Partnerships and Community Engagement Key to Policy, Systems, and Environmental Achievements for Healthy Eating and Active Living: a Systematic Mapping Review

Introduction Policy, systems, and environmental (PSE) change approaches frequently address healthy eating and active living (HEAL) priorities. However, the health effects of PSE HEAL initiatives are not well known because of their design complexity and short duration. Planning and evaluation frameworks can guide PSE activities to generate collective impact. We applied a systematic mapping review to the Individual plus PSE Conceptual Framework for Action (I+PSE) to describe characteristics, achievements, challenges, and evaluation strategies of PSE HEAL initiatives. Methods We identified peer-reviewed articles published from January 2009 through January 2021 by using CINAHL, Web of Science, MEDLINE, PsycINFO, and CAB Abstracts databases. Articles describing implementation and results of PSE HEAL initiatives were included. Activities were mapped against I+PSE components to identify gaps in evaluation efforts. Results Independent reviewers examined 437 titles and abstracts; 52 peer-reviewed articles met all inclusion criteria. Twenty-four focused on healthy eating, 5 on active living, and 23 on HEAL. Descriptive analyses identified federal funding of initiatives (typically 1–3 years), multisector settings, and mixed-methods evaluation strategies as dominant characteristics. Only 11 articles reported on initiatives that used a formal planning and evaluation framework. Achievements focused on partnership development, individual behavior, environmental or policy changes, and provision of technical assistance. Challenges included lack of local coalition and community engagement in initiatives and evaluation activities and insufficient time and resources to accomplish objectives. The review team noted vague or absent descriptions of evaluation activities, resulting in questionable characterizations of processes and outcomes. Although formation of partnerships was the most commonly reported accomplishment, I+PSE mapping revealed a lack of engagement assessment and its contributions toward initiative impact. Conclusion PSE HEAL initiatives reported successes in multiple areas but also challenges related to partnership engagement and community buy-in. These 2 areas are essential for the success of PSE HEAL initiatives and need to be adequately evaluated so improvements can be made.


Introduction
Policy, systems, and environmental (PSE) change approaches frequently address healthy eating and active living (HEAL) priorities. However, the health effects of PSE HEAL initiatives are not well known because of their design complexity and short duration. Planning and evaluation frameworks can guide PSE activities to generate collective impact. We applied a systematic mapping review to the Individual plus PSE Conceptual Framework for Action (I+PSE) to describe characteristics, achievements, challenges, and evaluation strategies of PSE HEAL initiatives.

Methods
We identified peer-reviewed articles published from January 2009 through January 2021 by using CINAHL, Web of Science, MED-LINE, PsycINFO, and CAB Abstracts databases. Articles describing implementation and results of PSE HEAL initiatives were included. Activities were mapped against I+PSE components to identify gaps in evaluation efforts.

Results
Independent reviewers examined 437 titles and abstracts; 52 peerreviewed articles met all inclusion criteria. Twenty-four focused on healthy eating, 5 on active living, and 23 on HEAL. Descriptive analyses identified federal funding of initiatives (typically 1-3 years), multisector settings, and mixed-methods evaluation strategies as dominant characteristics. Only 11 articles reported on initiatives that used a formal planning and evaluation framework. Achievements focused on partnership development, individual behavior, environmental or policy changes, and provision of technical assistance. Challenges included lack of local coalition and community engagement in initiatives and evaluation activities and insufficient time and resources to accomplish objectives. The review team noted vague or absent descriptions of evaluation activities, resulting in questionable characterizations of processes and outcomes. Although formation of partnerships was the most commonly reported accomplishment, I+PSE mapping revealed a lack of engagement assessment and its contributions toward initiative impact.

