Topic: Drinking Water

Exploring the Cost-Effectiveness of Strategies to Improve Child Health in Massachusetts

Posted on February 23, 2024

The information in this brief is intended only to provide educational information.

The CHOICES Project at the Harvard T.H. Chan School of Public Health, the Massachusetts Department of Public Health (MDPH), and the Massachusetts Department of Elementary and Secondary Education (DESE) worked together as part of the Massachusetts-CHOICES Project, a training, technical assistance, and modeling initiative, to develop a playbook of strategies to promote healthy weight and advance health equity in addition to studying how cost-effectiveness metrics are used by partners throughout the state.

Methods & Strategies Modeled

Using CHOICES cost-effectiveness analysis and local data, the MDPH and DESE team worked with CHOICES to create a virtual population that mirrors the current population of Massachusetts. Then, the teams examined the expected costs, health outcomes, impacts on health equity, and health care costs saved if the following strategies were implemented in Massachusetts over a 10-year timeframe (2020-2029):

• Movement Breaks in the Classroom
• Water Dispensers in Schools

Movement Breaks in the Classroom

Movement breaks in the classroom is a strategy to promote physical activity during the school day by incorporating five-to-10-minute movement breaks in K-5 public elementary school classrooms. To implement this evidence-based strategy,¹ the Massachusetts Departments of Public Health and Elementary and Secondary Education would collaborate to connect school districts to the School Wellness Coaching Program. This program helps school districts integrate movement breaks into their local wellness policies and meet state and federal physical activity recommendations.

Teachers in K-5 classrooms would receive training, technical assistance, and materials to support implementation. School wellness champions could also elect to be trained. This strategy aligns with the School Wellness Coaching Program² and the Whole School, Whole Community, Whole Child initiative to create school environments that prioritize students’ health, well-being, and ability to learn.

Additional Key Findings

If movement breaks were incorporated into classrooms in Massachusetts, it is likely to be cost-effective at commonly accepted thresholds³ based on net cost per population health improvement related to excess weight ($66,200 per quality-adjusted life year gained).

By training and equipping over 200 teachers and other school staff to incorporate movement breaks in the classroom, this strategy could help Massachusetts public schools cultivate a positive school climate and improve social emotional learning.⁴ Additionally, movement breaks allow students an opportunity for a “brain break” to refocus, reconnect and bring their attention back to their academic work.

To learn more about this strategy, read the research brief.

Good N, Bolton AA, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Massachusetts: Movement Breaks in the Classroom {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2023.

References

1.The Community Preventive Services Task Force. Physical Activity: Classroom-based Physical Activity Break Interventions. The Community Guide; 2021. Accessed Jun 20, 2023. https://www.thecommunityguide.org/pages/tffrs-physical-activity-classroom-based-physical-activity-break-interventions.html
2.School Wellness Initiative for Thriving Community Health (SWITCH). Initiatives: Massachusetts School Wellness Coaching Program. Published 2022. Accessed Oct 5, 2022. https://massschoolwellness.org/initiatives
3.Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. DOI: 10.1056/NEJMp1405158. PMID: 25162885.
4.Centers for Disease Control and Prevention. School-Based Physical Activity Improves the Social and Emotional Climate for Learning. CDC Healthy Schools. Published 2021. Accessed March 9, 2022. https://www.cdc.gov/healthyschools/school_based_pa_se_sel.htm

Water Dispensers in Schools

This strategy applies an equity lens to increasing water access by installing touchless water dispensers on or near school cafeteria lunch lines in K-8 Massachusetts public schools with identified needs. Priority schools would be those with elevated concentrations of lead in drinking water documented via state lead testing programs¹ and located in cities and towns with Environmental Justice designation based on the community’s share of households with lower incomes, limited English proficiency, or individuals identifying as Black, Indigenous, or people of color.²

Better drinking water access in schools has been shown to increase water intake and may help promote a healthy weight.³ The Massachusetts Departments of Public Health and Elementary and Secondary Education would provide outreach to school districts to encourage the installation of water dispensers through existing relationships.

Additional Key Findings

If water dispensers were installed in K-8 public schools in Massachusetts, it is likely to be cost-effective at commonly accepted thresholds⁴ based on net cost per population health improvement related to excess weight, at a cost of $72,700 per quality-adjusted life year gained.

Additionally, this strategy would prioritize installing water dispensers in schools that identify elevated concentrations of lead in their drinking water and in school districts located in communities meeting criteria for Environmental Justice designation.² Fifty percent of the students that would gain access to improved drinking water would be Black and Hispanic/Latinx, a higher proportion than the state’s student population overall.⁵

To learn more about this strategy, read the research brief.

