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Typical quantitative evaluations of public policies treat policies as a binary condition, without further attention to how policies are implemented. However, policy implementation plays an important role in how the policy impacts behavioral and health outcomes. The field of policy-focused implementation science is beginning to consider how policy implementation may be conceptualized in quantitative analyses (e.g., as a mediator or moderator), but less work has considered how to measure policy implementation for inclusion in quantitative work. To help address this gap, we discuss four design considerations for researchers interested in developing or identifying measures of policy implementation using three independent NIH-funded research projects studying e-cigarette, food, and mental health policies. Mini case studies of these considerations were developed via group discussions; we used the implementation research logic model to structure our discussions. Design considerations include (1) clearly specifying the implementation logic of the policy under study, (2) developing an interdisciplinary team consisting of policy practitioners and researchers with expertise in quantitative methods, public policy and law, implementation science, and subject matter knowledge, (3) using mixed methods to identify, measure, and analyze relevant policy implementation determinants and processes, and (4) building flexibility into project timelines to manage delays and challenges due to the real-world nature of policy. By applying these considerations in their own work, researchers can better identify or develop measures of policy implementation that fit their needs. The experiences of the three projects highlighted in this paper reinforce the need for high-quality and transferrable measures of policy implementation, an area where collaboration between implementation scientists and policy experts could be particularly fruitful. These measurement practices provide a foundation for the field to build on as attention to incorporating measures of policy implementation into quantitative evaluations grows and will help ensure that researchers are developing a more complete understanding of how policies impact health outcomes.

Background: Strategies used by wellness teams (WTs) to foster local wellness policy (LWP) implementation have been documented, yet there remains a need to better understand how WTs respond to district-level LWP requirements, particularly when bundled with additional health-related policies. This study's goal was to explore how WTs implement Healthy Chicago Public School (CPS), a district-led initiative focused on both LWP and other health policy implementation in the CPS district, one of the most diverse in the nation. Methods: Eleven discussion groups were conducted with WTs in CPS. Discussions were recorded, transcribed, and thematically coded. Results: Six overarching strategies used by WTs in working to achieve Healthy CPS include: (1) using district guides and resources to support planning, progress monitoring, and reporting; (2) under the leadership of wellness champions, as required by the district, facilitating engagement among staff, students, and/or families; (3) taking district guidance and adapting and integrating it into their schools' existing structures, curricula, and practices, often taking a holistic approach; (4) fostering linkages in the communities surrounding their schools to supplement internal school capacities; and (5) stewarding resources, time, and staff for sustainability. Implications: Strategies for LWP implementation by WTs in urban and diverse schools include planning for staff turnover, integrating health and wellness into existing curricula and structures, and leveraging relationships with the local community. Conclusion: WTs can play a critical role in supporting schools in diverse, urban districts to implement district-level LWP and the plethora of related policies that schools are subject to at the federal, state, and district levels.

Background: The Whole School, Whole Community, Whole Child (WSCC) framework supports the "whole child" across 10 domains. This study assessed state law and district policy WSCC coverage. Methods: Primary legal research was used to compile relevant district policies and state laws for a stratified random sample of 368 public school districts across 20 states for school year 2017-18. Policies/laws were evaluated on 79 items across the WSCC domains (range: 3-14 items/domain). Multivariable regressions examined the relationship between state laws and district policies, controlling for district characteristics, and weighted to account for the sample design and non-response. Results: On average, district policies and state laws addressed 53% and 60% of the 79 items, respectively. State law predicted district policy WSCC attention across items (coeff. = 0.26, 95% CI = 0.14, 0.38) and 4 domains: physical activity (coeff. = 0.57, 95% CI = 0.29, 0.86); health services (coeff. = 0.50, 95% CI = 0.39, 0.62); social and emotional climate (coeff. = 0.34, 95% CI = 0.23, 0.45); and family engagement (coeff. = 0.41, 95% CI = 0.28, 0.54). State law was associated with lower district-level coverage in 3 domains (health education; counseling, psychological, and social services; and community involvement). Conclusions: Although WSCC implementation is locally-driven, states have an active role to play in setting a policy "floor" for guiding district WSCC attention.

