A mixed-method evaluation of the New York State Eat Well Play Hard Community Projects: Building local capacity for sustainable childhood obesity prevention.

This study used a mixed-method, comparative case study approach to assess the level of capacity built for childhood obesity prevention among seven New York State Eat Well Play Hard-Community Projects (EWPH-CP). Data were collected through a self-reported survey in 2007, semi-structured interviews in 2009, and EWPH-CP program documentation throughout the 2006-2010 funding cycle. Quantitative and qualitative analyses were used along with an integrative framework for assessing local capacity building to characterize the capacity built by the study coalitions. Four coalitions rated membership characteristics as a challenge at the beginning of the funding cycle. Towards the end of the funding cycle, all seven coalitions reported activities that were initially focused on building their membership (i.e., member capacity) or positive working relationships (i.e. relational capacity), before eventually pursuing support and resources (i.e., organizational capacity) for implementing their chosen community-oriented programmatic goals (i.e., programmatic capacity). Five coalitions reported environmental changes aimed at increasing physical activity or fruit and vegetable intake. Technical assistance provided to coalitions was credited with contributing to the achievement of programmatic goals. These results suggest that the coalitions succeeded in building local capacity for increasing age-appropriate physical activity or fruit and vegetables intake in the target communities.

Outcome Evaluation of the You Can Do It Initiative to Promote Exclusive Breastfeeding Among Women Enrolled in the New York State WIC Program by Race/Ethnicity.

OBJECTIVE: To evaluate the effectiveness of You Can Do It at improving exclusive breastfeeding (BF) among New York State women enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DESIGN: Quasi-experimental study, September, 2013 through February, 2016. SETTING: Multicomponent intervention paired with a yearlong learning community in 12 clinics. PARTICIPANTS: Women who were enrolled in WIC during the first trimester, intended to breastfeed or were undecided, and continued in WIC after delivery, comprised 1 baseline cohort (n = 688) and 2 intervention cohorts: Breastfeeding Attrition Prediction Tool (BAPT) (consented, n = 362) and non-BAPT (declined, n = 408). INTERVENTION: The BAPT was offered to all eligible women in the intervention enrollment period. Consenting women received multiple counseling sessions tailored to individual BAPT results throughout pregnancy and were contacted promptly after delivery. MAIN OUTCOME MEASURE(S): Prevalence of exclusive BF at 7, 30, and 60 days. ANALYSIS: Multivariate logistic regression, stratified by race/ethnicity. Statistical significance set at P < .05. RESULTS: Prevalence of exclusive BF at 7 and 30 days was significantly higher among BAPT women compared with non-BAPT or baseline cohorts. Non-Hispanic black and Hispanic women in the BAPT cohort achieved significantly higher exclusive BF rates at 30 and 60 days compared with those in non-BAPT and baseline cohorts. CONCLUSIONS AND IMPLICATION: The initiative seems to be effective at increasing exclusive BF, particularly among non-Hispanic black and Hispanic women in the New York State WIC program.

Implementing a WIC-Based Intervention to Promote Exclusive Breastfeeding: Challenges, Facilitators, and Adaptive Strategies.

OBJECTIVE: Understand factors that contributed to the implementation of a successful multicomponent intervention to promote exclusive breastfeeding (EBF) within Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) clinics. DESIGN: Qualitative study of staff implementers' experiences using implementation status reports, facilitated group discussion immediately after implementation, and WIC administrative data. SETTING: WIC staff from 12 clinics participated in an EBF Learning Community composed of 8 intervention trainings and ongoing support from trainers and peers. PARTICIPANTS: A total of 47 WIC staff including 11 directors, 20 other administrators, 8 nutritionists, and 6 peer counselors. INTERVENTION: A WIC-integrated EBF promotion initiative, supported through a Learning Community, composed of prenatal screening, tailored trimester-specific counseling, and timely postpartum follow-up. PHENOMENON OF INTEREST: Challenges and facilitators to implementation within clinics. ANALYSIS: Iterative qualitative analysis using directed, emergent, and thematic coding. RESULTS: Implementation experiences were characterized by (1) perceived benefits of implementation, including improved EBF knowledge and counseling confidence among staff; and (2) managing implementation, including responding to challenges posed by clinic settings (resources, routine practices, values, and perceptions of mothers) through strategies such as adapting clinic practices and intervention components. CONCLUSIONS AND IMPLICATIONS: Implementation was shaped by clinic setting and adaptive strategies. Future WIC interventions may benefit from formal consideration of intervention fit with local clinic setting and allowable adaptations.

Trends in Breastfeeding Among Infants Enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children - New York, 2002-2015.