McCulloch SM, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Massachusetts: Water Dispensers in Schools {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2023.

References

1. MA Executive Office of Energy and Environmental Affairs. Lead and Copper in School Drinking Water Sampling Results. Accessed December 5, 2022. https://www.mass.gov/service-details/lead-and-copper-in-school-drinking-water-sampling-results
2. MA Executive Office of Energy and Environmental Affairs. Environmental Justice Populations in Massachusetts. Accessed April 7, 2023. https://www.mass.gov/info-details/environmental-justice-populations-in-massachusetts
3. Schwartz AE, Leardo M, Aneja S, Elbel B. Effect of a School-Based Water Intervention on Child Body Mass Index and Obesity. JAMA Pediatr. 2016; 170(3):220-226. doi:10.1001/jamapediatrics.2015.3778.
4. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. doi: 10.1056/NEJMp1405158. PMID: 25162885.
5. Massachusetts Department of Elementary and Secondary Education. 2022-23 Enrollment By Race/Gender Report (District). Updated December 1, 2022. Accessed April 7, 2023. https://profiles.doe.mass.edu/statereport/enrollmentbyracegender.aspx

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This document was developed at the Harvard T.H. Chan School of Public Health through the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This document is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

← Back to Resources

Strategy Report: Creating Healthier Afterschool Environments

Posted on November 17, 2023

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu for an accessible version of this report.

Suggested Citation

CHOICES National Action Kit: Creating Healthier Afterschool Environments Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; November 2023.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Dar Alon, Stella Zhu, Shilpi Agarwal, Ana Paula Bonner Septien, Jenny Reiner, Matt Lee, Zach Ward.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

← Back to Resources

Strategy Report: Promoting Water Consumption in Schools

Posted on November 17, 2023

Overview

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu for an accessible version of this report.

Suggested Citation

CHOICES National Action Kit: Promoting Water Consumption in Schools Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; November 2023.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Dar Alon, Stella Zhu, Shilpi Agarwal, Amy Bolton, Jenny Reiner, Matt Lee, Zach Ward.

Funding

For further information, contact choicesproject@hsph.harvard.edu

← Back to Resources

Strategy Profile: Creating Healthier Early Care and Education Environments

Posted on September 22, 2023

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

Improving nutrition, physical activity, & screen time policies & practices for children ages 3-5 by incorporating the Nutrition & Physical Activity Self-Assessment for Child Care (NAP SACC) Program into state’s Quality Rating and Improvement Systems (QRIS) for early care and education programs.

What population benefits?

Children ages 3-5 attending licensed early care and education programs that participate in their state’s Quality Rating and Improvement Systems (QRIS).

What are the estimated benefits?

Relative to not implementing the strategy
Promote healthy child weight.

What activities and resources are needed?

Activities	Resources	Who Leads?
Train early care and education health professionals to work with early care and education programs	• Time of state training consultant to train early care and education health professionals • Time of early care and education health professionals to be trained	State QRIS administrators
Provide consultation to early care and education program directors and staff for conducting self-assessments of program policies and practices, completing action plans, and implementing changes to improve nutrition, physical activity, and screen time environments in programs	• Time of early care and education health professionals to provide consultation to early care and education programs • Time of early care and education program directors and staff to participate in consultation	Early care and education health professionals
Provide materials and equipment for implementing NAP SACC program	• Cost for GO NAP SACC online license • Physical activity equipment costs	State QRIS administrators
Implement changes in early care and education programs to improve nutrition, physical activity, and screen time environments	• Time of early care and education program directors to implement changes	Early care and education program directors
Improve nutritional quality of meals served in early care and education programs	• Food costs for improving nutritional quality of meals	Early care and education program directors
Monitor compliance with NAP SACC program	• Time of state-level QRIS Administrators to monitor compliance	State QRIS administrators

Strategy Modification

In states where NAP SACC is already being implemented, the strategy could be modified to focus on increasing the number of early care and education programs that participate in NAP SACC. With this modification, the cost for the GO NAP SACC online license would not be needed, since it is a fixed annual cost paid per state (i.e., it does not depend on the number of participating programs). With this modification, the impact on health is expected to be similar, and the impact on reach and cost would vary according to the number of programs reached.

