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The SNAP-Ed Evaluation Framework offers a new suite of evaluation measures toward eliminating disparities that contribute to poor diet, physical inactivity, food insecurity and obesity., The United States Department of Agriculture’s Supplemental Nutrition Assistance Program Education, known as SNAP-Ed, is the country’s largest and most diverse community nutrition program. In 2017, nearly 140 SNAP-Ed implementing agencies (SIAs) and hundreds of contractors delivered nutrition education to almost 5 million people in nearly 60,000 low-resource sites. Millions more were impacted with social marketing campaigns and policy, systems, and environmental changes. This article introduces and describes the benefits of the newly developed SNAP-Ed Evaluation Framework (Framework) and companion Interpretive Guide to consistently measure SNAP-Ed outcomes across different settings. The Framework uses the social ecological model as its underlying theory and features 51 indicators across four levels: Individual, Environmental Supports, Sectors of Influence, and Population Results. Topline findings from the first-year Census to track Framework adoption found that most SIAs intended to impact indicators closer to the inner levels of influence: Individual (mean = 59% of SIAs; SD = 22%) and Environmental Settings (mean = 48%; SD = 23%). As yet, few SIAs targeted outcomes for long-term indicators (mean = 26%; SD = 15%), Sectors of Influence (mean = 20%; SD = 12%), or Population Results (mean = 30%; SD = 11%). An in-depth example of how one state is using the Framework is described. The SNAP-Ed Evaluation Framework offers a new suite of evaluation measures toward eliminating disparities that contribute to poor diet, physical inactivity, food insecurity and obesity. Practitioners will need technical assistance to implement the Framework, especially to measure longer-term, multi-sector and population results, and to maximize effectiveness in SNAP-Ed.

Background Collective impact theory suggests coalitions can encourage community-level policy and systems changes supported by the Supplemental Nutrition Assistance Program – Education (SNAP-Ed). A recent Cochrane review found coalition efforts improved health disparities, but insufficient knowledge of coalition characteristics limited understanding of underlying mechanisms. Objective Measure community coalition characteristics across time to identify potential areas for improvement. Study Design, Setting, Participants Trained SNAP-Ed staff administered the research-tested Wilder Collaboration Factors Inventory (Wilder) as a pretest and 2 years later as a posttest, at the level of the coalition. Community coalitions were established for at least 6 months, worked in the food systems (FS) or active living (AL) SNAP-Ed focus areas, and included at least 5 organizations and a SNAP-Ed representative. Seven coalitions (n = 73 members) completed the Wilder in both years, including 3 FS (n = 36) and 4 AL (n = 37) coalitions. Measurable Outcome/Analysis Within-group (by focus area) analyses across time: Wilcoxon signed-rank tests to compare scores for the 20 Wilder factors. Descriptive statistics for percentage of respondents whose scores for individual factors decreased. Results Across 2 years, coalition members reported improvements related to coalition purpose, collaborative environment, and perception of resources. Coalition processes and membership characteristics showed decreases. For FS coalitions: Unique Purpose improved significantly (P Conclusion Coalitions that persist over time may increase their level of collaboration, collective purpose, and resource security. They may need ongoing support to maintain internal processes and address membership characteristics. Implications of this work include successful measurement of short-term changes in coalition capacity outcomes; this highlighting of strengths and weaknesses may improve coalition efforts to address longer-term community-level objectives. Funding Supplemental Nutrition Assistance Program-Education.

To assess changes in written local wellness policies (LWPs) across time within Supplemental Nutrition Assistance Program Education (SNAP-Ed)-participating districts.Sequential, explanatory mixed methods.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.Sixteen local SNAP-Ed agencies worked with 57 districts.Districts' LWP revisions supported by SNAP-Ed agencies during the 2-year pre-post period.Policy comprehensiveness and strength from 0 (worst) to 100 (best), measured by the Wellness School Assessment Tool.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.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.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.

