (max 60) by sports medicine coverage was assessed using a Mann-Whitney U test.

RESULTS

There was heterogeneity in components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, while only 1.6% contained prevention strategies. Return-to-play was addressed more frequently than return-to-learn (74.5% versus 32.6%). The sample had a mean of 15.5±9.7 total components per protocol. Schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers (15 [8.5-22.5] versus 6 [3-10.5] median components; U = 377.5, p < .001) Conclusions: School-level written SRC protocols were often missing components of the state law and additional best practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and healthcare quality.

The Relationship between Written District Policies and School Practices among High-Need Districts in New York State

BACKGROUND

This study tested the hypothesis that written district wellness policies are associated with higher rates of implementation of nutrition and physical activity practices.

METHODS

Written wellness policies and building level practices were assessed for schools (N = 295) within high-need districts (N = 70) in New York State. The relationship between policies and practices was measured using multi-level mixed-effects logistic regressions.

RESULTS

Overall, stronger written district policies significantly increase the likelihood of practice implementation in schools. This relationship is strongest for physical education and physical activity items, followed by nutrition standards for competitive foods in middle and high schools. Most elementary schools implemented nutrition practices with or without a policy and there were differences in implementation rates between elementary and middle/high schools. When examined separately, policies were for the most part not significantly associated with implementation of corresponding practices.

CONCLUSIONS

Strong and comprehensive written policies are associated with higher rates of practice implementation overall, but the consistency of this relationship varies by policy-practice domain. The newer policy topics areas of school wellness promotion and marketing were less frequently included in written policies. Future research should examine whether districts that strengthen their written policies achieve greater implementation over time.

School readiness to adopt a school-based adolescent nutrition intervention in urban Indonesia

OBJECTIVE

To identify school community readiness to adopt a school-based adolescent nutrition intervention.

DESIGN

Cross-sectional study: mixed-methods design. The community readiness model was used to guide instrument development and qualitative analysis. Quantitative data are presented using descriptive statistics. Each statement was rated on a seven-point Likert scale, thereby producing scores between 1 (strongly disagree) and 7 (strongly agree).

SETTING

Ten of the twenty current public secondary schools in Bogor, Indonesia.

PARTICIPANTS

Ninety teachers and ten school principals.

RESULTS

Eating behaviour problem awareness was present among all participants; awareness of efforts to improve eating habits was also present, but these efforts were perceived as having low efficacy; support from the City Education Authority and Health Authority was present, but the support type did not match the perceived needs; nutrition education had not been implemented across the entire school community due to competing priorities; existing nutrition policies did not provide concrete scenarios and clear guidelines for nutrition-friendly schools; the availability and accessibility of healthy foods at schools were considered to be key factors in improved adolescent nutrition; positive attitudes existed among respondents towards the implementation of various nutrition programmes, and the median and mode were seven in all types of school-based intervention.

CONCLUSIONS

The school community readiness level regarding school-based adolescent nutrition interventions is currently in the action phase, implying that community leaders have begun organising efforts to address issues in adolescent nutrition and are aware of their consequences. Future support should be directed towards improving existing efforts and offering concrete ideas and clear policy guidelines for implementation.

Comprehensive Policies to Support Comprehensive Practices: Physical Activity in Elementary Schools

BACKGROUND

Schools are a setting in which students learn about the importance of lifelong physical activity (PA). Best practice guidelines indicate that schools should provide students with adequate physical education (PE) minutes and opportunities to engage in PA throughout the school day.

METHODS

Data from the nationally representative School Nutrition and Meal Cost Study in 2014-2015 were utilized to assess PA practices (including PE) at 412 public elementary schools. These data were linked to state- and district-level policy data from the National Wellness Policy Study to examine the relationships between state law and school district policies and school practices.

RESULTS

Just over half of the schools were in a state with a policy regarding PE minutes. The comprehensiveness and strength of PA policies were higher at the district level than the state level, but were still low overall. Comprehensiveness of PA policies at the state level, but not at the district level, was related to schools within those states that provide more PA practices.

CONCLUSIONS

Existence of PE and PA policies at the state level appears to be an important predictor of school PA practices. Having more comprehensive policies at the state level may be an important facilitator of school implementation of comprehensive PA practices.