FOR ADDITIONAL INFORMATION

Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Aff (Millwood). 2015 Nov;34(11):1932-9. doi: 10.1377/hlthaff.2015.0631. Supplemental Appendix with strategy details available at: https://www.healthaffairs.org/doi/suppl/10.1377/hlthaff.2015.0631/ suppl_file/2015-0631_gortmaker_appendix.pdf

Selected CHOICES research brief including cost-effectiveness metrics:

Adams B, Sutphin B, Betancourt K, Balamurugan A, Kim H, Bolton A, Barrett J, Reiner J, Cradock AL. Arkansas: Creating Healthier Child Care Environments: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) in the Quality Rating Improvement System (QRIS) {Issue Brief}. Arkansas Department of Health, Little Rock, AR, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2021. Available at: https://choicesproject.org/publications/brief-napsacc-arkansas

Kenney EL, Giles CM, Flax CN, Gortmaker SL, Cradock AL, Ward ZJ, Foster S, Hammond W. New Hampshire: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention {Issue Brief}. New Hampshire Department of Health and Human Services, Concord, NH, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017. Available at: https:// choicesproject.org/publications/brief-napsacc-intervention-new-hampshire

Browse more CHOICES research briefs & reports in the CHOICES Resource Library.
Explore and compare this strategy with other strategies on the CHOICES National Action Kit.

Suggested Citation

CHOICES Strategy Profile: Creating Healthier Early Care and Education Environments. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; September 2023.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

← Back to Resources

Strategy Profile: Promoting Water Consumption in Schools

Posted on August 30, 2023

School-aged girl drinking water from a reusable water bottle

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

Promoting increased water consumption among elementary and middle school students (grades K-8) with the installation of chilled drinking water dispensers in school cafeterias with viable plumbing in schools that participate in the National School Lunch Program.

What population benefits?

Children in grades K-8 attending schools with viable plumbing that participate in the National School Lunch Program.

What are the estimated benefits?

Relative to not implementing the strategy
Increase the availability of safe, free drinking water in schools. In turn, this would increase child water consumption and promote healthy child weight.

What activities and resources are needed?

Activities	Resources	Who Leads?
Purchase and install chilled water dispensers	• Staffing resources necessary for installing water dispensers • Costs associated with purchasing water dispensers	School personnel
Deliver training to school food service directors in cleaning and maintaining the chilled water dispensers	• Time to develop online training and materials • Time for food service directors to access and attend online training	School district food service staff
Maintain and clean water dispensers	• Time for food service staff to clean water dispensers • Cost of water dispenser filter replacement • Time for food service staff to replace filters	School food service staff
Increase utilities and disposable cup usage	• Cost of incremental increase in water and electricity usage • Cost of increased disposable cup usage	Schools
Test lead levels in drinking water and remediate issues	• Cost of lead testing and remediation for school drinking water	Schools
Conduct administrative review related to drinking water	• Time for the school district food service director to participate in administrative review • Time for the National School Lunch Program administrator to conduct administrative review	State government

Strategy Modification

Some state and local health agencies added to this strategy the costs of developing and disseminating educational materials on water consumption to further encourage water consumption among students. This would require additional time to develop and disseminate the educational materials and the additional cost of the educational materials.

FOR ADDITIONAL INFORMATION
Kenney EL, Cradock AL, Long MW, Barrett JL, Giles CM, Ward ZJ, Gortmaker SL. CostEffectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake. Obesity. 2019;27(12):2037-2045. doi:10.1002/oby.22615.

Selected CHOICES research brief including cost-effectiveness metrics:
Gouck J, Whetstone L, Walter C, Pugliese J, Kurtz C, Seavey-Hultquist J, Barrett J, McCulloch S, Reiner J, Cradock AL. California: Improving Drinking Water Equity and Access in California Schools {Issue Brief}. California Department of Public Health, Sacramento, CA, the County of Santa Clara Public Health Department, San Jose, CA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2021. Available at: https://choicesproject.org/publications/brief-water-schools-california

McCulloch SM, Barrett JL, Reiner JF, Cradock AL. Massachusetts: Water Dispensers in Schools {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2023. Available at: https://choicesproject.org/publications/brief-water-dispensers-ma

Browse more CHOICES research briefs & reports in the CHOICES Resource Library.
Explore and compare this strategy with other strategies on the CHOICES National Action Kit.

Suggested Citation

CHOICES Strategy Profile: Promoting Water Consumption in Schools. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; April 2022; revised August 2023.

