Despite the link between school-lunch participation and student health, only half of adolescents with the program in their schools participate on a given day. A multi-pronged school lunch promotion intervention was implemented in middle and high schools in an urban, low-income school district to improve school lunch participation and reduce food waste. This dissertation assesses the impact of the intervention on student and teacher perceptions of school lunch and explores how leadership shaped intervention implementation.

Using student survey data, paper 1 explores the theoretical pathways (perceptions of school-lunch quality and convenience) through which the intervention was expected to increase school-lunch participation and decrease plate waste. We observed modest changes in perceptions of school-lunch quality and no changes in perceptions of school-lunch convenience. Results suggest that additional efforts are needed to improve school-lunch participation and dietary intake.

Paper 2 utilizes teacher survey data to assess the impact of the intervention on teacher perceptions, modeling, and encouragement related to school lunch. Results indicate that the intervention had a modest effect on teacher-reported frequency of eating in the cafeteria with students and on encouraging students to participate in the school lunch program. There was no change, however, in teacher perceptions of or participation in the school lunch program. The paper concludes that improvements in teacher perceptions of school meals may not be needed in order for teachers to promote the school-lunch program to students.

Paper 3 focuses on the implementation of the intervention. Through qualitative interviews, the paper characterizes implementation leadership in the context of the intervention; and contextualizes emergent findings in the existing implementation science literature. Four major themes emerged reflecting the ways in which leaders are perceived to influence implementation effectiveness: (1) leader understanding of the technical and operational details of the intervention; (2) leader ability to develop and communicate intervention plans; (3) leader supervisory oversight over implementation staff and contractors; and (4) leader acknowledgment that ‘innovation’ requires time and stakeholder input —the absence of which can threaten cohesion and buy in. Implementation leadership functions in a school nutrition context appear similar to those identified in the implementation science literature. Results are the first to illustrate how these leadership dimensions are performed in a school nutrition setting.

Introduction

Methods

Results

Conclusion

Diet-related diseases such as type II diabetes and cardiovascular disease are leading causes of death in the United States. Sugar-sweetened beverages (SSBs) are the top source of added sugar in the United States diet, and consumption of SSBs is a major contributor to disease. Although consumption of SSBs declined in recent decades, rates remain high with 50% of adults consuming them daily. It is well documented that policy changes can impact population health. As such, SSB taxation is an increasingly popular policy-level intervention being implemented in cities across the United States and around the world to reduce SSB intake and improve population health. The overall objective of this dissertation is to evaluate the impact of SSB taxes on SSB consumption, social norms, and tax perceptions. Since both SSB intake and its associated health outcomes disproportionately affect low-income and racially/ethnically marginalized individuals, we specifically consider the impact of SSB taxes on these outcomes among low-income populations. Multiple cities across the California Bay Area passed SSB taxes in recent years. This dissertation utilized data collected between 2014-2021 via repeated cross-sectional street intercept surveys in low-income areas of Berkeley, Oakland, San Francisco, and Richmond, CA to assess the impact of SSB taxes.

Chapter 1 assesses people’s awareness and perceptions of SSB taxes following ballot measures and tax implementation in Berkeley, Oakland, and San Francisco. We document overall low awareness of SSB taxes in the year following successful ballot measures. We also document moderate perceptions of benefits of SSB taxes to communities and children’s health with differential findings based on educational attainment. People with lower levels of education had lower awareness, and perceived fewer benefits, of SSB taxes. We discuss the implications of these findings for public health campaigns and consider the value of the public understanding how SSB taxes work and whom they may benefit.

Chapter 2 evaluates if reported SSB consumption declines following SSB taxes in Berkeley, Oakland, and San Francisco. Considering documented SSB price increases post-tax, this study also examines whether perceptions of SSB prices changed following taxes in Oakland and San Francisco. We find varied impacts of SSB taxes on consumption. SSB consumption declined post-tax in Berkeley but did not significantly change in Oakland or San Francisco despite documenting higher perceived SSB prices post-tax in both cities. We discuss these findings in the context of a need for more research to better explore the differential impact of SSB taxes by income.

Chapter 3 considers how social norms have shifted over time in Berkeley, Oakland, San Francisco, and Richmond and examines whether SSB taxes in Oakland and San Francisco have an additional impact on social norms. We document promising improvements in social norms regarding SSB consumption over time in the California Bay Area and limited additional impact of SSB taxes on these already shifting norms in Oakland and San Francisco. This study highlights the opportunity to leverage SSB taxes and other policy interventions to further de-normalize regular consumption of SSBs.