Local School Wellness Policy as a Means to Advance Whole School, Whole Community, Whole Child: Assessing Alignment in Los Angeles County

BACKGROUND

District wellness policies provide an avenue to advance the Whole School, Whole Community, Whole Child (WSCC) model. The extent to which wellness policies currently align with WSCC is unclear; to-date, tools have been unavailable to examine this issue.

METHODS

We reviewed written health-focused policies among 37 school districts in Los Angeles County in 2017 utilizing a 54-item tool designed to examine the quality of policies in the 10 WSCC domains. Descriptive analyses explored overall and domain-specific comprehensiveness and strength; simple negative binomial regression models examined differences in the policy quality and structure by legislated status.

RESULTS

Approximately half of expected policies were present in wellness policies (mean comprehensiveness score = 52.65, ±18.09), < 20% were strong (mean strength score = 16.97, ±8.05). Content in WSCC domains addressed by legislative mandates was significantly more comprehensive and stronger, and more frequently located within the wellness policies, relative to content in non-legislated domains.

CONCLUSIONS

Opportunities exist for better alignment of wellness policies with WSCC. Education and health practitioners can utilize the tool developed for this study to identify priority areas where policy support is needed in their jurisdictions. Additional efforts are needed to help schools facilitate and document practice gains around WSCC-aligned policies.

School-based nutrition interventions for Indigenous children in Canada: a scoping review

BACKGROUND

Indigenous children in Canada (First Nations, Inuit, and Métis) are disproportionately affected by nutrition-related chronic diseases such as obesity and diabetes. Comprehensive school-based nutrition interventions offer a promising strategy for improving children's access to healthy foods and sustaining positive eating behaviors. However, little is known about school-based nutrition interventions for Indigenous children. The objectives of this scoping review were to identify school-based nutrition interventions for Indigenous children in Canada and describe their components.

METHODS

The scoping review consisted of searches in seven peer-reviewed databases and a general web search for grey literature. Eligibility criteria were applied by two reviewers, and data were extracted and charted by one reviewer using components of the comprehensive school health approach (social and physical environment, teaching and learning, policy, partnerships and services) and additional components with relevance to Indigenous interventions (cultural content, Indigenous control and ownership, funding source, evaluation). Numerical and descriptive summaries were used to present findings.

RESULTS

Thirty-four unique interventions met the inclusion criteria. The majority (97%) of interventions targeted the social and physical environment, most often by offering food programs. Over half of interventions also incorporated teaching and learning (56%) and partnerships and services (59%), but fewer included a policy component (38%). Many interventions included a cultural component (56%) and most (62%) were owned and controlled by Indigenous communities (62%). Finally, over half of interventions disclosed their source(s) of funding (59%), but less than half (41%) included an evaluation component.

CONCLUSIONS

The review suggests that school-based interventions for Indigenous children can be more comprehensive by incorporating culturally relevant nutrition education and professional development opportunities for teachers, written school nutrition policies, and activities that actively engage families and community members. The continued focus on Indigenous control and ownership and incorporation of content specific to individual communities may enhance cultural relevancy and sustainability of interventions. Furthermore, there is a need to increase intervention evaluation and the sharing of resources related to funding. These recommendations may be used by communities, as well as by researchers and professionals working with communities, in developing comprehensive school-based nutrition interventions to improve the eating behaviors of Indigenous children.

Quality of local school wellness policies for physical activity and resultant implementation in Pennsylvania schools

Background

In 2006, United States public schools participating in federal school meal programs were required to adopt school wellness policies. The effect of these policies on school nutrition environments is well documented; however, evaluation of physical activity policies has received less investigation. We aimed to evaluate how district wellness policies aligned to practice for physical activity implementation in 40 schools with high obesity rates (>24%).

Methods

Wellness policies were evaluated using the validated Wellness School Assessment Tool (WellSAT). Concurrently, schools completed the validated Alliance for a Healthier Generation's Healthy Schools Program (HSP) self-assessment to evaluate physical activity practices. Overall, 13 of 20 physical activity measures from WellSAT and 12 of 13 physical activity measures from HSP were aligned to match policy with practice.

