Jan Jernigan

An Evaluation Framework for Obesity Prevention Policy Interventions

As the emphasis on preventing obesity has grown, so have calls for interventions that extend beyond individual behaviors and address changes in environments and policies. Despite the need for policy action, little is known about policy approaches that are most effective at preventing obesity. The Centers for Disease Control and Prevention (CDC) and others are funding the implementation and evaluation of new obesity prevention policies, presenting a distinct opportunity to learn from these practice-based initiatives and build the body of evidence-based approaches. However, contributions from this policy activity are limited by the incomplete and inconsistent evaluation data collected on policy processes and outcomes. We present a framework developed by the CDC-funded Center of Excellence for Training and Research Translation that public health practitioners can use to evaluate policy interventions and identify the practice-based evidence needed to fill the gaps in effective policy approaches to obesity prevention.

Measurement of Compliance With New York City’s Regulations on Beverages, Physical Activity, and Screen Time in Early Child Care Centers

Introduction Policy interventions designed to change the nutrition environment and increase physical activity in child care centers are becoming more common, but an understanding of the implementation of these interventions is yet to be developed. The objective of this study was to explore the extent and consistency of compliance with a policy intervention designed to promote nutrition and physical activity among licensed child care centers in New York City. Methods We used a multimethod cross-sectional approach and 2 independent components of data collection (Center Evaluation Component and Classroom Evaluation Component). The methods were designed to evaluate the impact of regulations on beverages served, physical activity, and screen time at child care centers. We calculated compliance scores for each evaluation component and each regulation and percentage agreement between compliance in the center and classroom components. Results Compliance with certain requirements of the beverage regulations was high and fairly consistent between components, whereas compliance with the physical activity regulation varied according to the data collection component. Compliance with the regulation on amount and content of screen time was high and consistent. Conclusion Compliance with the physical activity regulation may be a more fluid, day-to-day issue, whereas compliance with the regulations on beverages and television viewing may be easier to control at the center level. Multiple indicators over multiple time points may provide a more complete picture of compliance — especially in the assessment of compliance with physical activity policies.

Implementing a farmers' market incentive program: perspectives on the New York City Health Bucks Program.

Introduction One strategy for lowering the prevalence of obesity is to increase access to and affordability of fruits and vegetables through farmers’ markets. However, little has been documented in the literature on the implementation of such efforts. To address this gap, the Division of Nutrition, Physical Activity, and Obesity (DNPAO) sponsored an evaluation of the New York City Health Bucks program, a farmers’ market coupon incentive program intended to increase access to fresh fruits and vegetables in underserved neighborhoods while supporting local farmers. Methods We conducted a process evaluation of Health Bucks program implementation. We interviewed 6 farmer/vendors, 3 market managers, and 4 program administrators, and collected data on site at 86 farmers’ markets, including surveys of 81 managers and 141 farmer/vendors on their perspectives on promotion and redemption of the incentive coupons; knowledge and attitudes regarding the program; experiences with markets and products; and facilitators and barriers to program participation. Results Results indicate that respondents view Health Bucks as a positive program model. Farmers’ market incentive coupon programs like Health Bucks are one strategy to address the problem of obesity and were associated with higher fruit and vegetable access and purchases in low-income communities. Conclusions This evaluation identified some areas for improving implementation of the Health Bucks program. Farmers’ market incentive programs like Health Bucks may be one avenue to increase access to and affordability of fruits and vegetables among low-income persons. Further research is needed to assess the potential effects of these programs on access and health outcomes.

Evaluation design of New York City's regulations on nutrition, physical activity, and screen time in early child care centers.

