Topic: Health Equity

Brief: Improving Drinking Water Equity and Access in California Schools

Posted on March 23, 2022

School-aged girl drinking water from a reusable water bottle

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

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 (2020-2030).

Installation of touchless water dispensers in schools in California is an investment in a more equitable future. By the end of 2030:
If touchless water dispensers were installed in schools in California, then, by the end of 2030, 1.88 million children would be reached with improved access to safe drinking water in schools over 10 years; $12 million would be saved in health care costs over 10 years; and this intervention would cost $6 per child per year to implement.

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

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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. 

  6. 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.

  7. California Department of Education. 2019-20 CNP Reimbursement Rates. https://www.cde.ca.gov/ls/nu/rs/rates1920.asp. Accessed December 12, 2020.

  8. 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. 

  9. 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.

  10. Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration, and health. Nutition Reviews. 2010 Aug;68(8):439-58.

  11. 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.

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February 2022 Coffee Chat Resource Round-Up

Posted on March 8, 2022

This document compiles resources and information shared during the February 24, 2022 coffee chat, which featured partners who shared creative ways they have brought attention to prevention and health promotion priorities in their communities.

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CHOICES Discussion Paper: Cost-Effective Strategies to Prevent Obesity & Improve Health Equity

Posted on January 13, 2022

Toddler girl eating an apple

The information in this discussion paper is intended only to provide educational information.

Abstract

We face growing prevalence of children and adults with obesity in the United States, and widening disparities by race, ethnicity, geography, and income. This growth is driven by many forces, including the marketing of foods and beverages that increase obesity risk as well as deeply rooted social and economic determinants and structural racism. This discussion paper is designed to help public health professionals and community members identify feasible and cost-effective intervention strategies that can prevent future obesity cases among children while improving health equity. We provide examples of such strategies in localities throughout the United States. We build on previous findings in CHOICES briefs that describe how Learning Collaborative Partnerships with health departments and their community partners, together with the CHOICES team, have assessed the future impact of a range of strategies on cases of obesity prevented and health equity. In all cases, the strategies have strong evidence for effectiveness and include: sugary drink excise taxes in Denver, Hawaii, California, and West Virginia; a clinical strategy to treat children with obesity in Denver; an intervention to reduce excess TV viewing in Oklahoma. Projections are made using the CHOICES microsimulation model, taking into account effectiveness of the intervention, expected reach in the population, evidence for intervention cost, and other relevant local data. Definitions of groups experiencing disadvantage and inequities were developed with local decision-makers and community members. Projected effectiveness is expressed as cases of obesity prevented, and improvements in health equity as changes in risk relative to a reference population. These examples describe feasible and cost-effective strategies that can prevent future obesity cases and improve health equity.

Continue reading in the full discussion paper.

Suggested Citation

Gortmaker SL, Bleich SN, Kenney EL, Barrett JL, Ward ZJ, Long MW, Cradock AL. Cost-Effective Strategies to Prevent Obesity and Improve Health Equity. Harvard T. H. Chan School of Public Health, 2021. For further information, contact choicesproject@hsph.harvard.edu and visit www.choicesproject.org

Funding

Funded by The JPB Foundation (Grant No. 1085), the National Institutes of Health (Grant No. R01HL146625) and the Centers for Disease Control and Prevention (CDC) (Grant No. U48DP006376). This work is solely the responsibility of the authors and does not represent official views of the CDC, the NIH, or other agencies.

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Intro to Economic Evaluation: How the CHOICES Framework Can Advance Chronic Disease Prevention & Address Health Equity

Posted on November 9, 2021

This is a recording of a training led by Dr. Michael Long and Dr. Stephen Resch. This introductory training looks at how economic evaluation and cost-effectiveness analysis can advance chronic disease prevention and health equity. This training is intended for anyone working in public health with an interest in learning about the key concepts of cost-effectiveness analysis to advance their work.

View the slides from this training.

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Brief: Healthy Incentives Program within the SNAP in Harris County, Texas

Posted on February 11, 2020

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

This brief summarizes a CHOICES Learning Collaborative Partnership simulation model of a Healthy Incentives Program (HIP) in Harris County, TX that aims to increase fruit and vegetable consumption among Supplemental Nutrition Assistance Program (SNAP) recipients by providing a financial incentive of $0.30 for every $1 spent on fruits and vegetables.

