Cost analysis and cost effectiveness of a subsidized community supported agriculture intervention for low-income families.

BACKGROUND: The food system has a dynamic influence on disparities in food security and diet-related chronic disease. Community supported agriculture (CSA) programs, in which households receive weekly shares of produce from a local farmer during the growing season, have been examined as a possible food systems-based approach for improving diet and health outcomes. The purpose of this study was to estimate the cost of implementing and participating in a multi-component subsidized community supported agriculture intervention and calculate cost-effectiveness based on diet and food security impacts. METHODS: Using data from the Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (n = 305; 2016-2018), we estimated programmatic and participant costs and calculated incremental cost-effectiveness ratios (ICERs) for caregivers' daily fruit and vegetable (FV) intake, skin carotenoids, and household food security from program and societal perspectives. RESULTS: F3HK cost $2,439 per household annually ($1,884 in implementation-related expenses and $555 in participant-incurred costs). ICERs ranged from $1,507 to $2,439 per cup increase in caregiver's FV intake (depending on perspective, setting, and inclusion of juice); from $502 to $739 per one thousand unit increase in skin carotenoid score; and from $2,271 to $3,137 per household shifted out of food insecurity. CONCLUSIONS: Given the known public health, healthcare, and economic consequences of insufficient FV intake and living in a food insecure household, the costs incurred to support these positive shifts in individual- and household-level outcomes via a F3HK-like intervention may be deemed by stakeholders as a reasonable investment. This work helps to advance a critical body of literature on the cost-effectiveness of subsidized CSAs and other economic and food system interventions for the sake of evidence-based allocation of public health resources. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered. https://www. CLINICALTRIALS: gov/ct2/show/NCT02770196 .

Fruit and Vegetable Preparation Changes During and After Cost-Offset Community-Supported Agriculture Plus Nutrition Education.

OBJECTIVE: Inadequate consumption of fruits and vegetables (FV) can negatively impact health. Cost-offset, or subsidized, community-supported agriculture (CO-CSA) may change FV preparation behaviors among caregivers in low-income households. We assessed changes in FV preparation frequency and methods during and after participation in a CO-CSA plus tailored nutrition education intervention. DESIGN: Longitudinal comparison of outcomes at baseline, end of CO-CSA season, and 1 year later. PARTICIPANTS: Caregivers of children aged 2-12 years from households with low income in rural areas of 4 US states (n = 148). INTERVENTION: Summer season, half-price CO-CSA share plus tailored nutrition education classes. Comparison to a control group not included in this analysis. VARIABLES MEASURED: Monthly frequency of preparing 9 FV for children's snacks and 5 vegetables for dinner; use of healthy preparation methods for dinner. ANALYSIS: Repeated measures ANCOVA including state with Bonferroni correction and 95% confidence. RESULTS: At baseline, caregivers prepared fruit for children's snacks and vegetables for dinner almost daily and vegetables for children's snacks every other day. The frequency of total FV preparation and most vegetable varieties increased during the intervention. Increases in total vegetables for snacks, dinner, and leafy greens were maintained 1 year later (n = 107). CONCLUSIONS AND IMPLICATIONS: Community-supported agriculture plus education is a promising approach to sustained increases in vegetable preparation for children's snacks and dinner meals.

Participation in Cost-offset Community Supported Agriculture by Low-income Households in the U.S. is Associated with Community Characteristics and Operational Practices.

OBJECTIVE: Subsidized or cost-offset community supported agriculture (CO-CSA) connects farms directly to low-income households and can improve fruit and vegetable intake. This analysis identifies factors associated with participation in CO-CSA. DESIGN: Farm Fresh Foods for Healthy Kids (F3HK) provided a half-price, summer CO-CSA plus healthy eating classes to low-income households with children. Community characteristics (population, socio-demographics, health statistics) and CO-CSA operational practices (share sizes, pick-up sites, payment options, produce selection) are described and associations with participation levels examined. SETTING: Ten communities in New York (NY), North Carolina (NC), Vermont, and Washington states in USA. PARTICIPANTS: Caregiver-child dyads enrolled in spring 2016 or 2017. RESULTS: Residents of micropolitan communities had more education and less poverty than in small towns. The one rural location (NC2) had the fewest college graduates (10%) and most poverty (23%), and poor health statistics. Most F3HK participants were white, except in NC where 45.2% were African American. CO-CSA participation varied significantly across communities from 33% (NC2) to 89% (NY1) of weeks picked-up. Most CO-CSAs offered multiple share sizes (69.2%) and participation was higher than when not offered (76.8% vs. 57.7% of weeks); whereas 53.8% offered a community pick-up location, and participation in these communities was lower than elsewhere (64.7% vs. 78.2% of weeks). CONCLUSION: CO-CSAs should consider offering choice of share size and innovate to address potential barriers such as rural location and limited education and income among residents. Future research is needed to better understand barriers to participation, particularly among participants utilizing community pick-up locations.