This article describes the multi-method cross-sectional design used to evaluate New York City Department of Health and Mental Hygiene’s regulations of nutrition, physical activity, and screen time for children aged 3 years or older in licensed group child care centers. The Center Evaluation Component collected data from a stratified random sample of 176 licensed group child care centers in New York City. Compliance with the regulations was measured through a review of center records, a facility inventory, and interviews of center directors, lead teachers, and food service staff. The Classroom Evaluation Component included an observational and biometric study of a sample of approximately 1,400 children aged 3 or 4 years attending 110 child care centers and was designed to complement the center component at the classroom and child level. The study methodology detailed in this paper may aid researchers in designing policy evaluation studies that can inform other jurisdictions considering similar policies.

What Evidence and Support Do State-Level Public Health Practitioners Need to Address Obesity Prevention:

Purpose. Obesity has reached epidemic proportions. Public health practitioners are distinctly positioned to promote the environmental changes essential to addressing obesity. The Centers for Disease Control and Prevention (CDC) and other entities provide evidence and technical assistance to support this work, yet little is known about how practitioners use evidence and support as they intervene to prevent obesity. The studys purpose was to describe how practitioners and CDC project officers characterized the obesity prevention task, where practitioners accessed support and evidence, and what approaches to support and evidence they found most useful. Approach or Design. Mixed-methods, cross-sectional interviews, and survey. Setting. State-level public health obesity prevention programs. Participants. Public health practitioners and CDC project officers. Method. We conducted 10 in-depth interviews with public health practitioners (n = 7) and project officers (n = 3) followed by an online survey completed by 62 practitioners (50% response rate). We applied content analysis to interview data and descriptive statistics to survey data. Results. Practitioners characterized obesity prevention as uncertain and complex, involving interdependence among actors, multiple levels of activity, an excess of information, and a paucity of evidence. Survey findings provide further detail on the types of evidence and support practitioners used and valued. Conclusion. We recommend approaches to tailoring evidence and support to the needs of practitioners working on obesity prevention and other complex health problems.

Relationship between child care centers' compliance with physical activity regulations and children's physical activity, New York City, 2010.

Introduction Physical activity may protect against overweight and obesity among preschoolers, and the policies and characteristics of group child care centers influence the physical activity levels of children who attend them. We examined whether children in New York City group child care centers that are compliant with the city’s regulations on child physical activity engage in more activity than children in centers who do not comply. Methods A sample of 1,352 children (mean age, 3.39 years) served by 110 group child care centers in low-income neighborhoods participated. Children’s anthropometric data were collected and accelerometers were used to measure duration and intensity of physical activity. Multilevel generalized linear regression modeling techniques were used to assess the effect of center- and child-level factors on child-level physical activity. Results Centers’ compliance with the regulation of obtaining at least 60 minutes of total physical activity per day was positively associated with children’s levels of moderate to vigorous physical activity (MVPA); compliance with the regulation of obtaining at least 30 minutes of structured activity was not associated with increased levels of MVPA. Children in centers with a dedicated outdoor play space available also spent more time in MVPA. Boys spent more time in MVPA than girls, and non-Hispanic black children spent more time in MVPA than Hispanic children. Conclusion To increase children’s level of MVPA in child care, both time and type of activity should be considered. Further examination of the role of play space availability and its effect on opportunities for engaging in physical activity is needed.

Neighborhood Disparities in Prevalence of Childhood Obesity Among Low-Income Children Before and After Implementation of New York City Child Care Regulations

Introduction New York City Article 47 regulations, implemented in 2007, require licensed child care centers to improve the nutrition, physical activity, and television-viewing behaviors of enrolled children. To supplement an evaluation of the Article 47 regulations, we conducted an exploratory ecologic study to examine changes in childhood obesity prevalence among low-income preschool children enrolled in the Nutrition Program for Women, Infants, and Children (WIC) in New York City neighborhoods with or without a district public health office. We conducted the study 3 years before (from 2004 through 2006) and after (from 2008 through 2010) the implementation of the regulations in 2007. Methods We used an ecologic, time-trend analysis to compare 3-year cumulative obesity prevalence among WIC-enrolled preschool children during 2004 to 2006 and 2008 to 2010. Outcome data were obtained from the New York State component of the Centers for Disease Control and Prevention’s Pediatric Nutrition Surveillance System. Results Early childhood obesity prevalence declined in all study neighborhoods from 2004–2006 to 2008–2010. The greatest decline occurred in Manhattan high-risk neighborhoods where obesity prevalence decreased from 18.6% in 2004–2006 to 15.3% in 2008–2010. The results showed a narrowing of the gap in obesity prevalence between high-risk and low-risk neighborhoods in Manhattan and the Bronx, but not in Brooklyn. Conclusion The reductions in early childhood obesity prevalence in some high-risk and low-risk neighborhoods in New York City suggest that progress was made in reducing health disparities during the years just before and after implementation of the 2007 regulations. Future research should consider the built environment and markers of differential exposure to known interventions and policies related to childhood obesity prevention.