The Issue

Over the past three decades, more and more people have developed obesity.1 The health care costs of treating obesity-related conditions in adulthood were $147 billion in 2008.2 As a strategy to reduce the risk of obesity and chronic disease, public health authorities emphasize the goal of increasing fruit and vegetable intake.3

In Harris County, nearly 69% of adults have too much excess weight.4 Nearly 265,000 adult Harris County residents are eligible for SNAP benefits.5 SNAP is a key strategy for reducing food insecurity among low-income populations. Regardless of SNAP participation, household purchases of fruits and vegetables are low.6 And, compared to eligible nonparticipants, SNAP participants may have a lower diet quality. Interventions may be needed that support the consumption of healthy foods like fruits and vegetables.7 Financial incentives are a proven strategy in increasing fruit and vegetable purchases.8,9

About the Healthy Incentives Program

Under this program, SNAP participants will receive an incentive of $0.30 for every $1 of SNAP benefits that they spend on targeted fruits and vegetables in SNAP-authorized grocery stores and farmers markets. Targeted fruits and vegetables include fresh, canned, frozen, and dried fruits and vegetables without added sugars, fats, oils, or salt, but exclude white potatoes and 100% fruit juice. SNAP participants will be automatically enrolled in the program; then, the incentive will be automatically credited back to the participants’ SNAP account after each household purchase of these products. The incentive will be capped at $60 per household per month to prevent misuse.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of providing SNAP participants with an incentive of $0.30 for every $1 of SNAP benefits that they spend on targeted fruits and vegetables in SNAP-authorized grocery stores and farmers markets over a 10-year time horizon with the costs and outcomes expected if no incentive is provided.

Implementing a Healthy Incentives Program in Harris County could increase fruit and vegetable purchases and improve health. By the end of 2027:
An infographic about the obesity and financial benefits of the fruit and vegetable incentive.

Conclusions and Implications

Providing SNAP participants with an incentive of $0.30 for every $1 of SNAP benefits that they spend on targeted fruits and vegetables in SNAP-authorized grocery stores and farmers markets could have a positive impact on health of the SNAP participants. This strategy could increase purchases of fruits and vegetables by more than 3 servings per week per person (a 36% increase)10 and promote better diet quality among participants. While not quantified here, this strategy may also increase fruit and vegetable consumption among children in households participating in SNAP.

A program incentivizing the purchase of fruits and vegetables among SNAP participants would require an investment of $479 per adult. For every $1.00 invested in implementing a Healthy Incentives Program, $0.03 in obesity-related health care costs would be saved. This strategy would prevent 393 cases of obesity in Harris County in 2027. Evidence is growing about how food pricing and incentive programs may help promote healthy diets and reduce the prevalence of obesity. These findings reinforce the importance of investing in preventive efforts that could have widespread community impact.

References

  1. Flegal MK, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. (2016). Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA, 315(21), 2284-91.

  2. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. (2009). Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 28(5).

  3. U.S. Department of Health and Human Services. (2010). Healthy people 2020 (2nd ed.). Washington, DC: U.S. Government Printing Office. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2010). Dietary guidelines for Americans, 2010 (7th ed.). Washington, DC: U.S. Government Printing Office.

  4. Texas Department of State Health Services. Texas Behavioral Risk Factor Surveillance System. 2014

  5. Texas Health and Human Services Commission. (2019)

  6. Grummon A & Taillie L. (2017). Nutrition profile of Supplemental Nutrition Assistance Program household food and beverages purchases. Am J Clin Nutr, 105(6). 1433-1442.

  7. Andreyeva T., Tripp A., Schwartz, M. (2015). Dietary Quality of Americans by Supplemental Nutrition Assistance Program Participation Status: A Systematic Review. Am J Prev Med. 49(4):594-604.

  8. Sturm R, An R, Segal D, Patel D. (2013). A cash-back rebate program for healthy food purchases in South Africa: results from scanner data. Am J Prev Med. 44(6):567-572.

  9. Gittelsohn J, Trude ACB, Kim H. Pricing Strategies to Encourage Availability, Purchase, and Consumption of Healthy Foods and Beverages: A Systematic Review. Prev Chronic Dis 2017;14:170213. DOI: https://www.doi.org/10.5888/pcd14.170213.

  10. Zhang FF, Liu J, Rehm CD, Wilde P, Mande JR, & Mozaffarian D. (2018). Trends and disparities in diet quality among US adults by Supplemental Nutrition Assistance Program participation status. JAMA network open, 1(2), e180237-e180237.