Background The AZ Health Zone administers Arizona's SNAP-Ed program. Our multi-year, statewide evaluations follow national evaluation standards, including accuracy and utility. The Rudd Center for Food Policy & Obesity developed the WellSAT to measure the quality of written SWPs, in consultation with an advisory board. The WellSAT has been updated twice to reflect changes to national regulations from the Healthy, Hunger-Free Kids Act. Objective To identify key characteristics of an accurate, useful system for large-scale SWP assessment. Study Design, Settings, Participants From October 2015—September 2018, the AZ Health Zone State Evaluation Team used a WellSAT scoring process to assess the quality of written school wellness policies (SWPs) from over 120 SNAP-Ed-qualified districts across Arizona's 15 counties. Local SNAP-Ed agencies submitted SWPs for WellSAT scoring and received back results and recommendations to use with districts. Measurable Outcome/Analysis We conducted a meta-evaluation to improve the WellSAT scoring process. Data from SWP meetings, evaluation meetings, debrief sessions, and interviews with Local SNAP-Ed Agencies were systematically analyzed to identify best practices for large-scale SWP assessment using the WellSAT. Results We identified five key characteristics of our scoring system. Use two consistent scorers. We enhanced accuracy by comparing results from two trained, independent scorers to catch errors and resolve discrepancies. Train scorers using state-specific guidelines. We further improved accuracy by developing a state-specific scoring template. Aim for rapid, responsive turnaround. We bolstered the utility of findings by generating results within four to eight weeks, or before district SWP meetings. Offer guidance on interpreting scores. We also enhanced utility by helping users understand how their scores compared to state averages and national trends. Create easy-to-use recommendations. We improved utility by providing users with editable, score-based recommendations on how to revise SWP language. Conclusion The accuracy and utility of large-scale SWP assessment can be enhanced using the five practices described above.

Objective Consumption of sugar-sweetened beverages (SSB) is linked to obesity. The authors hypothesized that school-based nutrition education would decrease SSB consumption. Design Self-selected interventional cohort with random selection for pre and post measurements. Setting Arizona Supplemental Nutrition Assistance Program–Education Program–eligible schools. Participants Randomly selected (9%) fourth- and fifth-grade classroom students. Intervention The University of Arizona Nutrition Network provided general nutrition education training and materials to teachers, to be delivered to their students. The University of Arizona Nutrition Network administered behavioral questionnaires to students in both fall and spring. Main Outcome Measure(s) Change in SSB consumption. Analyses Descriptive statistics were computed for student demographics and beverage consumption on the day before testing. Paired t tests evaluated change in classroom averages. Linear regression assessed potential correlates of SSB consumption. Results Fall mean SSB consumption was 1.1 (± 0.2) times; mean milk and water intake were 1.6 (± 0.2) and 5.2 (± 0.7) times, respectively. Beverage consumption increased (3.2%) in springtime, with increased SSBs (14.4%) accounting for the majority (P = .006). Change in SSB consumption was negatively associated with baseline SSB and water consumption but positively associated with baseline milk fat (P ≤ .05). Conclusions and Implications The results suggest the need for beverage-specific education to encourage children to consume more healthful beverages in warmer weather.

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.