Community supported agriculture plus nutrition education improves skills, self-efficacy, and eating behaviors among low-income caregivers but not their children: a randomized controlled trial.

BACKGROUND: Adults and children in the U.S. consume inadequate quantities of fruit and vegetables (FV), in part, due to poor access among households with lower socioeconomic status. One approach to improving access to FV is community supported agriculture (CSA) in which households purchase a 'share' of local farm produce throughout the growing season. This study examined the effects of cost-offset (half-price) CSA plus tailored nutrition education for low-income households with children. METHODS: The Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (2016-2018) assigned caregiver-child dyads (n = 305) into cost-offset CSA plus education intervention or control (delayed intervention) groups. Following one growing season of CSA participation, changes in children's diet quality, body mass index (BMI), and physical activity; caregivers' nutrition knowledge, attitudes, behaviors, and diet quality; and household food access and security were examined using multiple linear or logistic regression, with adjustment for baseline value within an intent-to-treat (ITT) framework in which missing data were multiply imputed. RESULTS: No significant net effects on children's dietary intake, BMI, or physical activity were observed. Statistically significant net improvements were observed after one growing season for caregivers' cooking attitudes, skills, and self-efficacy; FV intake and skin carotenoid levels; and household food security. Changes in attitudes and self-efficacy remained one-year after baseline, but improvements in caregiver diet and household food security did not. The number of weeks that participants picked up a CSA share (but not number of education sessions attended) was associated with improvements in caregiver FV intake and household food security. CONCLUSIONS: Cost-offset CSA plus tailored nutrition education for low-income households improved important caregiver and household outcomes within just one season of participation; most notably, both self-reported and objectively measured caregiver FV intake and household food security improved. Households that picked up more shares also reported larger improvements. However, these changes were not maintained after the CSA season ended. These results suggest that cost-offset CSA is a viable approach to improving adult, but not child, FV intake and household food security for low-income families, but the seasonality of most CSAs may limit their potential to improve year-round dietary behavior and food security. TRIAL REGISTRATION: ClinicalTrials.gov . NCT02770196 . Registered 5 April 2016. Retrospectively registered.

Fruit and Vegetable Intake Assessed by Repeat 24 h Recalls, but Not by A Dietary Screener, Is Associated with Skin Carotenoid Measurements in Children.

Accurate measurement of fruit and vegetable (FV) intake is important for nutrition surveillance and evaluation of dietary interventions. We compared two tools for reporting FV intake to objective measurement of skin carotenoids among children. FV cups/day was assessed by repeated 24 h dietary recalls (24H FV) and the National Cancer Institute's All-Day Fruit and Vegetable Screener (NCI FV). Skin carotenoids were measured by repeated resonance Raman spectroscopy (RRS) of the palm. FV cups were regressed on RRS scores in unadjusted, field-based, and research-setting models with covariates feasible in each scenario. Data were baseline values from children aged 2-12 years in low-income households enrolled in a healthy eating randomized trial in four U.S. states (n = 177). Twenty-four-hour FV cups were associated with skin carotenoids in all models (p < 0.001) but NCI FV cups were not. Predicted RRS scores for discrete 24H FV cups provide a guide to interpretation of RRS in children (2 cups FV intake ~36,000 RRS units), with the research-setting scenario generally providing the narrowest prediction range (+/-1924). When self-reported data are required, 24 h recalls are more accurate than NCI FV screener data; and, when limited time, resources, or literacy must be considered, RRS scores can be quickly obtained and easily interpreted.

Making community-supported agriculture accessible to low-income families: findings from the Farm Fresh Foods for Healthy Kids process evaluation.