Breastfeeding is widely accepted as the optimal method of infant feeding (1,2). New York Special Supplemental Nutrition Program for Women, Infants and Children (WIC) has prioritized the promotion of breastfeeding. To assess breastfeeding trends among New York WIC infants, indicators for measuring breastfeeding practices reported by the New York Pediatric Nutrition Surveillance System (PedNSS) during 2002-2015 were examined. The prevalence of breastfeeding initiation increased from 62.0% (2002) to 83.4% (2015), exceeding the Healthy People 2020 (HP2020)* objective of 81.9% in 2014, with improvements among all racial/ethnic groups. The percentage of New York WIC infants who breastfed for ≥6 and ≥12 months increased from 30.2% and 15.0% (2002) to 39.5% and 22.8% (2015), respectively. The prevalence of exclusive breastfeeding for ≥3 and ≥6 months increased from 8.9% and 2.9% (2006) to 14.3% and 8.0% (2015), respectively. Despite improvements in breastfeeding initiation, increasing the duration of breastfeeding and of exclusive breastfeeding among infants enrolled in the New York WIC program remains challenging. Identifying targeted strategies to support continued and exclusive breastfeeding should remain priorities for the New York WIC program.

Use of a mixed-method approach to evaluate the implementation of retention promotion strategies in the New York State WIC program.

This research assessed the implementation of strategies piloted at 10 Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinics aimed at increasing retention in the program, by enhancing participants' shopping experiences. Under WIC Retention Promotion Study: Keep, Reconnect, Thrive (WIC RPS), clinics were recruited and assigned to implement one or a combination of strategies: a standardized Shopping Orientation (SO) curriculum, a Guided Shopping Tour (GST), and a Pictorial Foods Card (PFC) from November 2012 through August 2013. This paper presents results from the process evaluation of the retention strategies, using a mixed-methods comparative case study design employing WIC administrative data, interviews, and focus groups. Qualitative data were inductively coded, analyzed and mapped to the following implementation constructs: organizational capacity, fidelity, allowable adaptations, implementation challenges, and participant responsiveness, while quantitative data were analyzed using SAS to assess reach and dose. Several sites implemented the SO and PFC interventions with the necessary fidelity and dose needed to assess impact on participants' shopping experiences. Sites that were assigned the GST strategy struggled to implement this strategy. However, use of the standardized SO enabled staff to use a "consistent list of shopping tips" to educate participants about the proper use of checks, while use of the PFC increased participants' awareness of the variety of WIC-allowable foods. During follow-up telephone calls, 91 percent of participants reported the shopping tips as helpful. Future analyses will assess the impact of enhanced shopping experience on retention at intervention sites.

Relation between annual trends in food pantry use and long-term unemployment in New York State, 2002-2012.

We examined the correlation between trends in meals provided through food pantries and long-term unemployment from 2002 through 2012. The New York State Hunger Prevention and Nutrition Assistance Program provided about 192 million meals through food pantries in 2012-double the number before the Great Recession. Annual food pantry use was strongly correlated with long-term unemployment and remained on an upward trend from 2006 through 2012, even after the Great Recession had ended. These findings suggest that efforts to reduce hunger and food insecurity should continue to be priorities.

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.

Association of prenatal participation in a public health nutrition program with healthy infant weight gain.

OBJECTIVES: We tested the hypothesis that early enrollment in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is associated with a reduced risk of rapid infant weight gain (RIWG). METHODS: We used a longitudinal cohort of mother-infant pairs (n = 157,590) enrolled in WIC in New York State from 2008 to 2009 and estimated the odds of RIWG, defined as a 12-month change in weight-for-age z score of more than .67, comparing infants of mothers enrolled during the first, second, or third trimester of pregnancy with those who delayed enrollment until the postpartum period. RESULTS: After adjusting for potential confounders, the odds of RIWG (odds ratio [OR] = 0.76; 95% confidence interval [CI] = 0.74, 0.79) were significantly lower for infants of women enrolling during the first trimester versus postpartum. Birth weight-for-gestational-age z score (OR = 0.33; 95% CI = 0.32, 0.33) attenuated the estimate of prenatal versus postpartum enrollment (OR = 0.92; 95% CI = 0.88, 0.95; first-trimester enrollees). CONCLUSIONS: The results demonstrate that prenatal WIC participation is associated with reduced risk of RIWG between birth and age 1 year. Improved birth weight for gestational age may be the mechanism through which early prenatal WIC enrollment protects against RIWG.

Evidence of the adoption and implementation of a statewide childhood obesity prevention initiative in the New York State WIC Program: the NY Fit WIC process evaluation.

