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 循证公共卫生政策具有通过以下方式减少癌症健康不平等的巨大潜力 在重点人群中解决癌症风险因素。这种影响只有在政策良好的情况下才能实现- 在风险最高的人群中实施。了解不同地区的政策实施情况 背景对于制定量身定做的、以股权为重点的实施战略至关重要，但机会 评估这些变化是稀疏的。这项研究评估了联邦政策执行中的变化。 旨在减少儿童粮食不安全和改善新冠肺炎危机期间的膳食摄入量，以期 为未来的实施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，以缓解儿童食品不安全，这是与 有许多癌症危险因素(例如，不良饮食、哮喘、肥胖、慢性病)，而且不成比例 在黑人和西班牙裔/拉丁裔儿童以及低收入家庭的儿童中很普遍。提供CNP 在被录取的儿童中实现和减少粮食不安全和改善饮食质量 国家方案的执行情况各不相同，尤其是在夏季。CNP的要求相当严格，这限制了采用和 在一些地区(例如，高度城市/农村或资源不足)，并扼杀了改善执行和 扩大学生的覆盖面。然而，在新冠肺炎危机的非常情况下，美国国务院 农业部允许更大的灵活性，以便CNP可以使用新的实施战略来继续服务 在减少病毒传播的同时减少用餐(例如，通过公共汽车路线送货上门，免除收养要求)。 了解这些战略的采用和实施情况--特别是资源不足地区的差异 地区--对于倡导更公平的政策和提供量身定制的执行支持至关重要(例如， 国家实体的技术援助)为危机后的国家方案提供技术援助。这项研究利用了一项全国性的研究 协作对最初的COVID期间的六项研究的实施数据进行二次分析- 19个CNP实施者(如食品服务总监)的回应(~2020年春至夏)，结合 与CNP实施者和家庭进行初步响应后的数据验证(至2022年秋季)。由动态驱动 可持续发展框架和疾病预防控制中心的政策分析框架，我们的目标是：(1)描述系统-和环境- 新冠肺炎期间CNP政策实施的水平差异，包括挑战和促进者，关键 合作伙伴、能力和适应；以及(2)描述保持政策灵活性的潜力， 实施支助需求和关键政策杠杆，以继续实施新的实施战略 新冠肺炎危机期。调查结果可以为更公平的政策和量身定做的实践指导提供参考，以及 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 制定新的CNP实施战略，以减少粮食不安全和促进健康公平。

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.