A randomized trial of Farm Fresh Foods for Healthy Kids (F3HK) was initiated across 4 states and 12 farms to test whether cost-offset community-supported agriculture (CO-CSA) could improve diet quality among children in low-income families. Intervention households purchased a 50% subsidized share of local produce and were invited to nine complimentary nutrition classes. The purpose of this study was to assess F3HK reach, dose, and fidelity via a mixed methods process evaluation. Screening and enrollment records indicated reach; study records and postlesson educator surveys tracked dose delivered; CSA pickup logs, lesson sign-in sheets, postseason participant surveys, and postlesson caregiver surveys assessed dose received; and coordinator audits and educator surveys tracked fidelity. Educator interviews contextualized findings. The results of this study were as follows. Reach: enrolled caregivers (n = 305) were older (p = .005) than eligible nonenrollees (n = 243) and more likely to be female (p < .001). Dose: mean CSA season was 21 weeks (interquartile range [IQR]: 19-23). Median CSA pickup was 88% of the weeks (IQR: 40-100). All sites offered each class at least once. Most adults (77%) and children (54%) attended at least one class; few attended all. Eighty-two percent of caregivers indicated that their household consumed most or all produce. Median lesson activity ratings were 5/5 ("very useful"). Fidelity: CSA locations functioned with integrity to project standards. Educators taught 92% of activities but frequently modified lesson order. This study demonstrates the feasibility of pairing a CO-CSA intervention with nutrition education across geographically dispersed sites. Greater integration of intervention elements and clearer allowance for site-level modifications, particularly for educational elements, may improve intervention dose and, ultimately, impact.

Perceptions of nutrition education classes offered in conjunction with a community-supported agriculture intervention among low-income families.

OBJECTIVE: To examine participants' experiences with nutrition education classes that were implemented with and designed to complement a cost-offset community-supported agriculture (CSA) programme. DESIGN: Qualitative analysis of data from twenty-eight focus groups with ninety-six participants enrolled in Farm Fresh Foods for Healthy Kids (F3HK). Transcribed data were coded and analysed by a priori and emergent themes. SETTING: Rural and micropolitan communities in New York, North Carolina, Vermont and Washington (USA). PARTICIPANTS: Ninety-six F3HK participants. RESULTS: Participants found recipes and class activities helpful and reported improvements in nutrition knowledge, food preservation skills and home cooking behaviours for themselves and their children; they also reported that classes promoted a sense of community. Some educators better incorporated CSA produce into lessons, which participants reported as beneficial. Other obligations and class logistics were barriers to attendance; participants recommended that lessons be offered multiple times weekly at different times of day. Other suggestions included lengthening class duration to encourage social engagement; emphasising recipes to incorporate that week's CSA produce and pantry staples and offering additional strategies to incorporate children in classes. CONCLUSION: Complementing a cost-offset CSA with nutrition education may enhance programme benefits to low-income families by improving nutrition knowledge and cooking behaviours. However, future interventions will benefit from ongoing coordination between educators and local growing trajectories to maximise timely coverage of unfamiliar produce in lessons; synchronous scheduling of CSA pick-up and classes for participant convenience and creative strategies to engage children and/or provide childcare.

Knowledge, Attitudes, Beliefs and Behaviors regarding Fruits and Vegetables among Cost-offset Community-Supported Agriculture (CSA) Applicants, Purchasers, and a Comparison Sample.

Community-supported agriculture (CSA) participation has been associated with high fruit and vegetable (FV) consumption, which may be due to better access to FV for CSA purchasers, or to positive knowledge, attitudes, and beliefs (KAB) regarding healthy eating among CSA applicants. The objective of this study was to examine KAB and consumption, in association with application to a cost-offset CSA (CO-CSA) program, and with CO-CSA purchase among applicants. We conducted a cross-sectional survey of CO-CSA applicants and a comparison sample in August 2017. All respondents were English-reading adults with a child 2-12 years old and household income of <185% of the federal poverty level. Among CO-CSA applicants, some were CO-CSA purchasers (n = 46) and some were not (n = 18). An online comparison sample met equivalent eligibility criteria, but had not participated in CSA for three years (n = 105). We compared CO-CSA applicants to the comparison sample, and compared purchasers and non-purchaser sub-groups, using Mann-Whitney U tests and chi-square analysis. CO-CSA applicants reported better knowledge, self-efficacy, home habits, and diet than the comparison sample. Among applicants, CO-CSA purchasers and non-purchasers had equivalent KAB, but children in purchaser households had higher FV consumption than in non-purchaser households (4.14 vs. 1.83 cups, P = 0.001). Future research should explore associations between CO-CSA participation and diet using experimental methods.

Capacity Building for and Implementation of Policy, Systems, and Environmental Change: Results from a Survey of the National Comprehensive Cancer Control Program.