Suggested Citation:

Flax CN, Barrett JL, and Cradock AL. Houston Healthy Incentives Program within the Supplemental Nutrition Assistance Program in Harris County, TX {Issue Brief}. Houston Health Department, Houston, TX and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2019.

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 Houston Health Department through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders.

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Brief: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention in Oklahoma

Posted on November 6, 2017

The information in this brief is intended for educational use only.

This brief summarizes the CHOICES Learning Collaborative Partnership simulation model of the impact of integrating the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program into Oklahoma’s Reaching for the Stars Quality Rating and Improvement System. Child care programs achieving Level 2 or higher would complete NAP SACC.

The Issue

Over the past three decades, more and more people have developed obesity.1 Today, nearly nine percent of 2-5 year olds have obesity.2 Now labeled as an epidemic, health care costs for treating obesity-related health conditions such as heart disease and diabetes were $147 billion in 2008.3 While multiple strategies are needed to reverse the epidemic, emerging prevention strategies directed at children show great promise.4 A large body of evidence shows that healthy eating, physical activity, and limited time watching TV helps kids grow up at a healthy weight.

In Oklahoma, 41% of 2-5 year olds attend a licensed child care center or family child care home, and most of them attend a program involved in Reaching for the Stars.5 Child care programs can offer healthy, nurturing environments for children; Reaching for the Stars can encourage and empower programs to voluntarily improve nutrition, physical activity, and screen time standards.

About NAP SACC and Reaching for the Stars

NAP SACC is an evidence-based, trusted intervention for helping child care programs improve their practices regarding nutrition, active play, and screen time and has demonstrated impacts on reducing childhood obesity.6,7 In NAP SACC, child care directors complete self-assessments of their nutrition, active play, and screen time practices and receive training and technical assistance to implement changes that create healthier environments. Integrating NAP SACC into Reaching for the Stars would incentivize and support participation in the program and broaden its availability.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of integrating NAP SACC into Reaching for the Stars over 10 years with costs and outcomes associated with not implementing the program. This model assumes that 67% of OK children in child care centers and 36% in family child care homes attend a program at Level 2 or higher in Reaching for the Stars and thus will benefit. The model also accounts for swapping out some existing childhood obesity trainings for NAP SACC, making NAP SACC implementation a less costly approach.

Implementing NAP SACC in child care programs throughout Oklahoma is an investment in the future. By the end of 2025:
Chart summarizing the conclusions and implications of the brief

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids in child care have opportunities to eat healthy foods and be physically active, no matter where they live or where they go for child care. A state-level initiative to bring NAP SACC to Oklahoma’s child care programs through Reaching for the Stars could prevent almost 1,600 cases of childhood obesity in 2025 and ensure healthy child care environments for 140,000 of Oklahoma’s young children.

For every $1.00 spent on implementing NAP SACC in Reaching for the Stars, we would save $0.15 in health care costs. These results reinforce the importance of investing in prevention efforts, relative to other treatment interventions, to reduce the prevalence of obesity. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future, whereas introducing small changes to young children can help them develop healthy habits for life.

Evidence is growing about how to help children achieve a healthy weight. Programs such as NAP SACC are laying the foundation for a healthier future by helping child care providers create environments that nurture healthy habits. Leaders at the federal, state, and local level should use the best available evidence to determine which evidence-based programs and policies hold the most promise to help children eat healthier diets and be more active.

References

  1. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA. 2016 Jun 7;315(21):2284-91.
  2. Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016 Jun 7;315(21):2292-9.
  3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
  4. 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.
  5. Oklahoma Department of Health Services (DHS). Early Care & Education Licensing Database (2016)
  6. Ward DS, Benjamin SE, Ammerman AS, Ball SC, Neelon BH, Bangdiwala SI. Nutrition and physical activity in child care: results from an environmental intervention. Am J Prev Med. 2008 Oct;35(4):352-6.
  7. Alkon A, Crowley AA, Neelon SE, Hill S, Pan Y, Nguyen V, Rose R, Savage E, Forestieri N, Shipman L, Kotch JB. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014 Mar 1;14:215.
Suggested Citation:

Macedo C, Case S, Simpson K, Khan F, U’ren S, Giles CM, Flax CN, Cradock AL, Gortmaker SL, Ward ZJ, Kenney EL. Oklahoma: Nutrition and Physical Activity Self-Assessment For Child Care (NAP SACC) Intervention {Issue Brief}. Oklahoma State Department of Health and Oklahoma State Department of Human Services, Oklahoma City, OK, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017.

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 Oklahoma Department of Health and Human Services through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders.

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