Implementing a Produce Prescription Program in Partnership With a Community Coalition.

Healthy eating reduces risk for chronic disease, but can be out of reach for many Americans experiencing food insecurity. Produce Prescription Programs (PPPs) have emerged as an intervention to address barriers related to fruit and vegetable consumption. Using a social prescribing model, PPPs connect patients with referrals to community resources to reduce barriers to healthy eating. There is evidence of success of PPPs at improving dietary intake, yet little discussion within the literature of practical aspects of implementation. As interest grows around establishing PPPs within communities, increased attention to strategic planning and implementation remains necessary to develop robust and effective programming. We describe implementing the Pontiac Prescription for Health pilot program, highlighting the participatory planning process with partners. Development and implementation included a program model, recruitment methods and materials, a voucher contract and tracking system with produce vendors, physical activity opportunities, culturally competent health education sessions, and evaluation tools. We offer insight into lessons learned and practical implications for future "on-the-ground" planning and implementation. Engaging in a rigorous participatory planning process with all community partners, allowing adequate time to establish service agreements and a voucher system with vendors, and engaging program participants in different ways and spaces throughout the community can enhance program success.

Socioeconomic and racial disparities of sidewalk quality in a traditional rust belt city.

Neighborhood walkability is key to promoting health, accessibility, and pedestrian safety. The Accessible, Connected Communities Encouraging Safe Sidewalks (ACCESS) project was developed to assess sidewalks throughout an urban community in Pontiac, Michigan. Data were collected from 2016 to 2018 along eighty miles of sidewalk for tripping hazards, cracking, vegetation, obstructions, overhead coverage, street lighting, buffers, and crosswalks. Data were mapped in ArcGIS with sociodemographic characteristics by U.S. Census block group. The majority of sidewalks had moderate (57.6%) or major (29.4%) sidewalk quality issues, especially maintenance-related impediments (68.6%) and inadequate street lighting or shade coverage (87.2%). The majority of crosswalks had a curb ramp to improve access for people with disabilities (84.4%), however over half lacked a detectable warning strip (55.8%). Degraded sidewalk quality was associated with lower neighborhood socioeconomic status and a higher proportion of Black and Latinx residents. Equity-centered pedestrian infrastructure improvement plans can address these disparities by increasing accessible, safe active transport options that promote physical activity and reduce health disparities. Evaluations like ACCESS can connect public health professionals with municipal planners to advance Complete Streets plans and promote healthy living.

The role of food gateways at increasing access to alternative retail food outlets.

Alternative retail food outlets (ARFOs), places where customers purchase foods outside of traditional supermarkets, grocery stores, or food service establishments, may play a role in improving food access in communities that are food deserts. This study was conducted to understand the way ARFOs function to support food systems and access to fruits and vegetables in low-resource communities. This qualitative study conducted 16 interviews with managers, volunteers, and customers in two produce market ARFOs in a primarily minority urban community. Findings demonstrate that produce market volunteers and customers may act as "food gateways," or an intermediate step in accessing food resources, in their communities by providing transportation to ARFOs, distributing food to isolated community members, and providing advocacy support to ARFOs. Interventions to increase food equity and access via ARFOs should examine how people serving as "food gateways" can assist in improving food access as intermediaries.

Quantitative Evaluation of Content and Age Concordance Across Developmental Milestone Checklists.

OBJECTIVE: Clinicians and caregivers rely on milestone checklists as tools for tracking a child's development. In addition, medical students and residents use milestone checklists to learn about normal child development. However, there are multiple published milestone checklists that vary qualitatively in structure and content, hindering their effective use in developmental surveillance and medical education. This project systematically evaluated the consistency and variability between commonly used milestone checklists. METHODS: A team of child psychologists and developmental pediatricians reviewed a total of 1094 milestones derived from 4 published checklists (2 developed for providers, 2 developed for caregivers) to create a comprehensive set of 728 discrete developmental observations, with each observation mapped to corresponding milestones. This observation-milestone relational database was then used to determine the degree of content overlap and milestone age range concordance across milestone checklists. RESULTS: Of the 728 discrete developmental observations, 40 (5.5%) were mapped to milestones in all 4 milestone checklists, and an additional 90 (12.4%) were mapped to 3 checklists. Among these 40 "universal" observations, most (42.5%) were in the motor domain. Of those 130 observations mapped to milestones in at least 3 of the 4 checklists, 26.9% (35/130) were mapped to milestones that were discordant in their associated age range. CONCLUSION: Four commonly used developmental milestone checklists were found to have limited overlap in content, and those that overlapped were inconsistent in their associated age ranges. The resulting observation-milestone relational database could be used to further validate age estimates of milestones and facilitate milestone surveillance through the electronic health record.

Qualitative Focus Groups: Perceived Influences on Decision Making About Diet and Physical Activity Among Hispanic/Latino Participants.