Funding

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

← Back to Resources

Brief: Creating Healthier Afterschool Environments (OSNAP) in Boston, MA

Posted on July 28, 2023

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining the implementation of the Out of School Nutrition and Physical Activity (OSNAP) initiative that helps afterschool programs improve practices and policies that increase physical activity and consumption of healthy snacks.

The Issue

Every child should have opportunities to grow up healthy. Regular physical activity, healthy eating, and adequate hydration can help children maintain a healthy weight. Over 6,000 students in kindergarten to fifth grade participate in afterschool programs in Boston.¹ These educational settings can provide essential opportunities for children to learn healthy eating habits and promote physical activity and wellness. However, not all programs offer the same opportunities for healthy eating and physical activity.² Helping more afterschool programs adopt policies and practices that incorporate more physical activity, healthier snacks, and improved water access during program time can help ensure that all children in Boston’s afterschool programs have opportunities to grow up healthy.

About Creating Healthier Afterschool Environments

OSNAP is a proven initiative implemented in multiple communities that helps afterschool programs create environments that promote increased physical activity and consumption of healthy snacks.^3-6 Creating healthier afterschool environments can contribute to higher quality afterschool programming. To implement this initiative, the Boston Public Health Commission would provide professional development opportunities for afterschool program leaders serving students in grades K-5. Afterschool staff leaders would participate in three learning collaborative sessions and receive technical assistance to assess⁷ and modify their programs’ practices and policies³ to meet the OSNAP nutrition and physical activity goals. The Boston Public Health Commission would supply program leaders with materials to support implementation and offer continuing education units for their participation.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2029) of implementing the OSNAP program with the costs and outcomes associated with not implementing the program.

Creating healthier afterschool environments is an investment in the future. By the end of 2029:

Conclusions and Implications

Opportunities for physical activity and access to healthy foods in afterschool programs are important to parents² and can help enhance the quality of afterschool programing. Over 10 years, this strategy could train more than 600 afterschool teachers and directors. By equipping afterschool leaders with these skills and resources, afterschool programs could adopt healthier practices and policies and we project that 10,800 children would benefit from more physical activity and improved diet. We project that 37 cases of obesity would be prevented and $34,100 in healthcare costs related to excess weight would be saved in 2029. We expect this strategy would cost $18.30 per child per year to implement in Boston and is projected to be cost-effective at commonly accepted thresholds⁸ based on net population health improvement related to excess weight ($72,100 per quality-adjusted life year gained).

In addition to promoting healthy weight, this strategy may also support children’s health in other ways. Regular physical activity, healthy eating, and adequate hydration can improve children’s mental and emotional well-being and their heart, lung, and bone health.⁹ These healthy behaviors can also strengthen students’ attention, memory,^10,11 and cognitive functioning,¹⁰ all important components for learning and academic performance. Incorporating physical activity and healthy snacks in afterschool programs can help children nurture healthy habits and lay a strong foundation for overall health and well-being.

This strategy builds upon Boston Public Health Commission’s demonstrated success where, in 2015, more than 120 programs took steps to improve their screen time, physical activity, and nutrition practices through OSNAP, creating higher quality afterschool programs across Boston.¹¹ Broader implementation could reach all afterschool programs in Boston, improving practices and policies that promote increased physical activity and consumption of healthy snacks, furthering the Boston Public Health Commission’s goal of creating policy and systems changes in childcare to promote the health of all Boston residents.