Introduction
Obesity prevention and other public health initiatives emphasize policy, systems, and environmental (PSE) change in addition to traditional approaches that focus on individuals (1,2). Federal PSE initiatives include the Centers for Disease Control and Prevention's (CDC's) State Physical Activity and Nutrition Program, High Obesity Program, and Racial and Ethnic Approaches to Community Health program and the US Department of Agriculture's (USDA's) Supplemental Nutrition Assistance Program Education (SNAP-Ed) and Expanded Food and Nutrition Education Program (EFNEP).
Evidence is lacking for the health impact of PSE initiatives because of their complex nature, insufficient capacity and resources for program implementation (3,4), and absence of robust evaluation strategies (5). Several theory-based models and frameworks have informed PSE initiatives, including the RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) model (6), a systems thinking framework (7), a collective impact framework (8), a policy adoption model (2), and SNAP-Ed (9), along with an emphasis on health equity (10,11). A new framework is the Individual Plus Policy, Systems, and Environmental Conceptual Framework for Action (I+PSE) (12), informed by CDC's Social-Ecological Model (13) and the Contra Costa Health Services Spectrum of Prevention (14). I+PSE is unique in that it views determinants of health through social, commercial, and political lenses. It guides users to examine a range of tactics to and abstract. Records passed this phase if they contained any mention of PSE and dealt with a topic related to public health. All remaining documents were sorted into either "pass" or "fail" electronic folders.
In the second phase, the same researcher completed a more detailed review of the title and abstract records that passed the first review phase. During this step, articles were divided into 7 folders: 1) those eligible for full text review because their primary focus was PSE and HEAL, 2) those that did not specifically deal with PSE and HEAL, 3) those that described a PSE HEAL initiative's protocol or methods but no intervention results, 4) those that discussed a PSE evaluation framework that did not include application to a specific initiative, 5) conference abstracts, 6) reviews, and 7) commentaries. Meetings between the lead author and research coder confirmed appropriate sorting of the initial 20 articles and operational definitions for the 7 I+PSE components. Notes were written in the Mendeley annotations function for each article that was related to PSE and HEAL, providing the rationale for their folder assignment.
For the final review phase, 2 researchers were trained to independently examine the full text of articles describing PSE HEAL initiatives to determine if they included implementation and evaluation activities for any of the 7 I+PSE components. This training consisted of 2 coders and the lead researcher (L.C.S.) reviewing and coding the same 5 articles individually and then comparing their results. If any disagreements were noted, activities and components were discussed to determine final categorization. No reliability testing was done. For the remainder of the articles, coders noted any description of the 7 I+PSE components, whether or not specific activities were evaluated, and what evaluation frameworks and methods, if any, were used. Over several meetings, the 2 coders reviewed their coding for each article and reached consensus for either inclusion or exclusion. In instances of uncertainty, they consulted the lead researcher for a final decision. Additional notes were made to provide the rationale for these decisions.

Data extraction
One coder extracted and entered data into a results table (Table 2). A second coder compared the articles' content with table entries to confirm the accuracy of all content. The lead author reviewed all table content for consistency of descriptions. This table included the last name of the first author and publication date, funder(s) of the research described in the article, name and purpose of the initiative, study setting, and length of study. The table also indicated which of the 7 components of I+PSE were addressed in intervention activities, which were evaluated and how, accomplishments and challenges noted by the article authors, and comments from our coders on the extent of evaluations. This approach is an appropriate strategy for mapping reviews, rather than applying a more formal quality assessment tool (eg, Cochrane) (17). We used quantitative counts and qualitative content analysis strategies to summarize data and reveal themes as recommended by Miles et al (73). Themes from each column (eg, funding source, I+PSE components described) were inductively determined by first reviewing the content and subsequently creating categories. The same 2 researchers who entered and confirmed these data and the lead researcher determined the themes and categories together over several meetings. Counts were then generated for each category and summarized in narrative, table, or figure format. We did not attempt a meta-analysis because of the heterogeneity of initiatives and measured outcomes.