Results

Most policy items scored 0 or 1, indicating either 'no mention in the policy' or 'containing weak or vague language'. Corresponding HSP results indicated that school physical activity practices are 'not in place' or 'under development'. A strong, positive, correlation (r = 0.92, P < 0.001) indicated that a significant relationship exists between policy and implementation.

Conclusions

Results indicate that most districts currently have weak policies regarding physical activity, limiting the potential to positively influence school-based physical activity.

Practice Paper of the Academy of Nutrition and Dietetics: Comprehensive Nutrition Programs and Services in Schools

It is the position of the Academy of Nutrition and Dietetics, School Nutrition Association (SNA), and Society for Nutrition Education and Behavior (SNEB) that comprehensive, integrated nutrition programs in preschool through high school are essential to improve the health, nutritional status, and academic performance of our nation's children. To maximize impact, the Academy, SNA, and SNEB recommend specific strategies in the following key areas: food and nutrition services available throughout the school campus, nutrition initiatives such as Farm to School and school gardens, wellness policies, nutrition education and promotion, and consideration of roles and responsibilities. This paper supports the joint position paper of the Academy of Nutrition and Dietetics, SNA, and SNEB published in the May 2018 Journal of Academy of Nutrition and Dietetics. In alignment with the joint position paper, this practice paper provides registered dietitian nutritionists and nutrition and dietetics technicians, registered with an overview of current school nutrition services and opportunities for professional careers in school settings. The Academy of Nutrition and Dietetics has several position papers related to youth preschool through adolescence that cover specific nutrition needs in more detail at www.eatright.org.

School Wellness in Wisconsin: Evaluating Policies for Practices to Prevent Pediatric Obesity

BACKGROUND

We examined written language in Wisconsin school wellness policies (SWPs) for federal mandate compliance, quality related to obesity prevention, and school characteristics associated with variations in quality. This is the first near census of Wisconsin SWPs and examines whether adhering to federal mandates results in strong policies aimed at preventing pediatric obesity.

METHODS

Policies were coded using the WellSAT 2.0. Policy quality was computed as comprehensiveness and strength based on 6 subscales and 2 overall scores. Variations in policy quality were examined by district size, free/reduced lunch percentage, and year of last revision.

RESULTS

We received SWPs from 91% of districts. Six of the 8 federal mandates were addressed by the majority of districts, although less than one fourth addressed all. Most comprehensiveness scores were weak to moderate, and strength scores were weak. All school characteristics were significantly related to overall policy quality; effect sizes were small.

CONCLUSIONS

Our results confirm the necessity of statewide focus on SWP improvement and suggest that while districts may be meeting federal mandates related to pediatric obesity, few policies include health promotion practices beyond those required. Policies remain fragmented and lack focus on obesity prevention practices; we identify modifiable areas for improvement.

Factors Influencing the Implementation of Nutrition Policies in Schools: A Scoping Review

BACKGROUND

Although school nutrition policies (SNPs) have been highlighted as an important intervention to support childhood nutrition, their implementation and maintenance within real-word settings is complex. There is a need to understand the factors that influence implementation by consolidating existing research and identifying commonalities and differences.

AIMS

The purpose of this review is to determine what is known about the influence of broad and local system factors on the implementation of SNPs internationally.

METHOD

This scoping review involved identifying and selecting relevant literature that related SNP implementation in primary and secondary schools. Following the search process, 2,368 articles were screened and 59 articles were synthesized and charted and emerging themes were identified.

RESULTS

Across the final studies identified, factors emerged as barriers and facilitators to the implementation of SNPs, with system implications that related to five areas to support policy action: providing macro-level support may encourage policy implementation; addressing the financial implications of healthy food access; aligning nutrition and core school priorities; developing a common purpose and responsibility among stakeholders; recognition of school and community characteristics.

DISCUSSION

While SNPs can help to support childhood nutrition, strategies to address issues related to policy implementation need to be taken to help schools overcome persistent challenges.

CONCLUSION

The results of this review provide opportunities for action across multiple system levels to ensure synergy and coordinated action toward SNP goals to foster the creation supportive nutrition environments for children.

Utilizing the RE-AIM framework to understand adoption of nutrition policies at food pantries across the USA

One in five food pantries had a formal nutrition policy, and informal nutrition policies existed for half of the food pantries that responded to the survey.