Background: Few studies examine why rural public schools have weaker policies and practices related to school nutrition environments compared to their urban counterparts. It is important to understand this disparity because federal school meal standards aim for children to access health-promoting nutrition environments. In this study, we identify challenges and opportunities for the implementation of school meal standards in rural high schools. Methods: We interviewed 38 rural school professionals from 22 high schools across 7 states. School professionals included food service directors, principals, school nurses, and teachers. Team coding in Atlas.ti Qualitative Data Analysis software v8 and principles of comparative analysis were employed to generate themes related to challenges and opportunities. Results: Overall, school professionals described improvements with implementation experiences and student acceptance over time. Key challenges included the negative influences of home and community food environments and limited staff size and capacity. Key opportunities involved joining co-ops to enhance purchasing power, leveraging state technical assistance, and forming external partnerships. Conclusions: This study offers insights from a broad range of rural school professionals' implementation experiences. The findings can inform governments and technical assistance agencies working with rural schools and school districts to facilitate implementation and sustainability of initiatives.

Background: Under "Smart Snacks," state agencies can adopt a policy regulating infrequent school-sponsored fundraisers. Fundraiser exemptions allow noncompliant foods and beverages to be sold during the school day. This article examines fundraiser exemption policies in each state as of September 1, 2017. Methods: Laws were collected for all 50 states and the District of Columbia using Boolean searches of LexisNexis and Westlaw. Informal state-level policies (eg, memos) were collected through searches of state department of education and child nutrition program websites. Policies were analyzed to determine the number of exempt fundraisers allowed in each state. Results: By September 1, 2017, 47 states adopted a fundraiser exemption policy; 21 states adopted a zero exemption policy; 19 states regulated the number of exempt fundraisers; five states regulated the number of exempt fundraising days; one state regulated the number of exempt events; and one state approved all requested exemptions. Four states had not adopted a policy and default under the rule to zero exemptions allowed. Conclusions: A patchwork of state policies governs the school food-related fundraiser landscape. However, the overall goal of improving the school food environment should persist as an important factor in determining how many, if any, will be allowed each school year.

Purpose: The purpose of this study was to examine changes in school-based physical education (PE) attendance over time among nationally representative samples of U.S. high school students and how changes in PE attendance have varied across demographic subgroups. Method: Student demographic information and PE attendance data were obtained from 13 biennial cycles (1991-2015) of the national Youth Risk Behavior Survey (YRBS). Physical education variables derived from YRBS data included "PE attendance," "daily PE," "average PE days/week," and "PE frequency." Logistic regression models examined trends in "PE attendance," "daily PE," and "PE frequency" for the overall sample and demographic subgroups. Linear regression models examined trends in "average PE days/week" in the overall sample only. Results: Overall, there was no significant change in the percentage of students reporting "PE attendance" during 1991 to 2015. However, "daily PE" and "average PE days/week" declined significantly from 1991 to 1995 (41.6% to 25.4% and 4.64 days to 3.64 days, respectively) and then remained stable through 2015 (29.8% and 4.11 days, respectively). The percentage of students reporting a "PE frequency" of 3 days per week increased significantly from 1991 to 1995 (1.5% to 19.0%) before stabilizing through 2015 (9.1%). Trends across demographic subgroups revealed notable differences in PE attendance. Conclusions: Study findings showed that U.S. schools have not substantially reduced PE amounts in recent years. Still, the prevalence of PE attendance among U.S. high school students is well below recommendations. For PE to contribute to increased adolescent compliance with national physical activity guidelines, significant policy actions are needed to improve PE access for all students.

Background: The Healthy, Hunger-Free Kids Act of 2010 (HHFKA) directed the US Department of Agriculture (USDA) to revise school meal standards. Students are most affected by efforts to improve the school food environment; yet, few studies directly include students. This study examined high school students' experiences of school meal reform to gain insight into implementation recommendations. Methods: We conducted 5 focus groups with high school students (N = 15) from high schools across 9 states. We also conducted follow-up interviews to further explore personal experiences. Focus groups and interview transcripts were coded and organized in Atlas.ti v7 by analysts, following principles of constant comparative analysis. Results: Students reported overall positive perceptions of the revised school meal standards and supported continued efforts to improve the food environment. Recommendations to improve the food environment included engaging students, focusing on the quality and palatability of meal items, moving toward scratch-cooking, and addressing cafeteria infrastructure. Conclusions: Students' recommendations point to opportunities where school districts, as well as local, state, and federal organizations can work to improve the school food environment. Their insights are directly relevant to USDA's recently released Local School Wellness Policy final rule, of which school meal standards are one provision.

