Investigating Student-Level Outcomes of Equity-Focused Implementation Mapping in a Cluster Randomized Trial to enhance the impact of Universal School Meals - PROJECT ABSTRACT The overall goal of this R03 award is to provide Gabriella McLoughlin, PhD, MS, with funding to investigate the impact of an equity-focused implementation strategy on participation and uptake of Universal School Meals (USM) among the students most at risk for food insecurity and obesity, building on her current K01 award. Childhood food insecurity and obesity inequities have been exacerbated in recent decades, such that children from racial and ethnic minority and low-income backgrounds are most at risk, increasing the marginalization they face and unequal opportunities to accessing healthy and affordable foods. Multiple factors, such as increased food insecurity resulting in a low-quality diet, contribute to this increased threat. Since children and adolescents consume over half of their energy intake at school, providing free nutrient-rich breakfast and lunch to low-income youth through Universal School Meals (USM) is a key policy approach to addressing obesity inequities. Adoption of USM is linked with reductions in obesity risk for low-income students, improved diet quality, reduced food insecurity, and enhanced academic achievement. Unfortunately, evaluation of USM so far has focused mainly on school-level aggregate outcomes, potentially masking inequities in participation among students most at risk for food insecurity and obesity. Thus, the purpose of this R03 award is to investigate whether an equity-focused implementation strategy improves uptake of USM among students who are most at risk for food insecurity and obesity through a multi-method approach. The proposal builds on the PI's existing K01 project which aims to develop, implement, and test a novel implementation strategy to improve the impact of USM through a combined implementation and effectiveness cluster randomized trial. The goals of this R03 will be achieved through two aims: 1) Determine whether equity-focused implementation of USM leads to increased uptake of meals by students at high risk of food insecurity and obesity, and 2) Assess perceived acceptability and sustainability of equity-focused USM among students at high risk of food insecurity and obesity. This evaluation will require merging several student-level datasets: meal participation (primary outcome variable), food security, body mass index (BMI), demographic indicators (e.g., race, ethnicity, income status), attendance, and dietary intake to create a food insecurity and obesity risk index and run multi- level regression models to evaluate change in uptake among low, moderate, and high-risk participants. Aim 2 will require collecting qualitative interview data among students at varying risk for food insecurity and obesity on perceptions of equity-focused implementation. This work will enhance the impact of the PI's existing K01 by adding innovative student-level analyses, which will provide robust evidence on the impact of USM on socially and economically marginalized populations. This R03 award holds significant potential for public health impact and will provide preliminary data for Dr. McLoughlin to apply for a R01 award to test the resulting equity- focused implementation strategy in a larger cluster randomized implementation and effectiveness trial.