Together, these three chapters contribute to the growing literature on the impact of SSB taxes on a variety of outcomes. Long-term, the goal of SSB taxes is to improve health outcomes. Given that SSB taxes were still less than a decade old in the United States at the time of this research, to better understand the broad impact of SSB taxes on marginalized populations, it is important to consider more proximal outcomes, such as changes in consumption, social norms, and perceptions of SSB prices.

Purpose of review

Recent findings

Despite the link between health and learning, school districts typically do not have the resources or incentives to address the health conditions that influence academic performance. Although most educators understand that health is a condition of learning, they are often reluctant to reallocate limited education dollars from the classroom to invest in student health, which may have the unintended consequences for academic outcomes. Recognizing the reciprocal relationship between health and education, this dissertation explores strategies for and outcomes of funding for school-based health initiatives in an effort to identify practical opportunities to reduce health and education disparities among current and future generations of US children.

Using cases from around the country, Paper 1 reviews successful strategies that education stakeholders have used to fund school health initiatives that address “educationally-relevant” health disparities. These cases share three common facilitators: 1) a local champion, 2) alignment with district priorities, and 3) nontraditional funding mechanisms, including: “braiding” education dollars; local tax revenue; Medicaid; and cross-sector partnerships.

Paper 2 investigates whether California school districts are investing in Physical Education (PE), which has been cut disproportionately in schools serving predominately low-income students, and what characteristics are associated with those districts that do invest in PE. California, which in 2013 overhauled its school finance formula and now provides additional funding to districts serving more “disadvantaged” students, offers a unique opportunity to examine how school districts serving low-income students prioritize funding for health given more funding and flexibility for how it is spent. Controlling for other district-level characteristics, the paper concludes that districts with high percentages of disadvantaged students had greater odds of investing in PE compared to districts with lower percentages of disadvantaged students.

Paper 3 examines whether PE investments are associated with changes in students’ cardiovascular fitness levels. Controlling for other district-level characteristics, this paper finds that PE investments are associated with modest increases in student fitness levels among districts with fewer than 6,350 students (75th percentile of mean statewide enrollment), while among districts with 6,350 students or more, PE investments are associated with modest decreases in fitness levels. Consistent with prior research, this study also documents persistent and troublesome disparities in fitness levels between students in low- and high-income districts. Finally, the study finds great variability in the cardiovascular fitness data over time, particularly among small districts, which raises important questions regarding the value of the FITNESSGRAM aerobic capacity test to reliably monitor student health outcomes.

Physical activity is critical for children's health, but activity levels are low. Physical education (PE) provides an ideal opportunity for all students to be physically active and learn the skills to support activity throughout life. Eighty-six percent of states have policies mandating the minimum PE minutes that students should receive. In California, the state with the largest number of public school students, education policy mandates elementary students receive 200 minutes of PE every 10 days. Yet policy compliance both nationally and in California is low, especially at the elementary level. The purpose of this dissertation was to use participatory action research methods, which include deliberate power sharing and collaboration between the researcher and the researched, to objectively assess and improve PE quality and quantity in elementary schools in the San Francisco Unified School District (SFUSD), with a focus on PE policy compliance. After forming a strategic alliance between the SFUSD, the San Francisco Department of Public Health, and UCSF, we conducted a 2-year quasi-experimental study to (1) assess PE policy compliance in 20 elementary schools in the spring of 2011 (Time 1); (2) share results within the school district and publically disseminate data on non-compliance; and (3) examine changes in PE from 2011 to 2013 (Time 2) that may have resulted from the work of the strategic alliance, including publically disclosing data. PE schedules were collected and PE classes were directly observed (Time 1, n= 91; Time 2, n=101) using a validated systematic observational tool. Results from Time 1 were shared throughout the district and received local media coverage. From Time 1 to Time 2, the proportion of schools meeting the PE mandate increased from 20% to 30% (p<0.03). PE increased by 11 minutes/week based on teachers' schedules (95% CI: 3.0, 19.6) and by 14 minutes/week (95% CI: 1.9, 26.0) based on observations. Key stakeholders reported increases in priority and funding for PE and attributed improvements to the public disclosure of local data on the status of PE. Public disclosure could be a method for increasing PE quantity and ensuring greater policy compliance. Testing this approach in other settings is warranted.