Disparities in minority health are strongly associated with reduced access to culturally familiar food and physical activity opportunities. This qualitative study explores a Midwest, urban Hispanic/Latino community, the members' experiences with their multidimensional environment and its influence on their nutrition and physical activity choices. Using the principles of community-based participatory research in collaboration with a trusted, local Hispanic/Latino community agency, we conducted five bilingual focus groups with a total of 46 self-selected participants (44 women and 2 men). We find that one's perception of the environmental factors of access, convenience, affordability, and safety influence food and physical activity decision making. Findings can be used to inform interventions to enhance culturally appropriate outreach, increase food equity, and decrease health disparities.

Development and Evaluation of an Educational Initiative to Improve Hospital Personnel Preparedness to Care for Children with Autism Spectrum Disorder.

OBJECTIVE: To evaluate the effectiveness of a multimodal educational curriculum on increasing hospital personnel's awareness of successful strategies and comfort in caring for children with autism spectrum disorder (ASD). METHODS: We developed a 3-part training for front-line staff (i.e., front desk, clinical assistants, and phlebotomists) in 8 outpatient hospital departments frequented by patients with ASD. Following a needs assessment, participants completed an online educational module and then attended an in-person seminar tailored to each department. To evaluate training effectiveness, we administered pre-, immediate post-, and 1 month post-training surveys assessing personnel attitudes, comfort, perceived knowledge, and behaviors around caring for patients with ASD. RESULTS: We trained 168 staff members from 8 departments. On the needs assessment, participants (N = 129) reported a mean 2.5 behavioral incidents involving patients with ASD over the previous 3 months; 92% believed that the training would be helpful for their work. Across pre-, immediate- and 1-month post-training surveys, scores improved on all questions related to personnel attitudes about the importance of ASD-friendly care, comfort interacting with patients with ASD, perceived knowledge about ASD, and self-reported frequency of behaviors intended to help children with ASD adjust to the hospital setting (p < 0.05). There was no difference in baseline scores or change in scores between clinical and nonclinical personnel. On a program evaluation (N = 57), 81% rated the training as "very good" or "excellent," and 87% reported that they would be able to apply training material immediately to their role. CONCLUSION: This training initiative led to improvement in attitudes, comfort level, perceived knowledge, and self-reported behaviors of hospital personnel working with patients with ASD, which was maintained over 1 month.

Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder.

CASE: Kendra is a 4-year-old girl with autism spectrum disorder (ASD) who presents for follow-up of feeding problems to her pediatric clinician. She is an only child in a family where both parents are scientists. Feeding concerns date to infancy, when she was diagnosed with Gastroesophageal Reflux Disease (GERD) associated with persistent bottle refusal and the acceptance of few pureed foods. At 13 months, milk and peanut allergies were diagnosed. Following a feeding clinic evaluation at 24 months, she was prescribed a soy milk supplement and an H2 blocker. There was no concern for oral-motor dysfunction. She was also referred to early intervention for feeding therapy. However, her parents terminated participation after 6 months because she became anxious and had tantrum prior to treatment groups.She was seen in another feeding program at 3 years; zinc, folate, thyroid, and a celiac panel were normal, and an endoscopy was negative for eosinophilic esophagitis. She began individual feeding therapy, where concerns for rigidity, difficulty transitioning, and limited peer interactions led to a neuropsychological evaluation. Kendra was diagnosed with an ASD and avoidant/restrictive food intake disorder (ARFID). Her cognitive skills were average, and expressive and receptive language skills were low average.Her diet consisted of French fries, Ritz crackers, pretzels, and 32 ounces of soy formula daily. She had stopped accepting Cheerios and saltines 2 months prior. She controlled other aspects of feeding, insisting on a specific parking spot at a fast food restaurant and drinking from a particular sippy cup. Her parents accepted these demands with concern about her caloric intake, which they tracked daily.Following diagnosis with ARFID, she resumed feeding therapy using a systematic desensitization approach with rewards. At the first session, she kissed and licked 2 new foods without gagging. Her mother appeared receptive to recommendations that included continuing the "food game" at home, replacing 1 ounce of soy formula by offering water each day, limiting between-meal grazing, and refusing specific feeding demands.Currently, her parents plan to discontinue feeding therapy with concerns that the treatment was "too harsh." Her father produces logs of her caloric and micronutrient intake as evidence that she did not replace missed formula with other foods and reports that she subsequently became more difficult to manage behaviorally. Her father now demands to see randomized controlled trials of feeding therapy approaches. Her weight is stable, but she has now limited her pretzel intake to a specific brand. How would you approach her continued care?

Cutaneous Disease in Autism Spectrum Disorder: A Review.

Dermatologic comorbid symptoms and conditions in persons with autism spectrum disorder (ASD) are compelling for several reasons, including problems with tactile sensory dysfunction in this population, a large number of syndromes with dermatologic findings and high rates of autism, nutritional and hormonal problems in ASD and their dermatologic manifestations, and the potential for overrepresentation of dermatologic symptoms that are neurobehavioral in nature. The current article reviews the available literature on the prevalence of comorbid dermatologic symptoms and conditions in children with ASD and identifies strategies for diagnosing and managing cutaneous disease in this population.