Background The Supplemental Nutrition Assistance Program-Education (SNAP-Ed) encourages nutrition and physical activity in districts and schools where over 50% of students receive free-and-reduced-price lunch. In Arizona, the AZ Health Zone implements SNAP-Ed, which includes support for developing, implementing, and evaluating local wellness policies (LWPs). Objective To assess changes in written LWPs among SNAP-Ed-participating districts across Arizona. Study Design, Settings, Participants The AZ Health Zone developed a scoring system using the WellSAT 2.0 tool to measure the quality of written LWPs and encourage use of findings among partner districts. From October 1, 2015 to September 30, 2016, local SNAP-Ed agencies in 13 Arizona counties submitted 57 LWPs and received back scores and customized recommendations to share with districts. LWPs from the same districts were scored again between October 1, 2017 to September 30, 2018 to assess changes. Measurable Outcome/Analysis We completed the six-section WellSAT 2.0 to generate scorecards for each LWP. Scorecards included section and total scores for comprehensiveness and strength, from 0 (worst) to 100 (best). We used the paired t-test to compare scores across time, and we explored changes in scores as they related to SNAP-Ed interventions, federal requirements, and state administrative reviews. Results From 2016 to 2018, total comprehensiveness and strength scores increased significantly (comprehensiveness: M = 12.33, SD = 16.05, P P P P Conclusion Written LWPs in Arizona's SNAP-Ed-supported school districts have improved in recent years. SNAP-Ed interventions may have worked synergistically with state administrative reviews and federal LWP guidelines to influence improvements. Further research is needed to understand these interrelationships.

Background The Supplemental Nutrition Assistance Program-Education (SNAP-Ed) encourages healthy nutrition and physical activity (PA) behaviors for SNAP eligible adults. In Arizona, one way the AZ Health Zone SNAP-Ed program promotes behavior change is through direct education classes. While it might be presumed that SNAP-Ed participants enter classes with similar behaviors, we found that baseline behaviors differed between English and Spanish speaking cohorts. Objective To describe differences in nutrition and PA behaviors before education between English and Spanish-speaking SNAP-Ed participants in Arizona. Study Design, Settings, Participants The AZ Health Zone used two validated surveys to measure baseline nutrition and PA behaviors among184 adults in eight Arizona counties between October 1, 2017—September 30, 2018. Sixty adults completed the surveys in English; 124 completed them in Spanish. Adults were surveyed before direct education classes at sites such as schools, libraries, family shelters, and senior centers. Measurable Outcome/Analysis Surveys included 16 nutrition questions and 20 PA questions. Depending upon data type, we used t-tests (PA data), Wilcoxon signed-rank tests (nutrition - Likert data) and Chi-square tests (nutrition - binary data) to compare responses between language groups. Results For nutrition behaviors, we found that Spanish speakers drank more milk (P Conclusion Significant differences were found between SNAP-eligible English and Spanish speakers in Arizona before participating in direct education. Spanish speakers showed healthier behaviors but greater food insecurity. More evaluation is warranted to see if this finding is replicable, and to explore the underlying reasons for the observed differences.

To assess the reliability of the Kids' Activity and Nutrition Questionnaire (KAN-Q) as part of a tiered process for developing Supplemental Nutrition Assistance Program-Education tools.The KAN-Q was administered at 2 time points to assess internal consistency using standardized values of Cronbach α and test-retest reliability using the intraclass correlation coefficient for continuous variables, Cohen's kappa (κ) statistic for categorical variables, and the weighted κ statistic for ordinal data.Data were collected from 119 fourth graders. Cronbach α was adequate for behavior (.71) and knowledge (.72) scales and nutrition behavior (.78) and nutrition knowledge (.75) subscales. Test-retest reliability was generally acceptable, with intraclass correlation coefficients from 0.40 to 0.75 and κ coefficients showing fair to substantial agreement (0.30 to 0.72).The KAN-Q is a practical and reliable questionnaire for school-based administration that aligns directly with Supplemental Nutrition Assistance Program-Education evaluation priorities.

Schools eligible for Supplemental Nutrition Assistance Program Education (SNAP-Ed) can offer programs to address overweight and obesity among low income youth. This study assessed changes in knowle...