References

Boston AfterSchool & Beyond. SY 21-22 Programs. In. Boston, MA: Boston AfterSchool & Beyond; 2021.
Kids on the Move: Afterschool Programs Promoting Healthy Eating and Physical Activity. Washington, D.C.: America After 3pm, Afterschool Alliance; 2015.
Kenney EL, Giles CM, deBlois ME, Gortmaker SL, Chinfatt S, Cradock AL. Improving nutrition and physical activity policies in afterschool programs: results from a group-randomized controlled trial. Prev Med. 2014;66:159-166. doi:10.1016/j.ypmed.2014.06.011
Cradock AL, Barrett JL, Giles CM, et al. Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative: A Cluster-Randomized Controlled Trial. JAMA Pediatr. 2016;170(2):155-162.
Lee RM, Giles CM, Cradock AL, Emmons KM, Okechukwu C, Kenney EL, Thayer J, Gortmaker SL. Impact of the Out-of-School Nutrition and Physical Activity (OSNAP) Group Randomized Controlled Trial on Children’s Food, Beverage, and Calorie Consumption among Snacks Served. J Acad Nutr Diet. 2018 Aug;118(8):1425-1437. doi: 10.1016/j.jand.2018.04.011.
Lee RM, Barrett JL, Daly JG, Mozaffarian RS, Giles CM, Cradock AL, Gortmaker SL. Assessing the effectiveness of training models for national scale-up of an evidence-based nutrition and physical activity intervention: a group randomized trial. BMC Public Health. 2019 Nov 28;19(1):1587. doi: 10.1186/s12889-019-7902-y.
Lee RM, Emmons KM, Okechukwu CA, Barrett JL, Kenney EL, Cradock AL, Giles CM, deBlois ME, Gortmaker SL. Validity of a practitioner-administered observational tool to measure physical activity, nutrition, and screen time in school-age programs. Int J Behav Nutr Phys Act. 2014 Nov 28;11:145. doi: 10.1186/s12966-014-0145-5.
Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. DOI: 10.1056/NEJMp1405158. PMID: 25162885.
Health Benefits of Physical Activity for Children. Centers for Disease Control and Prevention. https://www.cdc.gov/physicalactivity/basics/adults/health-benefits-of-physical-activity-for-children.html. Published Jan 12, 2022. Updated 2022-01-12T05:06:09Z. Accessed Dec 7, 2022.
Childhood Nutrition Facts. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyschools/nutrition/facts.htm. Published 2022. Updated 2022-08-05T03:49:26Z. Accessed Dec 12, 2022.
Blanding N. Afterschool Programs in Boston, MA, Expand Opportunties for Obesity Prevention. Centers for Disease Control and Prevention; 2016. http://nccd.cdc.gov/nccdsuccessstories

Suggested Citation:

Carter S, Bovenzi M, Clarke J, Bolton AA, Reiner JF, Barrett JL, Cradock AL, Gortmaker SL. Boston, MA: Creating Healthier Afterschool Environments (OSNAP) {Issue Brief}. Boston Public Health Commission, Massachusetts, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; July 2023.

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Boston Public Health Commission through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

← Back to Resources

Brief: Water Dispensers in Massachusetts Schools

Posted on June 28, 2023

Water fountain and filling station on a wall in a school

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to improve access to drinking water in schools in Massachusetts. This strategy involves the installation of touchless chilled water dispensers on or near school cafeteria lunch lines in K-8 public schools with adequate plumbing.

The Issue

All students should have access to safe, clean, and appealing drinking water, no matter where they go to school. Yet, nearly half of K-8 public schools in Massachusetts have identified elevated concentrations of lead in their drinking water and need to improve their drinking water infrastructure.¹

Providing access to appealing drinking water gives students a healthier alternative to sugary drinks, like sweetened fruit drinks, sports drinks, and soda. In 2021, most adolescents in Massachusetts reported consuming sugary drinks,² which has been linked to excess weight gain, type 2 diabetes, and heart disease.^3,4 Students drink more water when schools provide access to water at lunch at no charge,⁵ and improving school water access may help kids grow up at a healthy weight.^6,7 Creating a healthy, equitable school environment with appealing drinking water access can help set children up for a healthy future.

About the Water Dispensers in Schools Strategy

This strategy applied an equity lens to increasing water access by installing touchless water dispensers on or near school cafeteria lunch lines in K-8 Massachusetts public schools with identified needs. Priority schools would be those with elevated concentrations of lead in drinking water documented via state lead testing programs¹ and located in cities and towns with Environmental Justice designation based on the community’s share of households with lower incomes, limited English proficiency, or individuals identifying as Black, Indigenous, or people of color.⁸ Better drinking water access in schools has been shown to increase water intake and may help promote a healthy weight.⁶ The Massachusetts Departments of Public Health and Elementary and Secondary Education would provide outreach to school districts to encourage the installation of water dispensers through existing relationships. Putting this strategy into place would require resources for administering the program, installing and maintaining dispensers, utility costs, disposable cup provision, and lead testing and remediation.

Comparing Costs and Outcomes

A CHOICES cost-effectiveness analysis compared the costs and outcomes of installing touchless water dispensers in schools with the costs and outcomes associated with not implementing the voluntary water equity and access program over 10 years (2020-2029).

The installation of touchless water dispensers in schools in Massachusetts is an investment in a more equitable future. By the end of 2029:

Conclusions and Implications

Installing water dispensers in K-8 public schools is an effective strategy for increasing access to clean and appealing drinking water, and over 10 years, it could improve drinking water access for 265,000 students in 304 schools in Massachusetts. Adequate water consumption can support well-being and cognitive function.⁹ Fluoridated water intake also prevents dental caries.¹⁰ Such preventive strategies play a critical role in promoting child health. This strategy is also projected to prevent 525 cases of childhood obesity in 2029 and cost, on average, $9 per child to implement each year. It is likely to be cost-effective at commonly accepted thresholds¹¹ based on net cost per population health improvement related to excess weight, at a cost of $72,700 per quality-adjusted life year gained.