A Case Study of a New State Model for Assessing Local Wellness Policies

BACKGROUND

In 2016, the United States Department of Agriculture issued a final rule to strengthen local wellness policies (LWPs). As school districts pursue compliance, states can provide critical guidance by leveraging support from intermediary programs such as the Supplemental Nutrition Assistance Program-Education (SNAP-Ed). After Arizona SNAP-Ed piloted a statewide model for assessing LWPs, we evaluated that model by exploring local SNAP-Ed agency experiences with the pilot. Our case study objectives were to determine the model's feasibility and utility from the perspective of local agencies supporting school districts during LWP review and revision.

METHODS

We used open-ended semistructured interviews with the 13 local SNAP-Ed agencies who engaged in each LWP assessment phase and analyzed data using constant comparative analysis.

RESULTS

Participants found the model feasible and useful. Five themes emerged, 3 of which tracked strongly with successful LWP review and revision: local agency staff comprehension, the openness of local agency staff and district/school personnel to the process, and the local agency's engagement of the district/school throughout the process.

CONCLUSIONS

Leveraging local agency support can be an effective strategy to improving LWPs, given understanding, buy-in, and staff engagement. Findings can inform agencies seeking to engage intermediaries in LWP assessment and revision.

Wellness Committee Status and Local Wellness Policy Implementation Over Time

INTRODUCTION

Local Wellness Policies are school-district documents containing guidelines for schools to promote nutrition/physical activity. In cross-sectional studies, schools with wellness committees are more likely to implement Local Wellness Policies. This prospective cohort study examines associations between wellness committee status over time and change in Local Wellness Policy implementation using a biennial, statewide survey.

METHODS

School administrators completed surveys following the 2012-2013 (Wave I) and 2014-2015 (Wave II) school years, including a 17-item Local Wellness Policy implementation scale. Four wellness committee status categories included established (both Waves, 35%); new (Wave II only, 22%); discontinued (Wave I only, 13%); and never (neither Wave, 30%). Linear mixed models conducted in 2017-2018 compared LWP implementation change across status groups, accounting for clustering and school characteristics.

RESULTS

Of 1,333 schools, 701 had Wave I data (53%); 748 Wave II (56%); and 441 both (33%). Schools were 69% elementary, 56% suburban, and 35% and 28% had majority (≥75%) African American/Hispanic or low-income student body, respectively. At Wave I, schools with wellness committees (established/discontinued groups) had higher Local Wellness Policy implementation (mean=32.0, SD=11.5, and mean=28.3, SD=11.4, respectively) compared with schools without committees (never/new: mean=15.4, SD=10.7 and mean=17.6, SD=11.4, respectively, F=64.9, p≤0.001). Over time, never and established groups maintained low and high Local Wellness Policy implementation, respectively. Compared with never, new committees increased implementation by 9.9 points (SE=1.8, p<0.001), and discontinued committees decreased by 11.2 (SE=2.1, p<0.001).

CONCLUSIONS

Forming and maintaining wellness committees encourages Local Wellness Policy implementation and should be a recommended strategy for school wellness promotion.

Implementing School-Based Policies to Prevent Obesity: Cluster Randomized Trial

INTRODUCTION

Healthier school environments can benefit students, and school wellness policies may result in meaningful enhancements. Schools participating in federal child nutrition programs must implement wellness policies as mandated by law. The primary study objective is to assess effectiveness of implementing school-based nutrition and physical activity policies on student BMI trajectories.

STUDY DESIGN

Cluster randomized trial using 2 × 2 factorial design.

SETTING/PARTICIPANTS

Twelve randomly selected schools in an urban district. Students were followed for 3 years through middle school, fifth to eighth grades (2011-2015, n=595 students, 92.3% participation, 85.2% retention).

INTERVENTION

Specific to randomized condition, support was provided for implementation of nutrition policies (e.g., alternatives to food-based rewards/celebrations) and physical activity policies (e.g., opportunities for physical activity during/after school).

MAIN OUTCOME MEASURES

Sex-/age-adjusted BMI percentile and BMI z-score; behavioral indicators. Data collected via standardized protocols.

