Expanding the impact of cancer prevention policies through collaborative implementation research: a qualitative secondary analysis of federal child nutrition assistance policies during COVID-19

摘要 循证公共卫生政策在减少癌症健康不公平方面具有巨大潜力， 解决重点人群中的癌症风险因素。只有在政策得当的情况下，这种影响才能实现- 在风险最大的人群中实施。了解政策实施在不同领域的差异 背景对于制定量身定制、注重公平的实施战略至关重要，但 估计这些变化是稀疏的。这项研究评估了联邦政策实施的变化 旨在减少儿童粮食不安全和改善2019冠状病毒病危机期间的膳食摄入， 为今后的执行和维持战略提供信息。儿童营养计划（CNP）由联邦政府资助， 以证据为基础的方案，以减轻儿童粮食不安全，这是一个健康的社会决定因素， 具有许多癌症风险因素（例如，不良饮食，哮喘，肥胖，慢性病）， 在黑人和西班牙裔/拉丁裔儿童以及低收入家庭中普遍存在。提供CNP 减少入学儿童的粮食不安全状况，改善饮食质量， CNPs的实施情况各不相同，尤其是在夏季。CNP的要求相当严格，限制了采用， 在某些地区（例如，高度城市化/农村化或资源不足），阻碍了改善执行情况的努力， 扩大学生覆盖面。然而，在COVID-19危机的特殊情况下，美国国务院 允许更大的灵活性，使CNPs可以使用新的实施策略， 进餐同时减少病毒传播（例如，通过公共汽车路线送货上门，放弃收养要求）。 了解这些战略的采用和实施情况-特别是在资源不足的 地区-对于倡导更公平的政策，并为有针对性的实施支持提供信息至关重要（例如， 国家实体的技术援助）。这项研究利用了一项国家研究， 合作对最初COVID期间六项研究的实施数据进行二次分析， CNP实施者的19个响应（~ 2020年春夏）（例如，食品服务主管）， CNP实施者和初始响应后家庭的数据验证（~ 2022年秋季）。由Dynamic驱动 可持续发展框架和CDC的政策分析框架，我们的目标是：（1）描述系统和设置- COVID-19期间CNP政策实施的水平变化，包括挑战和促进因素，关键 合作伙伴、能力和适应;（2）描述维持政策灵活性的潜力， 执行支助需要，以及在今后继续执行新的执行战略的关键政策杠杆 COVID-19危机时期。调查结果可以为更公平的政策和有针对性的实践指导提供信息， 为混合实施试验生成数据，以比较覆盖范围、有效性和维持潜力 新的国家方案实施战略，以减少粮食不安全和促进卫生公平。

ABSTRACT Evidence-informed public health policies have tremendous potential to reduce cancer health inequities by addressing cancer risk factors among priority populations. This impact is only achievable if policies are well- implemented among populations at greatest risk. Understanding how policy implementation varies across contexts is critical to developing tailored, equity-focused implementation strategies, but opportunities to evaluate these variations are sparse. This study evaluates variations in implementation of federal policies aimed at reducing child food insecurity and improving dietary intake during the COVID-19 crisis, in order to inform future implementation and sustainment strategies. Child nutrition programs (CNPs) are federally-funded, evidence-based programs to mitigate child food insecurity, a social determinant of health that is associated with many cancer risk factors (e.g., poor diet, asthma, obesity, chronic disease), and is disproportionately prevalent among Black and Hispanic/Latino children and those in low-income households. CNPs are offered year-round and reduce food insecurity and improve diet quality among enrolled children, yet reach and implementation of CNPs varies, especially in summer. CNP mandates are quite rigid, which limits adoption and in some districts (e.g., highly urban/rural or under-resourced), and stifles efforts to improve implementation and expand student reach. In the extraordinary circumstance of the COVID-19 crisis, however, the US Department of Agriculture allowed more flexibility so that CNPs could use novel implementation strategies to keep serving meals while reducing virus spread (e.g., home delivery via bus routes, waived adoption requirements). Understanding adoption and implementation of these strategies—especially variations across under-resourced districts—is critical to advocate for more equitable policies, and inform tailored implementation support (e.g., technical assistance from state entities) for CNPs following the crisis. This study leverages a national research collaborative to conduct a secondary analysis of implementation data from six studies during the initial COVID- 19 response (~Spring-Summer 2020) among CNP implementers (e.g., food service directors), combined with data verification with CNP implementers and families post-initial response (~Fall 2022). Driven by the Dynamic Sustainability Framework and CDC’s Policy Analytical Framework, we aim to: (1) describe system- and setting- level variations in CNP policy implementation during COVID-19, including challenges and facilitators, key partners, capacity, and adaptations; and (2) describe potential for sustainment of policy flexibilities, implementation support needs, and critical policy levers to continue novel implementation strategies beyond the COVID-19 crisis period. Findings can inform more equitable policies and tailored practice guidance, and generate data for a hybrid implementation trial to compare the reach, effectiveness, and sustainment potential of novel CNP implementation strategies to reduce food insecurity and promote health equity.