Policy, systems, and environmental (PSE) approaches are commonly used to improve population health. Cancer-related examples include providing data and education to stakeholders about policies that support healthy living, or health systems changes such as universal reminders about recommended cancer screening. The National Comprehensive Cancer Control Program (NCCCP) funds health departments to form cancer coalitions that develop and implement cancer plans. NCCCP initiated a demonstration program in 13 of 65 funded grantees to determine whether skilled, dedicated staffing and using a strategic process to examine data, form a workgroup, and develop an agenda would enhance their capacity to implement PSE approaches, recruit new partners, and provide data and education to stakeholders. The objective of this study was to compare demonstration program grantees to other NCCCP grantees on their ability to develop and implement PSE strategies, and the short-term results that were achieved. Program directors (PDs) from each NCCCP-funded jurisdiction completed web surveys at 2 time points during implementation to assess changes in their capacity for PSE approaches, identify implementation activities, and document short-term outcomes. Responses from demonstration program PDs and other PDs at both time points were compared in a descriptive analysis. Demonstration program grantees experienced greater increases in skills and capacity to address PSE approaches, engaged in necessary implementation activities more often, and achieved greater improvements in stakeholder and decision maker awareness and support for PSE strategies, compared to nonparticipating NCCCP grantees. These findings support continued implementation of PSE approaches for sustainable cancer prevention and control.

Fruit and Vegetable Preferences and Practices May Hinder Participation in Community-Supported Agriculture Among Low-Income Rural Families.

OBJECTIVE: Describe fruit and vegetable (FV) preferences and other factors that may influence participation in community-supported agriculture (CSA). DESIGN: In-depth, semi-structured interviews. SETTING: Eight rural/micropolitan communities in 4 US states. PARTICIPANTS: There were 41 caregivers and 20 children (8-12 years of age) from low-income, English-speaking households. PHENOMENA OF INTEREST: Knowledge, attitudes, and behaviors regarding FVs; perceived barriers to CSA participation. ANALYSIS: Transcribed verbatim and iteratively coded. RESULTS: Caregivers and children believed FVs were important to health, yet FVs were not featured in dinners or snacks and consumption was challenged by limited preferences and neophobia. Few caregivers and children knew about the seasonality of FV. Most caregivers were unfamiliar with CSA and had concerns about CSA cost, accessibility, produce quality, and selection. CONCLUSIONS AND IMPLICATIONS: These qualitative data support improvements in: 1) CSA distribution practices to offer flexible payment and pick-up options, more fruits, and self-selection of FV; 2) public awareness of produce seasonality and the CSA distribution model as necessary precursors to participation, and lower cost for low-income families who highlighted this barrier; and 3) capacity to prepare FV by enhancing skills and providing time-saving kitchen tools. Approaches to aligning CSA practices with the needs and preferences of low-income families warrant further research.

The perceived influence of cost-offset community-supported agriculture on food access among low-income families.

OBJECTIVE: To examine perspectives on food access among low-income families participating in a cost-offset community-supported agriculture (CO-CSA) programme. DESIGN: Farm Fresh Foods for Healthy Kids (F3HK) is a multicentre randomized intervention trial assessing the effect of CO-CSA on dietary intake and quality among children from low-income families. Focus groups were conducted at the end of the first CO-CSA season. Participants were interviewed about programme experiences, framed by five dimensions of food access: availability, accessibility, affordability, acceptability and accommodation. Transcribed data were coded on these dimensions plus emergent themes. SETTING: Nine communities in the US states of New York, North Carolina, Washington and Vermont. SUBJECTS: Fifty-three F3HK adults with children. RESULTS: CSA models were structured by partner farms. Produce quantity was abundant; however, availability was enhanced for participants who were able to select their own produce items. Flexible CSA pick-up times and locations made produce pick-up more accessible. Despite being affordable to most, payment timing was a barrier for some. Unfamiliar foods and quick spoilage hindered acceptability through challenging meal planning, despite accommodations that included preparation advice. CONCLUSIONS: Although CO-CSA may facilitate increased access to fruits and vegetables for low-income families, perceptions of positive diet change may be limited by the ability to incorporate share pick-up into regular travel patterns and meal planning. Food waste concerns may be particularly acute for families with constrained resources. Future research should examine whether CO-CSA with flexible logistics and produce self-selection are sustainable for low-income families and CSA farms.

Adults and Children in Low-Income Households that Participate in Cost-Offset Community Supported Agriculture Have High Fruit and Vegetable Consumption.

