Potential Public Health Impact
The OSNAP Initiative has the potential to reach a large number of children with one of the key evidence-based interventions for obesity prevention – replacing the consumption of sugar sweetened beverages with water. The 2013 Robert Wood Johnson Foundation (RWJF) Healthy Eating Research includes the following beverage recommendations for children and youth ages 5 to 18: "Water—Including carbonated water, with no added sweeteners,” and “Require access to free, safe drinking water wherever beverages are served and/or sold." The RWJF Key Panel Findings include: "Water should be available and promoted in all settings where beverages are offered. Water provides a healthy, low-cost, zero-calorie beverage option, and water consumption is associated with a number of health benefits including preventing obesity, reducing dental caries, supporting proper hydration, and improving cognitive function." Given recent local and national policy requiring greater access to water for school children yet the surprising lack of physical access to potable water in many schools, this simple intervention could be readily scaled up to meet this need. Key to long term maintenance may be the organizational and stakeholder support initiated through the learning communities. A strong local school wellness policy process could be a vehicle for creating and maintaining this same level of support.
Reach: In the randomized trial testing the policies and practices to improve afterschool water availability, the participating schools served racially, linguistically, and economically diverse populations. The student populations of participating schools were 38% black, 11% white and 40% Hispanic. On average, 81% of the children qualified for free/reduced-price lunch. The intervention approach was designed to minimize cost so that all schools could participate regardless of resources. In Boston, nearly half of the school age children participate in afterschool programs. Nationally, more than 1 million children at nearly 25,000 afterschool programs are provided with snacks.
Effectiveness:Increased access to fresh potable water and decreased access to sugar sweetened beverages is a necessary first step in implementing recent new policies regarding beverages served in schools. The OSNAP intervention resulted in an increase of 3.6 ounces of water served per day (p less than 0.01, 95% CI=1.3,5.9) and a decrease in beverage calories served by 60.9 kcals (p=0.03,95% CI= 4.5, 117.4. The frequency with which water was served increased significantly by an additional 0.6 times per day, equivalent to having served water 3 additional times over a 5-day school week. While ultimately, it will be important to determine whether the change in beverage access effects change in consumption, this is a very important first step.
Adoption: The OSNAP Initiative was designed for relatively easy adoption in any afterschool setting. The learning community effort that laid the groundwork for afterschool program adoption of this and other nutrition and physical activity interventions involved participation in three sessions, each three hours long, and staff were reimbursed $40 each for participating in each session. While finding the time and resources (compensation may not be needed if staff are given time away from other responsibilities but this may still require paying substitute staff) may be something of a barrier, the learning community likely resulted in benefits significantly beyond that of the afterschool water program. It is not known from the current studies whether the OSNAP initiative to increase drinking water access would be easily adopted by schools without the learning community model.
Implementation: Afterschool programs used different strategies in how they implemented the program, as determined by their available resources and facilities. Two basic water delivery systems were able to accommodate all of the programs: 1) filling insulated jugs with water from the tap and 2) filling pitchers with bottled water from water coolers. Given a wide range of facilities in the participating schools, this suggests that scaling up the implementation to other settings and states should not be a problem. Implementation of the learning community process is described under adoption given the focus at the organizational level.
Maintenance: Beginning the initiative with the learning community, which engaged afterschool program staff, along with engaging food service staff, is likely an important factor toward achieving long term maintenance. If renewed efforts to strengthen local school wellness policies through national policy are successful, this may provide a mechanism similar to the learning communities. At the practical level, given the relative simplicity of the water delivery system, it seems likely to be implemented into routine afterschool program practices and thus maintained over time. Thus the combination of policy support, ease of implementation, and organizational mission, should enhance the potential for long term maintenance.