RESULTS

Analyses followed intention-to-treat principles, with planned secondary analyses (conducted 2016-2018). Students at schools randomized to receive support for nutrition policy implementation had healthier BMI trajectories over time (F=3.20, p=0.02), with a greater magnitude over time and cumulatively significant effects 3 years post-intervention (β=-2.40, p=0.04). Overall, students at schools randomized to receive the nutrition intervention had an increase in BMI percentile of <1%, compared with students in other conditions, whereas BMI percentile increased 3%-4%. There was no difference in student BMI between those in schools with and without physical activity policy implementation. Examining behavioral correlates in eighth grade, students at schools randomized to the nutrition condition consumed fewer unhealthy foods and sugar-sweetened beverages, and ate less frequently at fast-food restaurants (all p<0.03).

CONCLUSIONS

This cluster randomized trial demonstrated effectiveness of providing support for implementation of school-based nutrition policies, but not physical activity policies, to limit BMI increases among middle school students. Results can guide future school interventions.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02043626.

Barriers and Enablers to the Implementation of School Wellness Policies: An Economic Perspective

BACKGROUND

Local wellness policies (LWPs) are mandated among school systems to enhance nutrition/physical activity opportunities in schools. Prior research notes disparities in LWP implementation. This study uses mixed methods to examine barriers/enablers to LWP implementation, comparing responses by student body income.

METHOD

Schools ( n = 744, 24 systems) completed an LWP implementation barriers/enablers survey. Semistructured interviews ( n = 20 random subsample) described barriers/enablers. Responses were compared by majority of lower (≥50% free/reduced-price meals; lower income [LI]) versus higher income (HI) student body.

RESULTS

In surveys, LI and HI schools identified common barriers (parents/families, federal/state regulations, students, time, funding) and enablers (school system, teachers, food service, physical education curriculum/resources, and staff). Interviews further elucidated how staffing and funding served as enablers for all schools, and provide context for how and why barriers differed by income: time, food service (HI schools), and parents/families (LI schools).

CONCLUSIONS

Findings support commonalities in barriers and enablers among all schools, suggesting that regardless of economic context, schools would benefit from additional supports, such as physical education and nutrition education resources integrated into existing curricula, additional funding, and personnel time dedicated to wellness programming. LI schools may benefit from additional funding to support parent and community involvement.

Pilot-Testing an Intervention to Enhance Wellness Policy Implementation in Schools: Wellness Champions for Change

OBJECTIVE

To develop and pilot-test Wellness Champions for Change (WCC) to enhance local wellness policy (LWP) implementation by forming wellness teams.

DESIGN

Randomized, controlled school-level pilot study.

SETTING

Five Maryland school districts.

PARTICIPANTS

A total of 63 elementary, middle, or high schools.

INTERVENTION(S)

Developed from stakeholder interviews, focus groups, and existing programs. Schools were randomized within district to (1) WCC training (6-hour, single-day teacher training), (2) WCC training plus technical assistance (TA), or (3) delayed training (control).

MAIN OUTCOME MEASURE(S)

Online teacher/administrator survey pre-post (spring, 1 year apart) that examined the direct effect of the intervention on active wellness team formation (postintervention, 8-item sum score) and LWP implementation (29 items, not implemented to fully implemented)/indirect effect of intervention on LWP implementation via active wellness team formation.

ANALYSIS

Adjusted linear or logistic regression and mediation modeling.

RESULTS

Postintervention, WCC plus TA and WCC had more active wellness teams (vs control, β = 1.49, P = .02 and β = 1.42, P = .03, respectively). No direct effect of intervention on LWP implementation was found. Formation of active wellness teams mediated the association between both WCC plus TA and WCC and LWP implementation (WCC plus TA confidence interval [CI], 1.22-16.25; WCC CI, 10.98-15.61 [CI was significant without 0]).

CONCLUSIONS AND IMPLICATIONS

The WCC intervention approaches indirectly affected LWP implementation through the formation of active wellness teams. These results support building and school-level wellness teams.