This paper examines fruit and vegetable intake (FVI) in low-income households that participated in a cost-offset (CO), or 50% subsidized, community-supported agriculture (CSA) program. CSA customers paid farms upfront for a share of the harvest, and received produce weekly throughout the growing season. A cohort of adults and children 2-12 y in a summer CO-CSA were surveyed online twice: August 2015 (n = 41) and February 2016 (n = 23). FVI was measured by the National Cancer Institute's (NCI) Fruit and Vegetable Screener (FVS) and an inventory of locally grown fruits and vegetables. FVI relative to United States (US) recommendations and averages, and across seasons, were tested with non-parametric tests and paired t-tests (p < 0.05). Both adults and children in the CO-CSA had higher FVI than the US averages, and more often met recommendations for vegetables. Some summer fruits and vegetables were more often eaten when locally in-season. The CO-CSA model warrants further examination as an avenue for improving vegetable consumption among adults and children in low-income households. However, causality between CO-CSA participation and FVI cannot be inferred, as CO-CSA participants may be positive deviants with respect to FVI. A multi-state randomized controlled trial is currently underway to evaluate impacts of CO-CSAs on FVI and related outcomes.

Farm Fresh Foods for Healthy Kids (F3HK): An innovative community supported agriculture intervention to prevent childhood obesity in low-income families and strengthen local agricultural economies.

BACKGROUND: Childhood obesity persists in the United States and is associated with serious health problems. Higher rates of obesity among children from disadvantaged households may be, in part, attributable to disparities in access to healthy foods such as fruits and vegetables. Community supported agriculture can improve access to and consumption of fresh produce, but the upfront payment structure, logistical barriers, and unfamiliarity with produce items may inhibit participation by low-income families. The aim of this project is to assess the impact of subsidized, or "cost-offset," community supported agriculture participation coupled with tailored nutrition education for low-income families with children. METHODS/DESIGN: The Farm Fresh Foods for Healthy Kids community-based, randomized intervention trial will build on formative and longitudinal research to examine the impact of cost-offset community supported agriculture on diet and other health behaviors as well as the economic impacts on local economies. The intervention will involve reduced-price community supported agriculture shares which can be paid for on a weekly basis, nine skill-based and seasonally-tailored healthy eating classes, and the provision of basic kitchen tools. Low income families with at least one child aged 2-12 years will be recruited to join existing community supported agriculture programs in New York, North Carolina, Vermont, and Washington. In each program, families will be randomized 1:1 to intervention or delayed intervention groups. Data will be collected at baseline, and in the fall and spring for 3 years. The primary outcomes are children's intake of fruits and vegetables and foods high in sugar and/or (solid) fat, as well as diet quality; secondary outcomes include physical, behavioral, psychosocial, and environmental variables. Cost-effectiveness and economic impact at the farm and community levels also will be assessed. DISCUSSION: This integrated project will provide important information and contribute to the evidence base regarding the use of local agricultural interventions to improve children's dietary behaviors and weight maintenance. Findings also will inform the development of a toolkit for farmers and education modules related to local food system innovations for undergraduate and graduate students. TRIAL REGISTRATION: ClinicalTrials.gov NCT02770196 . Registered 5 April 2016.

Developing an agenda for research about policies to improve access to healthy foods in rural communities: a concept mapping study.

BACKGROUND: Policies that improve access to healthy, affordable foods may improve population health and reduce health disparities. In the United States most food access policy research focuses on urban communities even though residents of rural communities face disproportionately higher risk for nutrition-related chronic diseases compared to residents of urban communities. The purpose of this study was to (1) identify the factors associated with access to healthy, affordable food in rural communities in the United States; and (2) prioritize a meaningful and feasible rural food policy research agenda. METHODS: This study was conducted by the Rural Food Access Workgroup (RFAWG), a workgroup facilitated by the Nutrition and Obesity Policy Research and Evaluation Network. A national sample of academic and non-academic researchers, public health and cooperative extension practitioners, and other experts who focus on rural food access and economic development was invited to complete a concept mapping process that included brainstorming the factors that are associated with rural food access, sorting and organizing the factors into similar domains, and rating the importance of policies and research to address these factors. As a last step, RFAWG members convened to interpret the data and establish research recommendations. RESULTS: Seventy-five participants in the brainstorming exercise represented the following sectors: non-extension research (n = 27), non-extension program administration (n = 18), "other" (n = 14), policy advocacy (n = 10), and cooperative extension service (n = 6). The brainstorming exercise generated 90 distinct statements about factors associated with rural food access in the United States; these were sorted into 5 clusters. Go Zones were established for the factors that were rated highly as both a priority policy target and a priority for research. The highest ranked policy and research priorities include strategies designed to build economic viability in rural communities, improve access to federal food and nutrition assistance programs, improve food retail systems, and increase the personal food production capacity of rural residents. Respondents also prioritized the development of valid and reliable research methodologies to measure variables associated with rural food access. CONCLUSIONS: This collaborative, trans-disciplinary, participatory process, created a map to guide and prioritize research about polices to improve healthy, affordable food access in rural communities.