Despite the widespread availability of oral rehydration therapy, diarrheal illness remains a major cause of morbidity and mortality around the world. Previous studies have shown individualized homeopathic therapy to be effective in treating childhood diarrhea, but this approach requires specialized training.A homeopathic combination medicine, if effective, could be used by health personnel on a widespread basis.A double-blind randomized controlled trial was conducted in Honduras to evaluate the effectiveness of a homeopathic combination therapy to treat acute diarrhea in children. A total of 292 children with acute diarrhea was recruited; 145 were randomized to the experimental group and 147 to the placebo group. Tablets containing a combined preparation of the five most common single homeopathic remedies used to treat diarrhea or placebo were administered by a parent after each unformed stool. Children were followed up daily for 7 days or until symptoms resolved, whichever occurred first. Time until resolution of symptoms, daily rate of unformed stools, and total number of unformed stools were compared between the two groups.There was no significant difference in the likelihood of resolution of diarrheal symptoms between the treatment and placebo groups (hazard ratio = 1.02, 95% confidence interval: 0.79-1.32), with a median time until resolution of 3 days for both groups. Children in the treatment group had an average of 2.6 unformed stools per day compared to 2.8 among those in the placebo group; this difference was not significant (p = 0.43). The median number of unformed stools was 7 among children in the treatment group and 8 among those in the placebo group (p = 0.41).The homeopathic combination therapy tested in this study did not significantly reduce the duration or severity of acute diarrhea in Honduran children. Further study is needed to develop affordable and effective methods of using homeopathy to reduce the global burden of childhood diarrhea.

Objectives. Using a mixed-method, participatory research approach, we investigated factors related to community health worker (CHW) community advocacy that affect social determinants of health. Methods. We used cross-sectional survey data for 371 CHWs to assess demographics, training, work environment, and leadership qualities on civic, political, and organizational advocacy. We present advocacy stories to further articulate CHW activities. The data reported are from the recently completed National Community Health Workers Advocacy Study. Results. CHWs are involved in advocacy that is community-focused, although advocacy differs by intrinsic leadership, experience, training, and work environment. We propose a framework to conceptualize, support, and evaluate CHW advocacy and the iterative processes they engage in. These processes create opportunities for community voice and action to affect social and structural conditions that are known to have wide-ranging health effects on communities. Conclusions. The framework presented may have utility for CHWs, their training programs, and their employers as well as funders and policymakers aiming to promote health equity.

Objective: To measure change in sugary beverage consumption with nutrition education among low-income 4th and 5th graders. Theory, Prior Research, Rationale: Fifteen percent of US children aged 6 to 11 years are overweight, with an additional 30% at risk. Sugary beverage consumption is linked to obesity and US Dietary Guidelines recommend limiting intake. We hypothesized that nutrition education would result in decreased sugary beverage consumption. Study Design, Setting, Participants, and Intervention: The University of Arizona Nutrition Network (UANN) provides general nutrition education training and materials, aligned with USDA guidelines, to teachers at SNAP-Ed eligible schools. UANN administered self-report behavioral questionnaires to students in 8% of participating 4th and 5th grade classrooms in 5 Arizona counties in both Fall and Spring. Outcome, Measures and Analysis: Descriptive statistics were computed for student demographics and beverage consumption on the prior day. Paired t-tests were used to evaluate change in classroom averages between Fall and Spring. Results: Thirty-three classrooms participated (N1⁄4770 pre, 765 post, 90% complete surveys). Participant characteristics: 71% 4th graders, 50.5% female, 10.1 years of age. Fall sugary beverage consumption was 1.05 ( 0.23) times the previous day; milk and water were consumed 1.58 ( 0.24) and 5.20 ( 0.70) times, respectively. As expected, Arizona springtime beverage consumption increased overall (3.2%). Sugary beverage consumption increased 14.4% and accounted for the greatest portion of the total increase (p1⁄40.006). Small increases in milk (p1⁄40.03) and water (p1⁄40.86) were observed. Conclusions and Implications: This study suggests the need for beverage specific education to shift the children toward more healthful choices. Further research is needed to assess beverage consumption patterns longitudinally, controlling for season. Funding: Supplemental Nutrition Assistance Program Education.