Use of a Model Wellness Policy May Not Increase the Strength and Comprehensiveness of Written School Wellness Policies

BACKGROUND

Many state agencies have developed model wellness policies (MWPs) to serve as examples for schools when writing their own school wellness policy (SWP). The purpose of this study was to evaluate if a MWP aids schools in writing stronger, more comprehensive SWPs.

METHODS

For this cross-sectional study, 91 school districts submitted their current SWP and completed a survey that classified districts into either districts that utilized the state MWP (N = 56; 61.5%) or those that did not (NMWP, N =35; 38.5%). The Wellness School Assessment Tool (WellSAT) was used to assess the strength, comprehensiveness, total overall score, and subsection scores of each policy. Dependent variables were compared between groups using t tests. Statistical significance was set at p ≤ .05. Data are presented as mean ±SD.

RESULTS

No significant differences were found between groups in total overall (MWP 76.8 ± 37.9; NMWP 62.1 ± 34.3), strength (MWP 25.3 ± 17.6; NMWP 19.1 ± 12.8), or comprehensiveness scores (MWP 51.5 ± 21.2; NMWP 43.0 ± 22.1). The only subsection score difference identified between groups was the Nutrition Standards comprehension score (p = .02).

CONCLUSIONS

These data suggest MWPs may not improve the quality of written SWPs. Further research is needed to better understand the needs of school districts in SWP development.

School Wellness Programs: Magnitude and Distribution in New York City Public Schools

BACKGROUND

Public schools provide students with opportunities to participate in many discretionary, unmandated wellness programs. Little is known about the number of these programs, their distribution across schools, and the kinds of students served. We provide evidence on these questions for New York City (NYC) public schools.

METHODS

Data on wellness programs were collected from program websites, NYC's Office of School Food and Wellness, and direct contact with program sponsors for 2013. Programs were grouped into categories, nutrition, fitness, and comprehensive, and were combined with data on school characteristics available from NYC's Department of Education. Numbers of programs and provision of programs were analyzed for relationships with demographic and school structural characteristics, using descriptive statistics and multiple regression.

RESULTS

Discretionary wellness programs are numerous, at 18 programs. Little evidence supports inequity according to student race/ethnicity, income, or nativity, but high schools, new schools, co-located schools, small schools, and schools with larger proportions of inexperienced teachers are less likely to provide wellness programs.

CONCLUSIONS

Opportunities exist to further the reach of wellness programs in public schools by modifying them for high school adoption and building capacity in schools less likely to have the administrative support to house them.

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

INTRODUCTION

The School Obesity-related Policy Evaluation (ScOPE) Study uses existing public surveillance data and applies a rigorous study design to evaluate effectiveness of school policies and practices impacting student behavioral and weight outcomes.

METHODS

The ScOPE Study used a cohort of 50 combined junior-senior and high schools in Minnesota to evaluate the change in weight-related policy environments in 2006 and 2012 and test the effect of policy change on students attending those schools in 2007 and 2013. Exposure variables included school practices about foods and beverages available in school vending machines and school stores, physical education requirements, and intramural opportunities. Primary study outcomes were average school-level ninth grade student BMI percentile, obesity prevalence, daily servings of fruits/vegetables, and daily glasses of soda.

RESULTS

Availability of fruits/vegetables in schools was associated with a significant increase in total daily intake among ninth grade students by 0.4 servings. Availability of soda in schools was associated with a significant increase in total daily intake among ninth grade boys by 0.5 servings. Less-healthy snack and drink availability in schools was associated with a small, significant increase (1%) in student BMI percentile at the school level.

CONCLUSIONS

Use of a school-level longitudinal cohort study design over a 6-year period uniquely adds to the methodologic rigor of school policy and practice evaluation studies. The ScOPE Study provides marginal evidence that school policies and practices, especially those that restrict vending and school store offerings, may have small effects on weight status among ninth grade students.

Implementation of Local Wellness Policies in Schools: Role of School Systems, School Health Councils, and Health Disparities

BACKGROUND

Written local wellness policies (LWPs) are mandated in school systems to enhance opportunities for healthy eating/activity. LWP effectiveness relies on school-level implementation. We examined factors associated with school-level LWP implementation. Hypothesized associations included system support for school-level implementation and having a school-level wellness team/school health council (SHC), with stronger associations among schools without disparity enrollment (majority African-American/Hispanic or low-income students).