Do entrepreneurial food systems innovations impact rural economies and health? Evidence and gaps.

A potential solution for weakened rural economies is the development of local food systems, which include affordable foods sources for consumers and economically feasible structures for producers. Local food systems are purported to promote sustainability, improve local economies, increase access to healthy foods, and improve the local diets. Four entrepreneurial food systems innovations that support local economies include farmers' markets, community supported agriculture, farm to institution programs and food hubs. We review current literature to determine whether innovations for aggregation, processing, distribution and marketing in local food systems: 1) enable producers to make a living; 2) improve local economies; 3) provide local residents with greater access to affordable, healthy food; and 4) contribute to greater consumption of healthy food among residents. While there is some evidence for each, more transdisciplinary research is needed to determine whether entrepreneurial food systems innovations provide economic and public health benefits.

Exploring the feasibility of combining chronic disease patient registry data to monitor the status of diabetes care.

INTRODUCTION: To provide direction and to support improvements in diabetes care, states must be able to measure the effectiveness of interventions and gain feedback on progress. We wanted to know if data from multiple health clinics that are implementing quality improvement strategies could be combined to provide useful measurements of diabetes care processes and control of intermediate outcomes. METHODS: We combined and analyzed electronic patient health data from clinic sites across Washington State that used the Chronic Disease Electronic Management System (CDEMS) registry. The data were used to determine whether national and state objectives for diabetes care were met. We calculated the percentage of patients that met standards of care in 2004. RESULTS: The pooled dataset included 17,349 adult patients with diabetes from 90 clinics. More than half of patients were above recommended target levels for hemoglobin A1c testing, foot examination, hemoglobin A1c control, and low-density lipoprotein cholesterol control. Fewer patients met recommendations for nephropathy assessment, eye examinations, and blood pressure control. In terms of meeting these standards, rates of diabetes care varied across clinics. CDEMS rates of care were compared with those reported by other data sources, but no consistent pattern of similarities or differences emerged. CONCLUSION: With committed staff time, provider support, and resources, data from clinical information systems like CDEMS can be combined to address a deficiency in state-level diabetes surveillance and evaluation systems--specifically, the inability to capture clinical biometric values to measure intermediate health outcomes. These data can complement other surveillance and evaluation data sources to help provide a better picture of diabetes care in a state.

Adapting logic models over time: the Washington State Heart Disease and Stroke Prevention Program experience.

Logic models are graphic representations of the relationship between program activities and their intended effects and are used for both program planning and evaluation. Logic models can provide an important foundation for program evaluation by identifying evaluation questions that most appropriately assess program processes and outcomes and by guiding measurement decisions. We demonstrate how logic models can be used to plan program evaluation by describing the adoption of logic modeling by the Washington State Heart Disease and Stroke Prevention Program (WaHDSPP) and by specifying the changes in process and use of logic models since the program's initial funding. Our paper describes how a logic model was used in generating the program evaluation plan for the WaHDSPP, including the identification of evaluation questions and development of indicators to track progress effectively. We describe the use of evaluation results, as well as steps state programs can take to use logic models in program evaluation.

A framework for developing evaluation tools used in Washington State's Healthy Communities projects.

Washington State's Healthy Communities pilot projects were developed to test approaches and recommendations of the Washington State Nutrition and Physical Activity Plan and to provide a statewide model for implementation. The Healthy Communities program included plans for ongoing process evaluation to ensure implementation. Two years into the first project, however, the evaluation team recognized that data for evaluation were inadequate to explain the experiences of the pilot community partnership. The team sought a framework through which to better understand how the community partnership functioned, including what worked well and how guidance and technical assistance could best be provided. The evaluation team identified the community health governance model of Lasker and Weiss through a literature search and applied this model to existing Healthy Communities project evaluation data. The team also designed a new survey tool based on the model and used it in the second pilot community. The new tool provides feedback to community partners to help guide project implementation and tests the applicability of a theoretical model to public health practice.