Results
We developed a PRISMA flowchart (18) ( Figure 1) noting reasons for inclusion and exclusion of articles through our 3-step review. We identified 455 articles and removed 18 duplicates. Of the remaining 437, most (n = 369) were removed because they were not PSE-or HEAL-related or because they did not describe an intervention. For articles undergoing full-text review, 16 were excluded because they described direct education, did not describe an intervention, the study was not complete, or the articles were reviews or commentaries. Of these, 52 initiatives met all inclusion criteria: 24 focused solely on healthy eating, 5 on active living, and the remaining 23 on a combination of both.

Initiative characteristics
The most common funding sources for selected studies were federal government agencies, with CDC (n = 23), the National Institutes of Health (n = 8), and USDA (n = 7) the most prominent (Table 2). Other funding sources included foundations (n = 12) and state governments (n = 5). Some initiatives received funding from several sources. Only 2 of the 52 initiatives, both in Australia, were from researchers outside the US. Often initiatives took place in multiple settings, the most common being schools, businesses, and community organizations (Table 3). Some studied specific groups, such as people with incomes below the federal poverty level or people with high rates of obesity, and some studied racial or ethnic communities. Most initiatives (73%) were funded for 1 to 3 years.
Methods for evaluating interventions included surveys, interviews, observations, photographs, and document reviews. Seven initiatives used only surveys, 2 used only individual or group interviews, and 6 used only reviews of documents such as reports, action plans, and meeting minutes. Most (n = 34) interventions used a mixed-methods approach, and 3 reported no evaluation activities at all. Only 11 of the 52 initiatives reported using a planning or evaluation framework, 3 of which used Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) (19,32,46). All other frameworks mentioned were used for a single initiative (20,29,31,36,38,39,62,72).
Figure 2. Number of activities described in 52 studies of PSE HEAL (policy, systems, and environmental healthy eating and active living) initiatives, sorted by the 7 components of the Individual Plus Policy, System, and Environmental Conceptual Framework for Action (I+PSE) (12): 1) strengthen individual knowledge and behavior, 2) promote community engagement and education, 3) educate intermediaries and service providers, 4) facilitate partnerships and multisector collaborations,5) align organizational policies and practices,6) sustain physical, natural and social settings, and 7) advance public policies and legislation. Graph A describes healthy eating initiatives (n = 24), B describes active living initiatives (n = 5), and C describes combined healthy eating and active living initiatives (n = 24). Initiatives may include multiple activities.
From the qualitative portion of the content analysis, we summarized each article's description of accomplishments and challenges (Table 2). Initiative accomplishments were (in descending order of frequency) partnerships formed, individual behavior change, environmental and policy changes, and provision of technical assistance. Challenges were almost exclusively insufficient early engagement or investment of participating communities, resulting in resistance to initiative implementation (20,34,35,46,48,67,72). Another common challenge noted was insufficient or variable implementation because of limited resources and time and staff turnover (41,45,46,49,50,54,57,66). Lessons learned, culled from the descriptions of both accomplishments and challenges, included the importance of recruiting staff who had local trust and connections (19,33) and the value of early achievements to promote community buy-in (34,35,45,72). Authors also reported variability in the extent of implementation between different sizes of sites (36,51,57), although there was no consistent finding that larger (or smaller) sites had stronger implementation. They also reported variability on extent of implementation because of the perceived strength of collaborative partnerships, most often informally assessed through interviews or surveys (23,(34)(35)(36)50,51,57,60,72).