METHODS

Online surveys were administered: 24 systems (support), 1349 schools (LWP implementation, perceived system support, SHC). The state provided school demographics. Analyses included multilevel multinomial logistic regression.

RESULTS

Response rates were 100% (systems)/55.2% (schools). Among schools, 44.0% had SHCs, 22.6% majority (≥75%) African-American/Hispanic students, and 25.5% majority (≥75%) low-income (receiving free/reduced-price meals). LWP implementation (17-items) categorized as none = 36.3%, low (1-5 items) = 36.3%, high (6+ items) = 27.4%. In adjusted models, greater likelihood of LWP implementation was observed among schools with perceived system support (high versus none relative risk ratio, RRR = 1.63, CI: 1.49, 1.78; low versus none RRR = 1.26, CI: 1.18, 1.36) and SHCs (high versus none RRR = 6.8, CI: 4.07, 11.37; low versus none RRR = 2.24, CI: 1.48, 3.39). Disparity enrollment did not moderate associations (p > .05).

CONCLUSIONS

Schools with perceived system support and SHCs had greater likelihood of LWP implementation, with no moderating effect of disparity enrollment. SHCs/support may overcome LWP implementation obstacles related to disparities.

Strength and Comprehensiveness of School Wellness Policies in Southeastern US School Districts

BACKGROUND

In 2004, Congress passed legislation mandating that all public school districts participating in federal school meal programs develop a school wellness policy (SWP) to direct efforts related to nutrition and physical activity. We examined the extent to which SWPs varied in comprehensiveness and strength in a representative sample of school districts in the southeastern United States, the area of the country with the highest rates of childhood obesity.

METHODS

Policies were assessed using an established 96-item coding tool by 2 raters to ascertain the comprehensiveness and strength of the policies as a whole, and across distinct subsections specified by federal legislation. In addition, variability in SWP comprehensiveness and strength was assessed based on district sociodemographic characteristics.

RESULTS

Overall, SWPs in the southeastern states are weakly written, fragmented, and lack requirements necessary for healthy school environments. District size, which was the only sociodemographic factor related to policy characteristics, yielded an inverse association.

CONCLUSIONS

To encourage continued promotion of healthy school environments, school districts will require technical support to improve the quality of their school wellness policies.

Bigger ≠ Better: The Comprehensiveness and Strength of School Wellness Policies Varies by School District Size

BACKGROUND

District size has been shown to impact the anticipated barriers to wellness policy creation and implementation. Therefore, the purpose of the present study was to determine if strength and comprehensiveness of wellness policies differs among school districts of varying size.

METHODS

Wellness policies were collected from 10 large, 29 medium, and 31 small school districts in a rural Midwest state. District size was categorized by the average daily membership in grades 9-11. Polices were coded using the Wellness School Assessment Tool (WellSAT). Strength and comprehensiveness of the full policy and policy sections were compared among small, medium, and large districts using 1-way analyses of variance (ANOVAs). Data are presented as mean ± SD. Statistical significance was set at p ≤ .05.

RESULTS

There was a difference in the total combined (p = .041), total comprehensiveness (p = .043), and total strength scores (p = .031) based on school district size, such that small districts had stronger, more comprehensive wellness policies than large districts. Section comparisons revealed the section focused on Standards for United States Department of Agriculture School Meals was primarily responsible for these differences.

CONCLUSIONS

These data suggest smaller districts write policies that are more comprehensive to governmental standards and use more definitive language than larger districts.

The School Food Environment and Obesity Prevention: Progress Over the Last Decade

The school food environment-including when and where children obtain food and the types of options available during the school day-plays an important role in children's consumption patterns. Thus, childhood obesity prevention efforts often focus on altering the school food environment as a mechanism for improving student dietary intake. This review examines the role school food programs and policies play in improving children's diet, weight, and health. Overall, research suggests that significant improvements have been made in school nutrition policies and programs. Due to the recent program changes made as a result of the 2010 Healthy, Hunger-Free Kids Act, an emphasis was placed on research conducted over the past decade and especially on the evaluation of foods and beverages served and sold since implementation of this national law. This review also examines remaining gaps in the literature and opportunities for further improvements in school food programs and policies.