The Michigan Healthy School Action Tools process generates improvements in school nutrition policies and practices, and student dietary intake.

The Michigan Healthy School Action Tools (HSAT) is an online self-assessment and action planning process for schools seeking to improve their health policies and practices. The School Nutrition Advances Kids study, a 2-year quasi-experimental intervention with low-income middle schools, evaluated whether completing the HSAT with a facilitator assistance and small grant funding resulted in (1) improvements in school nutrition practices and policies and (2) improvements in student dietary intake. A total of 65 low-income Michigan middle schools participated in the study. The Block Youth Food Frequency Questionnaire was completed by 1,176 seventh-grade students at baseline and in eighth grade (during intervention). Schools reported nutrition-related policies and practices/education using the School Environment and Policy Survey. Schools completing the HSAT were compared to schools that did not complete the HSAT with regard to number of policy and practice changes and student dietary intake. Schools that completed the HSAT made significantly more nutrition practice/education changes than schools that did not complete the HSAT, and students in those schools made dietary improvements in fruit, fiber, and cholesterol intake. The Michigan HSAT process is an effective strategy to initiate improvements in nutrition policies and practices within schools, and to improve student dietary intake.

Little association between wellness policies and school-reported nutrition practices.

BACKGROUND: The Child Nutrition and WIC Reauthorization Act of 2004 mandated written school wellness policies. Little evidence exists to evaluate the impact of such policies. This study assessed the quality (comprehensiveness of topics addressed and strength of wording) of wellness policies and the agreement between written district-level policies and school-reported nutrition policies and practices in 48 low-income Michigan school districts participating in the School Nutrition Advances Kids study. METHOD: Written wellness policy quality was assessed using the School Wellness Policy Evaluation Tool. School nutrition policies and practices were assessed using the School Environment and Policy Survey. Analysis of variance determined differences in policy quality, and Fisher's exact test examined agreement between written policies and school-reported practices. RESULTS: Written wellness policies contained ambiguous language and addressed few practices, indicating low comprehensiveness and strength. Most districts adopted model wellness policy templates without modification, and the template used was the primary determinant of policy quality. Written wellness policies often did not reflect school-reported nutrition policies and practices. CONCLUSIONS: School health advocates should avoid assumptions that written wellness policies accurately reflect school practices. Encouraging policy template customization and stronger, more specific language may enhance wellness policy quality, ensure consistency between policy and practice, and enhance implementation of school nutrition initiatives.

Facilitators to promoting health in schools: is school health climate the key?

BACKGROUND: Schools can promote healthy eating in adolescents. This study used a qualitative approach to examine barriers and facilitators to healthy eating in schools. METHODS: Case studies were conducted with 8 low-income Michigan middle schools. Interviews were conducted with 1 administrator, the food service director, and 1 member of the coordinated school health team at each school. RESULTS: Barriers included budgetary constraints leading to low prioritization of health initiatives; availability of unhealthy competitive foods; and perceptions that students would not eat healthy foods. Schools had made improvements to foods and increased nutrition education. Support from administrators, teamwork among staff, and acknowledging student preferences facilitated positive changes. Schools with a key set of characteristics, (presence of a coordinated school health team, nutrition policies, and a school health champion) made more improvements. CONCLUSIONS: The set of key characteristics identified in successful schools may represent a school's health climate. While models of school climate have been utilized in the educational field in relation to academic outcomes, a health-specific model of school climate would be useful in guiding school health practitioners and researchers and may improve the effectiveness of interventions aimed at improving student dietary intake and other health behaviors.

Effects of changes in lunch-time competitive foods, nutrition practices, and nutrition policies on low-income middle-school children's diets.

BACKGROUND: The School Nutrition Advances Kids project tested the effectiveness of school-initiated and state-recommended school nutrition practice and policy changes on student dietary intake in low-income middle schools. METHODS: Schools recruited by an application for grant funding were randomly assigned to (1) complete an assessment of nutrition education, policies, and environments using the Healthy School Action Tools (HSAT) and implement an action plan, (2) complete the HSAT, implement an action plan, and convene a student nutrition action team, (3) complete the HSAT and implement an action plan and a Michigan State Board of Education nutrition policy in their cafeteria à la carte, or (4) a control group. All intervention schools were provided with funding and assistance to make self-selected nutrition practice, policy, or education changes. Block Youth Food Frequency Questionnaires were completed by 1176 seventh-grade students from 55 schools at baseline and during eighth-grade follow-up. Nutrient density and food group changes for the intervention groups were compared to the control group, controlling for baseline dietary intake values, gender, race/ethnicity, school kitchen type, urbanization, and percent of students eligible for free or reduced-price meals. Analyses were conducted by randomization and based on changes the schools self-selected. RESULTS: Improvements in students' nutrient density and food group intake were found when schools implemented at least three new nutrition practice changes and established at least three new nutrition policies. Students in schools that introduced mostly healthful foods in competitive venues at lunch demonstrated the most dietary improvements. CONCLUSIONS: New USDA nutrition standards for à la carte and vending will likely increase the healthfulness of middle school children's diets.