Process evaluation of a large-scale environmental intervention to facilitate healthy eating by students at a four-year university

Thesis (D.P.H.)--Boston UniversityBackground: Diet-related chronic diseases and conditions include obesity, cardiovascular disease, diabetes, hypertension, some cancers, and osteoporosis. Interventions that focus on increasing nutrition knowledge, motivation, and healthy eating skills at the individual level alone have been ineffective at producing sustainable changes in eating behaviors. It is now widely recognized that multi-level interventions that support healthy eating practices are needed. Institutions of higher learning have opportunities to positively influence the food choices of large numbers of students for an extended period of time. To date, no evaluations or guidelines for implementing environmental interventions in a college setting have been published. Methods: A comprehensive and systematic process evaluation of a targeted health promotion intervention designed to transform the food environment at a four-year university was performed. Qualitative and quantitative methods were employed to assess the context, fidelity, dose delivered, dose received, and reach of intervention activities. Findings: Support and resources for intervention development and implementation were high. University administrators recognized a responsibility to provide a healthy eating environment for diners in their care at a formative age. Education, language, and cultural barriers negatively impacted fidelity. Perceived higher food costs described by some foodservice managers negatively impacted dose delivered. Dose received and reach were higher for students defining health in terms of absolute and specific eating behaviors compared to students defining health more moderately. Traditional entrees, make-your-own sandwiches, and pasta entrees had broader appeal than entrees with unfamiliar ingredients and vegan and vegetarian options. Research translation: Study findings were used to revise the program implementation manual. The manual includes operational guidelines for nutrition criteria, menu planning, promotional activities, and training of dining services staff and student employees. Strategies for addressing highlighted barriers to improve program implementation are also presented. Conclusion: A successful environmental intervention that has fidelity and reach has the potential to improve the eating habits of millions of young adults when implemented in college dining halls. This evaluation identified barriers that are likely to be common in other foodservice operations. More research is needed to determine if proposed strategies result in improved implementation, and ultimately, increased healthy eating behavior of college students