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

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.