Background: Recent federal policies aimed to ensure that all children have equitable access to healthy school nutrition environments. However, historically, disparities have persisted in the quality of school nutrition environments across geographic and socioeconomic groups. There is limited literature addressing if and how recent efforts to reform the school nutrition environment have influenced such disparities. The main objective of this study was to explore stakeholders' insights on how school nutrition reform intersected with issues of inequity. Method: Qualitative secondary analysis (QSA) offers a unique method to examine existing data with a related but distinct inquiry. This QSA analyzed three primary studies, including stakeholder interviews and focus group data with school professionals and students (total 60 transcripts). Two trained analysts iteratively coded all transcripts in Atlas.ti Version 7 and followed principles of constant comparative analysis. Measures to enhance "trustworthiness" were built into the primary studies and the QSA. Results: Broadly, stakeholders' complex insights about the school food environments' ability to compensate for healthy dietary options and "whole child" education that were perceived to be lacking in home environments. Despite the majority of respondents' positive perceptions of reforms, they also noted the challenges of addressing disparities due to family home environments and complex socioeconomic conditions. Overall, respondents reported that school food reform and nutrition education had the potential for long-term impacts on students' health, including the potential to improve disparities through enhanced academic achievement for disadvantaged populations. Discussion and Conclusion: QSA allowed for inquiry into frontline stakeholders' understandings of how school nutrition reform may affect health inequities. Qualitative methods allowed for the examination of complex motivations and perspectives involved in policy implementation. Understanding frontline stakeholders' perspectives is key to advance school nutrition reform in a sustainable manner, especially in light of the federal local school wellness policy final rule.

Background: The Healthy, Hunger-Free Kids Act of 2010 (HHFKA) directed the US Department of Agriculture (USDA) to revise school meal standards to increase healthy food offerings. A critical stakeholder in the implementation of standards is Food Service Directors (FSDs). We sought to examine FSDs' perspectives on revised school meal standards to gain insight into successful implementation strategies. Methods: Semistructured interviews were conducted with FSDs (N = 9) from high schools that had achieved HealthierUS Schools Challenge: Smarter Lunchrooms (HUSSC: SL) status. Qualitative interview data were team coded in Atlas.ti v7 and analyzed with principles of constant comparative analysis. Results: FSDs reported overall positive perceptions of the revised school meal standards and its potential impacts, as well as improved fruit and vegetable consumption, despite initial challenges with plate waste, procurement of whole grain-rich products, and fast paced sodium targets. Implementation was described as complex, ongoing processes; with time and in-service trainings, student acceptance to these changes improved. Conclusions: These findings are directly relevant to future reauthorization of the Child Nutrition Act and to revisions to the implementation time line for the federal school meal standards related to sodium, whole grains, and flavored milk. Insights into FSDs' strategies suggest that more time and targeted technical assistance at federal, state, and local levels is warranted.

The Education Sector of the recently updated National Physical Activity Plan (NPAP, 2023) was developed to assist schools, early care and education centers, and colleges and universities to establish policies and provide programmatic opportunities to support all students in adopting physically active lifestyles. The 2023 Education Sector strategies target K-12 education, preschool and early childhood education, as well as college and university contexts to develop and advocate for strong policies that promote physical education and physical activity for all students. Successful implementation of the Education Sector strategies has the potential to support high-quality program delivery. Specific to school physical education programs, the strategies' adoption has the capacity for a broad, lifelong impact. This article presents an overview of the Education Sector strategies and their related tactics, along with objectives specific for K-12 school physical education programming. [ABSTRACT FROM AUTHOR]

Background: Schools of low socioeconomic status (SES) tend to sell fewer healthy competitive foods/beverages. This study examined whether state competitive food laws may reduce such disparities. Methods: School administrators for fifth- and eighth grade reported foods and beverages sold in school. Index measures of the food/beverage environments were constructed from these data. Schools were classified into SES tertiles based on median household income of students' postal zip code. Regression models were used to estimate SES differences in (1) Healthy School Food Environment Index (HSFEI) score, Healthy School Beverage Environment Index (HSBEI) score, and specific food/beverage sales, and (2) associations between state competitive food/beverage laws and HSFEI score, HSBEI score, and specific food/beverage sales. Results: Strong competitive food laws were positively associated with HSFEI in eighth grade, regardless of SES. Strong competitive beverage laws were positively associated with HSBEI particularly in low-SES schools in eighth grade. These associations were attributable to schools selling fewer unhealthy items, not providing healthy alternatives. High-SES schools sold more healthy items than low-SES schools regardless of state laws. Conclusions: Strong competitive food laws may reduce access to unhealthy foods/beverages in middle schools, but additional initiatives are needed to provide students with healthy options, particularly in low-SES areas.