In Massachusetts, schools that participate in the state’s drinking water lead testing program are eligible to receive funding to install water dispensers.¹² Expanding participation in this opportunity for drinking water testing and fixture installation would provide students and staff with better access to more appealing drinking water. Additionally, the proposed outreach strategy would prioritize installing water dispensers in schools that identify elevated concentrations of lead in their drinking water and in school districts located in communities meeting criteria for Environmental Justice designation.⁸ Because these communities have a higher proportion of residents who identify as people of color or households with low income, this strategy could promote health equity. Fifty percent of the students that would gain access to improved drinking water would be Black and Hispanic/Latinx, a higher proportion than the state’s student population overall.¹³

Though investment is required, every student deserves access to clean, appealing drinking water at school and this strategy would support the health of both students and staff in Massachusetts’ schools.

References

MA Executive Office of Energy and Environmental Affairs. Lead and Copper in School Drinking Water Sampling Results. Accessed December 5, 2022. https://www.mass.gov/service-details/lead-and-copper-in-school-drinking-water-sampling-results
Massachusetts Department of Elementary and Secondary Education. 2021 Youth Risk Behavior Survey (YRBS) Results. 2021.
Malik VS, Pan A, Willett WC , Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(4):1084-1102.
Chen L, Caballero B, Mitchell DC, et al. Reducing consumption of sugar-sweetened beverages is associated with reduced blood pressure a prospective study among United States adults. Circulation. 2010;121(22):2398-2406.
Bogart LM, Babey SH, Patel AI, Want P, Schuster MA. Lunchtime school water availability and water consumption among California adolescents. J Adolesc Health. 2016; 58(1):98-103, doi: 10.1016/j.jadohealth.2015.09.007.
Schwartz AE, Leardo M, Aneja S, Elbel B. Effect of a School-Based Water Intervention on Child Body Mass Index and Obesity. JAMA Pediatr. 2016; 170(3):220-226. doi:10.1001/jamapediatrics.2015.3778.
Kenney EL, Cradock AL, Long MW, et al. Cost-Effectiveness of Water Promotion Strategies in Schools for preventing Childhood Obesity and Increasing Water Intake. Obesity. 2019;27(12):2037-2045.
MA Executive Office of Energy and Environmental Affairs. Environmental Justice Populations in Massachusetts. Accessed April 7, 2023. https://www.mass.gov/info-details/environmental-justice-populations-in-massachusetts
Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration, and health. Nutr Rev. 2010 Aug;68(8):439-58.
American Dental Association and Centers for Disease Control. Nature’s Way to Prevent Tooth Decay: Water Fluoridation. Published 2006. Accessed July 13, 2021. https://www.cdc.gov/fluoridation/pdf/natures_way.pdf
Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. doi: 10.1056/NEJMp1405158. PMID: 25162885.
The Massachusetts Clean Water Trust. About SWIG. Accessed May 5, 2022. https://www.mass.gov/service-details/about-swig
Massachusetts Department of Elementary and Secondary Education. 2022-23 Enrollment By Race/Gender Report (District). Updated December 1, 2022. Accessed April 7, 2023. https://profiles.doe.mass.edu/statereport/enrollmentbyracegender.aspx

Suggested Citation:

McCulloch SM, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Massachusetts: Water Dispensers in Schools {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2023. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health through the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

← Back to Resources

Strategy Profile: Creating Healthier Afterschool Environments

Posted on October 6, 2022

Creating healthier afterschool environments is a strategy to improve nutrition and physical activity policies & practices through the Out of School Nutrition and Physical Activity (OSNAP) initiative for children in grades K-5 attending state-administered 21^st Century Learning afterschool programs.

What population benefits?

Children in grades K-5 attending state-administered 21^st Century Learning afterschool programs.

What are the estimated benefits?

Relative to not implementing the strategy
Increase vigorous physical activity and improve nutritional quality of snacks and beverages offered in afterschool programs, and, in turn, promote healthy child weight.

What activities and resources are needed?