Training and technical assistance for compliance with beverage and physical activity components of New York city's regulations for early child care centers.

Introduction In 2006, the New York City Department of Health and Mental Hygiene (DOHMH) passed regulations for child care centers that established standards for beverages provided to children and set a minimum amount of time for daily physical activity. DOHMH offered several types of training and technical assistance to support compliance with the regulations. This article analyzes the association between training and technical assistance provided and compliance with the regulations in a sample of 174 group child care centers. Methods Compliance was measured by using a site inventory of beverages stored on premises and a survey of centers’ teachers regarding the amount of physical activity provided. Training and technical assistance measures were based on the DOHMH records of training and technical assistance provided to the centers in the sample and on a survey of center directors. Ordinal logistic regression was used to assess the association between training and technical assistance measures and compliance with the regulations. Results Measures of training related to physical activity the center received: the number of staff members who participated in Sport, Play and Active Recreation for Kids (SPARK) and other training programs in which a center participated were associated with better compliance with the physical activity regulations. Neither training nor technical assistance were associated with compliance with the regulations related to beverages. Conclusion Increased compliance with regulations pertaining to physical activity was not related to compliance with beverage regulations. Future trainings should be targeted to the specific regulation requirements to increase compliance.

Evaluating Public Health Resources: What Happens When Funding Disappears?

Introduction Although various factors affect the sustainability of public health programs, funding levels can influence many aspects of program continuity. Program evaluation in public health typically does not assess the progress of initiatives after discontinuation of funding. The objective of this study was to describe the effect of funding loss following expiration of a 5-year federal grant awarded to state health departments for development of statewide obesity prevention partnerships. Methods The study used qualitative methods involving semistructured key informant interviews with state health departments. Data were analyzed using thematic analysis for effect of funding loss on staffing, programs, partnerships, and implementation of state plans. Results Many of the programs that continued to run after the grant expired operated at reduced capacity, either reaching fewer people or conducting fewer program activities for the same population. Although many states were able to leverage funding from other sources, this shift in funding source often resulted in priorities changing to meet new funding requirements. Evaluation capacity suffered in all states. Nearly all states reported losing infrastructure and capacity to communicate widely with partners. All states reported a severe or complete loss of their ability to provide training and technical assistance to partners. Despite these reduced capacities, states reported several key resources that facilitated continued work on the state plan. Conclusions Decisions regarding continuation of funding are often dependent on budget constraints, evidence of success, and perceived ability to succeed in the future. Evaluating public health funding decisions may help guide development of best practice strategies for supporting long-term program success.

Developing Stories From the Field to Highlight Policy, Systems, and Environmental Approaches in Obesity Prevention

As obesity prevention initiatives increasingly shift toward approaches focused on policy, systems, and environmental change, opportunities to share experiences from the field and lessons learned are growing. Stories are a tool to illustrate processes and outcomes of initiatives that can complement quantitative results. The use of stories, however, is not widely recognized, and the methods and tools available to develop stories are limited. Therefore, we describe the methods used to collect, develop, and disseminate stories featuring comprehensive obesity prevention efforts that various state health departments are planning and implementing. We also discuss potential challenges and provide recommendations that public health practitioners may consider when developing similar stories.