Process evaluations are critical in determining whether outcome evaluations are warranted. This study assessed the extent to which a childhood obesity prevention initiative, NY Fit WIC, was adopted and implemented by the New York State Supplemental Nutrition Program for Women, Infants and Children (WIC). Process data came from qualitative telephone interviews of 101 WIC local agency directors, following NY Fit WIC trainings. Activities were summarized and cross-tabulated by target level (i.e. participant, staff, agency or community) and by theoretical construct (i.e. knowledge promotion, skill building, self-efficacy or role modeling). Approximately 528 activities were reported across all WIC agencies. When activities were grouped into similar categories, 123 unique activities were identified. Agencies were more likely to implement physical activity-related activities (67%) than nutrition-related activities (33%). The majority of activities targeted WIC participants (47%) and staff (22%) and focused on skill building/self-efficacy (67%) among participants and on role modeling (61%) among staff. The involvement of all agencies shows a high level of adoption of the initiative. The diverse number of activities suggests that WIC local agencies tailored implementation to match their resources and clients' needs as planned. These results suggest that an outcome evaluation is warranted to determine whether meaningful behavioral changes occurred among WIC participants and staff.

Feasibility of increasing childhood outdoor play and decreasing television viewing through a family-based intervention in WIC, New York State, 2007-2008.

INTRODUCTION: Active Families is a program developed to increase outdoor play and decrease television viewing among preschool-aged children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Our objective was to assess its feasibility and efficacy. METHODS: We implemented Active Families in a large WIC clinic in New York State for 1 year. To this end, we incorporated into WIC nutrition counseling sessions a community resource guide with maps showing recreational venues. Outcome measures were children's television viewing and time playing outdoors and parents' behaviors (television viewing, physical activity), self-efficacy to influence children's behaviors, and parenting practices specific to television viewing. We used a nonpaired pretest and posttest design to evaluate the intervention, drawing on comparison data from 3 matched WIC agencies. RESULTS: Compared with the children at baseline, the children at follow-up were more likely to watch television less than 2 hours per day and play outdoors for at least 60 minutes per day. Additionally, parents reported higher self-efficacy to limit children's television viewing and were more likely to meet physical activity recommendations and watch television less than 2 hours per day. CONCLUSION: Results suggest that it is feasible to foster increased outdoor play and reduced television viewing among WIC-enrolled children by incorporating a community resource guide into WIC nutrition counseling sessions. Future research should test the intervention with a stronger evaluation design in multiple settings, with more diverse WIC populations, and by using more objective outcome measures of child behaviors.

Trends in prevalence of obesity and overweight among children enrolled in the New York State WIC program, 2002-2007.

OBJECTIVES: We examined recent overweight and obesity trends in a multiethnic population of low-income preschool children. METHODS: We defined overweight as sex-specific body mass index (BMI)-forage > or = 85th and < 95th percentile and obesity as sex-specific BMI-for-age > or = 95th percentile, and calculated them using demographic data and randomly selected height and weight measurements that were recorded while 2- to < 5-year-old children were enrolled in the New York State (NYS) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during 2002-2007. RESULTS: Obesity prevalence peaked at 16.7% in 2003, declined from 2003 through 2005, and stabilized at 14.7% through 2007. Among both boys and girls, the downward trend in annual prevalence of obesity was evident only among Hispanic children (22.8% boys and 20.9% girls in 2002 vs. 19.3% boys and 17.5% girls in 2007) and non-Hispanic black children (15.6% boys and 14.2% girls in 2002 vs. 13.6% boys and 12.4% girls in 2007). In contrast, the annual prevalence estimate for overweight showed an increasing trend from 2002 through 2007. CONCLUSIONS: These results showed a slight decline in prevalence of childhood obesity and a continuing rise in prevalence of childhood overweight among children enrolled in the NYS WIC program during 2002-2007. Future research should investigate the extent to which the slight decline in childhood obesity prevalence may be attributable to population-based and high-risk obesity prevention efforts in NYS.

An innovative approach to enhancing the surveillance capacity of state-based diabetes prevention and control programs: the Diabetes Indicators and Data Sources Internet Tool (DIDIT).

The Diabetes Indicators and Data Sources Internet Tool (DIDIT) is an interactive Web-based resource with information on 38 diabetes indicators (e.g., diabetes-associated complications, care, lifestyle) and 12 associated data sources frequently used by state diabetes prevention and control programs. This tool is designed to strengthen the ability of states to conduct diabetes surveillance and to promote consistency in defining and tracking indicators across states. In this way, the DIDIT supports one of the 10 essential public health services: the timely and accurate assessment of public health. In addition to serving as a central repository of information on diabetes surveillance, the DIDIT also allows users to share experiences of using these indicators and data sources in their diabetes surveillance activities, data analysis, and tracking of diabetes-related objectives stated by Healthy People 2010. The DIDIT is an innovative approach to enhancing public health surveillance at the state and national levels.

Diabetes prevalence among Puerto Rican adults in New York City, NY, 2000.

This study assessed the prevalence of diagnosed diabetes and associated characteristics among Puerto Rican adults in New York City, NY, with a random-digit-dialed telephone survey with a dual-frame sampling design. Overall, 11.3% (95% confidence interval = 8.7%, 14.0%) had diagnosed diabetes; diabetes was significantly related to age, obesity, and family history; and the prevalence was high among those with the least education. This study showed the ability to obtain critically needed diabetes information from ethnic minorities at the local level.