Activities	Resources	Who Leads?
Issue regulations to improve nutrition and physical activity policies and practices in afterschool programs	• Time to issue and communicate regulations	State government
Provide training and technical assistance to regional Healthy Afterschool trainers on how to lead learning collaborative sessions	• Time for state Healthy Afterschool coordinator to lead trainings • Time for regional Healthy Afterschool trainers to be trained and receive technical assistance • Travel costs • Training material costs	State healthy afterschool coordinator
Conduct regional learning collaboratives with afterschool program staff including training and technical assistance on goals and implementation activities	• Time for regional Healthy Afterschool trainers to lead learning collaboratives and provide technical assistance • Time for afterschool program staff to attend learning collaboratives and receive technical assistance • Training material costs • Travel costs	Regional healthy afterschool trainer
Assess and implement actions to change program practices to meet Healthy Afterschool standards	• Time for afterschool program staff to conduct program practice self-assessments and implement changes at their program • Increase in food costs to provide snacks in compliance with nutrition standards to children attending Healthy Afterschool programs	Afterschool program director
Develop CEU-accredited course for local program staff	• Cost to create a CEU-accredited course	State healthy afterschool coordinator
Provide educational materials and incentives to local program staff	• Material and incentive costs	State government
Monitor compliance to ensure afterschool programs are following programmatic requirements	• Time for state monitoring and compliance staff to monitor compliance • Travel costs	State government monitoring and compliance staff
Establish a Healthy Afterschool recognition and monitoring website	• Time to create and maintain website	State government website developer

Strategy Modification

This strategy could be modified to benefit children who participate in out-of-school programs administered by other organizations (e.g., YMCA or Boys and Girls Club of America). With this modification, the activities necessary to carry out the voluntary recognition program may not be included (e.g., issuing regulations, creating a healthy afterschool nutrition website, and monitoring compliance). With this modification, the impact on health is expected to be similar, and the impact on reach and cost may vary.

FOR ADDITIONAL INFORMATION

Cradock AL, Barrett JL, Kenney EL, Giles CM, Ward ZJ, Long MW, Resch SC, Pipito AA, Wei ER, Gortmaker SL. Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood. Prev Med. 2017 Feb;95 Suppl: S17-S27. doi: 10.1016/j.ypmed.2016.10.017. Supplemental Appendix with strategy details available at: https://ars.els-cdn.com/ content/image/1-s2.0-S0091743516303395-mmc1.docx

Browse more CHOICES research briefs & reports in the CHOICES Resource Library.
Explore and compare this strategy with other strategies on the CHOICES National Action Kit.

Suggested Citation

CHOICES Strategy Profile: Creating Healthier Afterschool Environments. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2023.

Funding

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

← Back to Resources

May 2022 Coffee Chat Resource Round-Up

Posted on June 2, 2022

This document compiles resources and information shared during the May 19, 2022 coffee chat, which featured partners who shared how improving access to safe and appealing drinking water in schools and communities is a key strategy for helping children grow up healthy.

← Back to Resources

Brief: Improving Drinking Water Equity and Access in California Schools

Posted on March 23, 2022

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to improve access to drinking water in California schools. This voluntary water equity and access program involves the installation of touchless chilled water dispensers on or near school cafeteria lunch lines in K-8 non-charter California public schools that have adequate plumbing.

The Issue

All children should have access to clean, appealing, and free drinking water no matter where they live or where they go to school. Providing appealing access to drinking water gives students a healthier alternative to sugary drinks, like sweetened fruit drinks, sports drinks, and soda. Students drink more water when schools provide access to water at lunch at no charge,¹ and improving school water access can help kids grow up at a healthy weight.^2,3

In California, one in 10 schools reported having no access to free drinking water where meals are served despite state and federal requirements.^4,5 Additionally, only one in five schools reported meeting criteria considered the standard for excellence in water access.⁴ Creating a healthy, equitable school environment that includes appealing drinking water access can help set children up for a healthy future.

About the Water Dispensers in Schools Strategy

This strategy focuses on increasing water access by installing touchless water dispensers at schools serving primarily families with low income, which also have a greater share of Black/African American and Latino students than other schools in California. Promoting better drinking water access in schools has been shown to increase water intake during the day and may help promote a healthy weight.³ Thus, it is a strategy that can help local health departments reach the twin goals of increasing access to and promotion of safe drinking water while decreasing access to and consumption of sugary drinks.⁶ Putting this strategy into place would require resources for administering the program, installing and maintaining dispensers, utility and disposable cup usage, lead testing and remediation, and delivering water-promotion education.