Discussion
Our review of 52 PSE HEAL initiatives describes their key characteristics and maps the I+PSE action components most commonly included in the intervention-to-evaluation activities. It also characterizes these initiatives' achievements, challenges, and lessons learned. The review concludes by summarizing the evaluation matches and missed opportunities to strengthen the evidence for their outcomes.
Our review showed a gap between the most frequently reported achievement -forming partnerships -and the absence of as-sessments of the quality and impact of these partnerships. As the articles we reviewed stated repeatedly, weak engagement at both the coalition and community levels limited opportunities to achieve anticipated PSE Framework outcomes. Because the activities intended to foster such engagements were the least often evaluated, the influence and impact of these activities were largely unknown. Only 2 articles (49,55) mentioned measuring the quality of partnerships, but both described the use of surveys vaguely. Although the formation of coalitions and community relationships are an expected step in PSE work, the emphasis is often on documenting program implementation and outcomes. Asada and colleagues (5) concluded from their review of public health interventions that the use of valid and available evaluation tools would strengthen what we know about the impact of structural change initiatives. These include tools that measure partner engagement and collaboration. Measurement resources exist: Kegler and Swan (74) developed the Community Coalition Action Theory, which links participant engagement and resources to change community outcomes, including policy achievement. One research-tested tool to assess the effectiveness of collaborations is the Collaboration Factors Inventory offered by the Wilder Organization (75), which includes 22 success factors. Another tool is the Collaboration Framework developed by the University of Wisconsin Cooperative Extension Service, which characterizes the degree of collaboration based on a depth-of-relationship integration scale (76). I+PSE initiative leaders would do well to employ such partnership assessment tools to determine the quality and impact of their interventions.
A related finding was the lack of planning and evaluation frameworks. Brennan and colleagues (77) reviewed childhood obesity policy and environmental initiatives using the RE-AIM Framework and concluded that it was difficult to describe and summarize initiative outcomes because they lacked formal evaluations, and their multicomponent nature made it difficult to attribute outcomes to specific activities. In a scoping review of structural public health interventions, Asada and colleagues (5) reported insufficient application of theory-based evaluation frameworks and validated tools to measure change at the environmental level. Our mapping review also noted absence of planning and evaluation frameworks for all but 11 of the 52 initiatives reviewed (19,20,29,31,32,36,38,39,46,62,72). I+PSE was applied in this review because of its theoretical underpinnings, its acknowledgment and examination of the multidimensional components that support PSE change, and its adaptability to categorize HEAL initiatives. Frameworks that include assessment, engagement, and formation and strategies to strengthen coalitions and community involvement, such as I+PSE, will support the effectiveness of PSE initiatives.
We also found the limited funding period of just 1 to 3 years required by government and foundation funding sources to be disappointing but not unexpected. The time needed to establish or strengthen existing coalitions, assess needs, and prioritize PSE strategies can be lengthy but is essential for success (45,78). For example, after examining efforts to improve maternal and child health outcomes in 14 North Carolina counties, Schaffer and colleagues (8) concluded that more upfront time was necessary to form community action teams able to sustain community engagement. After Holston and colleagues (45) implemented multilevel obesity prevention interventions in 3 rural Louisiana parishes, they recommended identifying attainable early successes, not only to engage and strengthen partnerships but also in recognition of the time it takes for significant PSE change to be realized. When funding periods cannot be lengthened, funders, researchers and practitioners must identify realistic outcomes for these brief timeframes, such as the development of strong community linkages.
The need for technical assistance for I+PSE implementation and evaluation has been widely reported (2), including by those using the SNAP-Ed Evaluation Framework (79-81). Naja-Riese and colleagues (9) noted in their review of national SNAP-Ed results that implementing agencies still focused most of their activities and evaluation measures at the traditional individual-change level, despite the intended focus on PSE change. They posited that practitioners need technical assistance to learn to implement and measure multisector activities. Our review found similarly that delivery of individual behavior change activities was the second most frequent accomplishment. Herman and colleagues (82) noted from interviews with state and regional public health nutrition teams working in maternal and child health the need for technical assistance and the value it garnered in the development of PSE action plans. In our review, 7 initiatives provided technical assistance to coalition members leading PSE efforts or intermediary service providers (28,45,46,48,54,64,70), but none described in any detail recipient response to the value or effectiveness of the technical assistance. Assessing and addressing I+PSE implementation and evaluation capacity and readiness for teams leading the initiative is critical for success but was not even described in any of the 52 articles we reviewed.
Using a mapping review approach allowed us to visualize the match between intervention and evaluation activities across the 7 distinct components of I+PSE. Ours is the first attempt, to our knowledge, to examine and characterize PSE HEAL initiatives with the detail this I+PSE provides and with an evaluation focus. We found the framework to be adaptable and applicable to a variety of HEAL initiatives, and unlike other frameworks, it acknowledges and includes assessment of individual behavior change res-ulting from PSE approaches, which are common activities in PSE initiatives.
However, our review was not exhaustive. We did not seek out articles related to those in our review that did not meet the inclusion criteria themselves, nor did we search the gray literature. We also did not report funding amounts, which could have influenced the scope and reach of these initiatives, including their evaluation activities and results. Funding amounts would be an important component in future reviews, as would a more in-depth examination of the relationships between strength of coalition and community engagement and achievement of PSE outcomes. Future reviews also could explore the perceived value and application of evidence-based practice and practice-based evidence (83) in PSE HEAL initiatives for which there is no "best" intervention and evaluation design because of diversity in aims and approaches, and multicomponent complexity (5). Future research also could examine funding sources, I+PSE activities and evaluation components, and outcomes for different audiences (eg, by school level, initiative setting) to identify patterns specific to those audiences. Finally, despite the breadth of our search terms, only 2 initiatives were identified outside the US (48,83), and both of these were located in Australia. This limits the generalizability of our results.
As poor dietary patterns, sedentary lifestyles, diet-related chronic diseases, and associated health care costs increase in the US (84), the need is urgent for greater focus on and investment in learning how individual PSE change approaches can be optimized to advance healthy eating and active living across households, communities, and populations. Our mapping review shows potential gaps and suggests opportunities to advance research and practice in formulating, implementing, and evaluating PSE HEAL initiatives. Future initiatives should give special attention to closing the gap between activating community and service provider partnerships and evaluating the quality and impact of these relationships, because outcomes will rely on the strength of these relationships.     1. Strengthen individual knowledge and skills Enhance individual's, or household's decision-making and capability of participating in or benefitting from HEAL.

Promote community engagement and education
Connect with diverse groups of people to inform them about the benefits of HEAL and to establish bi-directional communication, trust, and support to advance HEAL approaches.

Activate intermediaries and service providers
Inform and educate intermediaries and service providers who transmit information about HEAL to others.

Facilitate partnerships and multisector collaborations
Foster relationships and cultivate multisector collaborations with stakeholders about individual, community, and/or population approaches to HEAL.
5. Align organizational policies and practices Revise or adapt policies, procedures, and practices within institutions that support HEAL.
6. Foster physical, natural, and social settings Design, foster, and maintain physical (built), natural (ecosystems), and social settings within institutions and public environments that support HEAL.

Advance public policy and legislation
Develop strategies to inform change to laws, regulations, and public policies (local, state, federal) that support HEAL.   (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.
(continued on next page)  (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.
(continued on next page)  (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.
(continued on next page)  (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.
(continued on next page)    (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.

PREVENTING CHRONIC DISEASE
(continued on next page)    (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.

PREVENTING CHRONIC DISEASE
(continued on next page) PREVENTING CHRONIC DISEASE VOLUME 19, E54 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2022 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
(continued)  (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.
(continued on next page) PREVENTING CHRONIC DISEASE VOLUME 19, E54 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2022 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
(continued)  (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.
(continued on next page) PREVENTING CHRONIC DISEASE VOLUME 19, E54 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2022 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
(continued)  (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.
(continued on next page) PREVENTING CHRONIC DISEASE VOLUME 19, E54 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2022 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
(continued)  (12) consists of 7 numbered components defined as follows: 1) strengthen individual knowledge and behavior; 2) promote community engagement and education; 3) activate intermediaries and service providers; 4) facilitate partnerships and multisector collaborations; 5) align organizational policies and practices; 6) foster physical, natural, and social settings; and 7) advance public policies and legislation. Numbers in brackets indicate which of 7 components the study addressed. Alignment with strategies describes how an aspect of the study's initiative/intervention related to a component (eg, included an online survey, provided documentation, evaluation methods). Strategies were coded as weak if they were vaguely described, imprecise, or provided insufficient coverage of intervention activities aligned with I+PSE components.