Comparing Costs and Outcomes

Installation of touchless water dispensers in schools in California is an investment in a more equitable future. By the end of 2030:

Conclusions and Implications

Installing water dispensers in K-8 public schools is an effective strategy for increasing access to clean, appealing, and free drinking water. Over 10 years, this strategy is expected to improve drinking water access and consumption for over 1.8 million students in California. This strategy is estimated to prevent 3,660 cases of childhood obesity in 2030 and would cost on average $6 per child to implement each year. Comparatively, the value of lunch served to students is $3 per day or about $600 per year.⁷ While the costs to implement this strategy would be $21,500 per school over 10 years, there would be an estimated $12 million in obesity-related health care cost savings over the same time period.

Improving students’ access to free, clean drinking water could promote health equity. Latino youth report less availability of drinking water access in schools,⁸ and Black/African American youth are less likely to be adequately hydrated compared with White non-Latino youth.⁹ Focusing drinking water access improvements in schools with high percentages of Black/African American and Latino students may benefit these populations the most. In addition to promoting a healthy weight, this strategy may also benefit children in other ways. Adequate water consumption can lead to improvements in well-being and support cognitive function.¹⁰ Fluoridated water intake also prevents dental caries.¹¹

Though investment is required, every student deserves access to clean, appealing drinking water, and this strategy can be a part of a suite of interventions that support children and their families. Many preventive strategies play a critical role in helping children establish healthy habits early on in life. Focusing on supporting these healthy habits now can help more children grow up at a healthy weight.

References

Bogart LM, Babey SH, Patel AI, Want P, Schuster MA. Lunchtime school water availability and water consumption among California adolescents. Journal of Adolescent Health. 2016; 58(1):98-103, doi: 10.1016/j.jadohealth.2015.09.007.
Schwartz AE, Leardo M, Aneja S, Elbel B. Effect of a School-Based Water Intervention on Child Body Mass Index and Obesity. JAMA Pediatr. 2016; 170(3):220-226. doi:10.1001/jamapediatrics.2015.3778.
Kenney EL, Cradock AL, Long MW, et al. Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake. Obesity. 2019;27(12):2037-2045.
Altman EA, Lee KL, Hecht CA, Hampton KE, Moreno G, Patel AI. Drinking water access in California schools: Room for improvement following implementation of school water policies. Preventive Medicine Reports. 2020;19:101143. Published 2020 Jun 8. doi:10.1016/j.pmedr.2020.101143.
California Department of Education. Drinking Water for Students in Schools. Reviewed January 14, 2020. https://www.cde.ca.gov/ls/nu/he/water.asp#:~:text=California%20Education%20Code%20Section%2038086%20states%20that%20if%20a%20school,reasons%20why%2C%20whether%20due%20to. Accessed February 16, 2021.
California Department of Public Health. FFY 2020-2022 SNAP-Ed Local Health Departments Programmatic Priorities. Published December 10, 2018. https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/NEOPB/CDPH%20Document%20Library/Branch16Add2FFY20-22SNAPEdLHD.pdf. Accessed January 29, 2021.
California Department of Education. 2019-20 CNP Reimbursement Rates. https://www.cde.ca.gov/ls/nu/rs/rates1920.asp. Accessed December 12, 2020.
Onfurak SJ, Park S, Wilking C. Student-reported school drinking fountain availability by youth characteristics and state plumbing codes. Preventing Chronic Disease. 2014; 11: E60, doi: 10.5888/pcd11.130314.
Kenney EL, Long MW, Cradock AL, Gortmaker SL. Prevalence of inadequate hydration among U.S. children and disparities by gender and race/ethnicity: National Health and Nutrition Examination Survey, 2009–2012. American Journal of Public Health. 2015; 105(8): e113-8, doi: 10.2105/AJPH.2015.302572.
Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration, and health. Nutition Reviews. 2010 Aug;68(8):439-58.
American Dental Association and Centers for Disease Control. Nature’s Way to Prevent Tooth Decay: Water Fluoridation. Published 2006. https://www.cdc.gov/fluoridation/pdf/natures_way.pdf. Accessed July 13, 2021.

Suggested Citation:

Gouck J, Whetstone L, Walter C, Pugliese J, Kurtz C, Seavey-Hultquist J, Barrett J, McCulloch S, Reiner J, Cradock AL. California: Improving Drinking Water Equity and Access in California Schools {Issue Brief}. California Department of Public Health, Sacramento, CA, the County of Santa Clara Public Health Department, San Jose, CA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2021. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the California Department of Public Health and the County of Santa Clara Public Health Department through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

← Back to Resources